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Free Nursing Dissertation Topics (2018)

1. Introduction to Nursing Dissertations

This guide gives you some ideas for dissertation titles. Nursing covers many areas, so there should be plenty to whet your appetite here.Nursing dissertations typically take one of two forms, focusing either upon collecting and analysing primary data or upon appraising secondary data only. Either type can be appropriate to your area of study. You will also find an overview of how to structure your dissertation in section three below.

2. Categories and List of Dissertation Titles

2.1 Mental Health Nursing

2.1.1 The value of family therapy for adolescents with eating disorders: a quantitative study in a London hospital.

2.1.2 To what extent do poor housing conditions exacerbate existing mental health issues A review of recent literature.

2.1.3Do complementary therapies have any role to play in the management of schizophrenia A qualitative study amongst UK patients and mental health nurses.

2.1.4 Which techniques are most effective in managing challenging behaviour amongst patients with mental health issuesA cross-UK quantitative study of 3 hospitals.

2.1.5 The impact of client-centred approaches upon users of mental health services: a qualitative study amongst out-patients with depression.

2.1.6 Sheer nonsense, or a story to tell Can listening to the content of delusions and ‘heard voices’ help with nursing the schizophrenic patientA review of recent literature.

2.1.7Quality or quantityIs time spent with patient or the quality of the interaction more important in mental health patient perceptions of nursing careA qualitative study.

2.1.8Nurse prescribing in mental health: to what extent is there tension between nurses and psychiatrists regarding medication for patientsA case study in one UK hospital.

2.2 Community Nursing, Health Car Programmes

2.2.1 Partnership, team work and health: To what extent has partnership working and a new emphasis upon team work been effective approaches in UK nursing A review of literature from the past 10 years.

2.2.2How successful was the programme to introduce ’community matrons’ in the UKA review of literature.

2.2.3Were the last Labour government in the UK successful in targeting health care programmes where they were most neededA case study of the ‘Healthy Living Centres’ programme.

2.2.4Self-management and community based care: to what extent can community nursing help patients with chronic obstructive pulmonary disease self-manage A qualitative study amongst UK nurses and patients.

2.2.5To what extent do nurses working in the community feel they have power to influence and / or change the policies which regulate their practice A qualitative review amongst 5 UK nurses.

2.2.6 Health and ethnicity: do people from different ethnic backgrounds make different use of community nursing facilitiesA qualitative study of inner-city Birmingham.

2.2.7Obesity education and prevention. Can an intervention to help adults notice, read and understand food labelling help address obesity problems in the UKAn intervention study amongst UK adults.

2.2.8Should stop-smoking programmes be targeted to client age, gender and other demographic variablesA review of recent literature.

2.3 History of Nursing, Nursing Education, Nursing Research, Structure of Nursing Profession

2.3.1 Can text messaging be used to improve communication between nursesPiloting a tool for reporting in a large UK hospital: an analysis of the results.

2.3.2Nurse’s attitudes towards evidence-based practice: a comparative, qualitative study of medical staff in the UK and in India.

2.3.3Is a constructivist model of learning the most effective framework for teaching evidence-based practice to nurses, or are other models more appropriateA review of the literature.

2.3.4 Nursing training and ageism: the extent to which there exists prejudice against older student nurses. A qualitative study of patient, nurse and educationalist attitudes.

2.3.5The practice of nursing: tacit or explicit knowledge. A qualitative investigation of ways of knowing in experienced nursing practitioners.

2.3.6Measuring the use of research practice among nurses: a qualitative study amongst nurses with one, three, five and ten years experience in the profession.

2.3.7Kind and caringComparing university trained nurse-practitioners with other hospital staff in terms of degree of empathy experienced by patients. A quantitative study.

2.3.8 Can a continuing relationship between patient and nurse improve patient outcomes A review of literature from the UK, USA and Europe.

2.4 General Nursing

2.4.1 ‘They bring it on themselves’: nurse’s attitudes towards patients attending A&E with alcohol-related injuries. A case study carried out in a Manchester hospital.

2.4.2To what extent do levels of stress amongst nurses improve as they develop professional experienceA quantitative study comparing nurses with one and ten or more years of experience.

2.4.3Gender, sexuality and sexual advice. What is the impact of sexual orientation on preference for a same-sex advisorA qualitative study in a London sexual health clinic.

2.4.4Are patients in a rural location more or less accepting of advice given by a nurse-practitioner compared to such advice given by a GPA comparative, quantitative study of two UK health centres.

2.4.5Are asthma self-management programmes more effective when they involve the family as well as the sufferer A quantitative test of a pilot programme for one or more family members.

2.4.6How effective are nurse telephone consultations in primary care A review of literature from the last 10 years.

2.4.7The effectiveness of meditation and breathing techniques in managing patient stress: a quantitative study of a programme to teach nurses to help patients relax.

2.4.8Communication and the emergency nurse practitioner (ENP): do increasing time and financial pressures mean that communication between nurse and patient is hampered A comparative literature review assessing the current situation in relationship to the role of the ENP in the 1980’s and 90’s.

2.5 Geriatric Paediatric Nursing

2.5.1 Is a holistic approach to nursing elderly patients the most effective in terms of patient satisfactionA quantitative study in UK nursing homes.

2.5.2Can reminiscence and life-story work help improve quality of life in terminally-ill elderly patients A case study of the impact of a nurse-led programme working with patient’s memories.

2.5.3Is there a need to improve student nurses’ attitudes towards caring for the elderlyA quantitative study amongst UK student nurses assessing the level of negative and stereotyped attitudes towards older people.

2.5.4Can a case be made for a dementia nurse specialist role, and what should this role involve A review of literature relevant to UK healthcare.

2.5.5How do nurses specialising in the care of elderly people understand the concept of ‘fragility’ A qualitative, in-depth study amongst specialist UK nurses.

2.5.6 What role can parents play in improving outcomes for children with congenital heart disease A review of recent literature.

2.5.7Are nurses attitudes towards pain management in children culture specific A review of literature.

2.5.8 Can the development of eating disorders in adolescents be predicted by behaviour in pre-adolescence An analysis of an early intervention programme for childhood eating disorders.

3. How to Structure a Nursing Dissertation, Tips

For details on how to structure a nursing dissertation, kindly check out the following post:

How to Structure a dissertation (chapters)
How to structure a dissertation (chapters and subchapters)
How to structure a dissertation research proposal

Also review how to write an Essay right here.

Free Essays

Effects of Post-Stroke Rehabilitation on Older Adults: Nursing-Care


Literature review is systematically written presentation on given area of study or topic (Burns and Saunders, 2005), and this paper is a systematic review, investigating the effects of post-stroke rehabilitation with special reference to older adults (?65). The Stroke Association [TSA] (2010b) defined stroke as disturbance to the brain’s blood supply resulting in damage(s) to brain’s cells/tissues (Figure1).

The rationale (see appendix1) is partly because National Audit Office [NAO] (2005p.4) stated that, over 110,000 strokes and 20,000 transient ischaemic attacks [TIA] occurs annually in England. Additionally, over 300,000 people are living with stroke related disabilities and, over 75% of all stroke fatalities occur in older adults aged ?65 (DH, 2007p.13). Various policy documents also informed the choice of topic (appendix2). However, little evidence exists on the effectiveness of post-stroke rehabilitation in relation to this adult-cohort.

Outcome parameters includes mortality rate, level of disabilities, mobility, speed of recovery, and Barthel Index [BI] scores on activities of daily living [ADL]. ADL is colloquially called activity of living [AL] in relation to nursing process however ADL is used in accordance with BI scale used in specialist stroke units [SSU] in England (SNPlacement, 2009).

There was paucity of studies on post-stroke rehabilitation in older adults though there is wealth of information on outcomes of different care structures. However, little evidential research exists that clarifies combination or individual rehabilitation pathways that better suited older adults. However, Stroke Unit Trialist’ Collaborations [SUTC] in 1993, 2001, and 2007 concluded that post-stroke fatality was lowest in Trusts with greater number of SSU care thus, nurses with advanced knowledge on stroke.

This write-up included only studies used in Cochrane collaborative reviews and meta-analysis, and similar collaborations. Consequently, reducing the risks associated with validity, reliability, generalizability, bias, and ethics often encountered when reviewing research studies (PHRU, 2006). Systematic approach, and various search engines were utilised for the literature searches (appendix3). The writer systematically organised the nine chosen research articles/studies (appendix4) into groups of three within three chapters:

Chapter One: Specialist Stroke Units Versus General/Neurological Wards.
Chapter Two: Specialist Stroke Units Versus Specialist Stroke Unit with Early Supported Discharge.
Chapter Three: Efficacy of Specialist Stroke Unit Care on Post-Stroke Rehabilitation: A Way Forward for Older Adults?

Informed consent (NMC, 2008) was, obtained from gatekeepers (appendix4) prior to visiting an SSU in Southern England for empirical fact-finding in March 2011. The term “the writer” refers to the author of this review to avoid ambiguity of terminology (Polit and Beck, 2010).

Figure 1: Damages to Brain Due to Stroke

(Source: NAO, 2010p.6)



According to RCN (2007) rehabilitation is a holistic person-centred, action-based process which entails individual’s ability to learn adaptive ways of dealing with changes in life circumstances due to incapacitation resulting from conditions such as stroke. It is the process by which stroke survivors learn new skills and or relearn skills that are lost or rendered dormant due to damages to areas of the brain. For example, hand to mouth co-ordination in order to feed oneself, and relearning mobility with the aid of walking devices. Indeed, paralysis to one-side of the body often leads to survivors needing to learn how to perform ADL with one-side of the body. The primary characteristics of evidence-based rehabilitative regime entails repetitive practice of specific skills in a carefully coordinated, and well-focused manner similar to those utilised when learning a new skill such as swimming or riding so as to achieve mastery or best possible level allowed by ones condition. Post-stroke rehabilitation for most survivors can be a lifetime activity. Moreover, very few cases of rehabilitation are time-limited.

The key political influence on rehabilitation process for older adults is the National Service Framework (DH, 2001) which emphasises the importance of rehabilitation and the availability of rehabilitation services. It has had huge impacts on the rehabilitation service provision and treatment for older people in the UK since 2002. Rehabilitation can be a lifetime activity moreover very few cases of rehabilitation are time-limited.

Over the years, stroke patients were cared for in general/neurological wards (GW). However, during the past two decades, specialist stroke units (SSU) have emerged as a preferred treatment option for stroke patients mainly due to evidence from various meta-analytic studies (SUTC, 1999; 2001; 2007). The results suggest that SSU care has beneficial effects by reducing post-stroke mortality, need for institutionalization, and improving ADL and speed of recovery. Indeed, SUTC (2007) published meta-analysis with 6936 participants from 31 trials were analyzed to assess whether SSU care was consistently associated with improved outcomes. The authors concluded that patients who received SSU care were more likely to survival, remain independent, and living at home 12 months post-stroke accident. Langhorne et al., (2002) proposed that the basic characteristics of SSU are stroke specialist staff including nurses; dedicated units; multidisciplinary team [MDT] care, and systematic diagnostic evaluation; acute monitoring and treatment; early post-stroke mobilization; and early immediate start of rehabilitation (cited in Indredavik, 2008p.1). However, not all SSU have these detailed characteristics thus for the purpose of this analysis, irrespective of structure, all studies with units similar to defined characteristics are given the blanket term of SSU.

Kalra et al., (2000Study1) in their prospective RCT study compared the efficacy of SSU with stroke team or domiciliary care using 457 acute-stroke patients (48% women) with an average age of 76 years (appendix1). During the 12 month follow-up, the data suggests that there was low mortality or institutionalisation for patients treated on SSU compared to patients who were treated by the GW stroke team (21/152 [14%] versus 45/149 [30%]; p<0.001) or domiciliary stroke care (21/152 [14%] 34/144 [24%]; p<0.03) stroke. The results suggest that SSU were more effective than GW with stroke team or domiciliary stroke care in reducing mortality, dependency and, institutionalisation post-stroke. This was similar to the findings in the prospective comparative cohort study by Glader et al., (2001study2) which is a two years follow-up study that investigated rate of stroke-case-fatality, and patients’ level of independent assistance for primary ADL before and post-stroke (appendix4). The authors found that with regard to stroke-case-fatality there was 30.2% of SSU and 34.0% of GW treated patients. There was 25.4% and 29.1% respectively for rate of case fatalities for SSU and GW patients who were independent in primary ADL prior to stroke (OR, 1.18; CI, 1.06 TO 1.30). The 3376 participants that completed the questionnaire had mean age of 74.3 years (SD, 10.6) with 1.4 years in age difference between SSU and GW treated patients. More SSU treated patients were still living in their own homes, and most maintained independence with primary ADL. Indeed, following case adjustment for differences in case mix, SSU treatment remained an independent predictor for patients retaining independence of assistance with ADL two years post-stroke. Conversely, with regards to patients dependence on assistance for primary ADL defined by BI, 354 patients that required assistance with primary ADL had an average age of 78.5 years (SD=9.8). SSU and GW treated patients had average age of 79.0 versus 77.6 years respectively with p-value of p=0.19 which is not statistically significant. Indeed, patients cared for in SSU had statistically significant less pain compared to GW patients, this statistical significant difference remained after adjustment for differences in case mix prior to stroke (OR, 0.75; CI, 0.61 to 0.91).

Kalra et al., (2000study1) in their own study suggested that the reduced mortality or institutionalisation amongst SSU patients was attributed to reduction in post-stroke mortality. Moreover, the benefits of SSU care was further emphasized because, the proportion of survivors without severe disability at 12 months follow-up was statistically significantly higher for SSU patients compared with GW stroke team (129/152 [85%] versus 99/149 [66%]; p<0.001) or domiciliary stroke care (129/152 [85%]) versus (102/144[71%]; p=0.002). These differences were present at both 3 and 6 months follow-ups post-stroke. Therefore, the results further suggest that SSU are more effective than GW with stroke team or domiciliary stroke care in reducing mortality, dependency and, institutionalisation post-stroke. Indeed, the ADL barthel score (15-20) was best for SSU patients at 3 months follow-up (82%) compared to 70% of patients in GW with stroke team and, 74% of patients in the domiciliary stroke care.

Zhu et al., (2009study3) in a recent comparative retrospective cohort study on the impact of SSU on length of hospital stay and case fatality further demonstrated the efficacy of SSU to reduce stroke fatality and speed-up recovery. They found that for all stroke patients, the adjusted odds on length of hospital stay (>7days) was reduced by 22% (p<0.0001) on SSU compared to GW. Congestive heart, dementia, and peptic ulcer disease were the co-morbidities (p<0.05) that predicted duration of hospital stay. Indeed, SSU care significantly reduced overall in-hospital case fatality (adjusted OR, 0.70, p<0.0001). The authors observed that reduction in case fatality for SSU patients was similar to the 5% mortality reduction observed in the follow-up of a similar study by Candelise et al., (2007).

In summary, the studies by Kalra et al., (2000); Glader et al., (2001); and Zhu et al., (2009) supports the efficacy that SSU care characterised by admission to an SSU with stroke-directed nursing care, physio and occupational therapy, and assessment by a stroke neurologist is beneficial and the preferred post-stroke care pathway. These results were similar to those from SUTC (2002; 2007) reviews/ meta-analysis of SSU. Indeed, Jarman et al., (2004) research on whether there was a link between reduced in-hospital mortality rates, and acute SSU and early Computerised Tomography scan suggests that acute-SSU were associated with >10% lower odds of death.

The proposal here is that, nursing process model of care which entails assessment; care-planning; implementation; evaluation with assessment; and evaluation as a continuous process until discharge and beyond (Holland et al., 2004) were beneficial in reducing stroke fatality; institutionalization or faster improvements in patients ability to be more independent in ADL for SSU patients compared to GW patients post-stroke. Results from a National Sentinel Audit (NSA) of stoke for UK except Scotland (Rudd et al., 2005) arrived at similar conclusions. Additionally, the beneficial effects of SSU compared to GW can be conceptualised in terms of specialist stroke, rehabilitation nurses’ expertise thus superior clinical judgement (Tanner, 2006). Indeed, the 24/7 characteristic of clinical nursing allows nurses to get to know the patient as an individual thus creating the unique bond that enable nurses to care, based on empirical knowledge of the patient instead of fitting rehabilitation models to the patient based on written medical judgement alone (McCaffery et al., 2000).

If rehabilitation is a continuous process that could last a life-time, when does rehabilitation commence post-stroke Hypothetically speaking, what happens after patients are discharged from GW or SSU, and does rehabilitative nursing care continue within the community Are patients better off in the community once stable; are the beneficial effects of SSU due to the 24/7 stroke specialist nursing care given to patients within a structured, MDT staffed, purpose-built stroke unit/ward?

From an economic point of view, patients occupying hospital beds post-stroke with each bed costing over ?400 per night is quite expensive (SNPlacement, 2009) especially when such patient is stable and can continue receiving rehabilitative nursing care within the community preferable in their own home. Having established that SSU have better patient outcome compared to GW, in view of the economic implication, the next chapter will investigate SSU with early supported discharge as a possible solution.



The Cochrane library (2000) classified SSU services that offer in-hospital patients an early discharge with a follow-up that consists of community-based rehabilitation as ‘early supported discharge’ [ESD]. NormalSSU may be defined as stroke unit treatment according to evidence-based recommendations (SUTC, 1997) combined with further inpatient rehabilitation when more long-term rehabilitation is necessary and a follow-up program organized by the primary healthcare system after discharge (Indredavik et al., 2000p.2990).

According to SUTC (2004) review, there are benefits to SSU care with ESD. Consequently, this chapter investigates the efficacy that ESD following treatment in SSU speeds-up recovery; reduces time spent in hospital; and empowers surviving patients to return faster to independence ADL. The later maybe attributed to the ideological belief that patients discharged home are able to continue their rehabilitation in familiar surroundings thus removing the institutional aspect of rehabilitative nursing care and general therapy (Kosh et al., (2000b).

Post-stroke discharge is a process at the end of the patient’s initial rehabilitation following stabilisation after a stroke. Because discharge planning is a joint responsibility, specialist stroke nurses in their role as patient advocate (NMC, 2008), and facilitator (Harms and Benson, 2003), actively liaise with other professionals in the best interest of the patient in accordance with NMC (2008) code.

Thorsen et al., (2005study4) evaluated the optimal effect of ESD and continued rehabilitation at home, in terms of patient outcome 5 years after stroke and changes over time. Amongst the 30 patients in the SSU with ESD (intervention group), there was significantly higher independence in extended ADL and, they were active in household chores compared to the 24 patients in the control group during evaluation five years post-stroke. Indeed, the results were similar to those from the study by Indredavik et al., (2000study5) which had a complex robust protocol of MDT post-discharge collaboration with each patient at the centre of every intervention and decision about his/ her care. The extended ESD post-discharge MDT is similar to a ‘community care service’ provision in the UK (DH, 2004). The study evaluated the short-term effects of an advanced SSU care service with essential ESD versus a normal standard SSU. The results suggests that at 6 weeks, 54.4% of the extendedSSU group and 45.6% of the normalSSU group were independent based on RS (P=0.118), and 56.3% versus 48.8% were independent based on BI (P=0.179). 33.1% of the extendedSSU patients were discharged to another institution (mainly rehabilitation clinics) versus 51.3% in the normalSSU group (p=0.001). Moreover, the proportion of patients at home was 74.4% (extendedSSU), and 55.6% (normalSSU) (P=0.0004), and the proportion in institutions was 23.1% versus 40.0%, respectively (P=0.001).

After 26 weeks, 65% (extendedSSU) versus 51.9% (normalSSU) group showed global independence (RS?2) (P=0.017), while 60.0% (extendedSSU) versus 49.4% (normalSSU) group were independent in ADL (BI ?95) (P=0.056). The OR for independence (extendedSSU versus normalSSU) were RS, 1.72 (95% CI, 1.10 to 2.70); BI, 1.54 (95% CI, 0.99 to 2.39). Additionally, 78.8% (extendedSSU group) versus 73.1% (normalSSU) were at home (P=0.239), while 13.1% versus 17.5% were in institutions (P=0.277). The average lengths of stay in an institution were 18.6 days (extendedSSU) and 31.1 days (normalSSU) (P=0.0324).

Additionally, Thorsen et al., (2005study4) study showed that, the Mean hospital stay was significantly shorter in home rehabilitated group [HRG] {HRG = extendedSSU} (14 versus 30 days; p=0.027). The percentage of patients independent in extended ADL was significantly higher in HRG compared to conventional rehabilitated group [CRG] {CRG = normalSSU}. HRG patients scored more favorably regarding motor capacity however, frenchay activities index [FAI] that assessed frequency of social activities was similar in the 2 groups. However, significantly more HRG patients were active in the items washing dishes (P=0.006), washing clothes (P=0.04), and reading books (P=0.01) (appendix4). There were similarities in both groups on data regarding falls (HRG 63%; CRG; 61%) and falls resulting in fractures (HRG19%; CRG 14%); and ?60% of patients had fallen during the 6 months period before the follow-up commenced. Indeed, patients improved independence in ADL found support in Kosh et al., (2000b) descriptive study on individualized intervention which suggests that patients experience through involvement and control in their own ESD encourages and empowers them to actively solve future related problems independently. Additionally, based on the findings from their study, Indredavik et al., (2000study5) suggested that extendedSSU with ESD improves functional outcome, and reduces the length of stay in institutions compared with treatment in normalSSU. This casts doubt on the 24/7 (presence of nurses) beneficial effects of specialist stroke nursing. However, Kosh et al., (2000b) theory on familiarity of environment goes a long way towards explaining the reason for the marked differences in patient outcome in favour of extendedSSU/HRG. Moreover, the writer believes that the nurse in the community still spends more time with the patient than all the other MDT members put together.

Indredavik et al., (2000study5) had a long-term follow-up of their study which was undertaken by Fj?rtoft et al., (2003study6) with the primary aim of evaluating the long-term effects of extendedSSU characterized by ESD. The authors data suggests that 56.3% (extendedSSU) versus 45.0% (normalSSU) were independent (RS?2) based on primary outcome of modified RS (P=0.044). The results showed that the number needed to treat (NNT) to achieve 1 independent patient in extendedSSU versus normalSSU was 9 (95% CI, 4.6 to 345). The OR for independence was 1.56 (95% CI, 1.01 to 2.44; p=0.045), with adjustment to independent variables, the effect of extendedSSU was even greater (OR 1.93; 95% CI, 1.12 TO3.32; P=0.018). There were no significant differences in BI score and patients final residence. Moreover, patients with moderate to severe stroke benefited most from the extendedSSU. Unlike the study by Indredavik et al., (2000study5), the number of patients residing at home was not significantly higher in the extendedSSU patients at 52 weeks (appendix4). It maybe deduced that in the long-run, all things being equal, the beneficial effects of extendedSSU over normalSSU though exists, are too minimal for statistical significance.

A subgroup analysis for patients in the study by Fj?rtoft et al., (2003study6) showed that the NNT to achieve 1 more independent patient in the extendedSSU group versus the normalSSU group was 7 (95% CI, 3.6 to 27.3). Additionally, 47% of the patients treated in the extendedSSU and 28% (normalSSU) were independent based on modified RS score (P=0.005). The average length of inpatient stay was 18.6 days (extendedSU group) and 31.1 days (normalSSU group) (P=0.0324). Using the fitted logistic regression model, the authors analyzed the relationship between the severity of stroke and the NNT in the extendedSSU group versus the normalSSU group to achieve 1 more independent patient. The authors analyzed the whole group, and patients were also divided into two age-groups: patients aged <75 years and patients aged ?80 years. Figures for the whole group suggests that, a baseline Scandinavian stroke scale [SSS] which according to Birschel et al., (2004) measures progression of stroke, score between 35 and 54 corresponds to a NNT <10. For older patients, the curves show the greatest benefit with SSS score >41 unlike the SSS score for younger patients which was between 28 and 50 (Fj?rtoft et al., 2003p.2689).

The results from these studies suggests that, irrespective of structure/pathway adopted, SSU care services are beneficial to stroke survivors in that it reduces, mortality, chances of post-stroke institutionalization, and or improves ADL. Additionally, when SSU is combined with ESD the benefits were even greater but mostly for patients with ‘mild’ to ‘moderate’ stroke. Indeed, these patients are often able to return to full pre-stroke ADL functionality. Based on the findings of the studies, extendedSSU with ESD improve functional outcome and reduces the length of stay in institutions compared with normalSSU. Moreover, the long-term studies suggests that extendedSSU care with ESD offers patients better long-term functional outcome after 12 months compared to patients offered normalSSU care services. It is the writer’s contention that, these results fly in the face of the ideology that 24/7 nurses presence was the catalyst for SSU beneficial effects because, extendedSSU occurred in the community without necessarily the 24/7 presence of nurses and nursing care. One fact remains constant, the 24/7 characteristic of SSU nursing allows nurses to get to know the patient as an individual thus creating the unique bond that enable nurses to offer more superior care (McCaffery et al., 2000).

ExtendedSSU offers patients better outcome with regards to ADL, and general functionality over time. Fj?rtoft et al., (2003study6) in their study, suggests that the older the adults, the greater the beneficial effects of extendedSSU compared to normalSSU. Indeed, the proposal here is that studies on extendedSSU utilised in this chapter could, inform future evidence-based care of post-stroke older adult (?65) patients. The UK Government not just the English NHS should take notice because extendedSSU may be the post-stroke rehabilitative care pathway that will offer older adults the best outcome, and for the Government, better economic outcome.

In view of the findings and proposals arrived at in this chapter, the next chapter will investigate the implications of post-stroke rehabilitative care of older adults by reviewing findings on stroke in the very old in relation to age related benefits; stroke in the very old; and extendedSSU.



For Smith (1999) one of the most difficult challenges facing nurses is to ensure that individual patient’s needs dominate within the hospital or healthcare professional’s programme, which can be difficult to achieve due to time, and financial constraints. Nurses 24/7 contact with patients within care-settings places them at the centre of all care-interventions and treatments prescribed for the stroke patient (RCN, 2004). Therefore, they are essential to the co-ordination of patient’s treatment and the care that the patient may require throughout the rehabilitation process in the care-setting and beyond. Rehabilitation framework contains components that take account of everyday skills, such as maintaining acceptable level of hygiene, dietary intake, and general mobility. In addition to these skills, the framework takes into account patient education and information the patient needs and, facilitates the patient to develop any additional knowledge. During rehabilitation, the nurse acts as the patient’s advocate, enabler, and empowerer placing the patient at the centre of care-interventions utilising nursing process to create care and rehabilitation plan tailored to individual patient needs. Rehabilitation nurses perform various roles (appendix6) including patient advocacy; facilitator; enabler; and empowerer (RCN, 2004).

We live in an aging society and aging has its own problems and with age, comes increases in co-morbid conditions and prevalence of stroke related conditions like arterial hypertension, atrial fibrilation, and dyslipidemia (Ellekja et al., 2001; Browner et al., 2001). Moreover, higher incidence of co-morbidities, decreases life expectancy, and alters metabolism (Saposnik and Black 2009). Though a sizeable number of strokes occur in older adults, there is worrying paucity of studies investigating effects of SSU care on older adults (?65 years). Roding (1986) proposed that with aging advancement, patients’ involvement in and control of their own rehabilitation becomes more important to self-worth therefore, reducing their control has an adverse effect on emotional and physical health. Kalra et al., (1993;1995) used non-randomized designs in their studies of significantly more older adults and, their results suggested that there are beneficial effects in SSU care of acute-stroke patients. How do we as the future nursing work force ensure that older adults are empowered and enabled to remain independent post-stroke therefore, are able to continue performing ADL independently, with reduced institutionalization, and or mortality?

Fagerberg et al., (2000study7) compared the effects of acute SSU care integrated with care continuum [this is called extendedSSU for current review] versus GW conventional treatment in a study of elderly stroke patients. They compared effects of GW treatment care versus effects of extendedSSU (acute-stroke unit) care integrated with geriatric care continuum (see appendix4). 162 patients who survived 12 months (95% CI, -10% to 16%) (101 (61%) and 49 (59%) post-stroke were randomized to extendedSSU and GW respectively.

They found that there were no significant differences in QALY or ADL, and after three months of extendedSSU care compared to GW, there was reduction in stroke fatality and institutionalization (28% versus 49%, respectively; 95% CI -40% to -3%) in patients with concomitant cardiac disease. However, after 12 months this effect was absent. 80% of extendedSSU group, and 72% of GW group (95% CI -4% to 18%) were discharged home. Indeed, results suggested that there was no significant effect on the number of patients living at home 12 months post-stroke. This was similar to two studies (Strand et al., 1985; Kaste et al., 1995) which proposed that extendedSSU care afforded patients positive outcomes in relation to functional state and need for institutionalization but, no effects on survival, and only transient effects on health-related QALY. Fagerberg et al., (2000study7) study suggests that the beneficial effects of acute-stroke care on degree of dependence and mortality were mainly present in those patients with severe stroke these are often older adults. Indeed, SUTC (1999) in a meta-analytic study suggested that, such favorable effects in older adults with severe stroke may have been overshadowed by patients with mild to moderate stroke in whom no obvious effect was obtained. For example, they found no significance on stroke fatality or institutional care in patients with mild stroke (95% CI, OR 0.57 to 1.24) compared with patients with severe stroke, in whom there was clearly significant effect of extendedSSU care (95% CI, OR 0.38 to 0.88). Fagerberg et al., (2000study7) concluded that extendedSSU neither led to improved ADL, nor increases in number of surviving older adults who were able to return home 12 months post-stroke. However, an effect on mortality or institutional care three months post-stroke was indicated in particular among elderly stroke patients with concomitant cardiac disease or severe stroke. Indeed, they found that elderly patients with stroke tend to delay seeking medical intervention following stroke onset which, suffices towards explaining the increase in acute-stroke in older adults apart from the biological explanations of natural aging effects (DH, 2007).

Saponsnik and Black (2009study8) research investigated hospital care case fatality disposition in the very elderly, and proposed that survival post-stroke decreased with age. For instance, stroke fatality at discharge by age-group were <69 (5.7%); 70-79 (8.6%); 80-89 (13.4%); >90 (24.2%). Indeed, for every 100 patients aged ?90 admitted with acute ischemic stroke, 38 died in hospital, 43 were discharged to institutions, and only 19 were discharged back to their pre-stroke residence. The risk adjusted fatality at discharge by age were <69 (6.3%); 70-79 (12.5%); 80-89 (22%); 36.1% (p<0.001). Moreover, older adults aged >90 are less likely (4.3 versus 13.0%; p<0.001) to be admitted to the intensive care unit [ICU], and discharged back to their pre-stroke residence (39.9% for >90s versus 57.3% for patients aged <90; p<0.001). This could be attributed to the ideology that due to age-related debilitation, ICU would be wasted on them as they have limited chance of full recovery thus, would not be cost-effective unlike in younger patients. After adjusting for covariates, the multivariable analysis showed that patients aged >90 were 5-8 times more likely to die, and there was a 55% (95% CI 48-60%) decrease in the odds of being discharged home in these patients compared to those aged 80-89 years. Risk-adjusted fatality at discharged among those >90 years was 6 times higher than in the youngest age group and 1.5 times higher than in those aged 80–89 years. Only 1 in 5 individuals >90 years were discharged home after an ischemic stroke versus 1 in 3 of those aged 80–89, and 3 in 4 for the youngest age group. Indeed, the data from this study informed the authors’ suggestion that, stroke patients aged >90 had higher mortality, increased incidence of hospitalization, and are list likely to be discharged to their pre-stroke residence. These results, suggests that the benefits of SSU decreases with age!

Saposnik et al., (2009study9) investigated whether the reduced mortality or institutionalization seen with SSU care was similar across all age groups. They found that, compared to patients admitted to GW (1892; 52.1%), SSU (1739; 47.9%) patients had lower case-fatality (10.2% versus 14.8%; P<0.0001) over a 30-days period with an ARR=4.6%; NNT=22. There were no significant differences in the mean organized care index score amongst different age-groups in access to SSU indeed, there was similar benefit for all age-groups when care in SSU was compared to care in GW (ARR for 30-day stroke fatality by age were <60 (4.5%); 60 to 69 (3.4%); 70 to 79 (5.3%); and >80 (5.5%). It was evident from the results that higher level of organized care positively correlates with increased stroke-survival thus reduced stroke-fatality or institutionalization. However, there is selection bias (Polit and Becks, 2010) because, patients who received palliative care intervention were less likely (40% versus 49%; P=0.008) than non-palliative patients to be admitted to SSU. Could this explain the increased beneficial effects of SSU, since palliative care patients were treated/ cared for in GW or similar setup Results from Fj?rtoft et al., (2003study6) in chapter two would disagree though it was premised on extendedSSU as opposed to standard.

Saposnik et al., (2009study9) 30-days stroke fatality by age-group suggests <59=6.7%; 60-69=7%, 70-79=10.9%, and >80=20.2%. 30-days risk-adjusted stroke fatality for organized care index scores was 16.6%=3; 21.9%=2; 29.1%=1; and 54.9%=0. Indeed, there were no substantial differences by age-groups in relation to SSU care benefits. In the multivariable analysis, SSU care remained an independent predictor of stroke fatality at 7 days (OR, 0.55; 95% CI, 0.40 to 0.77; c-statistics 0.79), and 30 days (OR, 0.66; 95% CI, 0.52 to 0.84; c-statistics 0.80) after adjusting for age, sex, stroke severity, Charlson index, and an age-by-SSU interaction term. The interaction terms examining age-by-SSU were not significant (P=0.80 for 7 days; P=0.98 for 30 days stroke fatality). After all analyses were investigated based on age modification, there was no evidence of effect. However, after adjustments for multiple prognostic factors, and exclusion of patients treated utilizing palliative care, the benefits of SSU care on survival remained. Similar findings were observed for the organized care index score (0 to 1 versus 2 to 3). For example, higher level of access to SSU care was associated with lower stroke fatality at 7 days (OR, 0.18; 95% CI, 0.13 to 0.25; c-statistics 0.83), and 30 days (OR, 0.31; 95% CI, 0.24 to 0.40; c-statistics 0.82). The interaction terms examining age-by-organized care index effect were again not significant (P=0.29 for 30-day stroke fatality and P=0.46 for 7-day stroke fatality) (Saposnik et al., 2009:p.3324). Therefore, the authors concluded that irrespective of patients’ age-cohort, SSU compared to GW care leads to significant reduction in stroke fatality or institutionalization.


Nurses 24/7 presence is characterised by making them the primary link between the patient and the other members of the MDT (RCN, 2004). A successful rehabilitation uses a framework to make an integrated care pathway in which the patient, the MDT members, and the formal and informal carers can be involved. Indeed, stroke accident can occur at any age though older adults (?65) make-up the largest cohort of victims (DH, 2008).

Chapter one of this paper, critically reviewed the efficacy of SSU to reduce stroke fatality; reduce level of institutionalization; reduce length of in-hospital stay; and improve general recovery through ability to maintain primary ADL independently. Having established that SSU are beneficial, chapter two investigated the efficacy of SSU with early supported discharge [ESD] in relation to speedy recovery, independence in ADL (BI=?95%), and reduced post-stroke mortality. The better outcome from extendedSSU with ESD when compared to normalSSU cannot be attributed to 24/7 nursing alone because both extendedSSU and normalSSU had 24/7 nursing though there was better coordinated continuity in terms of discharge plan with rehabilitative nursing for extendedSSU. Therefore, the proposal here is that extendedSSU better patients’ outcome was mainly because specialist stroke nurses offered more one-to-one rehabilitative nursing care compared to those in the normalSSU.

Studies reviewed in chapter one, and two suggests that SSU care is, beneficial to stroke patients especially extendedSSU with ESD in adults. There is the matter of older adults, what with normal aging processes that tends to be degenerative thus resulting in possible (increased) vulnerable. However, studies in chapter two and three suggests that extendedSSU care similar to acute care of older adults’ is the best option for older adults (?65). This was supported by Indredavik (2009); SUTC, (2007).

The main outcome of this paper is that SSU care is the way forward for all stroke patients, and the best possible option for older adults. This is because 75% of all strokes occur in older adults (?65 years); and SUCT (1997; 2001; 2002; 2007) reviews have determinately suggested that SSU care is the best option for reduced level of stroke fatality, institutionalisation, or improved post-stroke ADL [BI scores].

The findings of this literature review is important for UK policy makers in relation to post-stroke rehabilitation care pathway for older adults because it goes some way towards establishing that extendedSSU is better option for older adults. However, further research are necessary before such results can inform evidence-based practice thus, policies on stroke care in older adults.

Free Essays

Nursing health assessment is an important role for a patient being diagnosis and give appropriate treatment


Nursing health assessment is an important role for a patient being diagnosis and give appropriate treatment (Bellack, 1992, p.12). In my past clinical practice, only some simple assessments were conducted as it is able to reduce the affect of the problem but not solve it. After studied nursing health assessment, some more extensive and specific assessments should be done to identify patient’s health status. The actual problem, strengths deviations and the risk of the health problem are explored at a detail and in-depth way. This article is going to discuss about the specific nursing health assessment for a patient suffered from abdominal pain, who was met in my past practicum placement.

Case scenario

Ms. Ma, Age 54, housewife, admitted via A&E and complained she was having abdominal pain for 5 days. Sharp pain starts at mid-abdomen and then at right lower quadrant. Level of pain increased when coughing. She had had Panadol 500mg an hour ago but pain can not relief. Nausea and vomited small amount of undigested food twice in the past few days. No diarrhea. She feels tired but can not sleep because of the sharp pain. Her vital signs are: pulse 98, blood pressure 148/85 mmHg, temperature 39.2oC. Her skin is warm and dry. Rebound pain occurred at the right lower quadrant of abdomen. She has hypertension and need to take medicine 2 times per day.

Ms. Ma was diagnosed with acute appendicitis. Keep NPO and IV 500ml normal saline is established. Blood test, abdominal X-ray and ultrasound abdomen are planned.

Assessment of abdomen

In the past clinical practice, I only give analgesics by doctor’s order and the patient may sometimes relief pain after medication. However, abdominal assessment skills are necessary to identify Ms. Ma‘s condition for getting at the root and having a better outcome.

There are five important steps for evaluating abdomen: take health history, inspection, auscultation, percussion and palpation. These assessment skills will be discussed one by one in the following paragraphs.

Health history and lifestyle health practices

First, find out the patient’s chief complaint, record the details and observe Ms. Ma‘s general appearance.

Then, assess the abdomen pain by COLDSPA— character, onset, location, duration, severity, pattern and associated factors. It is the most accurate measurement to identify whether it is parietal peritoneal pain, visceral pain or referred pain (Judy, 2008).

After that, collect individual and family past and current health status. Ask if there was any injuries or trauma may cause the pain, any eating disorder, any abdominal surgery was done before, any food allergy, history of suffering inflammatory bowel disease, family history of cancer and chronic disease, etc. Also, collect Ms. Ma‘s lifestyle and health practices. Ask her if smoke, drink or not, her eating habit, bowel pattern and movement, the amount, colour and texture of stool, any change in appetite, weight and abdominal girth recently and her stress level (Medical Education, 1998).

Past history and current lifestyle health practices are the useful information to identify the risk factors of the problem.

After collecting all background information, the physical examination should be proceed. Physical examination is using senses to collect objective data. It is used to identify the actual and potential health problems, discover patient’s abnormalities and diagnosis the problem (Nursing 2010 Magazine, 2010).

For physical examination of abdomen, Ms. Ma needs to empty her bladder first in order to avoid the bladder irritation then, place Ms. Ma in a supine position. The hands should be at aside and knees slightly bent. Tell her keep relax of the abdominal muscles. The assessment should be started in the right lower quadrant of abdomen and then proceeding in a clockwise direction. Also, the examination should go forward in the order of inspection, auscultation, palpation and finally percussion for avoid affecting the quality of bowel sound and increase peristalsis (Bellack, 1992).

Physical examination of abdomen


Inspection is systemic visual examination. For abdominal examination, it should be started at the mouth, which is the beginning of gastrointestinal tract, and finally the rectum and anus (Bellack, 1992).

First, ask Ms. Ma opens her mouth and says “Ar” or use tongue depressor to inspect the structure of mouth cavity to see whether any inflection, ulcer or not. Then, give a swelling test to Ms. Ma for examine the swelling ability. Place a spoon with some water on the middle part of her tongue and ask her to swell the water slowly to observe any choking or water leaks out. After that, inspect the texture of abdomen, the condition and colour of skin, any bruises or scars presence on abdomen. Normally, abdomen is homogenous in colour. If redness or yellow orange appear, it may indicate inflammation or liver disease respectively. Normal abdomen should also be symmetry from side to toe, flat and have normal movement when smooth respiration. If the abdomen is asymmetric, obesity, abnormal enlargement of organs, fluid distention or even intestinal obstruction may be suffered. Also, aortic pulsation should be present as Ms. Ma is having hypertension. Finally, ask Ms. Ma to take a deep breathe and hold it, it is used to inspect the presence of hernias or not (Bellack, 1992).


Auscultation of abdomen is used to define the bowel sound, which are caused by the movement of air or fluid at small intestine, by stethoscope.

The examination is started at the right lower quadrant, where the clearest bowel sound can be heard. Normal bowel sounds are at high-pitched, bubbling sound and occur five to thirty times per minute. If hyperactive bowel sounds occur, it indicates diarrhea or early stage of gastroenteritis. If hypoactive or even absent of bowel sounds for five minutes, it indicates intestinal obstruction, peritonitis or pneumonia.

Besides bowel sounds, vascular sounds of aortic, renal, iliac, and femoral arteries can also be auscultated. It is an important examination to assess hypertension patient such like Ms. Ma whether she suffers from portal hypertensive and liver cirrhosis or not. If the vessels constricted or dilated, a bruit can be heard when blood flows (National Institute for Health and Clinical Excellence, 2008).


Palpation is using sense of touch to collect data. For abdominal examination, finding out the location of pain is a great help of diagnosis abdominal pain. Light palpation and deep palpation are used to assess the abdominal organs, to define the tenderness and presence of mass. It is essential to assess the liver and spleen in abdominal examination.

Light palpation which is not more than 1 am deep on each quadrant. Normal abdomen should be smooth and consistent. If broad-like hardness appears, it states peritoneal irritation is suffered.

Deep palpation, which is press deeply from5cmto8cm, is used to indicate the abdominal organs and detect some obscure masses. Palpate the liver to test Murphy’s sign of cholecystitis. Palpate on the right upper quadrant at midclavicular line and parallel to the midline. If Ms. Ma feels pain and has inspiratory arrest, it states positive Murphy’s sign and indicate cholecystitis. Then, palpate the spleen at costal margin on left upper quadrant to feel if the spleen is enlarged and Ms. Ma will feel pain when the peritoneum is inflamed.

Finally, as the rebound tenderness was being tested to Ms. Ma, that is pushing 90o angle at the right lower quadrant deeply and then release quickly. It is the reliable test of peritoneal inflammation if the patient feels sharp pain when the force released (Watkins, 2010).

Besides, obturator test and iliopsoas test can also be done for diagnosing appendicitis. For obturator test, Ms. MA need to hold her right leg above the knee at 90o angle, grasp the ankle and rotate her leg laterally and medically. If she feels pain, it states obturator muscle is irritated. For iliopsoas test, straight up Ms. Ma’s right leg and press deeply on her upper thigh and ask her to oppose the pressing force. If she feels pain, it states that she is suffering from appendicitis (Beltran, 2009).


Percussion collects data by vibrations and sounds. For abdominal examination, percussion is used to assess the amount of fluid or gas, the location of mass, the size of liver and spleen. Normally, tympanic sound is found at hollow organs such as stomach and intestine; dullness sound is found at liver, spleen or masses.

To estimate the liver is enlarged or not, the normal distance of liver is 6 to12cm, which depends on the body size and gender, at the midclaricular line.

To estimate the spleen by percussing behind the left midaxillary line. If the distance is greater than7cm, it states that the spleen is enlarged due to infection, mononucleosis or trauma.

Moreover, test of shifting dullness and fluid wave to assess ascites. If the ascites of abdomen is more than 500ml, shifting dullness will be found. Normally, tympany is produced at abdominal midline (Bellack, 1992). However, for the abnormal case, dull sound is produced because of the cumulated fluid. Ask Ms. Ma rolls to right side and percuss from top to bottom. If the fluid is present, sound will change from tympanis to dullness and fluid wave will be generate when percuss on a side of the abdomen. It also has great variate in the abdominal girth.


After the physical examination, documentation is necessary for the findings and development of care plan.

Current of illness

Ms. Ma states that her abdominal pain started five days ago. On the pain scale from 0 to 10, as 10 being the worst, she rates her pain is 7. Sharp pain occurs at mid-abdomen and then at right lower quadrant continuously. Level of pain increases when coughing. She has no known drug allergy and food allergy. She had Panadol 500mg an hour ago but pain can not relief. Nausea and vomited small amount of undigested food twice in the past few days. She has loss of appetite and lost about 3 pounds of body weight. No change in her abdominal girth. She has no diarrhea. She feels tired but can not sleep because of the sharp pain. She is having fever as her vital signs are: pulse 98, blood pressure 148/85 mmHg, temperature 39.2oC.

Past health history and lifestyle practice

Ms. Ma is a non-smoker and non-drinker. She has hypertension and need to take medicine 2 times per day. No abdominal surgery was dome before. She denies any injury or trauma occurs recently on her abdomen. She does not have history of suffering inflammatory bowel disease or family history of cancer and chronic disease.

She states that her eating habit is health and the amount, colour, texture of stool are normal, but constipation sometimes. She does not feel stress or depression.

Physical examination

Ms. Ma has normal structure of mouth cavity and good swelling ability. There is no bruise or scar presence on abdomen. Her abdomen is symmetric and homogenous in colour. Her skin is warm but dry. By using the stethoscope, her bowel sounds are normal and no bruits are heard. Ms. Ma has rebound tenderness at the right lower quadrant of abdomen, pain occurs at obturator test and iliopsoas test when palpation. Normal tympanic sound is produced at abdominal midline when percussion.

Action and responses

Ms. Ma is hospitalized. IMI 50mg Tramadol is given and her pain is temporary relief. Blood test was done and the result shows the level of white blood cell is high. The abdominal X-ray and ultrasound abdomen show her appendix is enlarged

Ms. Ma is booked for an urgent operation for appendectomy.


In conclusion, some early symptoms of disease are not obvious, which will be easily misdiagnosed. Therefore, collecting health history and physical examination are very important as the data collected are in-depth and specific. It helps to have fast and accurate diagnosis in order to provide appropriate treatments to solve the patient’s problem and the symptoms at the same time.


Bellack, J.P. (1992). Nursing assessment and diagnosis (2nd ed.).Boston : Jones andBartlett Publishers.

Beltran, M. (2009). Give this diagnostic test if appendicitis is suspected: early acute appendicitis may be difficult to diagnose. ED Nursing, 12 (5), 56-67.

Judy, B. (2008). Pain evaluation and assessment. London : Piper Books in association with Heinemann.

Medical Education. (1998). Nursing Assessment [Videotape].America: Meridian Education Corporation.

National Institute for Health and Clinical Excellence. (2008). Appendicitis [Brochure].England:Newcastle Health Information Centre.

Nursing 2010 Magazine. (2nd ed.). (2010).America: AuthorBio Publishing Group Ltd.

Watkins, J. (2010). Recognizing the signs of acute appendicitis. British Journal of School Nursing, 5 (10), 488-91.


Free Essays

Nursing Reflective Essay using Driscoll’s reflective cycle


In this reflective account essay, I will be describing nursing skills that I undertook during my practice placement, using Driscoll’s (2000) reflective cycle, a recognised framework for reflection to demonstrate my ability to reflect on different nursing skill.According to Driscoll’s (2000), there are three processes when reflecting on one’s practice. They are: What (what happened), so what (what were you feeling, what was good/bad about the experience and Now what (if it happens again what you would do differently). The application of Driscoll’s reflective cycle will enable me link theory to practice.

As outlined, in the Nursing and Midwifery Council (NMC, 2004), the practice of reflection will allow me to explore, through experience, area for development in providing the necessary quality of care (Taylor, 2006). Reflection is a significant part of attaining knowledge and understanding, to reflect on experiences which could be positive or negative allowing for self criticism (Bulman and Schutz, 2004).

My 1st skill will explores how communication can be enhanced for clients with communication impairments which I raised in one of the multidisciplinary team meeting (MDT). I will be drawing from knowledge and experience gained from that meeting which involve social workers, speech & language therapist, adult nurse, mental health nurse and a carer experience. Names have been changed to maintain confidentiality (NMC, 2007)

1st skill:

I discover the level at which nurses and support worker communicate with service user are not up to standard simply because they have an impairment see Appendix 1

This now lead me to carry out a research on this issues which I discover that it has been estimated that there are 2.5 million people in the UK with communication impairment (Communications Forum, 2008). It is estimated that 50% to 90% of people with intellectual disabilities have communication difficulties and about 60% of people with intellectual disabilities have some skills in symbolic communication using pictures, signs or symbols (Fraser & Kerr, 2003).

The World Health Organization’s classification of impairment, disability and handicap relating to communication disorders are impairment which disruption the normal language-processing or speech production system e.g. difficulty with finding the right words or with reading sentences, reduced spelling ability and reduced ability to pronounce words clearly (World Health Organization, 2001).

Communication is ‘a process that involves a meaningful exchange between at least two people to convey facts, needs, opinions, thoughts, feelings and other information through both verbal and non-verbal means, including face to face exchanges and the written word’. (DH, 2003)

Communication is a two-way process, involving at least two people who alternate in sending and receiving messages (Ferris-Taylor, 2007). When the message is received, it is interpreted and normally a response is given. In some people there may be a delay in response time as result of communication impairment. This was the problem encountered by Mr Kee whilst I felt frustrated sometimes as I felt nurses/support workers were not patient enough with him.

I propose both verbal and non verbal communication is important when dealing with Mr Kee as it is important to ensure the message put across is clear. There is a need to devise a strategy to communicate that would promote empowerment, building on existing strengths so as not to reinforce a sense of helplessness and power imbalance. Studies have showed that by using verbal and non verbal communication techniques appropriately can help us nurses/carers and families to communicate and enhance the communication experience for Mr Kee. For example we should create conducive environment, listen carefully to what he is trying to say, observing his body language, using positive body language to convey warmth and reassurance, speaking slowly, using short and simple words, give Mr Kee opportunities to talk in indirect ways and to express himself, I tried emphasis the need for us nurses/support worker to be creative, adaptable and skilful to avoid disempowering Mr Kee because of his communication impairment (Allan 2001, Feil & DeKlerk-Rubin 2002 and Alzheimer’s Association 2005). ‘One of the ways in which people with dementia are disempowered in communication is that of being continually outpaced, having others speak, move and act more quickly that they are able to understand or match’ (Killick and Allan, 2001, pp. 60–1)

The MDT experience has emphasised the importance of interprofessional working together as it encourages holistic care to be delivered. The learning gained from this experience will impact my future practice in various areas which include communication and empathy. I am mindful of the challenges faced by Mr Kee and this has increased my knowledge in clinical practice where I have observed that mental illness can impair patient’s ability to communication, for example dementia, schizophrenia, depression and psychosis cause’s cognitive impairment which can interferes with a person’s ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others, which often hinders the development of a therapeutic relationship. I have learnt a lot about The Mental Capacity Act, 2005 provides guidance as to what factors should be taken into consideration when making a decision in someone’s best interest.

As a qualified nurse my role would be to ensure decisions are made on behalf of the service user after much consultation with the service user as communication advocacy is universally considered a moral obligation in nursing practice as it is the crucial foundation of nursing (McDonald, 2007) Effective advocacy can transform the lives of people with learning disabilities enabling them to express their wishes and make real choices.

In Mental health nursing, empowerment usually means the intent to ensure that conditions are such that the individual can act as a self advocate (Webb, 2008)]

This experience has highlighted the difficulties that may be encountered in communicating and gaining valid consent which I will be aware of in future practice.

In conclusion steps towards better health care can be made by providing encouragement and support to improve communication between nurses/support workers and carers with communication disabilities [Godsell and Scarborough, 2006]. In order to battle any restriction for Mr Kee to access good health care and prevented anything against his wellbeing.


In this reflective account essay, I will be describing nursing skills that I undertook during my practice placement, using Driscoll’s (2000) reflective cycle, a recognised framework for reflection to demonstrate my ability to reflect on different nursing skill.According to Driscoll’s (2000), there are three processes when reflecting on one’s practice. They are: What (what happened), so what (what were you feeling, what was good/bad about the experience and Now what (if it happens again what you would do differently). The application of Driscoll’s reflective cycle will enable me link theory to practice.

This 2nd skill will define the concept of dignity and its important in relation to Mr Moses, an elderly patient, has difficulty hearing, frail, require assistant to walk, his trouser and shoes wet with urine and the smell of faeces. Actions and support according to the Code of Professional Conduct (Nursing and Midwifery Council (NMC, 2008) as suggested to be used in rendering care to Mr Moses. Also, the Nursing actions that will promote and maintain Mr Moses dignity during his care will be described.

2nd Skill

The way Mr Moses was treated by the staff gave me concern see appendix 2

This now gave me an interest into this topic as to acquit myself before escalating the matter.

I was involved in the care for Mr Moses who has diagnosed with dementia. Dementia is a chronic lifelong condition that causes memory loss, communication problems, incontinence and neglect of personal hygiene (Prime, 1994 p, 301). Mr Moses neglect of his personal hygiene was profound due to his incontinence condition

Dignity mean “Being treated like I was somebody” (Help the Aged, 2001).Relating dignity in the care Mr Moses, dignity will be define as care given to Mr Moses that will uphold, promote and not degrade his self respect despite his present situation (being wet with urine and smell of faeces), frail or his age (SCIE, 2006). Mr Moses despite his present circumstance should feel value before, during and after his care (Nursing Standard, 2007).

The concept of dignity has to do with privacy, respect, autonomy, identity and self worth thereby making life worth living for them (SCIE, 2006). However, each patient needs is unique, the level of these concept will varies on individual service user, such as the privacy that other service user need will be different from what Mr Moses require at the time of His care. When dignity is not present during his care, Mr Moses will feel devalued, lacking control, comfort and feel embarrass and ashamed (RCN, 2008).

Things that emerged in my observation for Mr Moses to be provided with care in a dignified way involves, delivery Mr Moses personal care in a way that maintain his dignity, having support from team members and an up to date training in delivering care, and supportive ward environment (NHS evidence, 2007). I did raise some issues with my mentor that was missing when attending to Mr Moses which includes: Respect, Privacy, Self-esteem (self-worth, identity and a sense of oneself) and Autonomy (SCIE, 2006).

Respect is a summary of courtesy, good communication and taking time (SCIE. 2006). It is the objective, unbiased consideration and regard for the right, values, beliefs and property of all people (Wikipedia, 2006).Mr Moses being particularly vulnerable because he solely dependent on staff to provide his personal care because of his age , frail and needing assistant to walk (Help the Aged, 2006) should be treated as an individual. He should not be discriminated. Emphasised should be on Procedures during care should be explained to Mr Moses and his care should be person centre rather than task-oriented (Calnan et al, 2005).

The dignity of Mr Len must be respected and protected as a person who is born free, equal in dignity and has basic human right (Amnesty international, 1999).Health service will need to recognise the specific needs of older people in caring for them, demonstrating respect for Mr Len autonomy, privacy during Mr Len care and avoiding poor practice that will deify Mr Moses dignity, such as: allowing him to remain wet and soiled or scolding him (Age Concern, 2008).

The NMC (2008) code of conduct state that the care of Mr Moses should be the nurse first concern, respecting Mr Moses dignity and treating him as an individual. Mr Moses will be approached in a dignified manner, he should be given choice to decide whether or where he want his care to be carried out, demonstrating appropriate communication, sensitivity and interpersonal skill during interaction. Dignity is defy when there is a negative interaction between staff and Mr Moses when freedom to make decision is taken from him (BMJ, 2001). Mr Moses appearance is essential to his self respect; Mr Moses will require support in changing his wet cloth. Mr Moses should not be neglected based on his appearance rather supported to maintain the standard he is used to (SCIE, 2006).

The NMC (2004), also instruct nurse to promote and protect the interest and dignity of service users irrespective of gender, age, race, ability sexuality, economic status, lifestyle, culture and religion or political beliefs. Mr Moses being an elderly man will not be problematic, because according to the code, care should be delivered, his culture preference , such as preferring a male staff to assist with his care .

Treating Mr Moses fairly without discrimination is part of the Code, Mr Moses should not be discriminated against because he smells of faeces and trouser wet with urine Quot but should be respected while attending to his needs.

Privacy is closely related to respect (SCIE, 2006). Mr Moses care should be deliver in a private area, ensuring Mr Moses receive care in a dignified way that does not humiliate him: Discussion about Mr Moses condition should be discussed with him where others are unable to hear and curtain or doors are closed during Mr Moses care (Woolhead et al, 2004).

Not giving Mr Moses the privacy that he needs makes feel that he was treated as incontinent because he was wet of urine and smell of faeces( which was stated in Mr Moses case not at the end of that shift “incontinent of urine and faeces). Incontinence is not uncommon; it may be cause by various reasons. It affects all age group (Godfrey and Hogg, 2002).

Incontinent is defined to be an involuntary or inappropriate passing of urine or faeces thereby having impact on social functions or hygiene of client (DOH, 2000). There are various types of incontinent such as: stress incontinent (this can occur when coughing, or during physical activities), urge incontinent (overactive bladder), reflex incontinent (incontinent without warning) and mixed incontinent (both urge and stress incontinent) (Chris, 2007). Mr Moses may have be a victim of any of the above.

In conclusion my knowledge about the concept of dignity and its importance to health care and the benefit to service users increased. NMC has made dignity clearer to understand by including dignity among its codes. This easy has also clarified that dignity has different meaning to various people.


In this reflective account essay, I will be describing nursing skills that I undertook during my practice placement, using Driscoll’s (2000) reflective cycle, a recognised framework for reflection to demonstrate my ability to reflect on different nursing skill.According to Driscoll’s (2000), there are three processes when reflecting on one’s practice. They are: What (what happened), so what (what were you feeling, what was good/bad about the experience and Now what (if it happens again what you would do differently). The application of Driscoll’s reflective cycle will enable me link theory to practice.

This 3rd Skill will look at the assessment I did.

One week into my placement at the community I was told by my mentor that I will be carrying out an assessment for a new patient that was referred to our service. To prepare for this I started to read the assessment note of other patient and doing research on the best method to get information from the patient.

Barker (2004) defines mental health nursing assessment as ‘the decision making process, based upon the collection of relevant information, using a formal set of ethical criteria that contributes to an overall evaluation of a person and his circumstances’. Assessment is a continuous process which includes collecting information in a systematic way from a variety of sources.

Assessment can be describe as a two stage process of gathering information and drawing inferences from the available data and decisions made regarding a person’s need of care. (Norman and Ryrie, 2007). The purpose of assessment include judging and understanding levels of need, planning programmes of care and observing progress over time, planning service provision and conducting research (Gamble and Brennan, 2006)

Meaningful and accurate assessment is essential if a person’s needs are highly complex so as to streamline the service user care requirement (DOH 2004). Assessment of person’s strengths and needs in social functioning is a fundamental stage in developing planned care that is familiar to practitioners. Making an accurate assessment of social functioning provides valuable information about the range of activities that a person can undertake on his or her own as well as those activities where a person requires support (Godsell and Scarborough, 2006)

During our (Mentor and I) brainstorm to identify the main communication needs of the new service user based on the referral letter/note that I need to use the open question as this will give the patient the opportunity of expressing himself as supported by crouch and Meurier (2005). I observed differences in perception of needs between disciplines. This was beneficial to the group as it enabled us to achieve a holistic view of possible needs.


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Free Essays

Transcultural Nursing in relation to Holistic Nursing Practice


Diversity of the world’s population has reached a point where it is vital to address and more importantly to understand, the ever growing challenge that transcultural nursing poses to the nursing profession. Addressing this issue avoids discrimination and promotes equality within holistic nursing practice in order to meet patients’ needs. Health care professionals should be qualified to deliver, on a daily basis, proficient care and sensitive skilled communication to culturally different individuals (Maier-Lorentz, 2008).

To exercise professional nursing in a conceptual way holistic nursing care focuses on physical, emotional, social, environmental and spiritual aspects as well as on the idea that any individual involved in treatment care should be treated as a whole and with dignity (Dossey & Guzzetta, 2005).

One of the areas to be discussed is Transcultural Nursing and Leininger’s Transcultural Theory of Culture Care Diversity and Universality and its research enablers: the Sunrise Enabler and the Ethnonursing Method.

Another area will be Holistic Nursing Practice and Nightingale’s Nursing Theory of Environmental Adaptation as well as the liaison between Transcultural Nursing and Holistic Nursing Practice.

Nightingale’s theory has been chosen over others because she was the first to acknowledge nurses’ work in a theoretical framework and also because she was considered to be the mother of nursing practices (Ellis, 2008).

The development of culture care theory introduced health care professionals into a new nursing dimension formed by issues such as culture background, spirituality, environment and others that demonstrated how culture and health care are linked (Leininger, 2002a).

Holistic Nursing Practice encourages active communication and reciprocal understanding, underlines the exercise of physiological and psychosocial awareness, it is based on logical thinking and supports values such as autonomy and patient wishes and tendencies (MacKinnon, 2010).

Transcultural Nursing

Transcultural nursing may be defined as a method to contrast and observe how individuals view health care, biased by their culture background. The principles of practising transcultural nursing are to provide complete nursing care to individuals or groups by treating them with respect and taking into account their cultural factors. It is all about nursing practice applied to cultural values and limitations (Leininger, 1991).

Definitions of transcultural nursing incorporate many factors that shape the individual’s cultural orientation. These include are age, sexual orientation and financial aspects. It has been suggested that by ignoring these culture background factors, health care professionals do not achieve enough cultural experience to be incorporated in holistic nursing practice (Barnes et al. 2000). This absence might lead to unsafe nursing care and both dissatisfied patients and professionals (Curren, 2006 cited in Leininger & McFarland, 2006, pp.159-160).

To promote transcultural nursing care, Narayan (2001) felt that there are four crucial attitudes to assume – caring, empathy, openness and flexibility. This shows the patients a cultural understanding, appreciation, consideration and willingness from health care professionals that are based on individual care.

Cultural education and the creation of culturally competent care professionals are one of the biggest challenges yet to tackle worldwide. For instance, in America, as the migrant population increases notably so it does the need for reducing inequalities and barriers such as language. Maier-Lorentz (2008) firmly understood that such a need could be met by the targeting of bilingual health care professionals coming from different backgrounds. Moreover, she suggested that in order to provide culturally competent nursing care, some knowledge of non-vocal communication signs could be of great value, as it is in eye contact, touch, silence, space and distance, and health care habits.

Green-Hernandez (2004) recommended that as a step towards multicultural competency, professionals that need to deal with farmers should familiarize themselves with their specific customs such as using animal medication for their own conditions as a consequence of living far away from the care institutions.

With the purpose of understanding culture, Andrews & Boyle (1997) gave out diverse illustrations. For example, they suggested that by understanding a people’s proverbs, professionals may grasp knowledge of the cultural values shared by that population. The authors also stressed the importance of culture knowledge when coming across two different ways to view stealing. For one culture it may not be acceptable whereas for another one, e.g. gipsy people, it may be ok, as long as it is coming from a better-off person. Furthermore, they also found, through researchers, that different cultures may think that by being a demanding patient, the treatment they receive may improve.

Riley (2004) reported that a foremost test for nurses in an ethnically different society is communication. Not just words but also tone and volume form spoken communication which in diverse cultures differs greatly. For example, Thai people are regarded as not talking too much as they believe it is a sign of idiocy whereas Cuban people are happy with talking vociferously. He also pointed out that Europeans are not afraid of talking about emotions whereas Asians are hesitant to do so.

With regards to communication without words Riley (2004) explained that eye contact is not always expected. For instances, in Native America and Asian cultures it is offensive and among Muslim Arab women it is allowed only to their husbands. Therefore, he identified the importance for healthcare professionals to be culturally aware.

Phillimore (2011) explored the challenge of provision of diversity needs in the UK based on studies done on health care service provision to new migrants, during 2007/08 in Birmingham. She stated that with political forces wanting to reduce welfare support for new migrants, such provision becomes quite a challenge. She also believed that, in the long run, this disregarding of health care needs will lead to further issues for the health care system that otherwise could be avoided by just providing what is needed now: cultural and language services and health support.

It was also suggested that in today’s political climate offering of ethnically specific provision by the community and for the community, results in the local needs not being met, as the existing GP systems are already overstretched. She concluded that a number of migrants are condemned to an unwelcoming future since UK seems to embrace a tendency of anti-migrant sentiment and a move to community institution instead of multicultural provision (Phillimore, 2011).

The Culture Care Diversity and Universality Theory by Madeleine Leininger

In the 1950’s Madeleine Leininger, a nurse-anthropologist, realised that nursing practice was requiring a theory to allow people to transform nursing into a more advanced and beneficial discipline that challenges nurses to open up to cultural variety and universality (Leininger, 2006).

This was developed as a response to the demand for multicultural care which was immense and yet incomplete as many healthcare systems did not consider the need for bringing together culture and nursing care (Giger & Davidhizar, 2008).

The culture care diversity and universality theory developed by Leininger in 1991 (Leininger, 2002a) is unique in that it focuses on competent care, can be used upon any culture and is based not only on individuals but groups and families too.

The theory addresses the importance of a consistent cultural competence instrument to acquire cultural awareness through a constant learning attitude and approval towards human differences and rights by health care professionals (Burford, 2001, cited in Baxter, 2001, pp. 202-203).

Leininger (2002a) insisted on the importance of transcultural knowledge as a tool to avoid human acts such as the event of September 11, 2001. She then proposed the culture care theory as the most holistic approach to gradually transform the health system. This much needed transformation requires understanding of individuals in ways that identify and respect their cultural background and will lead us to understand such transcultural dismay.

The theory was used in a study among Hispanic home care patients in the US, 2007, in order to identify cultural needs. As a result, care delivery improved in some areas and there was a suggestion describing the use of the model as a tool to reduce costs in the health care system (Woerner et al. 2009).

Leininger’s theory applies not only to races from different backgrounds but also to today’s controversial groups such as transgendered people, disabled people , the youth, poverty and the homeless that may pose a certain degree of difficulty of understanding to healthcare professionals. There is also an agreement that, thanks to Leininger’s culture care theory, the nursing profession today knows how to allow for culture when looking after individuals and has a widely spread caring philosophy in hospitals (Clarke et al. 2009).

For this model to assist the health care professional to understand factors as important as management and policies, as well as being able to reflect on their decisions and actions, Leininger designed two tool assessments, The Sunrise Enabler and the Ethno Nursing research method, which are based on monitoring treatment care on a daily basis (Hubbert, 2006, cited in Leininger & McFarland, 2006, pp. 354-356).

The sunrise enabler focuses mainly on total life ways and caring factors influencing health and well-being, disabilities and death. It also identifies features influenced by the patient’s cultural background whereas ethnonursing finds ways in which multicultural care could be better. In doing so, the reflected culture becomes part of the holistic nursing practice (Leininger, 2006).

The Sunrise Enabler

The Sunrise Enabler is used as an assessment tool to enable multidisciplinary teams to deliver suitable and competent cultural assessments that impede intolerance and stereotype behaviour. This is to supply the healthcare system with a guide to cultural vicinities ranging from religious beliefs to economic factors (Giger & Davidhizar, 2008).

Wherever a healthcare professional starts the model either from the top or from the bottom, the most important feature is to listen to the individuals, trying to grasp ideas and concepts rather than enforcing them (Leininger, 2002a).

Healthcare professionals struggled to understand the meaning of factors influencing the care practice so crucial when applying the culture care theory. Such factors as culture beliefs, environment and religion were to be included in the nursing care, therefore Leininger (1997) built the Sunrise Enabler to illustrate such aspects.

The Ethno-nursing Method

This method was developed to fit the purposes of qualitative research methods. It is a systematic method for studying multiple cultures and care factors within a familiar environment of people and to focus on the interrelationships of care and culture to arrive at the goal of culturally congruent care. Ethnonursing is a particular research method developed by Leininger to inspect the theory. It was developed to allow health care professionals to discover new ways of helping different cultural groups distinguish features of nursing care (Leininger, 2006).

Leininger (2006, p.6) stated that the ethnonursing method “…was new and unknown in nursing and was different from other qualitative methods including ethnography”.

Holistic Nursing Practice

The exercise of modern nursing is based on the view of holism that underlines the individual’s wholeness. Healing viewed as an indication of nursing practice that treats people as whole, developed in the late 20th and early 21st century into a popular subject in nursing in order to clarify the meaning of wholeness and holism. As a result, alternative therapies surfaced as approaches of practice in holistic nursing (Locsin, 2002).

The definition of holistic came into effect in the 20th century. Then the word holism included the physical, emotional, mental, social, cultural, and spiritual view. This view of holism was envisioned by Florence Nightingale who is seen today as an example to follow, although many of her studies are not used in today’s nursing practice (Beck, 2010).

“Holistic nursing care embraces the mind, body and spirit of the patient, in a culture that supports a therapeutic nurse/patient relationship, resulting in wholeness, harmony and healing. Holistic care is patient led and patient focused in order to provide individualised care, thereby, caring for the patient as a whole person rather than in fragmented parts” (McEvoy & Duffy, 2008, Vol.8, p. 418).

Furthermore, it addressed the expansion of multidisciplinary and collaborative teams as a way to applying holistic care into practice and asserted that the practice of holistic care by health professionals should avoid intrusion and, when really needed, as it is the case of unconscious patients, should use skills that include aspects such as consideration, disciplined criticism and liability in order to exercise nursing in a holistic approach (McEvoy & Duffy, 2008).

Since individuals from different culture backgrounds may appreciate holistic nursing practice and care choices in different ways so is the healthcare provided in different ways (Locsin, 2001). It may also be the case that some individuals may feel embarrassed to mention alternative remedies used in the past, therefore the assessment should be supportive rather than disapproving (Maddalena, 2009).

Pearcey (2007) ran a study on clinical practices amongst student nurses to draw on a few key points related to holistic nursing practice. It was found that the notion of holistic care was not clear within nursing practice. Some students claimed not to know the right meaning of holistic nursing practice and also claimed that tasks and routines are what nursing is all about. The study showed an evident lack of professionalism and knowledge amongst care professionals as well as a huge gap between what is taught and what is really applied at work. The author concluded that there is a real risk of inconsistency within the profession.

Within the practice of holistic care there has been lately a huge influence of alternative or complementary medicine which care experts have tried to professionalise by setting certain values to be met. A study amongst nurses and midwives accomplished in England, 2008, revealed this but also the lack of initiative from the NHS to incorporate such practices, even though it was demonstrated that a huge variety of them were successfully applied on patients where biomedicine seemed not to work. Such practices included reflexology, aromatherapy, acupuncture and massage that actually underlined biomedicine rather than substituted (Cant et al. 2011).

Whilst carrying out an interview on medical students in the UK, a student suggested that it is actually a catch-22-situation when looking after patients from diverse races as they have diverse predominance of whatever conditions that eventually will require different treatment, a world apart from what is being taught in medical schools with regards to treating everyone in the same way (Roberts et al. 2008).

A quick look to Harrison (2008) for a concluding comment on multicultural nursing in relation to holistic care, offers us this brief view: a Western health care organism that has not managed to treat minority communities in a holistic manner is a system that claims to care for one and all identically.

The Theory of Environmental Adaptation by Florence Nightingale

According to Nightingale’s Theory of Environmental Adaptation, an individual’s health is improved by looking after the surrounding environment. It goes further than this and asks for the environment to be operated by the health care professionals as an approach to healing (Howett et al. 2010).

Florence Nightingale defined nursing as “…the act of utilising the environment of the patient to assist him in his recovery” (Funnell et al. 2009). She determined that the deficiency of factors such as uncontaminated air, clean water, sanitation, hygiene and sunlight is unhealthy to the human being. Furthermore, she reasoned that temperature, environment and nutrition affect the patient (Kozier, et al. 2008).

This theory of nursing includes inspection, recognition of environment changes and their execution and supporting the patient health care by allowing the environment to benefit the patient (Neils, 2010).

Selanders (2010) reviewed and compared this theory’s aspects with modern day practice and reported that Nightingale’s concept, such as air, light, noise and cleanliness is equal to today’s concept of physical environment; health recommendations to psychological environment; food to nutritional status and observation to nursing management. The author also estimated that the theory has been used in several qualitative works and some studies on the childbirth process.

Transcultural Nursing vs. Holistic Nursing Practice

According to Leininger (2002b) patients are not provided full holistic care by health professionals. Factors such as kinship, religion, environment and culture are largely missing. For that reason, care professionals should avoid being judgmental when delivering holistic care and rather provide an all-inclusive care that respects the individual’s cultural background (Maddalena, 2009).

As a student nurse, it is vital to value the development of cultural awareness and competency within the profession in order to encourage and address all stages of holistic nursing practice as it is meaningful to today’s multicultural society. Leininger (1997) also claimed that essential practice is needed to create a regulation of multicultural nursing that could be of use to much ignored cultures.

For example, acute medical treatment, medication, and patient fulfilment can be improved by understanding care beliefs when bringing in nursing care which, in turn, could save the health care system financially and also have a desired positive outcome on patients (Woerner et al. 2009).

Individuals or groups may clash with health professionals if they are not showing respect for each other’s cultural beliefs resulting in poor treatment and patients losing hope in the health care system. Hogg (2010a) also underpinned this understanding as crucial to delivering accurate holistic nursing practice. However, not only patients may lose faith in the system. Hogg (2010b) also affirmed that nurses from black and minority ethnic have suffered, at some point, racial harassment as well as lack of opportunities according to their numbers in the nursing profession.

As holistic nursing practice centres on recognition of patients’ rights and choices (Potter, 2005 cited in Dossey et al. 2005, p.347), it is subsequently supporting the meaning behind multicultural care. The association of both precepts confirms an ongoing engagement to pursue equality and diversity as promoted by the Nursing & Midwifery Council (2008).

“Inherent in nursing is respect for human rights, including cultural rights, the right to life and choice, to dignity and to be treated with respect. Nursing care is respectful of and unrestricted by considerations of age, colour, creed, culture, disability or illness, gender, sexual orientation, nationality, politics, race or social status” (The International Council for Nurses, 2005).

When assessing, planning, implementing and evaluating a patient’s needs as to medication, health professionals should take into account culture’s physiologic traits, as it can seriously impact the treatment. For instances, due to genetics, for one patient a normal given dose may develop a reaction whereas for another it may not work at all (Anon, 2005).


It is obvious that cultural competency is a must when performing holistic nursing practice, in order to deliver a responsive and high quality care system. It is therefore recommended that specific cultural training should be given to all health care professionals so as to not overlook the great multi-cultural society we all are in.

As society becomes more diverse, health care professionals should expand guiding principles that sponsor cultural skills as a way to deliver enhanced holistic healthcare.

By carrying out this essay, the author realises the significance of treating people in a holistic way and not making assumptions just because they are from different cultures. This is something that seems yet not to be well implemented in my workplace (NHS since 2007). The author will, from now on, be more aware of his practice when caring for individuals from different culture backgrounds.

It can be considered that nursing as a profession is also an example of human culture so indispensable for a in peak condition community, as seen looking through the theories of nursing and its tools presented in this paper, which if not recognized may affect the execution of holistic practice and its results, i.e. it is a profession whose culture needs to be elastic if it is to fulfil its function.


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Woerner, L., Espinosa, J., Bourne, S., O’toole, M., & Ingerson, G., L., (2009). Project Exito!: Success through diversity and universality for outcomes improvement among Hispanic home care patients. [Online]. Nursing Outlook. 57 (5), p.271. Available from: [accessed 30th March 2011].

Free Essays

Principles and practice of mental health nursing


This essay will discuss the development of Cognitive Behavioural Therapy (CBT) and its role in mental health nursing. A brief definition of CBT will be given, and treatment modalities used before the advent of CBT for the treatment of anxiety will be explored. The essay will evaluate the principles and practice of CBT, and equate this with the recovery process. The essay will also explore two CBT approaches that can be use to work with anxiety. The limitations of CBT will be discussed, likewise the relevance CBT to mental health nursing. The essay will be concluded by highlighting the learning I derived by writing this essay.

CBT is an umbrella classification of the different approaches in psychotherapy treatment which helps patients to understand how their thoughts and feelings influence their behaviour. CBT is evidenced based, collaborative, structured, time limited, and empirical in approach (Westbrook et al, 2007). According the National Institute for Health and Clinical Excellence CG22 guideline, (2010) it should be recommended to patient and carers for the management of major mental health problems. The CBT process normalise recovery which is important in therapeutic alliance as oppose to the medical model of care which pathologies recovery. The socialization process fit with that of the recovery model both of which are patient centred, giving hope and optimism to the patient, and using a set of outcomes set by the patients (Till, U. 2007).

According to Hersen, M (2008), the earliest origin of CBT can be traced back to the times of Siddhartha Gautama (563-483 BC) and Epictetus (A.D. 50-138) both of whose work reflected the concept of CBT in their teaching. CBT was developed from two parts way: ‘Behaviourism’ and ‘Psychoanalysis’

Behavioural therapy was developed from the principles of animal learning to humans from two main principles called classical and operant conditioning (Shawe-Taylor & Rigby, 1999). Classical conditioning theory was based on the work of Pavlov (1927) while “Operant Conditioning” theory was based on the work of Skinner (1938). Psychoanalysis was developed by Sigmund Freud and looks at the functioning and behaviour of human. BT arose as a response to the psychodynamic image, when Freudian psychoanalysis was questioned for its lack of a scientific base.

The application of behavioural science resulted in merging CT & BT approaches, resulting to the treatment of anxiety disorder and inappropriate behaviours, and little progress in depression and psychosis (Shawe-Taylor and Rigby, 1999). However, the failure and criticism following the use of strict behavioural concept to explain complex behaviour brought about the emergence of the cognitive behavioural therapy. The major difference between the two approaches is the inclusion of the meditational approach in CT. (Hersen, M and Gross, A. 2008). Rational emotive behavioural therapy (REBT), developed by Albert Ellis (1913-2007) was one of the treatment approach used during this period.

CT was developed in the 1960’s by Aaron Beck, and this approach became popular for its effective treatment of depression. The significant result from the merge of BT & CT was the outcome of treatment for panic disorder by both Clark and Barlow in the UK and US respectively. Their combination in the 80’s and 90’s has resulted in CBT being a sort after therapy for mental health disorders.

Anxiety is an example of a mental health problem. Anxiety is a common and treatable mental health disorders which manifest as feelings of uneasiness such as worry or fear which could be mild or severe, and a normal part of human condition Barker (2009). The feelings of fear and worry are sometimes helpful in psychologically preparing us to face the problem and physically triggering the flight and flight response. This affects 1 in every 10 people (RCPSYCH, 2010).

The major types of anxiety disorder are: generalised anxiety disorder, panic disorder, obsessive compulsive disorder (OCD), post traumatic stress disorder and social phobia or social anxiety disorder. The symptoms of anxiety manifest through the mind via frequent worries, lacking concentration, feeling irritable, feeling tired and sleeping badly. While in the body symptoms include palpitations, sweating, muscle tension, fast breathing and faintness (RCPSYCH, 2010). Social anxiety disorder is use for discussion in this essay.

Treatment modalities before the coming of CBT include those from psychoanalysis and Behaviourism. Anxiety treatments available before CBT include: refraining people from excess exercise in other not to increase the strain on the nervous system, administering Strychnine, arsenic and quinine and applying a white hot iron along the spine in severe cases. Exposure treatment which is still being use till date, use of Radionics by attaching patients to various devices with the belief that healthy energy is vibrated to unhealthy parts of the body, Use of Rational emotive behaviour therapy (REBT), and the use of Gamma-amino-butyric acid (GABA) facilitating drugs. Insulin shock therapy was also used (Marlowe, J 2011)

Cognitive approaches use in working with social anxiety is: cognitive restructuring and exposure therapy. Cognitive restructuring according to Heimberg and Becker (2002) is the identification and challenging of irrational thoughts, which include beliefs, assumptions and expectations and replacing them with those that are rational, realistic and adaptive. The principle is not only challenging the negative thinking pattern that contribute to the anxiety, it also helps to replace them with more positive and realistic thought pattern by suggesting alternatives and by reinforcing the client belief in the alternative interpretations and ideas suggested (Norman and Ryrie, 2009).

For a person having a fear of public speaking in social anxiety disorder, the way he or she feels is not determined by the situation but by his or her perception of the situation, thus the thought, emotion and behaviour is important in therapy. The therapist, in collaboration with the client uses the situation-emotion-thought-behaviour (SETB) to structure how the treatment will go. Cognitive restructuring is done in three steps, with full collaboration between the client and the therapist after building up a working therapeutic relationship. The first step is identifying the content and occurrence of the unhelpful thought. The therapist will ask the client to write down his or her thoughts, using thought monitoring records. Client may come up with thought like: I am not good at preparing speeches; I will make a fool of myself, or what will people think if I say the wrong thing. The therapist starting question could be, “If we could make one thought go away, which one will you choose to make a difference in the way you feel”, or “what is the worst thing that could happen?” Such questions are asked to uncover underlying fear. (Norman and Ryrie, 2009, Padesky and Greenberger, 1995).The second step is challenging the negative thoughts. Here, the therapist will help to dispel the irrational thoughts and beliefs to loose much of its power over the patient at this stage. The third step is replacing the negative thoughts with realistic thoughts which are more accurate and positive, with the therapist teaching the client about realistic calming statements he/ she can say when such anxious situation comes up.

Systematic desensitization is a type of behavioural therapy use to treat social anxiety. It was developed by Joseph Wolpe, a South African psychiatrist. Systematic desensitization also called graded exposure, is the process of facing the anxiety or fear producing triggers from the less feared to the most dreaded ones, and the pre – planned grading of the triggers for exposure is referred to as “hierarchy” while habituation is “the reduction of anxiety over time when a person encounters an anxiety or fear – provoking trigger without the use of safety behaviours” (Norman and Ryrie, 2009). Systematic desensitization helps a client to gradually challenge his or her fears or anxiety, build confidence over time and master skills for controlling his or her anxiety. The process involves the therapist first teaching the client some relaxation techniques like deep muscle relaxation and assesses their ability to utilise this. For example, a person who is anxious of facing the public and due to give a lecture, the step is to create a hierarchy of the anxiety or fear experience. The questions the therapist can ask to evoke triggers are: “What places, thing or people make you uncomfortable“What brings your fear/anxiety/worry on(Norman and Ryrie, 2009). Then the therapist ask the client to set an exposure task according to his hierarchy of triggers, which should be graded, focused, repeated, and prolonged using the daily exposure diary. The client then work through the list with the guardian of the therapist, and the goal is to stay in each situation until the anxiety or fear subsides. The whole process is carried out with both parties collaborating together to achieve the goal, first through “in vivo exposure, such as imagining giving a speech and when the situation become easier, then the client progresses to the situation in the real world. The use of home work is also use.

Despite all the good attributes associated with CBT, it is not without its own limitations. CBT is very complex to implement having a poor outcome with substance users who have a higher level of cognitive impairment (Patient UK). The availability of well trained and experienced qualified therapist is hard to get in the rural communities (Robertson, 2010). CBT does not work for everybody, and requires high commitment from the patient who see the home work as difficult and challenging (Patient UK). Some aspects of CBT therapy cannot be applied on people with learning disability and language is a barrier for those who English is not their first language.

Nurses interact and undertake more roles with patient, and they are the first contact complaints are made to, which could give them an opportunity to offer CBT skills in the nursing process if it was incorporated in their training. (Padesky and Greenberger, 1995) Thus, the teaching of basic CBT skills is now being incorporated into the curriculum of the Mental Health Nursing pre/post registration programme. According to Gournay, K (2005), mental health nurses are now taking up challenging roles in management and nurse prescribing, giving advantage of freeing up the psychiatrist to undertake the more complex cases. The case for a nurse cognitive-behavioural therapist has been made glaring by the shortage of qualified therapist as a result of the widening evidence base for the approach and the recommendation by the NICE guidance for the provision of CBT for the treatment of hallucination and delusions (National Institute for Clinical Excellence, 2002). As recovery is all about inspiring hope to the patients, the mental health nurses will be better equipped to offer a person centred care required for patient recovery. The incorporation of CBT to mental health nurses curriculum will prepare nurses to be more collaborative in approach, and allow patients to have more input in their care which will improve the therapeutic relationship between the nurse and the patient and make nurses more approachable. With the advent of computer based CBT, the need for patients to meet with the therapist on a one on one basis is reduced, thus addressing the shortages of therapist and opening a new window for the people who are depressed or withdrawn to use the approach. (Robertson, 2010). There is prospect for mental health nursing considering the boost in career prospect this will bring to the profession and their position in the multidisciplinary team.

This assignment has been an eye opener for me as a mental health student. It has exposed me to various issues in mental health, past & present. And given me the opportunity to plan ahead of the future in shaping my direction in the profession. The essay has also given me the opportunity to know about the history of CBT and the various treatment approaches used before its era. It has given me the opportunity to see the interrelationship between CBT and recovery in care practice and also shown me that CBT skills will greatly enhance the quality of care provided by the mental health nurse. CBT should be made mandatory for all mental health nurses as a matter of necessity.


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Hersen, M. and Gross, A. (2008) Handbook of Clinical Psychology. Volume 1. John Wiley & Sons.

Heimberg, R. and Becker, R. (2002) Cognitive-behavioural group therapy for social phobia: basic mechanisms and clinical strategies. 1st edt. New York: Guilford Press.

Marlowe, J. (2011) ‘Historical treatments for anxiety’ (Online). Available at:

Norman, I. and Ryrie, I. (2009) The Art and Science of Mental Health Nursing. 2nd edn. Milton Keynes: Open University Press.

National Institute for health and clinical excellence (2010) Summary of cognitive behavioural therapy interventions recommended by NICE. Available at:

Padesky,C. and Greenberger, D. (1995) Clinicians Guide to Mind Over Mood. London. Guilford Press.

Patient UK (2011) what is cognitive-behavioural therapyAvailable at:

RCPSYCH (2010) ‘Anxiety, Panic and Phobias’. Available at: (Assessed: 4 March 2011).

Robertson, D. (2010) The Philosophy of cognitive Behavioural Therapy: Stoicism as rational and cognitive psychotherapy. London: Karmac.

Shawe-Taylor, M. and Rigby, J. (1999) ‘Cognitive behaviour therapy: its evolution and basic principles’, The Journal of The Royal Society for the Promotion of Health, 199(4), pp. 244-246.

Till, R. (2007) ‘The values of recovery within mental health nursing’, Mental health practice, 11(3), pp.32-36.

Westbrook, D. Kennerley, H. And Kirk, J. (2007) An Introduction to Cognitive Behaviour Therapy- skills and applications. London: Sage.

Free Essays

Explore the effects of a needs orientated approach to care using a nursing model alongside a nursing process in order to create a framework


The aims of this assignment are to provide a needs orientated approach to care using a nursing model alongside a nursing process in order to create a framework. The nursing model for the purpose of the assignment will be Roper, Logan and Tierney (RLT). A nursing model is used to determine what is important and relevant to providing individualized care (Barrett, Wilson, Woollands 2009). RLT state that a nursing model helps to identify the “core of nursing activities across any field of nursing practice” (Holland, Jenkins, Soloman and Whittam, 2004). This will be discussed in detail providing evidence of strengths and weaknesses of the model. The nursing process that will be discussed will be APIE which is assess, plan, implement and evaluate. A nursing process is a systematic approach which focuses on each patient as an individual ensuring that the patients holistic needs are taken into consideration. These include physical, social, psychological, cultural and environmental factors. . The nursing process is a problem solving framework for planning and delivering nursing care to patients and their families (Atkinson and Murray 1995). When used collaboratively the nursing model and the nursing process should provide a plan of care that considers the patient holistically rather than just focusing on their medical diagnosis (Moseby’s 2009). It will also discuss an example of a care plan done for a fictional patient Mabel Dunn and evaluate and discuss how the nursing plan and the nursing process have created a plan of care and how effective this was or was not.

Care planning is a highly skilled process used in all healthcare settings which aims to ensure that the best possible care is given to each patient. The Nursing and Midwifery council state that care planning is only to be undertaken by qualified staff or by students under supervision. The Department of health (2009) says that ‘Personalised care planning is about addressing an individual’s full range of needs, taking into account their health, personal, social, economic, educational, mental health, ethinic and cultural background and circumstances’ with the aim of returning the patient to their previous state before they became ill and were hospitalized considering all of these needs to provide patient centered care. It recognizes that there are other issues in addition to medical needs that can impact on a person’s total health and well being.

It provides a written record accessible to all health professionals where all nursing interventions can be documented. Care planning is extremely important as it enables all staff involved in the care to have access to relevant information about the patients current medical problems and how this affecting them in relation to the 12 activities of living as well as any previous medical history. Barrett et al (2009) state that taking care of an individual’s needs is a professional, legal and ethical requirement.

There are many different nursing models all of which have strengths and weaknesses and it’s up to the nurse to choose the right one for individual patient, the model which is used will vary between different specialties depending on which is more relevant to the patient and their illness and needs. Although a vast majority of hospitals now use pre-printed care plans it is important to remember that not all the questions on them will be relevant to all patients. An example of this would be that activity of breathing may not have any impact on a healthy young adult be would be a major factor for an elderly man with COPD.

There are four stages to the nursing process which are Assess, plan, implement and evaluate (APIE) but Barrett et al state that there should be six stages to include systematic nursing diagnosis and recheck (ASPIRE) as although they are included in the nursing process they are not separate stages and could be overlooked.(Barrett et al 2009). It is important that a nursing process is used and it is set out in a logical order, the way in that the nurse would think this helps minimize omissions or mistakes. Roper, Logan and Tierney model of nursing suggests that there are five interrelated concepts which need to be taken into consideration when planning and implementing care which are activities of living, lifespan, dependence/independence continuum, factors influencing activities of living and individuality in living (Roper, Logan and Tierney 2008).


Assessment is a fundamental nursing skill required to gather all the information required about the patient in order to meet all or their needs (Hinchliff, Norman and Schober 2008). ‘Assessment is extremely important because it provides the scientific basis for a complete nursing care plan’ (Moseby’s 2009). The initial assessment untaken by nurses is to gather information regarding the patients needs but this is only the beginning of assessing as the holistic needs of the patient including physical, physiological, spiritual, social, economic and environmental needs to be taken into consideration in order to deliver appropriate individualized care (Roper, Logan and Tierney 2008). When using the 12 activities of living (ALs) for assessment it gives a list a basic information required but must not just be used as a list as the patient will respond better to questions asked in an informal manner and when just part of the general conversation. RLT (2008) state that although every AL is important some are more important than other and this can vary between patients. It is important for nurses to obtain appropriate information through both verbal and non-verbal conversation patients are more likely to give correct information but without jumping to conclusions or putting words into their mouths. ‘Assessment is the cornerstone on which a patients care is planned, implemented and evaluated (RLT 2008). ‘Poor or incomplete assessment subsequently leads to poor care planning and implementation of the care plan’ (Sutcliffe 1990). Information can be gained from the patient, the patients family and friends as well as any health records (Peate I, 2010)

During this process of gathering information it is important to find out what the patient can do as well as what they cant. , McCormack, Manley and Garbett (2004) state that gathering the information requires a certain kind of relationship between the nurse and the patient and nurses need to be able to communicate effectively in order to be able to build this relationship. A full assessment needs to consider how the patient was before they became ill or hospitalized in relation to their medical diagnosis as well as how the patient was dealing with it, how they are now, what is the change or difference if any, do they know what is causing the change, what if anything they are doing about it, do they have any resources now or have they have in the past to deal with the problem (barrett et al). RLT (2008) state that there are 5 factors that influence the 12 activities of living which are biological, psychological, sociocultural, environmental and politicoeconomic, these may not all have an effect on each patient but all need to be taken into consideration.The more information gained in the assessment process the easier the other steps will follow. RLT (2008) suggest that assessing is a continuous process and that further information will be obtained through observations and within the course of nursing the patient. At the end of the initial assessment the nurse should to identify the problems that the patient has.

There are limitations to using a nursing process which are the 12 als are often used as a list as part of a core care plan and are not always individualized Walsh (1998) argues that the 12 activities of living may just be used as a list which could result in vital information being missed which could be detrimental to the patient. The Nursing and Midwifery Council (NMC 2008) states a nurse is personally and professionally accountable for actions and omissions in practice and any decisions made must always be justifiable. There are many benefits to using a nursing process it is patient centered and enables individualized care for each patient. It also gives patients input into their own care and gives them a greater sense of control it is outcome focused using subjective and objective information which helps and encourages evaluation of the care given. It also minimizes any errors and omissions.

When I carried out the assessing stage on mabel I did this using the 12 activities of living as suggested by Roper et al (2008) but this was used too much like a checklist. I didn’t gather enough information in order to be able to do the best plan of care possible for her although I don’t feel this could have been detrimental to the care she received it needed more information than I had. I also found it difficult deciding which information should go where so I ended up repeating information in more than one of the 12 als, Which although this wouldn’t have made a difference to the planning of the care plan there was too much irrelevant information which could mean that it wasn’t read thoroughly just skimmed over as it would take too much time. As I am inexperienced in doing this I realized when writing the care plan that there were many questions that I didn’t ask so there where many parts that could not be filled in. I also didn’t gather enough objective data for certain parts so I didn’t have any evidence that the care had worked or how effective it had been.

If using ASPIRE rather than APIE the next stage would be systematic nursing diagnosis where a nursing diagnosis is established which differs from the medical diagnosis but the two do overlap (Barrett et al 2009). The nursing diagnosis takes into account the medical diagnosis as well as the holistic needs of the patient considering their biopsychosocial and spiritual needs (Hinchliff et al 2008) and the effect these may have on the patient and how they deal with their illness. The next part of the systematic diagnosis is to establish baselines of where the patient is now in relation to the 12 als and their illness and set goals accordingly in collaboration with the patient in a way in which they understand (Barrett et al 2009).


The next stage of the nursing process is planning this is where all the information gained in the assessment part to plan the care of the patient. The planning stage of the process is where achievable goals need to be made through discussion with care givers and the patient or the patients representative. Kemp and Richardson (1994) Suggest that ‘One of the advantages of goal setting is that it can act as a stimulus for the patient’ and encourages them to work towards this. The plan of care is to solve the actual problems the patient has and to prevent potential problems from becoming actual ones, it also aims to help the patient cope with their illness in a positive way and to make them as comfortable and pain free as possible (RLT 2008).

Marriner (1983) states that ‘The patient should be included in the planning of his nursing care’ goals set need to be agreed with nursing staff, the patient and the patients relatives or representative although some of them will be more focused towards the patient and some of them will require the expertise of the nurse. Individualised care aims to have the best possible outcome for the patient by educating the patient and involving them in their care.

There are disadvantages to providing individualized care one of these being the time it takes to write the care plan which is why core care plans are often used but Roper et al (2000) say that these can be used effectively when used appropriately such as in post-operative care. Although when using core care plans it is important not to standardize care as patient react differently to illnesses and treatments. Faulkner (2000) Suggests that one of the benefits of using a core care plan is that potential problems can be foreseen.

The more information gathered in assessment the easier the plan of care will be. The main objective of a nursing plan is to ‘provide the information on which systematic, individualized nursing can be based and individualized nursing can be based and implemented by any nurse’ (RLT 2008). Through a detailed individualized plan of care any nurse caring for a particular patient should be able to see exactly what is required of them as all the information will be recorded in the care plan. The NMC (2008) says that nursing interventions need to be specific for that particular patient, based on best evidence, measurable and achievable.

There are many different criteria for setting goals just one of these is PRODUCT which stands for, Patient centered, recordable, observable and measurable, directive, understandable and clear, credible and time related. This is just meant as a way of helping nurses to set goals by giving them guidelines to follow (Barrett et al 2009). When planning care a great emphasis needs to be based on the dependence/independence continuum which will have been established in the assessment phase. The care to be given will encourage the patient to get back to as reasonably possible or as close to where they were on the continuum as they were before they were admitted to hospital. Planning also needs to take into account the resources available to implement the care as they need to ensure that the care they are planning is achievable and will not be compromised by lack of resources or a shortage of nursing staff (Roper et al 2008).

When I did a plan of care for mabel it quickly became evident how inexperienced I was. I didn’t gather enough information in the assessing period to be able to do an effective plan of care. I also didn’t know how achievable the goals where as I wasn’t aware of how long they would take to improve or if they where achievable or not, I also found it difficult determine which problems were interrelated and as a result tried to link anxiety in with another problem when in fact it was a problem on its own. I was able to write the needs statements effectively that were not long but on a couple of these the influencing factors were missed out which would be necessary when providing holistic care. Planning care for a patient requires a great deal of knowledge in the chosen specialty which is why it must be carried out by a qualified member of staff or a student under supervision.


Implementation is the next part of the nursing process and where all the goals which were set in the planning stage are put into motion and the goals can start to be achieved through nursing and medical interventions. ‘Implementation is the actual giving of nursing care’(Marriner 1983).This is done with nursing staff, the multidisciplinary team members involved in the patients care such as doctor, dieticians and physiotherapists and the patient themselves in order for the patient to be able to return to how they were previously before they were admitted to hospital.

The plan of care will be specific to the particular patient and will focus on the biopsychosocial aspects of the patient (Marriner 1983) and how these will affect the patients ability to carry out the activities of living.

Implementation also provides emphasis on individualized care which is why it is important to establish in the previous phases where they are on the dependence/independence continuum and what they are able to do now and what they were able to do before. If this hasn’t been established then it will be impossible to evaluate how effective the care has been.

Individualised care is associated with how the patient did things before such as how the person carries out the ALs and how often they carry these out. An example of this would be when carrying out the AL of personal cleansing and dressing to individualise the care it would be necessary to have determined in the assessing stage how the patient usually did this and how often it wouldn’t be individualized if in the care plan it was stated that they got a shower every morning if at home they only did this once a week. The NMC (2008) state that nurses are required to ‘Make the care of people your first concern, treating them as individuals and respecting their dignity’.

Core care plans may be used in certain situations this can provide a greater level of care as potential problems can be foreseen if related to a certain problem on the other hand it is also important not to standardize care as patients react differently to different illnesses and treatment. (Faulkner A, 2000).

In order to deal with certain problems or situations people often develop coping strategies which can be either adaptive or maladaptive. Adaptive coping strategies are usually helpful to the patient whereas maladaptive ones could be detrimental to their health such as smoking or drinking, the patient may feel this helps them to deal with a present situation but it is actually causing them harm. Patients need to be discouraged from using maladaptive coping strategies this could be done by introducing them to adaptive coping strategies and encouraging them to change their maladaptive ones into adaptive ones.

During the implementation of Mabel I found that although I was able to implement the care effectively I hadn’t recognized all of the nursing interventions needed to provide holistic care and I wasn’t fully aware of timescales of the planned care. I feel I also needed to research further into Mabel’s problems in order to gain the appropriate knowledge to provide the best care available as this would ensure that are the interventions are evidence based and best practice (NMC 2008).

Barrett et el (2008) state that this is where recheck should take place which would enable the health care provider to establish how effective the plan of care is before the treatment ends this would enable them to re-evaluate the plan of care while the treatment is still ongoing and adjust the goals accordingly.


Evaluation is where the care that has been given can be assessed to evaluate the care given and whether it has worked or not. Chalmers (1986) describe that it is an ongoing and continuous process and also occurs at timed points in a formal setting.

Roper et al (2000) say that evaluating care also provides a basis for ongoing assessment, planning and evaluation.

There are two different parts to evaluation summative evaluation and formative evaluation. Formative evaluation is done with the patient taking into account whether they feel the care given has worked when done with consideration of the dependence/independence continuum information regarding the patients previous place on the dependence/independence continuum can be obtained from the patient, their friends and relatives as well as other health care professionals in the multidisciplinary team involved in the care of the patient.

Summative evaluation is when the holistic view of the patient is taken into consideration how they feel about the treatment, whether they felt that the goals were achievable. It so where all the measureable data stated in the baselines and data received after this time is analyzed to show how effective or not the treatment has been.

When evaluating care consideration needs to be given to the influencing factors such as biological factors as the bodies physical ability varies according to age the physical ability of an older person is generally less efficient, therefore the plan of care needs to take this into consideration so that when the evaluation takes place it its hoped to have been effective. A nurse needs to evaluate her patient’s status regularly for some patients this will be just once a day but for others it will be much more frequent depending on their illness and healthcare status. RLT (2008) says that evaluation must be individual to the specific patient and not just a standard goal that is related to a specific problem. If goals haven’t been achieved then it is up to the nursing staff to determine why. Maybe the goals set weren’t measureable or achievable. Parsley and Corrigan (1999) say that if goals haven’t been measureable or achievable then new goals need to be set. It could also be that the nursing interventions were not successful in which case new interventions should be set.

There are also legal and ethical issues that may have an impact when evaluating care The Nursing and Midwifery Council (NMC 2002) state ‘you must obtain consent before you give any treatment or care’. If consent wasn’t gained then the care to be implemented wouldn’t have been effective and goals will not have been achieved.

Through my evaluation of Mabel it was evident that I did not require all the information to do a comprehensive plan of care. Although I did set baselines which meant I could compare data I wasn’t experienced enough to set goals to the correct timeframe I also didn’t obtain enough measureable information in certain problems to be fully able to assess how effective or ineffective the care had been. Had I had more experience I feel that the evaluation wouldn’t be a problem. Evaluation requires checking and rechecking in order to see the effectiveness of the care delivered. It requires knowledge and expertise to be able to effectively evaluate and amend the goals and interventions set as necessary. The whole care planning process took me a long time and I still was not very good at certain aspects of it. When setting goals a lot of detailed information is required in order for the plan of care to be effective so I can now understand why it is necessary for a trained member of staff to carry out the task.


This assignment has shown that when used together the nursing process and the nursing model provide a good basis to providing care. It sets out a systematic approach to providing care. Care needs to be set out in a way that both the nurse and the patient know exactly what is happening as well as any other health care professional in the multidisciplinary team providing care for the patient. It has also shown that involving patients in their care enables them to feel they are part of the team and are more likely to help themselves with their care.

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NMC (2002), The NMC code of professional conduct, Nursing and Midwifery Council Publications

Marriner A (1983) The nursing process. Ascientific approach to nursing care p170, Mosby:London.

Barrett D, Wilson B, Woolands A (2009) Care planning a guide for nurses: Pearson, Essex. Date accessed 11/04/2011

Free Essays

Does the professionalisation of nursing and other occupational groups employed in healthcare and the expansion of their roles signal a levelling of the medical hierarchy or medicine’s continued dominance?


The sociology of nursing continues to be dominated by its focus on the subordination of nursing in relation to the medical hierarchy. This is despite significant interventions through the professionalization of the nursing field and the expansion of their roles. In addition, other occupational groups employed in healthcare have also seen a shift in their roles as healthcare professionals. To assess the extent of medicines continued dominance we must first look at defining a profession and changes to nurse training with assistance from Eliot Friedson’s work (1970, 1986). This essay also makes reference to Svensson’s (1996) analysis of the negotiated order between nurses and doctors with relation to other social theorists such as Porter (1991) and Hughes (1980). Changes in gender status will also be assessed and finally conclusions will be drawn on whether or not medicine continues to dominate or whether there has been a levelling of the medical hierarchy.

We should consider the bureaucratic nature of a hospital environment; this, according to Weber (1914) means that there must be an organisational hierarchy. Within a hospital, for example, this will be split into professional groups, between professional groups, between primary and acute care and between different medical specialities. Specialist expertise must be employed and there are an abundance of specialist workers within a hospital, both medical and technical. Impersonal rules are used and discipline enforced to maintain social order within the organisation. Salaries are often paid to their workers instead of wages, and there are definite career ladders within the hospital. The bureaucratic nature of hospitals limits freedom, autonomy and initiative (Turner & Stanley, 1995) due to the fact that those in managerial positions create policy and those in medical positions follow it.

Looking at Friedson’s (1970) work we can distinguish key characteristics that produce a profession. Firstly there must be a body of specialised knowledge and this must be produced and assessed by those who are members of that profession. Secondly, there must be a monopoly maintained through the registering of all members, the restriction of employment to those only on that register, and competence assessments made only by those in the same field. The Formation of the Royal College of Nursing in 1916 led to a state registration in 1918. There must be autonomy in decision making and reviews of professional changes as well as a code of ethics to dictate the ideology of service to be carried out by members. There is an associated social status concerning professions and there is a definite “hierarchical divide between the knowledge-authorities in the professions and a deferential citizenry”. The nursing profession has witnessed a change in the way that they become trained, now having to obtain a degree or a diploma that is recognised by the Nursing and Midwifery Council to be registered with the profession. This was through the ‘Professionalisation project’ which introduced training taken out of the working environment (Project, 2000) with a degree structure and status. There were distinctions made between basic care and clinical care and a development of a specific knowledge base. Specialist clinical roles were also introduced, and through further education nurses can become a nurse practitioner or a prescribing nurse. This has led to the nursing profession being recognised more adequately on the medical hierarchy.

The medical professions are definitely hierarchal in nature with surgeons and specialist doctors at the primary position. The “Dominance of doctors was supported at various levels: over the content of their own work (characterised as autonomy), over the work of other health care occupations (authority) and as institutionalised experts in all matters relating to health in the wider society (sovereignty)” (Willis, 2006:42). Their training is longer and significantly more taxing then that of lay therapists and occupational workers, meaning that they receive higher salaries and acquire status for their chosen professions. Nurses are seen further down the organizational hierarchy, however the professionalisation of the nursing occupation has meant that there has been a leveling of the chain of command. Now there is a ladder within the nursing profession, from nursing specialists, to staff nurses and then unqualified nursing support in the form of healthcare assistants and auxillary nurses. The Wanless review carried out by The Royal College of Nursing (2005), showed plans that the nursing practitioners could take over around 20% of the work currently completed by physicians. The leveling of the medical hierarchy is only going to continue with this and the introduction of the European Working Directive which will “inevitably result in a handing over of responsibilities to nurses, as doctors are unlikely to be available all of the time” (Fagin & Garelick, 2004:278).

Nursing roles have changed considerably over the past. Looking at doctor-nurse interaction, specifically Porters (1991) study into the doctor nurse relationship, we note that “nurses reported feeling less subservient to doctors and experienced much greater participation in informal decision making”. The theory of a negotiated order between doctors and nurses was largely developed through symbolic interactionism to understand social order within organisations. “Key changes in the health care context have created ‘negotiation space’ for nurses, leading to the evolution of new working relationships with doctors” (Allen, 1997:1). The negotiated order between doctors and nurses leads us to better understand the changing hierarchal laws within the medical and nursing professions. Svensson’s (1996) study of medical and surgical wards is the most “appropriate theoretical framework for understanding patterns of doctor-nurse interaction” (Allen, 1997:1) and proved that through continuous negotiation between doctors and nurses a social negotiated order has been produced. According to Strauss, social order is “something at which members of any society, any organization, must work”. By way of explanation, negotiated order symbolises the progression of change, along with the relative nature of order and the persistent change of society. “While there was a theoretical ideal of the independent nurse, and of nursing as a separate field of knowledge, during the early Nightingale era its connection with medicine in reality was qualified by the nurses’ subordination to the medical profession” (Svensson, 1993:382). However, the hierarchal role of the nurse seems to have altered, “the field of negotiation has widened; rules and norms that once were scarcely negotiable are now possible and legitimate to modify” (Svensson, 1996:381). This is impart due to the social nature of their roles, they are in close contact with patients and therefore “powerfully placed to contribute to patient management given the centrality of ‘the social’ to holistic” (Allen, 1997:501). The nurse’s roles have been shaped through this leading to them coming to conclusions on medical diagnosis of patients and appropriately negotiating with the doctor. Nurses have a very significant role “in certain respects as regards not only defining the rules for interaction on the ward, but also defining the patients’ medical status” (Svensson, 1996:381). This can lead to us makings some positive determinations about the leveling of the medical hierarchy due to the increase role of nurses in the diagnosis of patients.

In relation to junior doctors, doctor-nurse interaction is again of a different nature. The nurses role had extended to guiding junior doctors in diagnosis. Hughes noted that nurses “often prepare necessary equipment even before doctor has directed what treatment should be given” (Hughes,1988:11). This makes sure that the diagnostic decision is not taken from the doctor but instead gives the less experienced a “general indication of particular diagnosis” (Hughes,1988:11). Showing again a leveling of the medical hierarchy. Casualty nurses also have increased involvement in decision making when it comes to the diagnosis of a patient and relevant treatment. The fast pace, heavy work demands and urgency of potential treatment have all lead to a definite “qualitative shift in nurse-medical staff relationships” (Hughes,1988:16). Nevertheless skills are not lost by the doctors and they still have overall responsibility for the patient’s diagnosis and treatment, and so medical dominance is, at the same time, retained.

The changes to gender equality within the workplace have affected the medical hierarchy and expanded nurse’s roles. Attitude surveys have shown that the public identifies ‘alertness to the needs of others’ (Oakley, 1984) as a characteristic of a good woman and a good nurse. Caring for people are seen as a women’s job and caring is “portrayed as intuitive, instinctive and as something you’re born with by virtue of your gender” (Smith, 1992:2). The doctor-nurse relationship is “deep rooted in societies status differentiation, women’s position in society and the biomedical orientation of care” (Digeall & McIntosh, 1978) and the “notion of a collegial, mutual relationship between medicine and nursing is a comparatively new one’ (Dingwall and Mclntosh 1978). The number of female medical staff has risen by 69% since 1998. The number of male medical staff increased by 31% over the same period. The improvement of women’s social status within the workplace may have contributed to a leveling of the medical hierarchy.


Through the expansion of nursing roles and the increased interaction between nurses and doctors there has been a levelling of the medical hierarchy. Now, there are specialist roles for nurses to release some pressure from the doctors, but also given qualified nurses more responsibility towards patients medical care and diagnosis. There has not been transference of overall skills, and the status associated with being a doctor or a surgeon certainly still outweighs that of a nursing professional. Medicines dominance can still be seen, as those at the primary spot on the hierarchal chain are biomedically trained, however the expansion of nursing and occupational roles certainly signals an overall shift in responsibilities and power. Nursing still relies predominantly on medical knowledge, however the professionalisation of the field was a further step for the recognition that nursing staff deserve.

Free Essays

Essay on Gibbs Nursing Model on Reflection


There are a number of different models of reflection that are utilised by professionals to evaluate past experiences. The two main types of professional reflection are reflection-on-action and reflection-in-action (Somerville and Keeling, 2004). Reflection-on-action encourages individuals to re-live past events, with an emphasis on developing a more effective action plan for any future, similar events that may occur. However, this type of reflection does tend to focus more on the negative aspects of our actions rather than the positive behaviours that were demonstrated during the event that is being reflected upon (Somerville and Keeling, 2004). Reflection-in-action is a deeper and more interactive form of reflection that encourages individuals to observe and reflect on past situations from the point of view of themselves and of others around them at the time of the event. Self-reflection and reflection upon events that happened within a work environment are important for individuals within the nursing profession (Paget, 2001). Reflection allows medical professionals to challenge and develop their existing knowledge, maximising the opportunity for learning and to avoid mistakes that may have been made in the past (Royal College of Nursing, 2012).

The Gibbs (1988) model of reflection suggests that the process of reflection is systematic and follows a number of specific steps in order to be successful. This model of reflection is a type of formal reflection, which draws on research and puts forward a theory as to how most effectively put into practice to process of reflection. The process can be broken down into six key steps:

Description: this step explores the context of the event and covers fine details such as who was present at the event, where it happened and what happened.
Feelings: this step encourages the reflector to explore their thoughts and feelings at the time of the event.
Evaluation: this step encourages the nurse to make their own judgement about the event and to consider what went well and what went less well about the event.
Analysis: this step delves even deeper into reflection on the event and encourages the nurse to break the event down into smaller episodes in order to facilitate analysis.
Conclusions: this step explores the potential alternatives that may be used to deal with the situation that is being reflected upon.
Action Plan: this is the final step in the reflection process. The action plan is put into place in order to deal more effectively with the situation if or when it may arise again.

The Royal College of Nursing (2012) believes the Gibbs (1988) model of reflection to be particularly superior because emphasises the role of emotions and acknowledges their importance in the reflection process. Nursing can often be an emotionally charged career, especially for nurses working in areas such as psychiatric health and palliative care. Therefore, reflection on these emotions and exploration of how to manage them and improve management of them in the future is of particular importance in the nursing profession.

Case Study

Step One (Description)

A young male patient aged 16 years came into the clinic around three days ago. He complained of low self-esteem and is feeling fed up and depressed because of pimples and spots on his face. The patient was worried thatgirls would not be attracted to him because of the spots. The consultation took place with just myself present, no other nurses were in the room at the time of the appointment. The consultation lasted around half an hour, during which time myself and the patient discussed the history of his problems with his skin and the emotional distress that the spots were causing him. The patient disclosed that he had begun to get spots at around age 14 when he had started puberty and that it had begun to make him feel extremely self-conscious. The patient described the negative effect that the acne was having. For example, he has been bullied at school and is feeling apprehensive about starting sixth form in September because he believes that he will be the only sixth former with spots. Based on the reasonably lengthy history of the acne, the presence of acne on the face and the negative emotional effect that the acne was having, a three month dosage of oxytetracycline was prescribed for the patient.

Step Two (Feelings)

During the consultation I had a number of feelings. Primarily I felt sympathy for the client because his situation reminded me of my own time as a teenager. I suffered from bad skin from the ages of 14 to about 20 and it severely affected my own self-esteem. In a review of the literature, Dunn, O’Neill and Feldman (2011) have found that patients suffering from acne are more at risk of depression and other psychological disorders. However, the review also found that acne treatment may lead to improvement of the psychological disorder that are so often co-morbid. This made me feel re-assured that prescribing oxytetracycline had been the right thing to do. My own experiences of acne also meant that I was able to relate well to the patient. I also felt some anger during the consultation. This anger was directed at the patient’s peers who had been cruel enough to taunt and tease the patient because of his acne. I also felt regret and guilt. I regretted not referring the patient onwards for emotional support and for not exploring the psychological impact of the acne in more detail. I also felt a sense of pride that this young man had the courage to come to the clinic by himself to seek help for his acne. I remembered how upsetting acne was as a teenager and I remembered that I would have been too embarrassed to have ever gone to a clinic or to have sought help from an adult. In turn, I also felt happiness. I felt happy that this young man had come to the clinic and I felt happy that I was able to help him.

Step Three (Evaluation)

On evaluation, the event was good in a number of ways. Firstly it added to my experience of dealing with young people and in dealing with the problems that are unique to this population of patients. I have not had many young patients during my nursing career and I welcome the opportunity to gain experience with this group. Furthermore, it re-affirmed my career choice as a nurse. During your career you always have doubts as to whether you have chosen the correct path. However, there are points in your career when you feel sure that you have made the right choice. However, there were also some negative elements. Firstly, the appointment was quite short and I am worried that this may have made the patient feel rushed and uncomfortable. After the consultation I did some research into the effects of acne in young people. Purvis et al. (2006) have found that young people with acne are at an increased risk of suicide and that attention must be paid to their mental health. In particular, the authors found that directly asking about suicidal thoughts should be encouraged during consultations with young people. This information only served to make me feel more anxious and I wished that I had bought this up with the patient.

Step Four (Analysis)

On reflection, being able to relate to the patient increased my ability to deal more effectively with the situation. I feel that the patient was able to open up more to me because he sensed my sympathy for him and his situation. Randall and Hill (2012) interviewed children aged between 11 and 14 years about what makes a ‘good’ nurse. It was found that the ability to connect to them was extremely important and so I think this is why the patient felt comfortable opening up to me. On reflection, I am also now convinced that the patient coming to see me was a very positive event. The patient could have chosen to go on suffering and could have chosen not to open up and talk about the problems his acne was causing. In a review of the literature, Gulliver, Griffiths and Christensen (2010) found that young people perceived embarrassment and stigma as barriers to accessing healthcare. Therefore, it could have been very easy for the patient to have avoided coming and seeking help. I felt a range of both positive and negative emotions during the consultation, and I think this re-affirmed for me that I enjoy nursing and enjoy helping others. It is important to genuinely care about patients and to provide them with the best care possible. This would be hard to do if you did not feel empathy for patients. The experience also helped me realise that I need to actively search out training and learning opportunities regarding working with young people with mental health issues.

Step Five (Conclusion)

If the same situation was to arise again I think that I would approach it in a slightly different way. In particular, I would have offered to refer the patient to further support services. During the consultation the patient mentioned that he felt that the spots on his face made him unattractive to the opposite sex. In addition to providing medication to get to the biological and physiological roots of the problem, on reflection I think it would have been beneficial to the patient to have provided information about charities that offer self-esteem and confidence building. Such charities that offer these services include Young Minds ( and Mind ( In retrospect, I also believe that I should have given the patient a longer consultation time in order for us to have explored the psychological impact of his acne in more detail. Coyne (2008) has found that young people are rarely involved in the decision-making process when it comes to their consultations. Therefore, giving the patient more time to discuss his problems may have improved his sense of wellbeing as he felt more involved in his care process.

Step Six (Action Plan)

There are a number of elements to my action plan. Firstly, I will make sure that in the future the consultation room has leaflets and information pertaining to mental health problems in young people. This way, young people can access the information if they perhaps feel too embarrassed to talk about it. Hayter (2005) has found that young people accessing health clinics put a high value on a non-judgemental approach by health staff. Therefore, in future I would be sure to be aware of my attitude and make sure that either subconsciously or consciously; I am not making any judgements about the patient. Hayter (2005) also found that young people had serious concerns regarding confidentiality, especially during busy times at the clinic. Therefore, in the future I would be certain to reassure young people that their details and consultations are kept completely confidential. To re-assure young patients, I may ask them to sign a confidentiality form, which I will also sign in front of them. Furthermore, my action plan will include improving my knowledge and awareness of working with young people as a nursing professional. This will allow me to increase the tools and skills I have for dealing with young people with complex needs. During the consultation I felt anger toward the patient’s peers who had teased him. In the future, I will focus on being more objective when dealing with a patient who has been the victim of bullying.


Coyne, I. (2008) Children’s participation in consultations and decision-making at health service level: A review of the literature. International Journal of Nursing Studies, 45(11), pp. 1682-1689.

Dunn, L.K., O’Neill, J.L. and Feldman, S.R. (2011) Acne in adolescents: Quality of life, self-esteem, mood and psychological disorders. Dermatology Online Journal, 17(1). Available at: [Accessed 20 October 2013].

Gibbs, G. (1988) Learning by Doing: A guide to teaching and learning methods. Oxford: Further Education Unit.

Gulliver, A., Griffiths, K.M. and Christensen, H. (2010) Perceived barriers and facilitators to mental health help-seeking in young people: a systematic review. BMC Psychiatry, 10(1), pp. 113.

Hayter, M. (2005) Reaching marginalised young people through sexual health nursing outreach clinics: Evaluating service use and the views of service users. Public Health Nursing, 22(4), pp. 339-346.

Paget, T. (2001) Reflective practice and clinical outcomes: practitioner’s views on how reflective practice has influenced their clinical practice. Journal of Clinical Nursing, 10(2), pp. 204-214.

Purvis, D., Robinson, E., Merry, S. and Watson, P. (2006) Acne, anxiety, depression and suicide in teenagers: A cross-sectional survey of New Zealand secondary school. Journal of Paediatrics and Child Health, 42(12), pp. 793-796.

Randall, D. and Hill, A. (2012) Consulting children and young people on what makes a good nurse. Nursing Children and Young People, 24(3), pp. 14.

Royal College of Nursing (2012) An exploration of the challenges of maintaining basic human rights in practice. London: Royal College of Nursing.

Free Essays

Gibbs Nursing Model on Reflection


There are a number of different models of reflection that are utilised by professionals to evaluate past experiences. The two main types of professional reflection are reflection-on-action and reflection-in-action (Somerville and Keeling, 2004). Reflection-on-action encourages individuals to re-live past events, with an emphasis on developing a more effective action plan for any future, similar events that may occur. However, this type of reflection does tend to focus more on the negative aspects of our actions rather than the positive behaviours that were demonstrated during the event that is being reflected upon (Somerville and Keeling, 2004). Reflection-in-action is a deeper and more interactive form of reflection that encourages individuals to observe and reflect on past situations from the point of view of themselves and of others around them at the time of the event. Self-reflection and reflection upon events that happened within a work environment are important for individuals within the nursing profession (Paget, 2001). Reflection allows medical professionals to challenge and develop their existing knowledge, maximising the opportunity for learning and to avoid mistakes that may have been made in the past (Royal College of Nursing, 2012).

The Gibbs (1988) model of reflection suggests that the process of reflection is systematic and follows a number of specific steps in order to be successful. This model of reflection is a type of formal reflection, which draws on research and puts forward a theory as to how most effectively put into practice to process of reflection. The process can be broken down into six key steps:

Description: this step explores the context of the event and covers fine details such as who was present at the event, where it happened and what happened.
Feelings: this step encourages the reflector to explore their thoughts and feelings at the time of the event.
Evaluation: this step encourages the nurse to make their own judgement about the event and to consider what went well and what went less well about the event.
Analysis: this step delves even deeper into reflection on the event and encourages the nurse to break the event down into smaller episodes in order to facilitate analysis.
Conclusions: this step explores the potential alternatives that may be used to deal with the situation that is being reflected upon.
Action Plan: this is the final step in the reflection process. The action plan is put into place in order to deal more effectively with the situation if or when it may arise again.

The Royal College of Nursing (2012) believes the Gibbs (1988) model of reflection to be particularly superior because emphasises the role of emotions and acknowledges their importance in the reflection process. Nursing can often be an emotionally charged career, especially for nurses working in areas such as psychiatric health and palliative care. Therefore, reflection on these emotions and exploration of how to manage them and improve management of them in the future is of particular importance in the nursing profession.

Case Study

Step One (Description)

A young male patient aged 16 years came into the clinic around three days ago. He complained of low self-esteem and is feeling fed up and depressed because of pimples and spots on his face. The patient was worried thatgirls would not be attracted to him because of the spots. The consultation took place with just myself present, no other nurses were in the room at the time of the appointment. The consultation lasted around half an hour, during which time myself and the patient discussed the history of his problems with his skin and the emotional distress that the spots were causing him. The patient disclosed that he had begun to get spots at around age 14 when he had started puberty and that it had begun to make him feel extremely self-conscious. The patient described the negative effect that the acne was having. For example, he has been bullied at school and is feeling apprehensive about starting sixth form in September because he believes that he will be the only sixth former with spots. Based on the reasonably lengthy history of the acne, the presence of acne on the face and the negative emotional effect that the acne was having, a three month dosage of oxytetracycline was prescribed for the patient.

Step Two (Feelings)

During the consultation I had a number of feelings. Primarily I felt sympathy for the client because his situation reminded me of my own time as a teenager. I suffered from bad skin from the ages of 14 to about 20 and it severely affected my own self-esteem. In a review of the literature, Dunn, O’Neill and Feldman (2011) have found that patients suffering from acne are more at risk of depression and other psychological disorders. However, the review also found that acne treatment may lead to improvement of the psychological disorder that are so often co-morbid. This made me feel re-assured that prescribing oxytetracycline had been the right thing to do. My own experiences of acne also meant that I was able to relate well to the patient. I also felt some anger during the consultation. This anger was directed at the patient’s peers who had been cruel enough to taunt and tease the patient because of his acne. I also felt regret and guilt. I regretted not referring the patient onwards for emotional support and for not exploring the psychological impact of the acne in more detail. I also felt a sense of pride that this young man had the courage to come to the clinic by himself to seek help for his acne. I remembered how upsetting acne was as a teenager and I remembered that I would have been too embarrassed to have ever gone to a clinic or to have sought help from an adult. In turn, I also felt happiness. I felt happy that this young man had come to the clinic and I felt happy that I was able to help him.

Step Three (Evaluation)

On evaluation, the event was good in a number of ways. Firstly it added to my experience of dealing with young people and in dealing with the problems that are unique to this population of patients. I have not had many young patients during my nursing career and I welcome the opportunity to gain experience with this group. Furthermore, it re-affirmed my career choice as a nurse. During your career you always have doubts as to whether you have chosen the correct path. However, there are points in your career when you feel sure that you have made the right choice. However, there were also some negative elements. Firstly, the appointment was quite short and I am worried that this may have made the patient feel rushed and uncomfortable. After the consultation I did some research into the effects of acne in young people. Purvis et al. (2006) have found that young people with acne are at an increased risk of suicide and that attention must be paid to their mental health. In particular, the authors found that directly asking about suicidal thoughts should be encouraged during consultations with young people. This information only served to make me feel more anxious and I wished that I had bought this up with the patient.

Step Four (Analysis)

On reflection, being able to relate to the patient increased my ability to deal more effectively with the situation. I feel that the patient was able to open up more to me because he sensed my sympathy for him and his situation. Randall and Hill (2012) interviewed children aged between 11 and 14 years about what makes a ‘good’ nurse. It was found that the ability to connect to them was extremely important and so I think this is why the patient felt comfortable opening up to me. On reflection, I am also now convinced that the patient coming to see me was a very positive event. The patient could have chosen to go on suffering and could have chosen not to open up and talk about the problems his acne was causing. In a review of the literature, Gulliver, Griffiths and Christensen (2010) found that young people perceived embarrassment and stigma as barriers to accessing healthcare. Therefore, it could have been very easy for the patient to have avoided coming and seeking help. I felt a range of both positive and negative emotions during the consultation, and I think this re-affirmed for me that I enjoy nursing and enjoy helping others. It is important to genuinely care about patients and to provide them with the best care possible. This would be hard to do if you did not feel empathy for patients. The experience also helped me realise that I need to actively search out training and learning opportunities regarding working with young people with mental health issues.

Step Five (Conclusion)

If the same situation was to arise again I think that I would approach it in a slightly different way. In particular, I would have offered to refer the patient to further support services. During the consultation the patient mentioned that he felt that the spots on his face made him unattractive to the opposite sex. In addition to providing medication to get to the biological and physiological roots of the problem, on reflection I think it would have been beneficial to the patient to have provided information about charities that offer self-esteem and confidence building. Such charities that offer these services include Young Minds ( and Mind ( In retrospect, I also believe that I should have given the patient a longer consultation time in order for us to have explored the psychological impact of his acne in more detail. Coyne (2008) has found that young people are rarely involved in the decision-making process when it comes to their consultations. Therefore, giving the patient more time to discuss his problems may have improved his sense of wellbeing as he felt more involved in his care process.

Step Six (Action Plan)

There are a number of elements to my action plan. Firstly, I will make sure that in the future the consultation room has leaflets and information pertaining to mental health problems in young people. This way, young people can access the information if they perhaps feel too embarrassed to talk about it. Hayter (2005) has found that young people accessing health clinics put a high value on a non-judgemental approach by health staff. Therefore, in future I would be sure to be aware of my attitude and make sure that either subconsciously or consciously; I am not making any judgements about the patient. Hayter (2005) also found that young people had serious concerns regarding confidentiality, especially during busy times at the clinic. Therefore, in the future I would be certain to reassure young people that their details and consultations are kept completely confidential. To re-assure young patients, I may ask them to sign a confidentiality form, which I will also sign in front of them. Furthermore, my action plan will include improving my knowledge and awareness of working with young people as a nursing professional. This will allow me to increase the tools and skills I have for dealing with young people with complex needs. During the consultation I felt anger toward the patient’s peers who had teased him. In the future, I will focus on being more objective when dealing with a patient who has been the victim of bullying.


Coyne, I. (2008) Children’s participation in consultations and decision-making at health service level: A review of the literature. International Journal of Nursing Studies, 45(11), pp. 1682-1689.

Dunn, L.K., O’Neill, J.L. and Feldman, S.R. (2011) Acne in adolescents: Quality of life, self-esteem, mood and psychological disorders. Dermatology Online Journal, 17(1). Available at: [Accessed 20 October 2013].

Gibbs, G. (1988) Learning by Doing: A guide to teaching and learning methods. Oxford: Further Education Unit.

Gulliver, A., Griffiths, K.M. and Christensen, H. (2010) Perceived barriers and facilitators to mental health help-seeking in young people: a systematic review. BMC Psychiatry, 10(1), pp. 113.

Hayter, M. (2005) Reaching marginalised young people through sexual health nursing outreach clinics: Evaluating service use and the views of service users. Public Health Nursing, 22(4), pp. 339-346.

Paget, T. (2001) Reflective practice and clinical outcomes: practitioner’s views on how reflective practice has influenced their clinical practice. Journal of Clinical Nursing, 10(2), pp. 204-214.

Purvis, D., Robinson, E., Merry, S. and Watson, P. (2006) Acne, anxiety, depression and suicide in teenagers: A cross-sectional survey of New Zealand secondary school. Journal of Paediatrics and Child Health, 42(12), pp. 793-796.

Randall, D. and Hill, A. (2012) Consulting children and young people on what makes a good nurse. Nursing Children and Young People, 24(3), pp. 14.

Royal College of Nursing (2012) An exploration of the challenges of maintaining basic human rights in practice. London: Royal College of Nursing.

Free Essays

The Impact of Staff Availability and Morale on Nursing Home Residents’ Risk of Dehydration in a UK Based Sample

Introduction and Background

Dehydration is a fluid imbalance in the body caused by too quickly a loss of fluid or by too little fluid going into the body. As the body ages, it becomes increasingly difficult to maintain an optimum fluid balance as the body’s ability to recognise its need for fluid becomes dulled (Ainslie et al., 2002; Rolls and Phillips, 2009). Dehydration can occur particularly quickly in the elderly, with potentially harmful effects (see for example Weinberg et al., 1995; Davidhizar, Dunn and Hart, 2004) including increased risk of hospitalisation (Gordon et al., 1998; Xiao, Barber and Campbell, 2004) and increased risk of fatality (Warren et al., 1994). Recent figures (Press Association, 2011) show that high numbers of nursing home residents are dying in the UK as a result of dehydration and research from America shows that this could be due to low staffing numbers (Harrington et al., 2000; Schnelle et al., 2004; Bostick et al., 2006; Shipman and Hooten, 2007).

Study Rationale

Low staff numbers and staff morale could lead to a higher risk of dehydration in nursing home residents for a number of reasons including low motivation to carry out duties. This may create a vicious circle in which low staff morale leads to more staff absences and short staffing as a result. Identifying low staff numbers and low staff morale as a predictor of risk of dehydration could help nursing home providers tackle the problem more effectively and reduce resident risk of dehydration.

Research Question
Can under-staffing and low staff morale predict a higher risk of resident dehydration in UK nursing homes
Literature Review

A literature review was carried out to identify the gap in knowledge relating to dehydration in UK nursing homes. The key words and terms used to carry out this search were: “dehydration”, “nursing homes”, “UK”, “understaffing”, “risk” and “staff low morale”. The literature review revealed some relevant studies, most of which had been carried out primarily in America.

Although there are causes of dehydration that arguably cannot be caused by poor nursing home conditions or under-staffing, there are many that can. Excessive sweating, too little fluid intake or fluid accumulation could be caused by patient neglect, such as failure to escort a patient to the toilet or something as simple as failing to notice an elderly patient is having trouble pouring from a water pitcher (Kayser-Jones et al., 1999; Mentes, 2006). Understaffing has been associated with a decrease in patient care quality in general. For example, Harrington et al. (2000) found that fewer registered nurse hours in nursing homes had a significant, negative relationship with quality of care. Schnelle et al. (2004) used three different data collection methods to compare nursing homes that had reported differing statistics about staff numbers and quality of care. It was also found that higher staffed homes performed significantly better on processes of care than lower staffed nursing homes. However, Harrington et al. (2000) found that facility characteristics and state were stronger predictors of care quality within nursing homes and by their own admission state that much more work is needed in the area.

The Royal College of Nursing’s (2010) guidelines on safe nurse staffing levels in the UK state that avoidable complications can only be avoidable if effective nursing care is delivered effectively and consistently. They report that nurses with no more than six patients under their care rarely feel that patient care is compromised, whereas a ratio of one to eight leaves nurses feeling that patient care is being regularly compromised. In nursing home settings, there is an average of 18 patients per registered nurse during the day, and 26 patients per registered nurse at night (Royal College of Nursing, 2010). These numbers suggest that nursing homes are continuously under staffed.

Morgan et al. (2003) have suggested that dehydration may not simply be a result of the aging process, but also a result of dependent living. This sentiment has been echoed by later research. Bossingham, Carnell and Campbell (2005) found that elderly adults who lived out in the community were matched to young adults in terms of hydration balance. In contrast, Mentes et al. (2006) found that 31% of 35 nursing home residents they observed over a six month period were suffering from dehydration. Kayser-Jones et al. (1999) found that nursing home residents were more at risk of dehydration when staffing was inadequate and supervision of residents was poor. It was also found that mean fluid intake of the residents was inadequate. In the UK, recent figures from the Health Service Journal (Press Association, 2011) online obtained from the Office for National statistics show that between 2005 and 2009, 667 elderly residents of care homes died as a result of dehydration. These figures suggest that understaffing in nursing homes has a role to play in high levels of dehydration in UK nursing homes. They also suggest that elderly individuals in the care of nursing homes may be at more risk of dehydration than if they were to be cared for in the community.

Dyck (2007) has commented that despite the importance of both numbers and type of staffing in nursing homes on residents health, the research behind the relationship has been minimal and there are currently a number of key gaps in the literature. Firstly, the majority of research has been carried out in America. Therefore, research into the issue in the UK is lacking. Secondly, the literature fails to take into account the potential role of staff morale in the relationship between staff numbers and care quality. The decrease in quality of care thought to be associated with low staff numbers could be also partly due to low staff morale. Registered nurses with high morale in the workplace may be able to cope better in situations where staff numbers are low and reduce the impact these low numbers have on resident care. Finally, there are few studies that have focussed on the impact that low staff numbers and morale have on dehydration in particular.

Purpose of the Study

The purpose of this study is to investigate the degree to which under-staffing and low staff morale has an impact of resident risk of dehydration in UK nursing homes.

Research Design and Methodology

This study will use a quantitative method in the form of closed statement questionnaires.

Data Protection Procedures

See ethical considerations.


The interviews will be carried out within each nursing home. Resident’s will be interviewed either within their own rooms or in communal areas. Staff will be interviewed independently, within a suitable, quiet room within the nursing home premises.


Local nursing homes will be invited to take part by letter. Invitation letters will be followed up by a telephone to call to confirm whether the nursing home is interested.

Data Collection

Residents will be asked the following statements to assess risk of dehydration:

I often feel thirsty during the day.
I don’t have adequate access to water during the day.
I am not given a choice of what liquid I can drink during the day.
I am offered plenty of water throughout the day.
I find it hard to help myself to water.
I am able to go to the toilet whenever I need to.
I often feel uncomfortably warm during the day.
My water needs are always met promptly.

Nursing home staff will be administered a separate questionnaire with the following statements:

I enjoy my job.
I look forward to coming to work every morning.
If I was offered a new job elsewhere I would take it immediately.
I feel that I am supported adequately during my duties at work.
I have low morale when it comes to my job.
I feel that the nursing home is adequately staffed on a daily basis.
I struggle to attend to all my residents.
I feel that my level of pay is good.

Residents and staff will be asked to state whether they strongly disagree, disagree, don’t know, agree or strongly agree to the statements. Each answer will be scored from one to five with one corresponding to a ‘strongly disagree’ answer and five corresponding to a ‘strongly agree’ answer. In addition to the interviews, the nursing home manager will be asked to provide the average ratio of staff to residents on day and night shifts.


Residents taking medicines that affect renal function should be excluded from the questionnaire as this will increase their risk of dehydration. Additionally, the questionnaires include statements that will be negatively scored. These are designed to identify participants who have not fully understood the questions or who are guessing the answers. In the residents’ questionnaire these are question numbers four, six and eight. In the staff questionnaire these are question numbers three, five and seven.

Ethical Considerations

Residents’ or staff personal details will be completely anonymised and each participant will be assigned a unique identifying number. Personal details of participants and of the participating nursing homes will also be anonymised and kept on a secure, password protected database.

Data Analysis

The questionnaires will be scored, categorised and entered into a SPSS (2010) database. Residents’ questionnaires will be scored into three categories: a score between 8 and 20 will be categorised as a low risk of dehydration, a score between 20 and 28 will be categorised as a medium risk and a score of between 28 and 40 will be categorised as a high risk of dehydration. The staff questionnaire will be scored in a similar way: a score between 8 and 20 will be categorised as low morale, a score of 20 to 28 will be categorised as normal morale and 28 to 40 will be categorised as high morale. Average staff to resident rations obtained from the nursing homes will also be categorised in to high, medium and low for both day and night shifts. Once all the data is entered into the database, a logistic regression will be performed to predict the outcome of resident risk of dehydration based on the predictor variables of staff morale and staff to resident ration.



Study Limitations

This research proposal has a number of limitations. The use of a questionnaire can result in social desirability bias, particularly in the case of the staff. Nursing home staff may feel worried about revealing their true feelings surrounding their job. Anonomysing results may go some way to reducing this limitation as will enabling staff to carry out the interview without the presence of an interviewer.

Another limitation is failure to obtain a direct measure of dehydration. However, nursing home managers are unlikely to disclose cases of dehydration or deaths related to dehydration unless required by law. However, use of a urine colour chart could have been useful in assessing whether a resident was suffering from dehydration at the time of completing the questionnaire.

Another limitation of the study is the use of a visual questionnaire. This format may mean that residents or staff with visual difficulties are unable to partake in the study. To tackle this limitation, questionnaires could be administered in interview format so that participants are able to answer orally.

Produce a time table, explore potential problem and includean estimation of resources.


Ainslie, P.N., Campbell, I.T., Frayn, K.N., Humphreys, S.M., MacLaren, D.P.M., Reilly, T. and Westerterp, K.R. (2002) Energy balance, metabolism, hydration, and performance during strenuous hill walking: the effect of age. Journal of Applied Physiology, 93(2), pp. 714-723.

Bossingham, M.J., Carnell, N.S. and Campbell, W.W. (2005) Water balance, hydration status, and fat-free mass hydration in younger and older adults. American Journal of Clinical Nutrition, 81(6), pp. 1342-1350.

Bostick, J.E., Rantz, M.J., Flesner, M.K. and Riggs, C.J. (2006) Systematic review of staffing and quality in nursing homes. Journal of the American Medical Directors Association, 7(6), pp. 366-376.

Davidhizar, R., Dunn, C.L. and Hart, A.N. (2004) A review of the literature on how important water is to the world’s elderly population. International Nursing Review, 51(3), pp. 159-166.

Dyck, M. J. (2007) Nursing staffing and resident outcomes in nursing homes: Weight loss and dehydration. Journal of Nursing Care Quality, 22(1), pp. 59-65.

Gordon, J.A., Lawrence, C.A., Hayward, R.A. and Williams, B.C. (1998) Initial emergency department diagnosis and return visits: Risk versus perception. Annals of Emergency Medicine, 32(5), pp. 569-573.

Harrington, C., Zimmerman, D., Karon, S.L., Robinson, J. and Beutel, P. (2000) Nursing home staffing and its relationship to deficiencies. The Journals of Gerontology, 55(5), pp. S278-S287.

Kayser-Jones, J., Schell, E.S., Porter, C., Barbaccia, J.C. and Shaw, H. (1999) Factors contributing to dehydration in nursing homes: inadequate staffing and lack of professional supervision. Journal of the American Geriatrics Society, 47(10), pp. 1187-1194.

Mentes, J. (2006) Oral hydration in older adults: Greater awareness is needed in preventing, recognising, and treating dehydration. The American Journal of Nursing, 106(6), pp. 40-49.

Mentes, J.C., Wakefield, B. and Culp, K. (2006) Use of a urine color chart to monitor hydration status in nursing home residents. Biological Research for Nursing, 7(3), pp. 197-203.

Morgan, A.L., Masterson, M.M., Fahlman, M.M., Topp, R.V. and Boardley, D. (2003) Hydration status of community-dwelling seniors. Aging Clinical and Experimental Research, 15(4), pp. 301-304.

Press Association, 2011. Hundreds of care home deaths caused by dehydration. Health Service Journal, [online] 31 January. Available at: [Accessed on 27 January 2012].

Rolls, B.J. and Phillips, P.A. (2009) Aging and disturbances of thirst and fluid balance. Nutrition Reviews, 48(3), pp. 137-144.

Royal College of Nursing (2011) Guidance on safe nurse staffing levels in the UK. London: Royal College of Nursing.

Schnelle, J.F., Simmons, S.F., Harrington, C., Cadogan, M., Garcia, E. and Bates-Jensen, B.M. (2004) Relationship of Nursing Home staffing to Quality of Care. Health Services Research, 39(2), pp. 225-250.

Shipman, D. and Hooten, J. (2007) Are nursing homes adequately staffedThe silent epidemic of malnutrition and dehydration in nursing home residents. Until mandatory staffing standards are created and enforced, residents are at risk. Journal of Gerontological Nursing, 33(7), pp. 15-18.

Warren, J., Bacon, E., Harris, T., McBean, A.M., Foley, D.J. and Phillips, C. (1994) The burden and outcomes associated with dehydration among US elderly, 1991. American Journal of Public Health, 84(8) pp. 1265-1269.

Weinberg, A.D., Minaker, K.L., Coble, Y.D. et al. (1995) Dehydration evaluation and management in older adults. The Journal of the American Medical Association, 274(19), pp. 1552-1556.

Xiao, H., Barber, J. and Campbell, E.S. (2004) Economic burden of dehydration among hospitalized elderly patients. American Journal of Health-System Pharmacy, 61(23), pp. 2534-2540.

Free Essays

The Nursing Profession


The definition nursing varies from one country to another. However, the international Council of Nurses defines nursing as a profession that covers autonomous and collaborative care of individuals of all communities, families, ages, groups, sick or well in all settings (Carol & Dawn, 2011). In a broader perspective, it includes promotion of health, care for the sick, disabled and prevention of illnesses. Professionals have labeled it as more of a calling than a profession because it involves intensive care giving, sometimes in extreme conditions. The role of nurses in the contemporary society has evolved from the medieval years, as they are considered primary care givers. Nurses are trained professionally in different areas of medicine. However, recent trends in nursing have welcomed specialization in nursing attributed to the complexities in the medical profession (Carol & Dawn, 2011). Apparently, advanced training is required to ensure nurses are competent as they deal with people and their lives.

Academic qualification for nursing

An article by Ipek C. G. & Kasikci (2011) reveals that practitioners of nursing must depict compassion and empathy because nursing entails more than just care giving. Given the rigorous duties entrusted in the hands of nurses, they need to attain certain level of training. A strong educational background in health sciences goes a long way in securing admission in an institution of higher learning. Biology and human physiology are areas the one intending to pursue nursing must demonstrate proficiency. Mathematics is also an instrumental in the medical profession as it demonstrates ones analytical skills to deal with the rigorous field of medical sciences (Ipek & Kasikci, 2011). I undertook training in emergency response and biological science. I believe this puts me in a uniquely qualified position to be considered for admission into a medical science program.

Skills in nursing

Undertaking a career in nursing is not an easy task, as it involves long hours of commitment and sacrifice. Learning how to deal with diversified cases requires individual commitment and enthusiasm. However, being passionate about nursing can immensely be rewarding and satisfying. Apart from the long career and voluminous course works, learning how to handle and deal with people is part of the nursing profession. Nurses encounter people from all occupations, and not all of these people will be nice always (Ipek & Kasikci, 2011). The situation is worse to the extent that some doctors look down on nurses as their inferior colleagues while some patients can be insufferable. Given the amount of work nurses do, incorporation by patients and doctors can be extremely essential in motivating and providing them with the much-needed moral support. As a result, nurses must exhibit skills of corporation and commitment toward their jobs (Hiscott, 1998).

Consequently, nursing requires an individual’s full commitment to the job. Nurses work in shifts that allow maximum output. At times, the job requires long hours of work, meaning that one can go hours without food or days without sleep just to save a life. This may lead to fatigue that may result in costly mistakes. Based on this aspect, it is important that nurses develop teamwork skills to enable them work in teams (Harrison & Journeaux, 2011). Teamwork is not an easy task as there are different people in the team with different characters and personalities. Being able to work together and delegate duties to colleagues helps in the smooth running of operations in health institutions. Matching these skills to my profession, I believe I am an ambitious, reliable and hardworking individual, looking for a challenging position. I possess the ability to work on own initiative with minimum supervision, but also enjoy working in a team. I have the ability to manage projects effectively and work well under pressure.

How do you succeed at an interview?
How did you hear of our programs

I am an avid reader of educational content with a passion for nursing. I first got a referral from one of my tutors to review some work done by one of your institution’s scholars. Afterwards, I found out that your institution had a competent and widely recognized medical sciences department.

How do you keep up with events and developments in medicine

Through medical and current affairs publications, I am able to keep up to date on developments in the medical field. I use the internet regularly, which gives me access to all the information I may require. I follow works by some of the institution’s top scholars, as they are involved in groundbreaking researches in different areas of medicine.

Given the wide professional area, what made you select nursing as your profession

I believe I have a passion for medical science. I had an experience in taking care of my pregnant aunt, and working at various healthcare institutions such as Chase Farm Hospital. My success during these times made me realize that I am fulfilled by helping other people in need. The gratitude given to me by those I care for is enough to motivate me to give fulltime care to those who need it most.

What unique qualities do you have that equip you for a career in nursing

I believe I am best suited for a position in your nursing program, as I have the basic training in emergency response and care. I have exceptional academic grades in health sciences and mathematics, which will help in my training. Having taken care of old relatives and volunteering at the local teenage shelters, I have the required experience that will enable me prosper as a nursing student. I have a Midwifery HE Diploma and BA Honors in Marketing Management from the University of Westminster.

What attracted you to this facility and what do you hope to achieve in this position

I was attracted to this facility by the innovative work done by people affiliated to this institution. I hope to get a nursing degree that will enable me to be a highly qualified caregiver.

Where do you see yourself in three years

In three years, I will have finished my nursing degree from this outstanding institution and on track for a prosperous nursing career.

What was your most significant achievement to date

My most significant achievement to date is taking part in a teenage pregnancy outreach program in an effort to reach young teenagers and young mothers. The program was aimed at empowering young mothers and pregnant teenagers.

Have you ever handled a difficult patientHow did you handle the situation

No, I have not, but in case I encounter one in the course of my duty, I would tolerantly ask the patient what the problem is before selecting that best way on how I can assist based on their response. In case I cannot address the concerns raised by the patient, I would consult with my immediate superior on the best course of action in relation to the patients concerns.

How would you rate your communication level

I believe I am an excellent listener who can communicate well with people since I have an open mind. I give people a chance to be heard and listen to their views.

What can you do to motivate patients

To motivate patients, I would always be positive and insightful. Inspiring patients to positive stories and having them smile will help in motivating a patient. Positive emotions means patients are optimistic and hopeful of their recovery. Given the nature of the profession, being positive should be a requirement for all nurses.


Campaign for normal birth: The royal college of midwives. Viewed 24 October 2012 from

Ipek C. G. & Kasikci, M. 2011, Development of the Attitude Scale for Nursing Profession. International Journal of Nursing Practice, 17 (5): 518-24

Harrison, J. & Journeaux, M. 2011, Promoting nursing and midwifery as a potential career for school leavers. Nursing Standard, 26 (9): 35-40

Carol H. & Dawn R. 2011, What Is NursingExploring Theory and Practice. NY: SAGE, 2011

Hiscott, R. 1998, Career Paths of Nursing Professionals: A Study of Employment Mobility. NY: McGill-Queens

Free Essays

Palliative Care Nursing


Palliative is a concept of care that provides coordinated medical service to patients with progressive incurable diseases.The allied health service is proactive and seeks to improve the lives of individuals that are faced with life threatening diseases and their families. Dying and death are part of life and as such palliative care offers the patients a holistic care service that includes social, psychological and spiritual care (1, p.33). Therefore palliative care aims at ensuring that the patients and their families lead the best quality of life without having to be stressed about their condition. This essay takes a critical look at the philosophy and principles of palliative care and how they apply in nursing care.

Discussion on the Statement

The philosophical statement given by the World Health Organisation on palliative care is directed at ensuring that the patients have the best quality of life even when they have terminal illnesses. Palliative care is extended to the family of the patients to ensure that they continue to lead normal lives despite the challenges caused by the terminal diseases. In the past, patients with terminal illnesses were seen as sufferers and with the continual advancement of the disease, care was focused was on lessening the pain for the dying patients. However, with the development of palliative care, the dying patients are no longer seen as sufferers but as other normal patients and are given specialised care from designated professionals (5, p. 23). These professionals maintain humaneness as a core value and must respect the law with regards to the patients and their families and include them in all key decisions.

The care is comprehensively provided to manage physical, psychological, social and spiritual needs of the patients and their families. Palliative care is governed by principles that govern its practice. In the nursing profession, the nurses affirm life and regard dying as a normal process. This is a message that is communicated to both the patients and their families to help them accept the harsh reality of life. Communication is an important part of the process and as such the nurses are required to communicate with the patients and their families in the best possible manner. The nurses are required not to hasten or postpone the death of the ailing patients. They are instead required to relieve the patients from pain and distress to ensure that they improve the patient’s quality of life.

Principles of Palliative Care in Nursing

Palliative care is governed by some core principles that the professionals like nurses, doctors, counsellors and social workers are supposed to adhere to. This section takes a critical look at the principles of palliative care as they apply to the palliative care of patients and families in nursing care. Successful incorporation of palliative care in nursing practice is not a function of complex specialist environments, medical interventions or availability of drugs and disciplines (3, p54). The principles highlighted here apply to nurses working in any environment where they encounter the dying. The principles are discussed under the following themes:

Emphasis on the quality of life

Palliative care should be centred on the quality of life of the patients and their families. The nurses are required to encourage the patients and their families and help them focus on the quality of the life of the patient and not the number of days left to live. Quality of life is defined differently depending on the patient and the disease. The nurses improve the quality of life of the patient by managing the distressing symptoms in order to positively impact the course of the illness. The nursing palliative care team should help the patients and their families enjoy their lives to the maximum while facing the complex medical conditions (10, p. 74). Communication plays an integral part in the nursing palliative care and as such the nurses are required to continually speak with the patients and their families about their wishes, desires and what quality of life means to them (6, p. 63). The communication on quality of life should start early in the course of the illness when the older members of the family are able to contribute before they get stressed and start making immediate decisions. The emphasis on quality of life improves management of symptoms and communication between the nurses and the family.

Patient and family are the focus of care

This is a core principle that cuts across all settings because the patients and their families are the unit of care, not the disease (2, p. 77). Palliative care addresses the meaning of suffering, life, death and disease within the context of each family unit. It recognises the fact that all family members will be part of the disease process and as such their views and individual care plans must be taken into account in the palliative care.

Symptom Management

The nurses are required to assess and treat symptoms using the least invasive ways that will not cause more distress than the original symptom (7, p. 80). Interdisciplinary collaboration, frequent assessment, communication and appropriate management are important concepts of symptom management in palliative care. Symptom management should always be the start of diagnosis in patients with life threatening diseases or those that are potentially life threatening. This should be continued throughout the treatment process in order to improve the patient’s quality of life (3, p. 87).

Communication and Decision Making

Communication with the patients and family should be done clearly, collaboratively and compassionately in order to improve the patient’s quality of life (8, p. 81). Communication with the patients and family is important as it ensures that the family and patients are consistently updated on the course of the disease and treatment. The patients and their families depend on frequent, consistent communication on sensitive and difficult information and may at times need repetition of facts. The communication should be both ways as the nurses should listen to the views of the patients and their families in order to be able to provide care that suits their needs in all ways including culturally and spiritually (11, p. 101). It also allows the family members to reveal more about the patient as this information may be useful in the treatment process depending on the disease.

Recommendations for Palliative Nursing Care

As already indicated earlier in the discussion, it is not easy to fully implement the principles of palliative nursing care. However, nurses should try hard to ensure that these principles are fully implemented in nursing care. Palliative care can be further incorporated through good hospital practice with nurses spending more time with the patients and their families to discuss and plan care within a multidisciplinary team framework (4, p. 15). The nurses should pursue a partnership approach and make good use of open and honest communication with the patients, relatives and the health team. Such ideology is important in nursing philosophy of individualised care that embraces a holistic approach and active patient participation in care (9, p. 71). The nurses should reintegrate palliative care into the culture of the hospitals. This reintegration into the hospital culture will be helpful to the patients particularly those with terminal illnesses. This is very critical because nurses are often at the forefront of general delivery of palliative care within the hospital. They are very well placed and should use their position to help uncover better ways of improving the quality of care to the patients and their families. Lastly, the nurses should receive palliative care education to ensure that they are equipped with the knowledge and management skills necessary for dealing with patients and their relatives as they have diverse personalities, cultures and beliefs.


Palliative care is very important to the patients and their families particularly those with terminal illnesses. This essay has explored the philosophy and principles of palliative care in nursing and has concluded by making recommendations on how hospitals can incorporate it within their cultures. For effective implementation of palliative care in nursing, the nurses need to be well educated on palliative care and how to conduct it in order to minimise misunderstands between them and the patients and their relatives. Proper implementation and execution of palliative care is important in improving the quality of lives of the patients and their families, especially those with terminal or potentially terminal illnesses. Therefore nurses should engage the patients and their relatives in all key decisions to ensure that they get as much information from them in time before the levels of stress get high. Such information is important and can be used in providing individualised care to the patients.


Aitken, Sandra. Community Palliative Care The Role of the Clinical Nurse Specialist. Chichester: John Wiley & Sons, 2009.

Bern-Klug, Mercedes. Transforming Palliative Care in Nursing Homes: The Social Work Role. New York: Columbia University Press, 2010.

Byrne, Judi. Palliative Care in Neurological Disease: A Team Approach. Oxford: Radcliffe Pub, 2009.

Foyle, Lorna, and Janis Hostad. Illuminating the Diversity of Cancer and Palliative Care Education: Sharing Good Practice. Oxford: Radcliffe Pub, 2010.

Lugton, Jean, and Rosemary McIntyre. Palliative Care: The Nursing Role. Edinburgh: Elsevier/Churchill Livingstone, 2005.

Matzo, Marianne, and Deborah Witt Sherman. Palliative Care Nursing: Quality Care to the End of Life. New York: Springer Pub. Co, 2010.

Payne, Sheila, Jane Seymour, and Christine Ingleton. Palliative Care Nursing Principles and Evidence for Practice.

Maidenhead, Berkshire, England: Open University Press, 2004.

Payne, Sheila, Jane Seymour, and Christine Ingleton. Palliative Care Nursing: Principles and Evidence for Practice.

Maidenhead: Open University Press, 2008.

Perrin, Kathleen Ouimet. Palliative Care Nursing: Caring for Suffering Patients. Sudbury, MA: Jones & Bartlett Learning, 2012.

Pfund, Rita. Palliative Care Nursing of Children and Young People. Oxford: Radcliffe, 2007.

Stevens, Elaine, Susan Jackson, and Stuart Milligan. Palliative Nursing Across the Spectrum of Care. Chichester: John Wiley & Sons, 2009

Free Essays

Partnership Care Nursing: A review of two Peer-reviewed Journals on Care Nursing


The concept of teamwork in health and social care has a vast literature. For instance, a policy developed by the Department of Health in 2007 mainly focused on eradicating inequalities in health service provision through partnership working between primary care providers and other social care agencies. Today’s healthcare service status demands teamwork, which is particularly true for nurses who have to deal with multiple of factors during their professional service provision. On the same breadth is the increased call for more patients’ involvement in their health, including on the right to make decision and seek legal support on the basis of their health. In other words, every patient receiving healthcare services, including nursing service is entitled to be actively involved in their own care. The philosophy behind partnership working in nursing is based on several concepts and principles: empowerment, autonomy & rights, power-sharing, information sharing, respect, making informed choices, and paternalism. The aim of this paper is to analyse ideas from two different articles by different authors on the topic of nursing, particularly on the partnership working in nursing.


Article I: Patient participation in nursing care: towards a concept clarification from a nurse perspective

In their study, “Patient participation in nursing care: towards a concept clarification from a nurse perspective” Sahlsten et al. (2007) explored the evolution of patient participation, a concept that has not only gained significant transformation overtime, but also brought with it more challenges on definitions and dimensions of patient participation. The authors used focus group interviews to collect data, conducting open interviews on the selected seven groups. While the data gathering took five months to accomplish, the researchers were able to uncover the respondent’s perspectives in depth. While the focus group interviews may have mainly focused on the meaning and implementation of patient participation in line with the study’s aim, the results can clearly reveal what nurses value most in terms of patient participation. Respondents rated equal partners’ participation, co-operation, and shared responsibility as the most significant factors in relational nursing (Sahlsten et al., 2007, pp. 635-636).

While the aim of the study was to explore “the meaning of patient participation in the nursing care from a nurse perspective” (Sahlsten et al., 2007, p.632), the review of other authors’ works reveals a plethora of issues in the nursing care and partnership working. The nurse-patient relationship is considered successful when both parties view each other as partners, with the nurse required to use professionalism, knowledge and positive ideas in the implementation of nursing care plan. Patient, on the other hand, is expected to have the intellectual ability to understand and make the right choices with regard to their own nursing care. The authors, however, faults the incongruence relationship between studies conducted in relation to patient participation on one side and definitions, elements and processes in literature and practice on the other side. Although there are a lot of empirical literature on nursing theories and patient participation, the authors claim that no empirically grounded theory has ever been established, calling for significant insight into more studies related to the concept of patient participation in their own nursing care. The authors claim that the traditional approach where patients were mere recipient of nursing care has changed, and subsequently replaced by the more active patients who are directly involved in their own care. More importantly, patients’ participation simply means the opportunity for them to participate in their own care, with regular adjustment as the situation may demand.

Article II: The relational core of nursing practice as partnership

Jonsdottir, Litchfield and Pharris (2004), while exploring “the relational core of nursing practice as partnership”, focused their analysis on the evolving relational core of nursing care in the backdrop of increased technology use and outcome-oriented approaches. The three authors, unlike their previously outlined counterparts, only focused on critical review of the available literature, espousing the role of evolving dialogue between nurse and patient in terms of partnership nursing and care. While technology is considered in the positive side in terms of medical breakthroughs, experts and general observers alike have associated it with distraction in health care services that need personalised attention including nursing (Jonsdottir, Litchfield and Pharris, 2004, p.241). In retrospect, the authors claim that the distracted modern nurse sees patient as a problem rather than partner to be attended to, consequently obscuring the humanness of nursing experience.

To emphasise on the need to correct the deteriorating relational nursing concept in the perspective of partnership, Jonsdottir, Litchfield and Pharris (2004) outline and analyse various research studies that backs the need for nurses to be real partners through presence, care, and attentiveness in every stage of care nursing. The authors categorically state that the patients need medical treatment as priority, but emphasis should also be given to proven holistic approaches to care nursing, which studies have revealed to be equally significant in the overall healthcare. The focus on holistic care nursing should thus be based on dialogue between nurses and patients, for example, where the former should be in a position to explain to the latter why a certain procedure or activity is necessary in the process of care nursing.


While the two set of authors had different approaches to their respective work, both articles exemplifies harmony in terms of the need for partnership care nursing. One may, however, notice that the former article largely referred to partnership in the perspective of increased patient participation in own care nursing. The latter article mainly focused on partnership as a dialogue between nurse and patient. It is prudent to state that the former authors’ focus on patient elevation is largely due to historical background of healthcare service provision that pushed patients to the periphery of their own health. Nonetheless, the difference in semantics and approach notwithstanding, the two sets of authors agree that both patients and nurses need to collaborate, and view each other as partners rather than either one party feeling superior to one another. After all, it is common knowledge in the health care cycle that post-modern health and social care services requires more than the post-war’s “one-size-fits-all” approach that dominated the universal health care service provision more than fifty decades ago.


Jonsdottir, H., Litchfield, M. and Pharris, M.D. 2004. The relational core of nursing practice as

partnership. Journal of Advanced Nursing, 47(3), 241-250.

Sahlsten M.J., Larson I.E., Sjostrom B., Lindencrona, C.S. and Ploskae. 2007. Patients

participation in nursing care: towards a concept clarification from a nurse perspective. Journal of Clinical Nursing, 16, 630-637.

Free Essays

How can spirituality in the practice of nursing profession?

While spirituality is widely used in alternative medicine today and in some cases careful studies proved their benefits, it has been neglected in the nursing practice. Since the claimed philosophy of practice today is holistic, without the spiritual component the holistic practice will be fragmented.

In a study dedicated to spiritual practice in psychiatry the following was sited:

“Practicing nurses today are continually confronted with issues of cultural and spiritual diversity. Although nurses claim to use a holistic approach to patient assessment, the spiritual aspect is often forgotten (Saudia, Kinney, Brown, & Young-ward,1991). Taylor, Amenta, and Highfield (1995) emphasized that “lack of time, a focus on physical needs, low nurse/patient staffing ratios, and high patient acuity also may interfere with the provision of spiritual care” (p.31). Many of the problems noted by Taylor et al. (1995) could be decreased, if the spiritual aspect of care were viewed by the administration of psychiatric facilities as essential to the well-being of the client.

Despite the fact that primary care replaced team nursing in 1960s, the choice between the two modes needs further research since the practice of the profession has changed considerably with the advances of technology.”(McRoberts et al, downloaded on 10 October 2006 from:

In my research I am going to investigate the feasibility of using spirituality in patient care and identify the best approach to integrating the spiritual practice in the holistic approach to patient care. It will also be one of the objectives of this research to identify the training needs of the nursing staff when spiritual practice is implemented.

My methodology for this research will be a move from literature review to empirical research applied in the workplace. It might be necessary to experiment in more than one site. However, this will be decided at the research design stage considering practical issues including number of RNs and LPNs  and patients in different wards to be involved in the study. Experimentation will be carried out in different wards using experiment group of patients and control groups who do not receive the spiritual care.

The patient’s perception of the nursing image of professionalism, based on the clothing worn by the nurse

The uniform worn by nurses is intended to play a number of roles. Firstly it is an identification for the nurse, not only for the patient but for any member of the public who comes to the hospital. In the UK for example people who need to be in the hospital can easily identify the nurses, the sister, the student nurse etc. from the uniforms style, colour etc.

The uniform also creates a professional first impression, convey trust and credibility. Moreover it has “an underlying psychological effect acknowledging that a dress does not have a gender, but denotes attributes of feminity, nurturing and caring, akin to nursing. In the same sense, it enhances and reinforces this image to the public, and in return the public fully support their nurses, a trait often called upon in industrial disputes.” (David and Dee, 2002)

Today, may be with the influence of TV programmes, tunics and scrubs are noticeably increasing and are justified by the claim that they are more practical. There is no doubt about the importance of a uniform for the profession of nursing. However, what needs to be studied and investigated is the perception of patients. How are they affected by the uniform and is care influenced by the uniform.

In this research I am going to study the perception of the patients about the uniform and how they relate this to the care provided by the nurse, trust in her professionalism and respect of her decisions.

The questions to be answered are: a) Does the dress make me distinct from nurses working in other units? b) Does the patient accept me as the trusted caregiver when I am in uniform or without though he can identify me personally? c) Does the uniform cover me from accidental or incidental physical exposure and protect me from avoidable embarrassment? d) Does this dress augment my professional disposition? etc.

Methodology of the research will be literature review and empirical research in the work place. Data to be analyzed will be collected by interviews, questionnaires and observation.

Practice in Intensive Care Unit and Hospital Wards: Does the differences in Job descriptions justify a difference in working hours?

Professional practice for nurses in intensive care units are thought to be more challenging and demanding than in other wards of the hospital. Because of the critical conditions of the patients the nurse on duty in the ICU is always alert and on the run. More importantly decision making in the ICU may be more difficult and stressful. The patient himself is also more demanding (when conscious) and requires special psychological handling.

This environment of practice added to the caution needed to avoid lawsuits make the professional practice in the ICU unusual and different to that of the classical wards in the hospital. Therefore, a working schedule of, for example, 8 hours in both places is thought to be unfair.

However, all these are observations and personal opinions of people involved. Therefore, it is necessary to carry out empirical research in order to confirm or rule out the hypotheses:

Working in the ICU is more stressful and puts a lot of pressure on the nurse that she should not work the usual shift hours.

Working in the ICU is almost similar to working in the traditional hospital wards and should not justify a change in the number of hours covered in one shift in the ICU?

My methodology will be a literature review followed by empirical research experiments on nurses working in the ICU and those who work in the traditional wards. How to obtain the data to be analysed will be detailed at the design stage.










Free Essays

Professional Nursing Synthesis Portfolio

In Appendix __ and ___ (Case studies and Rhabdomyisis), I have been able to exhibit  critical thinking. I have been able to undertake analysis, synthesis, and evaluation of data gathered from observation, experience, reflection, or communication as a guide to belief or action. I have also been able to acquire substantial clinical reasoning which entails a capacity to remember facts, organize them in a meaningful whole, and then apply the information in a clinical patient care situation. As a nurse, I can make use of reasoning to help in formulating principles or guidelines as a basis for my nursing practice judgment decisions.

II. Decision Making Skills

In Appendix ___ (Ethical Dilemma), I have significantly enhanced my decision making skills. As a novice, I acquire clinical judgment and skill over time. Knowledge is refined through actual clinical experience; this moves me from a rule-based, context-free stage to a more analytical, logical and intentional pattern of thinking. To effectively provide a conducive learning environment, I have been exposed to venues for examining and developing my problem solving and reasoning skills towards making clinical judgments. These venues transpire through numerous learning experiences, one of which are ethical dilemmas.

III. Nursing Care and Management of Clients

In Appendices __ and ___ (Case studies and Mariners Harbor project), I have effectively enhanced my skills in nursing care and management of clients. These experiences can help me in developing the learner from the novice phase to being an advanced beginner in nursing. Experiences such as this enable the formation of meaningful related information on the basis of what I have learned in the classroom. There is an expectation that with more experience, I can move from the level of advanced beginner to the level of competence by program completion.

Clinical judgment is defined as nursing decisions about which areas to assess, analyzing health data, prioritizing which task to do, and who should carry it out. For clinical judgment to be assessed as sound, it should be arrived at using critical thinking and logical reasoning, that will enable the deduction of valid conclusions, and the decisions that may be borne from these.

IV. Effective Communication, Collaboration and Negotiation

In Appendix ___ (Visiting hours in the ICU), I have been able to appreciate the importance of working with multidisciplinary professionals. I realized that synergy and collaboration are important for the ultimate welfare of the patient. This set-up also allows for his holistic healing.

V.  Professional values and behaviors

In Appendix __ (Nursing Philosophy), I was able to hone my professional values and behaviors. I believe that while technical competence is a core requisite to becoming a successful nurse practitioner, being values and ethics driven are equally important. In the absence of policies or concrete guiding principles, values are the only guideposts on which decisions may be hinged or anchored against. I am thankful that I was taught ethics and have also had the opportunity to make ethical decisions on the basis of such knowledge. I realized that deciding with a clean conscience makes for competent and sound nursing practice, which substantially determines nursing effectiveness.

VI.    Teaching and Learning

My experience in being a nurse educator has further been honed through Appendix __ (Mariners Harbor Outreach) where I was able to instruct indigents and minority patients about palliative care. I felt that this has brought me a step closer to my aspiration of being a nurse educator. As a future nurse educator / coach, I would like to conduct research projects, participate in professional associations and interact with other nursing academics and practitioners. I would also continue to practice my profession in the clinical setting. This is an effective tool in ensuring that I continue to be clinically competent as I train future nurses.

VII.   Research

Through integrated literature reviews and critiques (Appendix __ and ___), I have been able to hone my research skills. I have learned how to critically analyze both quantitative and qualitative data to be able to draw meaningful conclusions from them. These exercises on critical thinking and analysis have forged the theoretical foundation of my nursing practice, which is applied and honed in the clinical setting. These have taught me how to read and understand statistics, as well as data drawn from qualitative methods. Critiques have also allowed me to point out the limitations of research studies and ascertain the validity of research results.

VIII.   Leadership

Through Appendix __ (Nursing Philosophy paper), I have been able to strengthen my resolve in being a transformational leader-nurse. I have learned that being a charismatic or transformational leader entails articulate a realistic vision of the future that can be shared, stimulate subordinates intellectually, and pay attention to the differences among the subordinates. By defining the need for change, creating new visions, and mobilizing commitment to these visions, leaders can ultimately transform organizations. In effect, the ultimate goal was to make a real dent in the lives of people that I come in contact with by helping them authentically.

IX.     Management

In Appendices ___ and ___ (Nursing change paper/ Visiting hours paper), I have come to appreciate the importance of working within a multidisciplinary setting. Such appreciation has also helped me appreciate diversity and synergy in working with other professionals.

X.     Lifelong learning and professional career development

In Appendices __ and ___ (Alziheimers project/ Does advanced practice… nursing paper), I have broadened my career horizons. Through these, I have manifested how I have progressed in the practice and have also been able to open new doors for learning and for sharing these wins with my colleagues.

Free Essays

Nursing Shortage

Six years prior to the publication of Spetz and Given, reports of the US media indicate a shortage of registered nurses (RNs) in the US. In that article too, forecasts see the continuity of this trend, such as that of the Bureau of Health Professions projecting a shortage of 800,000 nurses by 2020. However, Buerhaus et. al. suggests that the nursing shortage may actually be satiated, with hospital RNs’ employment and earnings “increasing sharply in 2002.” No matter how we look at it, whether or not the shortage is easing, the problem of shortage is there. The question now is, what causes the shortage of registered nurses?

Spetz and Given discusses four reasons that account for the shortage of registered nurses, first of which are licensure delays. Since World War II, nursing shortages have occurred cyclically, and this led to the birth of studies regarding labor markets. They (Spetz and Given) found most of these studies agreeing on the point that “the delay between people’s choice of the nursing profession and the time they are licensed as nurses is a central reason for these recurrent shortages.”

Poor working conditions also account for the shortage of RNs, and this includes wage and benefits in general. Not much was mentioned by Spetz and given, but they have cited that these are “a primary cause of nursing shortage.” Aiken gives a more detailed explanation, stating that nurses spend an “inordinate amount of time in nonnursing tasks” resulting from “poor work design, underinvestment in information and other nurse-saving technologies.” They further add that is associated with high levels of nurse burnout and dissatisfaction.

The third reason for the nursing shortage is comprised of wages and demand. Spetz and Given maintains that “demand for RNs should decline as RNs’ wages increase during a shortage,” and they have seen evidences showing that wages do affect demand. However, there are reasons for demand to be not responsive in today’s labor market. Two of these reasons are the reluctance of health care institutions to reduce staffing, and the growing number of RN Unions that want to maintain, if not to expand, the current staffing levels.

Another scenario relating to the issue of wages and demand is seen in Aiken, where it was mentioned that “the Philippines is the leading primary source country for nurses internationally by design and with the support of the government.” A motivator for Philippine nurses to migrate to other countries is higher wages, which cannot be earned in the local setting. This may account for the shortage that the country itself was experiencing, as Aiken found that “there are more than 30,000 unfilled nursing positions in the Philippines.” Last of the causes of the nursing shortage, as discussed by Spetz and Given, are exits from the RN workforce. According to them, the magnitude of retirements poses the question of whether it is possible to raise the number of new RNs to meet future demands.

One solution to the nursing shortage, and maybe the most popular today, is to recruit foreign nurses. Spetz and Given consider this to be only a short-term option as it is expensive and the WHO reports majority of the countries experiencing nurse shortages, thereby putting a pressure on hospitals to limit foreign recruitment. Buerhaus et. al. goes farther to discuss other issues relating to the employment of foreign RNs to meet US health care demands. They cite impediments such as “likely negative impact on wages,” “quality of care,” and foreign policy.

Another solution suggested by Buerhaus et. al. is to retain older RNs. In order to do this, facilities of health care systems should be designed so as to minimize physical strain. According to them, “altering schedules (working fewer hours), developing new roles (becoming mentors to younger RNs), and offering economic incentives can help to retain older RNs.”

But among the three broad types of policy responses that Buerhaus suggested, I find increasing the flow of RNs in the workforce to be the most responsive, because that is exactly called for by the situation. This can be done either privately or by the government through raising money to increase faculty salaries and scholarship grants, and expand the physical learning space of nursing students.


Aiken, Linda, Buchan, James, Sochalski, Julie, Nichols, Barbara, and Mary Powell. “Trends in International Nurse Migration.” Health Affairs 23.3 (2004): 69-77. 25 November 2008,

Buerhaus, Peter, Staiger, Douglas, and David Auerback. “Is The Current Shortage of Hospital Nurses Ending?” Health Affairs 22.6 (2003): 191-198. 25 November 2008,

Spetz, Joanne, and Ruth Given. “The Future of the Nurse Shortage: Will Wage Increases Close the Gap?” Health Affairs 22.6 (2003): 199-206. 25 November 2008,

Free Essays


Community nurses are the nurses who work in a particular community for its welfare. With their ability to understand, they can deal with the health of residents living in any community. They work in the field of public health in order to perform tasks including population and community evaluation, development and implementation of community health programs and working in teams in order to work with discipline. Nurses in acute care settings work along with other health care specialists (Green, 27).

The nurse is involved in the healing, security and recovery of intensely sick patients, looking after the health of healthy patience and operations of patients who are suffer from life threatening ailment. They perform non-clinical job that are vital for health care. Death and birth care is also provided by the nurses. Nurses practice in variety of acute settings that are available to them. They work in hospitals, schools, pharmaceutical companies, clinics, camps, militaries (Burbach, 98).

Even though, nurses from different area of expertise seem to be more or less in abilities, we cannot conclude that nurses working in acute care settings are not capable. For example, Nurses working in critical care settings are experts on pregnancy and birth related aspects than community nurses. The question comes whether to justify that it is a false impression or a fact that a skill in one setting can be use as a skill in another (Humphrey, 19). When developing intermediary plans with requirements of constant management, the need of feedback and extra training is mandatory.

This can help the nurses to put into practice and increase experience in non acute care settings before complete service changes are ready. This would enable the nurses to use their abilities and be confident to work in non acute settings. Equally essential, it is important for non acute setting nurses to continue with their education (Conrad, 28).

The skills of dressing and taking care of wounds, having complete knowledge about the community’s resources, information on diabetes, patient family support and good communication skills with third party payers are very important when working in the community. These are the skills that help the nurse when working in the community. These nurses work under their leaders, learn in the learning atmosphere and accommodate themselves to adjustments to changes (Feldman, 17). They have the ability to work efficiently which has been dictated to them.

They have the ability to work in a peaceful atmosphere and ignoring their colleague’s weaknesses. Nurses working in acute settings require the information, capabilities and experience to take care of their patients and the families. At the same time, the nurse creates loving, kind and restoring health environment. At the same time, they fulfill various responsibilities. They work directly with patients, they provide education to fresh nurses, they work as researchers, and they are managers (Shea, 67).

A community nurse works independently as compared with nurses who work in acute settings. The main aim of a community nurse is to focus on the population and persons who do not necessarily seek out the services. Nurses working in acute care settings differ from community nurses in many ways. Nurses working in acute care settings do not have the access to direct clinical practice.

They do not have the advance skills to provide education and teaching skills to patients and family (Loreti, 32). They work under superiors. They are not consultants and they do not take part in research. They carry out duties that are instructed to them. They do not require any leadership quality. They do not write policies or build partnerships.  They are restricted in certain working conditions (Stephany, 13).

Nurses working in the acute care settings assess the critical and acute patient’s health status. Community nurses have to demonstrate the ability to make decisions for a variety of situations. They also need to demonstrate the need for promoting the rights of clients. They have to ensure the safety of their patients. Communications skills are very important for nurses working in the community and acute care settings. However community nurses require effective communication skills as compared with nurses working in acute care settings because the former might interact with poor and marginalized sections of society.

A community nurse has to reflect primary health care principles to ensure that clients become independent and responsible (Brent, 10). An acute setting nurse on the other hand has to keep and document the health history of critical and chronically ill patients. A community nurse must have leadership and management skills to ensure that multiple approaches are used to assist the client in health issues (Wood, 17).

Community nurses have to apply a public health framework to build community health nursing. They must plan and integrate health promotion into the aspects of community health nursing. They must also apply knowledge of health promotion to achieve public health policies (Hunt, 36). They must coordinate the development and implementation of health promotion plans. An acute settings nurse on the other hand is more concerned with assessing the needs of additional screening after initial assessment findings. They must have adequate skills to assess the impact of acute or chronic injuries on the individual (Bailey, 714).

A nurse working in acute settings needs to be very quick and capable of working with complex and dependant patients. In the community settings, assessment and decision making abilities play an important role in the delivery of patient care. Nurses in the acute settings must quickly identify outcomes based on actual or potential diagnosis (Sobolewski, 12). Intervention plans are individualized according to the characteristics of the patients. The plan is developed in collaboration with other health professionals and family members.  They ensure that there is continuity of care and properly documented.

A community nurse on the other hand must demonstrate the ability to have effective problem solving strategies. They must also make the use of systematic decision making techniques. These decisions need to be based on experience and clinical judgment. Community nurses have a higher degree of autonomy as compared with nurses working in acute settings. They have to participate in decision making to ensure accountability. They must also make appropriate solutions in response to a range of options (Harris, 14).

Nurses in the community need to demonstrate the ability to make autonomous decisions and independence. They have to resolve complex situations using multiple approaches. A nurse working in the acute setting on the other hand does not have a high degree of autonomy. They also do not need to demonstrate a level of independence. Nurses working in the community differ from those who work in acute settings. They have work in developing community health programs and teams. Nurses in acute settings on other hand work for healing and recovery of intensely sick patients.

Works Cited:

Burbach CA. Community health and home health nursing: keeping the concepts clear. Nurse and Health Care. 1988; 9(2):96-100.

Green PH. Meeting the learning needs of home health nurses. J Home Health Care Practice. 1994; 6(4):25-32.

Conrad MB. Issues in home health nursing education. Home Healthcare Nurse. 1991; 9(4):21-28.

Humphrey CJ. Home care nursing orientation model: justification and structure. Home Healthcare Nurse. 1992; 19(3):18-22.

Shea AM. Transitioning professional nurses into home care: a 6-month mentorship program. J Home Health Care Practice. 1994; 6(4):67-72.

Feldman R. Meeting the educational needs of home health care nurses. J Home Health Care Practice. 1993; 5(4):12-19.

Stephany TM. Health hazard concerns of home care nurses: a staff nurse perspective. J Nurs Adm. 1993; 23(12):12-13.

Loreti ST. Easing the transition from hospital nursing to home care: a research study. Home Healthcare Nurse. 1991; 9(4):32-35.

Wood MJ. The educational needs of home health nurses. Home Healthcare Nurse. 1986; 4(3):11-17.

Bailey C. Education for home care providers.JOGNN 1994; 23(8):714-719.

Hunt P. When orientation is not enough.Home Healthcare Nurse. 1992; 10(6):36-40.

Brent NJ. Orientation to home healthcare nursing is an essential ingredient of risk management and employee satisfaction.Home Healthcare Nurse. 1992; 10(2):9-10.

Harris MD, Yuan J. Educating and orienting nurses for home healthcare. Home Healthcare Nurse. 1991; 9(4):9-14

Sobolewski S. `See you in home care.’ Am J Nurs(Part 2: Career Guide). 1996; January:10,12,14.





















Free Essays

Nursing Opportunities in NYU Downtown Hospital

Nurses are indispensable members of the work force unit division in health care system whose main role is to provide for doctor’s assistance and cater to the health status and palliative care of the patients. Technically though, the nurses have higher specialized forms or masteral degrees which elevates them to a higher position in hospital departments (e.g. perioperative nurse).

The NYU Downtown Hospital is the only hospital in Manhattan that caters to the healthcare of the Lower Manhattan Community specifically that of the Chinese community. The hospital employs wide and diverse medical professionals to provide for quality healthcare of the community and amongst the members of the workforce are the nurses.

In NYU Downtown, the hospital’s selection of nurses for a specific job requires a basic New York Registered Nurse qualification and related experiences. The nursing opportunities for the hospital vary from jobs descriptive of leadership, staffs and per diem positions.

Vacancies in leadership positions are on the following types: Nurse Manager for the peri-operative division, clinical nurse specialist in the Maternal Child Health Division, Nursing Administrative Supervisors for morning and evening shifts, and Registered Nurse Case Manager.

For the staff positions, there are vacancies in the following departments and the corresponding time table: Emergency Room, Operating Room and Labor and Delivery for 12 hr duty day or night and Licensed Practical Nurses (LPNs) positions for 7.5 hr per day. Per diems are available for all units in the hospital on all shifts.

The workplace is suitable for nurse employment because aside from sufficient wages and benefits, the hospital meets the standards of the healthcare system in terms of management and services rendered.
The salary of registered nurses in the district is $53, 065 as of 2002 with an annual increase rate of 1% per year. Benefits include health,  dental , liability insurance, disability and  compensation programs, refunds and  annuity plans. Subsidies for houses, parkings and discounts are also available for employees.

NYU Downtown Hospital’s vacancies for nursing positions mirror one of the stigmas of the New York medical profession nowadays — nursing shortage. As previously mentioned the singularity of the hospital in the area implies a huge demand for medical practitioners including the nurses. Unfortunately, in the entire New York, the supply of nurses does not meet the high rate of nurse demand.

Although there are more than 234,000 Registered Nurses and 68,900 LPNs in 2001, the prediction for nurse sustainability is bad since there was an overall drop for the 1999 to 2001. Slow growth rate for Registered Nurses may indicate problems for the quality healthcare and   according to he National Sample Survey of registered Nurses, the state ranked second to the last in terms of RN percentage employment.

The nursing shortage in New York are caused by several factors: aging workforce, increased job opportunities for women, low wages and benefits and other related factors which caused a decreased in the supply. Manhattan’s Downtown Hospital is aggravated, because as the lone hospital they must cater to both the resident and the non-resident community. (Non-residents are approximated at almost 400,000 per day.)

The general trend for nursing shortage creates opportunities for work in the nursing arena in the New York Downtown Hospital. Although, the workplace and the salaries are sufficient enough for nursing occupation, NYU Downtown’s nursing problems may be fueled by a larger economic workforce crisis in the nursing arena.


Beu, B. “The nursing shortage and the nurse reinvestment act.” AORN Journ., 79(2004):1061-1063.

Downtown Hospital. (2008). New York Downtown Hospital. Retrieved February 14, 2008, from New York Downtown Hospital database.

Mitchell, G. J “Nursing shortage or nursing famine: Looking beyond numbers?” Nursing Science Quarterly, 16(2003), 219-24.

The Registered Nurse Population. National Sample Survey of Registered Nurses- March 2000.

Preliminary Findings, February 2001. Bureau of Health Professions, Division of Nursing.


Free Essays

Nursing in Perspectives

Nursing is a profound profession which requires professional skills and knowledge, high level of expertise and managerial skills. Following Parker & Clare (2006): “Critical thinking is a vital skill to have as a nurse. Nurses are engaged in providing care to people who have a right to high quality professional conduct and health services (p296).Applied to nursing profession, critical thinking aims to improve healthcare services through new methods and self-developed professional skills of nurses.

Critical thinking combines the ability to meet the requirement of a new age and respond effectively to technological innovations and scientific discoveries. Changing economic environment and globalization process has a great impact on the nursing science, and compel to specify concepts of management and its fields.

During the last decades, the definitions of critical thinking in nursing have been changes. For instance, Ennis & Milman in 1985 defined critical thinking in nursing as “reasonable, reflective thinking focused on what to believe or do” (Critical Thinking in Nursing 2007). In five years, McPeck, (1990) defined it as: “the propensity to engage in an activity with reflective skepticism” (Critical Thinking in Nursing 2007). Monitoring was an important method that helped to search for new trends in nursing.

Today, nurses take into account internal and external factors that influence a patient. The most recent explanation of critical thinking is proposed by the University of New Mexico (2007): “nursing utilizes critical thinking as diagnostic reasoning and professional or clinical judgment. Critical thinking in nursing is based on a triggering event or situation, a starting point, scaffolds, processes, and outcomes that make up a continuous or iterative feedback loop” (Critical Thinking in Nursing 2007).

In modern world, critical thinking in nursing is a broad concept with include advanced knowledge and discovering, creativity and passion, authenticity and ability to foresee coming changes. Critical thinking in nursing aims to extend traditional nursing roles in order to keep abreast of time and rapidly changing technology. Daniels (2004) underlines that it may be exercised as an attribute of position or because of personal knowledge or wisdom. Modern nurses see themselves more as conservators and regulators of the exist­ing order of affairs with which they identify, and from which they gain rewards. Critical thinking helps to create a sense of identity which does not depend upon membership or work roles.

On the one hand, nursing gendered identity and cultural identity has a great impact on their skills and ability to deliver high quality service. Many problems associated with the relationships between people of different cultures stem from variations in norms and values. Modern society is marked by cultural diversity problems which influence healthcare services and service delivery. Critical thinking is crucial for culturally competent nurse because it helps to communicate with diverse clients and meet their needs. For instance, Hindus and Asians share specific beliefs as for parts of the body and health, and in this case a nurse should take into account cultural and religious practices of these patients.

Following Dreher and Macnaughton (2002): “the health care system has nested the accountability for cultural competency with the clinician who provides direct services to individuals, where the application of cultural information is likely to be least useful” (p181). For a nurse, the key advantages of convergence are that ideas and techniques developed in one cultural or national setting may be transferred to another and used effectively. These variables shape the values and hence the behavior of people (Potter & Perry, 2005).

Critical thinking determines the quality of decisions and actions of a nurse. A higher level of professional autonomy and shared governance should be seen as the main features of critical thinking. Critical thinking is exercised through greater knowledge and exper­tise. It may also be based on the per­sonal qualities of the nurse and the manner in which authority is exercised. In contrast to traditional theories of nursing leadership, nursing expert power is based on new knowledge about technology and critical thinking used in nursing profession. Critical thinking is based on credibility and clear evidence of knowledge or expertise; for example, the expert knowledge of ‘functional’ specialists.

Stone (2000) states that if the information is satisfactorily ascertained from secondary sources, the nurse opts to complete this component of the assessment by relying on past records. Documentary data obtained from patients’ records is often termed ‘secondary’ because the information has originally been collected by other people and for other purposes.

Thus, critical thinking determines further actions and behavior patterns which support clinical and service development. In several decades ago, nurses were limited by strict rules and tasks which prevented them to respond effectively to changing environment (Potter & Perry 2005). Today, technology and information technology demands critical thinking and decision making in nursing (Sharp, 2000). Also, there is a great shift in organizational values and personal traits of the nurses. Changing social environment influences human values and conflicts with human dignity and importance (Sullivan & Decker, 2005).

The balance of power has undoubtedly shifted to nurses who have more choice over how to conducts relationships with their administration, colleagues and patients. Critical thinking in nursing is aimed to improve influences on the environment and determine perspectives of further development on the macro- and micro- level. In this situation, to be an effective and professional nurse, it is necessary to exercise the role of critical thinker based on advanced knowledge and expertise (Durgahee, 2003).

A common view is that the job of the nurse requires the ability of critical thinking and that leadership is in effect a sub-set of management. In terms of critical thinking, there is a need to be flexible and be ready to innovate and to adopt new technologies as they come along. The way in which healthcare organization has to employ the latest technology can be an important determinant of its competitive advantage. For instance, increased role of computers and technological solutions require new skills and decision making practices in medicine. For instance, if technology does not work properly and it threatens life of a patient, a nurse should react accordingly to the situation and replace it with alternative solution (Kozier et al 2004).

Critics (Sullivan & Decker, 2005) admit that three decades ago nurses were not ready and prepared to apply critical thinking to their work and this led to high death rates caused by technology failure. Healthcare is one of the main industries responsible for exceptional service quality and interpersonal communication. Service quality is determined by technological processes and innovations in its field.

Critical thinking has speeded up health delivery processes, transformed working practices and increased the efficiency of healthcare services. Interestingly, it is in the technological environment that it is some­times possible for large healthcare organizations to actually exert influence rather than be the recipients of it. Respect and personal worth of every patient are the core human-related factors employed by the nurses (Garrison 2004).

Nursing staff is responsible for communication and interaction with the patients. For this reason, nurses should be flexible to respond effectively to changing environment and customers groups. As a result, high degree of autonomy cannot be effectively used by all nursing staff. Healthcare organizations start to apply ‘critical thinking’ into practice seeing it as a high level of specialist practice and competitive advantage in healthcare services.

Also, critical thinking in nursing is concerned with those activities involved in recruiting of professional staff, training, and development within the healthcare infrastructure, namely the systems of planning, finance, medical service control, etc. which are crucially important to an strategic capability in all healthcare activities (Potter & Perry, 2005). Today, a special attention is given to proper function of medical staff and empowerment which helps to improve efficiency of medical practice.

Critical thinking is one of the main requirements in modern service learning. In learning, “critical thinking [is] a reasoning process reflecting on ideas, actions, and decisions in clinical experience by the nursing student and others (Anaya et al 2003, p99). The advantages of critical thinking in nursing are fast response to changing conditions and environment and ability to apply recent technologies into practice. It increases confidence of nurses and level of healthcare services.

Using critical thinking approach, nurses are able to shift the situation using these new creative approaches based on advanced relationships and inquiry. Also, it is strongly influenced by resources outside the healthcare organization which are an integral part of the chain of activities between the healthcare service design and the level of medial treatment (Sharp, 2000). Change is a threat to routine and their role in healthcare management. It is also true that many nurses do not know what their role is, and in recent years attempts have been made to clarify individual roles.

Critical thinking is ‘a vital skill’ for nurses because it determines the style of management and leadership. Critical thinking can be interpreted as a response to the need to meet heightened customer expectations and face intensi­fied technology solutions. Critical thinking encourages nurses to adopt a positive attitude and have personal involvement in service delivery. Also, it allows healthcare organization to expose nursing staff to new forms of service and management. Critical thinking is constructed on a rational basis and allows nurses respond to patients’ needs in an appropriate manner. For a modern nurse, it is crucial to be accountable to patients’ families, and close friends who come to visit them.


1.  Anaya, A., Doheny, M.O., Panthofer, N., Sedlak, C.A. (2003). Critical Thinking in Students’ Service-Learning Experiences. College Teaching, 51 (3), 99-104.

2. Critical Thinking in Nursing The University of New Mexico (2007). Retrieved 31 May 2007, from

3.  Daniels, R. (2004). Nursing Fundamentals: Caring and Clinical Decision Making, Thomas Learning, Oregon.

4. Dreher, N., Macnaughton, N. (2002). Cultural competency in nursing: foundation or fallacy? Nursing Outlook, Sep-Oct; 50 (5):181-6.

5.  Durgahee, T. (2003). Higher level practice: degree of specialist practice?
Nurse Education Today. Apr; 23 (3), 191-201.

6. Garrison, D.R., Morgan, D.H., Johnson, J.G. (2004). Thriving in chaos: Educating the nurse leaders of the future. Nursing Leadership Forum. Fall; 9 (1), 23-27.

7. Kozier B., Erb G., Berman A. & Snyder S. (2004). Fundamentals of Nursing: Concepts, Process and Practice, New Jersey, Pearson Education Inc.

8. Potter, P. & Perry, A. (2005). Fundamentals of Nursing. Elsevier PTE LTD, Singapore.

9.  Sharp, Nancy. (April 2000). The 21st century belongs to nurse practitioners. Nurse Practitioner, p. 56

10. Sullivan, E.J., Decker, Ph. J. (2005). Effective leadership & Management in Nursing 6th ed. Pearson Hall.


Free Essays

Nursing Informatics

Computers are becoming increasingly essential in the workplace. A vast majority uses internet or email at work. In addition, employees around the world also use computers for graphics and design, programming, calendar and scheduling. This is done by using word processing, spreadsheet and database applications or software. They are used mostly by managers or for people in customer, technical, sales or administrative support departments.

Fewer operators, laborers and fabricators use the computer in their workplace.Computers greatly help in retrieving, gathering, storing, processing information. Most importantly, they help in making big decisions. Clinical and Nursing Services have greatly benefited from the use of computers. As technological progress takes place it promises to revolutionize healthcare completely. It will provide quicker and direct solutions to patient care. For e.g. it will shorten the time period of documentation and access to data of patient. The implementation of light pens, touch screens, handwriting, voice recognition applications and bar codes, in hospitals will make using computers easier for nurses.

Computers can also help in planning nursing care which will include the patients health history, adminstered medicines, dosage therapy and precribed diet. Pateints will be provided the best care with the introduction of a computerized nurse care plan. The use of computers can help in interpretatation and the monitoring of various Physiological Variables.

The Cardic rate, B.P and T.P.R of the patient can be assessed from computer assistance. Computers can also calculate the correct drug dosage according to the patient’s age, weight and his body surface area. Another benfit is that computers can help in forecasting the number of nurses needed at a particlar time or date. Their nursing schedules can be made keeping in mind their patient load, numbers of operations performed, location, availability and acuteness. Lastly, computers store and record data about admissions, materials, personnel, inventories, billing, payroll, insurance and discharges as well.

In my opinion computers make things easier overall for the nursing profession. It greatly reduces human errors, manual paper work and documentation. In this way they spare time for more eveideence based, professional, knowledge-driven and personalized patient care. As a nurse I wiill be able to help save more lives by the knowledge and understanding of Nursing Informatics.


Ramachandra, Hooli, S (Feb 2003). Computers in Nursing. Retrieved May 31, 2007, from

The Digital Workplace. (n.d). National telecommunications and Information Administration. Retrieved May 31, 2007, from


Free Essays

Nursing: Promising Pathways

I once heard it said that vocation should be the place where your greatest talents meet the world’s greatest needs.  For me the intersection between those two things lies in nursing.  Without question nursing has become one of our country’s greatest needs, as the deficit for certified nurses rises and more and more people in our nation’s hospitals are cared for by unqualified nurses.   Likewise, I believe that my greatest talents lie in this field and that my skill set will help me to provide the highest standard of care at a time when patients need it the most.

Nursing is not the glamorized profession that one often sees on popular television shows.  It is not about looking pretty in a white uniform.  From my experience, being a nurse is actually the opposite of all that.  It entails working long hours and doing a lot of hard work. These are all part of why I chose to be a nurse. All the hard work and the fatigue pay off in the end when one has been able to save lives and make patients feel more comfortable during their times of need.

In addition to the need that I will be fulfilling in my nursing career, I believe that it will be a rewarding job, as I will have the opportunity to help and to care for many people.  I have a passion for working closely with patients, regardless of their background or beliefs, and I believe that nursing is not merely a way to make a living, but a means of giving back to society.

Not only will nursing be a rewarding and meaningful career for me, but my specific skill set gives me a great deal to offer my patients and my colleagues.  I am competent in Professional Health Care Management with the ability to provide and promote the highest standards in the rapidly changing and ever demanding Healthcare sector, driven by a vast global economy and vibrant technological innovation. I am attentive to detail, highly organized with strong analytical and decision-making skills.

I have excellent communication and interpersonal skills, allowing me to provide care, compassion, and emotional support for irritable, stressed and ill patients.  I am highly knowledgeable in current and pertinent issues within and without the Healthcare sector.  I am able to work under pressure for long hours and to do a considerable amount of lifting such as moving patients, assisting with toileting needs and responding to emergencies.  I have a polished professional demeanor, which enables me to develop and maintain relationships with professionals in the healthcare sector. Furthermore, I have excellent conversational skills in three international languages; English, Spanish and Italian.

I believe that my prior experience and my education will also help me to contribute significantly to this field.  I received a Pre-Med and Trustee scholarship to attend Suffolk University in Boston, where I major in Radiation Biology.  I have also become certified as a Phlebotomy technician, EKG technician and a Medical Clinic assistant.  Furthermore, I am pursuing a nursing assistant course as a State Certified Nursing Assistant (CNA) at the American Red Cross in Peabody, MA where I am learning procedures such as psychosocial care, restorative care, resident personal care, resident rights, communication, general safety procedure and infection control.

In addition to my training, I have also held several positions in the medical field that have both increased my knowledge and proved to me that nursing is indeed the field that I want to dedicate myself to.  Since 2006 I have worked as a Radiation Therapist Intern at the Massachusetts General Hospital/ Brigham and Women Hospital / DFCI Boston. My responsibilities include accurate positioning of patients for treatment, operation of advanced medical equipment, quality assurance and providing competent patient care.

I am also in charge of assisting the oncologist and the physician with treatment plans during delicate procedures.  From 2005 to 2006, I worked as a Medical Assistant at Alexyenko Medical Associates Lynn, MA. My duty was to assist in phlebotomy and EKG procedures. These are delicate procedures that demand the maintenance of high standards, both of which I believe I showed great aptitude for.

I aim to work for an organization where personal growth is encouraged, human values are nurtured and talents are utilized in the attainment of organizational goals. I would like to be able to apply what I have been learning so far by taking a hands-on and direct approach.  I would like to attain a Masters Degree in order to gain the knowledge and experience to better prepare myself for medical school.  By earning my degree, I am being both practical and responsive to the needs of the time.  It is practical because I have chosen a career that will allow me to utilize my talents and experience, and responsive because there is an overwhelming need for qualified nurses.

I believe that I have had an abundance of valuable experiences and talents to offer the healthcare field.  My prior positions have taught me both technical and soft skills. Technical competence is a core requisite of being successful in any profession. And yet more than this, my exposure in these institutions has taught me fortitude, patience, love of authentic service, and a strong spirit of volunteerism. My desire to be of real service to others has compelled me to move ahead and take advanced studies in this field.  It is with great joy and excitement that I join the place where my talents meet one of our country’s critical needs.


Free Essays

Nursing Reflection

Going back through previous experiences and tracing back the footsteps we have made allows us to reminisce about the good things that have happened in our lives. Somehow the undesirable memories would also seep in as they are part and parcel of our existence that we cannot do away with. This process gives us an opportunity to encounter past events that can necessarily aid us in the future. In the Nursing practice, reflection is a retrospective approach that evaluates historical processing of experiences that takes place in a structured form and is deemed highly essential (Eliis, Kenworthy and Gates, 2003, 156).

In the clinical practice, this retrospective activity facilitates in the promotion of quality care. The art of reflection however in the nursing practice focus on self rather than on the situation as the care provider (Quinn, 2000, 252). The process is a reflective practice that is a cognitive act by which we are allowed to make sense of our thoughts and memories (Taylor, 2000, 43).

This method therefore allows a practitioner to generate a complementary or alternative form of knowledge and a set of choices in the evaluation of the best course of action. It is a “deep learning” experience that reflects on our knowledge and theories and go beyond merely thinking about what we do but involves recalling what had occurred and analyzing the situation by interpreting important information recalled (Taylor, 2000, 4).

In Nursing, the reflective process is aimed about our own practice (Taylor, 20000, 3); that nursing education and research cannot do without as a common practice in the learning mechanism in which we all engage in a regular basis (Slevin and Basford, 2000, 483). With a main purpose of enabling the practitioner to learn from experiences and increase clinical effectiveness, reflection is highly essential to the nursing practice.

For this process to be effective, Johns has provided a guided reflection which employs different models of self-inquiry to enable a practitioner to realize desirable and effective practice (2002:3). Considering that this involves a cognitive and emotional component that is expressed through analysis, different models would aid us feel comfortable about the activity. John’s model can be used in preparation for or during clinical supervision and applicable to specific incidents rather than more general day to day issues and particularly applicable to those who prefer a structure approach (Ellis, Kenworthy and Gates, 155).

Gibbs Model use term description rather than “a return to the entire experience” as a form of reflection is considered as a simpler method but one where a mentor or facilitator is likely needed(Davies, Bullman and Finlay, 2000, 84). Both models however in supervision practice can be used to facilitate clinical governance through the promotion of quality care where an exchange between two professionals employing this technique seeks to improve their practice (Watkins, Edwards and Gastrell, 2003, 266).

To maximize the potential benefits of clinical supervision, nurses have to learn to be comfortable with this retrospective activity with the aid of Gibbs or John’s models depending on where one feels most comfortable working with (Ellis, Kenworthy and Gates, 156).

Gibbs Model for reflection

As a simple and easily attainable method, Gibbs model uses term description rather than a return to a previous experience (Davies, Bullman and Finlay, 84). In psychology and teaching, reflection facilitates as purposeful change and competencies such as psychological-mindedness and self-regulation (Clutterback and Lane, 2004, 196). Usually this process involves a mentor, teacher or supervisor working with a student at different stage while allowing for individuality.

Although less specific than re-evaluating an experience; Gibbs in his cycle or reflection makes the action planning a more overt component of reflection (Davies, Bullman and Finlay, 84). Gibbs provides that in one’s own practice, an essential aspect of working as an autonomous practitioner involves a critical analysis of one’s role and responsibilities from a personal perspective (Gibbs, 1998,13). It is a process that requires others to become involved that encourages feedback and constructive comment to recognize your role and value in a health team (Humphris and Masterson, 2000, 77).

John’s Model for reflection

John’s model uses the concept of guided reflection to describe a structure supportive approach that helps the practitioner learn from their reflections and experiences (Quinn, 2000, 572). The approach involves the use of a model of structure reflection, one-on-one group supervision and the keeping of a reflective diary (Quinn, 572). The practice would aid the practitioner in learning from a reflection of their experiences. John’s model is more detailed as it provides a checklist of specific points necessary for reflection (Davies, Bullman and Finlay, 85).

The only problem cited with John’s model if it imposes on a framework that is external to the practitioner leaving little scope for inclusion as cite by other theories. John’s model can be used in preparation and during clinical supervision consisting of 6 steps that is applicable t specific incidents rather than more generalized day to day issues facing the supervisee (Ellis, Kenworthy and Gates, 155). This model is highly attractive to those who prefer a structured approach but others may find this type more restricting (Ellis, Kenworthy and Gates, 156).

Criticisms against the reflective process

Reflection involves cognitive and emotional components that are expressed through analysis and to maximize the potential benefits of the clinical supervisor nurses have to learn to feel comfortable with this retrospective activity both during and in preparation for supervision sessions (Ellis, Kenworth and Gates, 157). This could be deemed time–consuming in an institution where time is often an important element in the delivery of care. A time for reflection can be done positively only when a situation or a need arises. This is probably why reflection method is considered a radical approach to nursing education and practice given the ample time training can afford (Slevin and Basford, 483).

Yet reflection is valuable if done in partnership with someone else which led Davies et al to believe that the approach is quasi-therapeutic (Davies, Bullman and Finlay, 86). The principles have been transferred directly from client-centered psychotherapy and may trigger more powerful responses such as guilt and anxiety. Practitioners are therefore evaluated before they are given a chance to try this one out according to conservative studies. However with practice, it is assumed that a reflective process may not hold as much negative impact for the learned practitioner in an answer to the demands for a continuous review of a practice in a critical and analytical manner that support the reflective concept.

The Value of Reflection for the Student Nurse

As an essential component of scholarly practice, reflection, reflection is a method for generating a complementary alternative form of knowledge and theory (Humphris and Masterson, 2000:78).  Regardless of any negative criticism a reflective method may elicit from critics, I consider this to be a valuable tool. For the student, this is a process were one internally examines and explores an issue of concern triggered by an experience that clarifies the meaning of perspectives (Canham and Bennett, 2001, 185). The nursing practice has been surrounded by a world of silence and reflection is a way for nurses to reflect that is enhanced and introduced in the nursing curriculum (Guzzetta, 1998, 102).

Often in the professional practice, nurses have encouraged silence among themselves in their health environment and setting while usually developing a shared professional voice with her team. Oftentimes, her relationship with the rest of the health team and other professionals faced difficult efforts because of the autonomy. The process of reflection allows one to air out her sentiments and ideas within her group or to a mentor or a supervisor during moments of reflection that could be produced as a shared voice for the team.

Developing a habit of reflection is therefore a must for nursing education in order to uncover dimensions of experiences such as hidden and explicit meanings of behavior that can aid a student nurse in identifying her own perspective of the nursing practice that is highly useful in her entry to the profession (Guzzetta, 1998, 103).

For a student in nursing, one must therefore develop a habit of reflection in order to uncover experiences and the meaning of behavior, values and thoughts that could readily prepare one for professional practice. It should be noted that the reflective process can helpfully aid in teamwork where one has the chance to relay sentiments after reflection of her past experience.Nursing education must therefore develop and evaluate innovative strategies to prepare nurses to meet the challenges of the rapidly changing health care system and for lifelong learning (Johns and Freshwater, 1998, 149).

Reflection and reflective practice are currently receiving attention as a strategy yet little is known about the process of becoming a reflective thinker, how to teach skills needed for reflection, or the barriers and facilitators to becoming a reflective practitioner (Clutterback and Lane, 2004, 198). However a reflection process is worthy of study and practice that should initially be started and adapted as a core training for everyone wishing to professionally practice nursing as a positive way to analyze the development of reflective practice abilities.


Canham, Judith and Bennett, JoAnne, 2001, Mentoring in Community Nursing: Challenges and Opportunities, Blackwell, London, 2001.

Clutterback, David and Lane,Gill, 2004, The Situational Mentor: An International Review of Competencies and Capabilities in Mentoring, GowerHouse, London.

Davies, Celia, Bullman, Anne and Finlay, Linda, 2000, Changing Practice in Health and Social Care, Sage, London.

Ellis, Roger, Kenworthy, Neil and Gates, Bob, 2003, Interpersonal Communication in Nursing: Theory and Practice, Elsevier Sciences, Orlando.

Gibbs, Graham, 1998, Learning by Doing: A Guide to Teaching and Learning Methods, Oxford, London.

Guzzetta, Cathie, 1998,Essential Readings in Holistic Nursing, Jones Bartlett, Maryland.

Humphris, Debra and Masterson, Abigail Masterson, 2000, Developing New Clinical Roles: A Guide for Health Professionals, Elsevier, Florida.

Johns, Christopher, 2002, Guided Reflection: Research in Practice, Blackwell Publishing, Perth.

Johns, Christopher and Freshwater, Dawn, 1998, Transforming Nursing Through Reflective Practice. Blackwell, Perth.

Quinn,   Francis M. 2000, The Principles and Practice of Nurse Education, 4rth ed., Nelson Thorne, London.

Slevin, Oliver and Basford, Lynn, 2003, Theory and Practice of Nursing: An Integrated Approach to Caring Practice, Nelson Thomas, London.

Taylor Beverly, 2000, Reflective Practice: A guide for Nurses and Midwives, Allen and Unwin, St. Leonard.

Watkins, Dianne, Edwards, Judy and Gastrell,Pam, 2003, Community Health Nursing: Frameworks for Practice, Elsevier Sciences, Orlando.





Free Essays


Nursing is like breathing for me. It is more than a purpose. Being a nurse will complement not only most people but my well-being as well. To become a nurse you need to be compassionate and able to pass college algebra and several science courses such as microbiology, chemistry, anatomy and physiology. I also need to take psychology, social sciences, and be proficient at written and oral communication. I need to be able to read at a tenth grade level.

For many, 9/11 was a turning point in their professional lives. People began to find they were not satisfied in jobs that didn’t make a difference in someone’s life. Others had always wanted to become a nurse but other factors influenced their decisions and now they want to pursue a career in nursing. I might find it easier than you thought to have a second career as a nurse. Nursing is extremely hard work, both physically and emotionally. Not everyone is cut out for it. It’s not just the blood and gore that might make you think twice. I have to understand what nursing involves before you choose this route.

I don’t have to just work in a hospital to be a nurse. I am about to find out more opportunities for nurses as well as the educational requirements to achieve these roles. Healthcare is one of the fastest growing professions throughout the world. The population ages, and healthcare costs rise, the demand for nurses will continue to increase as well. The health care delivery system is shifting, and nurses, particularly those with advanced education, will be in demand for quite some time.  With the rising costs of healthcare, physicians are spending less time with patients, and nurses are shifting into an ever expanding role of health educator, as well as providing more direct care to the patients.

Effects of Nursing Shortage The present population of nurses is aging and approaching retirement. This will compound the current shortage of nurses worldwide. I am bent to become one of one the thousands of nurses that aspire to undertake this profession. The shortage nurses are causing a dramatic increase in salaries for nurses but this is not a hindrance to become a nurse. For one to become a nurse, he or she should be more than dedicated with his profession. Patients are to be treated like they are family as well, so as to feel at home during their confinement in the hospital.

Hospitals and other facilities are competing for nurses with sign-on bonuses, and packages including cars, childcare and/or eldercare assistance, and housing assistance. Attractive salaries, bonuses, and job security are not the only benefits for nurses. Caring for others and making a difference in the lives of others everyday is a rewarding aspect to a career in nursing. It’s something that can be said to be missing in many careers. The shortage of nurses has forced employers to not only adjust salaries, but to look outside the box at alternative and flexible working conditions.

Many more opportunities are available for per diem, part time as well as full time employees. Flexible work schedules and job sharing opportunities are emerging in the field to help nurses meet the demands of their families while managing a rewarding career. One way you can see for yourself first hand is to become a patient, but that is not the recommended route. Many young people choose nursing because of past experiences as a patient or through the experiences of a loved one or a close friend. Other ways include volunteering in a local hospital. Many still use candy stripers, or have auxiliaries which train volunteers to read to patients, to assist with wheelchair transportation at discharge, running library carts, etc.

Another way is to seek out a shadow day experience. Talk to your guidance counselor and see if it is possible to set one up. Sometimes local hospitals and clinics offer these periodically. Call your local facility and inquire. Perhaps you ca help them to do this if they don’t already. Nursing schools may offer shadow day experiences. Some are beginning to offer Nursing Camps for a week during the summer. You live on campus and attend events and tours of their hospital facilities. You shadow nurses, and earn your CPR. You may also learn to take vital signs and visit laboratory facilities. You may get to enter a hyperbaric chamber and observe in the Emergency rooms and Operating Rooms. Yet this is what I aspire to be. Nursing is not just a profession for me it is passion that will take me places and would complement me as a person.

Free Essays

Mentoring to Retain Nursing Staff

The purpose of the study aims to investigate the results of the education-based preceptor program of a community hospital intended to address the declining retention rate of nursing staff in the hospital. The implementation of the program is supported by the perceptions of newly graduated nurses that they still need mentoring even after undergoing orientation. Retention rate should increase through the program.

The study employed convenience sampling by considering as respondents, the 40 newly graduated nurses of the community hospital. The research design is a combination of qualitative and quantitative approaches. Data collection is through a survey guided by a questionnaire made up of closed and open ended questions and visual analogue scales. To ensure validity, all the respondents were informed about how the visual analogue scales work. Reliability was achieved by using standard visual analogue scales and variables supported by literature.

Results showed that after undergoing the program, there was an increase in retention rate by 29 percent and a decrease in vacancy rate by 9.5 percent.

The primary strength of the study is the combination of qualitative and quantitative approaches to derive rich data. Its major weakness is the use of convenience sampling, which means that the results reflect the situation of the respondents but this may not be subject to generalizations.

Masny, A., Ropka, M., Peterson, C., Fetzer, D., & Daly, M. (2008). Mentoring nurses in familial cancer risk assessment and counseling: Lessons learned from a formative evaluation. Journal of Genetic Counseling, 17(2), 196-207.

The study sought to explore the mentoring of nurses to take on the counselling of individuals wanting to learn information on cancer risk in the community. The need to train nurses for this work is because of the rise in community-based activities of the health care institution. The research looked into the results of the 5-day training of nurses on assessment and counseling of cancer risk together with long-distance mentorship to facilitate continuing skills development.

Initially, selection of the respondents applied convenience sampling by considering the nurses who completed the training as respondents. The 40 nurses were then randomly assigned to their counterpart in the long-distance mentoring and the scheduling of the mentorship as either immediate or delayed.

The study employed the quantitative approach. The data collection instrument is a formative sampling that covers the various aspects of the program. Reliability is ensured by using an instrument already tested by previous studies.

Results showed appreciation for mentoring with improved efficacy after 6 months and continuation of the mentoring program to support continuous community-based work.

The main strengths of the study are the long period of data gathering that ensured observation of results and use of formative evaluation, which is an accepted measurement tool. The weakness is the focus on quantitative data that could have provided insights from the perspectives of the nurses.

Latham, C., Hogan, M., & Ringl, K. (2008). Nurses supporting nurses creating a mentoring program for staff nurses to improve the workforce environment. Nursing Administration Quarterly, 32(1), 27–39.

The study sought to determine the impact of mentoring in improving work environment of nurses and patient outcomes based on the underlying recognition that a good work environment supports nursing staff retention. Through a mentoring program, workplace issues such as lack of communication and collaboration are addressed. The mentoring relationship involves a 3-year partnership involving the staff of two hospitals.

Research participants were determined through purposive sampling by seeking out the nurses engaged in the mentoring programs of the two hospitals.

The research approach is qualitative by considering observations of results and outcomes and comparing these with previous base data. Data collection method is observation and document analysis to support the comparative study. Validity is achieved by considering variables that determine the expected outcomes.

Results showed that the mentoring program developed mutual respect and reinforced the support culture in both hospitals. This means higher retention rate.

The strength of the study is the consideration of data on long-term results and focus on outcomes. The weakness of the study is reliability since observation data could vary when replicated.

Wagner, L., Seymour, M. (2007). A model of caring mentorship for nursing. Journal of Nurses in Staff Development, 23(5), 201-211.

The study sought to investigate the relationship between mentoring and the personal and professional growth of nurses. This is based on the recognition that health levels of personal and professional growth of nurses supports higher rates of retention. The paper reports on the results of a mentoring program conducted in the form of a workshop involving student nurses and professional nurses.

Participants were selected through convenience sampling depending on the nursing students and nurses that signed up for the seminar.

The study employed the qualitative approach as a research design because the intention is to derive accounts of the experiences of the mentoring seminar participants. The data collection instrument is focus group interview and individual interviews. Reliability is achieved by taking the personal accounts of the participants and validity is ensured by using questions intended to draw the experiences of the participants on the aspects of personal and professional growth with implications on retention.

Results showed that personal and professional growth occurred for both student nurses and practicing nurses. This supports higher entry and retention rate of nurses.

The strength of the study is the derivation of rich and in-depth data to support conclusions while the weakness of the study is the short period of data collection that limited data collected on outcomes.






Free Essays

Nursing Students at any College

Considering a nursing career can be both challenging and at the same time rewarding.  It is a commitment that needs time and effort in order to help others while constantly studying to update their knowledge.  Nursing is not for everyone, it is for the elite.  Even though it is a trend it does not mean everyone can pursue the career.  For students who are in this field it has never occurred that someone took it so lightly.  The pressure is always there yet they need to put a smile on their faces in front of their patients no matter how hard it is to work and study at the same time.

One student in a prestigious school is at his third year.  He knew it along that he was going to pursue a nursing career.  He has his mind-set since he was a kid and now only a year to go before he graduates.  Although he wanted to be a nurse, he could not deny the fact that stress is the main hindrance to his goal.

On the other hand another student from a different school is at his fourth and final year in nursing.  At first he never wanted to be a nurse, thinking that it would be hard to care for someone he barely knows.  After the span of four years he realized that everything was a misconception.  It is not just the hard work.  It is the feeling of fulfillment when he sees his patient go out of the hospital thanking him for the care that he has given.

After interacting with some students, I realized that nursing is not a walk in the park career.  Nursing is not as simple as caring it requires knowledge and grace while performing a task.

Stress is always present in any job.  Nursing is a good example of a very stressful career.   It is never a sedentary job that requires time and energy while performing your job.  Even as student, they are trained under pressure.  Every nursing student cares for their patients while thinking about their report which is one of the scenarios of stress in any student taking up this course.

It is admirable to see students managing their time.  They tend to think about their priorities than having fun with their peers.  During weekends, there are times that they don’t even have a break.  Somehow they have to go to the hospital during weekends to get their patient’s data before their exposure in the hospital the following day.

The profession is based on taking care of other people but it is very important to take care of your own well-being.  One awry of students is that they think more about their patients and they forget about themselves.  It is essential to be vigilant on personal health.  You need to take good care of yourself before you can take care of others.

Learning is constant in this career.  There are always new updates of the old concepts that every student should be aware of.  Books are not just the source of information these days.  With the theoretical knowledge a student is equipped with the know how in applying it in the field.

One of the most important aspects of nursing is teamwork.  Collaborating with the co-nurses is a must in maximizing the treatment for each patient.  Planning with the team can result to lesser effort and more effective intervention.

Even as student nurses, they are considered as modern day heroes.  But as humans there are also limits.  It is very important to know your limitations, students should never intervene with the duties that only a registered nurse can do.  Instead of helping they might end up making the situation worse.


Antai-Otong, Deborah (2003). Psychiatric Nursing, Biological and Behavioral Concepts .

Singapore: Thomson Asian Edition

C. Dailing, Personal Communication, July 28, 2007

M. Sharks, Personal Communication, July 29, 2007





Free Essays

Nursing Shortage In America

This paper examines the issue of nursing shortage in the light of the report published by the American Association Of  Colleges of Nursing on the subject . This report examines the issue in detail citing various reasons and issues concerning the problem . A brief overview of the report and further supportive facts are as under :

Issue of Nursing Shortage: Ever since Florence Nightingale revolutionized nursing practices, nursing has been playing a pivotal role in the delivery of health care. This has been due to the ever increasing demand made upon the health profession in all stages of its delivery. With increasing population and the plethora of diseases to combat, hospitals around the world are facing a lot of problems, nursing shortage being one of them.

According to a report published by the American Association of colleges of nursing it has been cited that recent researches have pointed out that an acute shortage of nurses is being observed in the different states across America. It is projected that by the year 2024 the shortage would increase by 340,000 as compared to the current shortage of 118,000 nurses. The reasons for this shortage are the short term policies which have been formulated in this respect (AACN, 2007).

Influencing Factors : Though a lot of factors are contributing towards the shortage of nurses , however the five main areas which need special emphasis in this regard include:

1)      Training

2)      Poor job environment

3)      Increased patient turnover

4)      High nurse turnover and vacancy rates

5)      Slow rate of growth of nurses

A lot of attention has been given to producing medical doctors, very less attention has been given to the training of nurses. The other reasons cited in the report are the poor job environment, increased burden of patients, lower turnout. These factors are constantly challenging the health professionals. This is having an adverse impact on patient care. With the time slot available for each patient the level of nursing care has decreased a lot since the past few years. The increased frequency of errors being reported is also a result of these shortages.

Other Studies: Besides the fact sheet which has been prepared by the American Association of colleges of nursing , a lot of studies have been carried out on this subject. Due to paucity of space a few of them are being presented for review: In an article published in readers digest in 2003, by John Prekannan has very rightly pointed out that if significant attention is not paid to the currently dwindling nursing population might adversely affect patient care.

The increasing family pressure on nurses and their failure to tend to every case was cited as among the reason for a higher mortality rate. Another important point which has been made is the aloof attitude the patients experience from the nurses involved in their care. As compared to yester years when patients were received warmly by the nursing staff the present day health care is a constant reminder of the toll inadequate staffing may take on the already overburdened nurses (John Prekannan, 2003).

In another research project which has taken a look over the reasons for this shortage has brought four main points in the lime light viz ageing workforce, declining enrolment, changing work climate and poor image of nursing (Goodin 2003). The answer to all these problems lies in formulating policies to combat this dearth of nursing professionals. Adequate resourcing and financing is the key when it comes to training programs. The grants which are being offered for the revival of nursing industry are not the only means of a revival but to change and bring about a powerful image of the nurses and to glamorize the profession is the key (Chandra , 2005)  .

Solution : The focus needs to change from producing just doctors to the production of quality nurses so that the new trends and advancements which are taking place every now and then in the medical filed can be put into practical use by the sufficiently qualified nursing staff. Nursing programmes should be devised so that nurses may have a chance to develop and groom themselves according to the needs of the modern society.


American Association of Colleges of Nursing, Nursing Shortage Fact Sheet, Published 2007

John Pekkanen, Nursing shortage is America’s biggest health care crises, Article published in Reders Digest, September 2003

Janiszewski Goodin HGoodin , The Nursing Shortage in The United States Of America-an integrative review of literature, Published din Journal of advanced nursing, Volume 43 , Number 4 , August 2003.

Chandra, Ashish, Willis, William K Importing Nurses: Combating the nursing shortage in America Copy right 2005 Heldref Publications


Free Essays

Nursing Shortage

This paper aims at analyzing the consequences of understaffing nurses. Some of the outcomes I observed this semester are nurse burnout and dissatisfaction that arise due to nurse shortage. The focus of this context is on the socio-economic impact in the nursing field, ethical bias, legality of the matter and psychological interference that have adverse impact to the nurses, patients, clinical working field and the nursing sector. In this paper, I will look at some of the problems associated with the nursing profession.


These are stipulations and circumstances, which enhance persistence and commitment to work comfortably as a nurse, with all due satisfaction and dignity for human life, for better supply of work force toward a proper medical care to the patients.


This is a character associated with nurses when they become psychologically or emotionally exhausted to attend the patients. This is because of being overworked, exploited, due to fatigue or due to dissatisfaction in their field of work.


In order to curtail on the trauma of nurse shortage, I would like to say that nurses’ shortage only creates some awareness that patients are at risk of substandard health care and the working nurses are being overworked. This is because in this semester, I have observed that small nurse/patient ratio does not guarantee for better patients’ outcomes and assurances of proper health services. When nurses become physically exhausted due to being overworked, they cannot perform their duty efficiently.

Nursing is a professional course and a career that need to be addressed from all perspectives, to encourage proper working conditions for the nurses in order to have a maximum labor output for the wellbeing of the patients.


Actually, overworking nurses by allowing them to work for long hours and overtime makes nurses to be susceptible to making prescription errors. This is highly exaggerated when the salary income does not correspond with the work nurses do.

However, if these errors occur, it is contrally to the nurses’ professional ethics, it is illegal to prescribe a wrong dosage to a patient and again there is abuse of human rights in that the patient can suffer psychological torture if he realizes that he was specified a bad prescription. This is what raises the legal issue of nurses. Because of such mistakes, nurses are forced to spend too much money in hiring private lawyers or insuring themselves against such bias. Beside legal issues, wrong prescriptions of drugs leads to wastage of medicines that could be used by another patient effectively, hence wastage resources since medicines are among the most expensive items.

Additionally, Wrong prescription of drugs can lead to loss of life, retardation or other body malfunction. This can cause more harm to the Nation by losing individuals. If overall effects of such errors were analyzed, the conclusion would be wastage of time when prescribing wrong dosage, wastage of resources and drugs, loss of human labor and abuse of human rights. Therefore, there would be bleach of law, socio-economic impact and denial of safe health care. Eventually, this would be a great loss to the nation and the impact is felt in the near future.

Therefore, means of solving the above problems need to be realized. I think labor motivations, recruitment of more nurses and retention of the registered nurses should be encouraged in order to maintain successful dedication of nurses to their nation as they work smoothly without strain. Understanding of the staffs’ requirements and avoidance of understaffing in this sector is of paramount importance.

According to the article on “Allied Health Source and ProQuest Nursing”, the executive summary is that nurses are not satisfied in their career. Due to this outcome, some of the repercussions are that physically exhausted nurses do prescribe wrong dosage to patients or they may prescribe right drug but misguide patients on how to use the drugs.

Another outcome is that most nurses are leaving the nursing profession and pending nurses are not willing to join the sector. Low level of job satisfaction is the main reason as to why most nurses are migrating to other fields of employments. This again leads to understaffing of hospitals leading to high death rate, failure to provide safe and effective care to the patients. Eventually this results to failure to rescue the patients from undesired death especially in the surgical department where the patients are not rescued.

From the same article on nurse staffing and hospital outcomes (Linda H. and Julie S.),it is found that the dissatisfaction is caused by law salary income, poor working conditions such as nonflexible hours of work that do not give married nurses time to look after their siblings. Another finding is that starting salary or wages do not increase with the prolonged period of work, therefore, there is successive exploitation to the nurses.

According to the article on “Allied Health Source and ProQuest Nursing”, work conditions that affect the outcomes of nurses involve lack of labor motivations such as baby boomer packages, failure to provide flexible working hours for the nurses, failure for the government to provide scholarship to nurses who want to advance their knowledge on this career.

According to the same article by Linda H. and Sean P. pg 4, nurse burnout is the main consequence of overworking staffs and it can lead to more outcomes. Actually, patients/nurses ratios that are more constructive result to lower nurse burnout and high job satisfaction among the registered nurses. Understaffing nurses can extremely influence patients’ outcomes.

Working conditions that affect the outcome of nurses include poor working conditions such as understaffing that leads to overworking the nurses without paying them their due overtime. (Agency for Healthcare Research and Quality (AHRQ) <>

Another condition that affects nursing profession is failure by the health ministry to provide encouraging packages to the nurses and other benefits. These benefits involve giving nurses flexible working hours such that they can concentrate on their family matters or providing nursing homes for their children and care.

Other factors include lack of offering free seminar services to the nurses in order to update and sensitize them on the need and benefits to be a nurse and to encourage those leaving the sector to rejoin it. Lack of recognizing their efforts and contributions to this sector is another issue that does not address their working conditions. Nurses must also be insured in order to safeguard their wellbeing and protection in their line of duty. Finally, lack of labor motivations to the nurses such as gifts, prizes and awards to the best performing nurses is something that derails their morale and dedications to be a nurse and can lead to nurse burnout.

In this semester, I have also observation that there is high nurses work overload and low technology application. Therefore, there is need to mitigate death rate and increase retention of staffs (nurses) in hospitals. More number of nurses to patients’ ratio can lead to a better patient outcome. Therefore, work force balance for the nurses is maintained in order to enhance proper working conditions for the nurses.


My experience with the nursing profession tells me that nursing career is not an easy profession the way most people perceive. It needs a call to be dedicated in this service. Note that nursing involves taking care mostly to sick people from casualties to labor ward and mostly contamination is a loaming threats to the nurses. Therefore, the nurse should have a maternal feeling and concern of the high level in order to safe lives strictly obeying the code of ethics.


Mostly labor motivation is the main tool to fight decrease of nurses from nursing sector. These will include providing nurses with proper and flexible working hours or services that are more rewarding. Another way is by means of helping them to solve family matters or factors that lead to their failures to work comfortably. These include if possible giving nurses services of caring for their children, the aged or by providing nursing homes to them with free or minor charges.

Another solution is to offer aided scholarship to those nurses willing to advance their career especially in areas where more nurses are needed e.g. in gerontology and provision of geriatric clinicians. Again, nurses should be hired or employed from different regions irrespective of ethnicity and racial segregation. Application of latest technologies in nursing sector and outsourcing can be tried to improve working conditions in this sector.

Some of the proposals that address outcomes for the nurses are varied to improve the outcomes for the patients. Understaffing of nurses indirectly affects the outcome of the patients. Therefore, proposals for outcomes of the nurses are determining factors to improve the outcomes of the patients.  Mostly labor motivation is the main factor to fight decrease of nurses from nursing sector and this can improve the outcomes of the patients. These will include providing nurses with proper and flexible working hours or services that are more rewarding.

By allowing nurses to work comfortably, nurse burnout can be avoided, hence patients can be attended with all due care because nurses wont be exhausted. Patients should be allowed to interact freely with the nurses to air their problems and complications. Again, patients should accorded all due respect in their treatment and assured of life continuation through proper medical care. Application of latest technologies in nursing sector and outsourcing can be tried to improve working conditions in this sector.


Some of the problems associated with the nursing profession include poor working conditions that have effects to both the nurses, patients and the nursing sector at large. After analyzing these problems, I have decided to draw a conclusion that creative solutions and labor motivations are the major factors that need to be addressed in order to safe the situation as far as nursing career is concerned.


Burnout, staffing and outcomes of nurses, retrieved on 7TH NOVEMBER 2007, available at

Dohm A, “Gauging the Work Force Effects of Retiring Baby-Boomers,” Monthly Labor Analysis (July 2000):17-25

National union for Nursing, retrieved on 7TH NOVEMBER 2007, available at 

Strategies to repeal the New Nursing scarcity, retrieved on 7TH NOVEMBER 2007, available at



Free Essays

Nursing Research Article

Lung cancer has been named the second leading killer of American women second to heart disease.  It is estimated that 20% of deaths among women occur from lung cancer (  According to the American cancer society, lung cancer accounts for up to 28 % of mortality rates among men.  The risk factors associated to lung cancer are smoking of cigarettes, marijuana, exposure to talcum and radioactive gases and asbestos and so on. These compounds are said to trigger growth of malignant cells thus causing cancer (

Melissa Conrad Stoppler, MD a board certified Anatomic pathologist based in US in her article lung cancer (medicine points out that lung cancer is a life threatening cancer that spreads very fast to other parts of the body and is a very difficult cancer to treat.  She clears up the myth that lung cancer only occurs among smokers.  Non-smokers are also prone to developing lung cancer and of the 170,000 lung cancer deaths in America, 10% of them are non-smokers.

Of these deaths among non-smokers, not all the cases can be traced to any identifiable risk factors but dominantly, passive smoking can be underpinned to be the major causal factor for lung cancer among non-smokers.  Melissa also tries to shed light or the group that is most prone to suffer from lung cancer.  She purports that smokers, Asbestos workers, the elderly, passive smokers, people exposed to workplace chemicals and residents of air pollution prone zones.

According to the American cancer society, 70% of people suffering from cancer are elderly say over 65 years and only 3% under 45 years. Melissa points out that in the 1930, lung cancer was a rare disease however, with the rise of tobacco smoking and pollution, the disease cases have increased unprecedented.  The number of deaths among tobacco smokers is highest among cigarette smoker as opposed to cigar and pipe smokers.

The risk getting lung cancer further compounds with each increase of cigarette smoked.  Defined in medical terms as pack-years (the number to packs of cigarette smoked per day in a year), Melissa suggest that the higher the number of pack years, the higher the risk of developing lung cancer.  To be precise she elaborates that out of seven people who smoke 2 to 3 packs of cigarettes in a day, one will die of lung cancer.  (

This is because cigarette contains carcinogenic compounds that trigger abnormal cell growth in the lungs and thus cancer.  It then seems that lung cancer is a disease for smokers, or at least that is according to common misconceptions.  Melissa in her article submits that research findings indicates people who share living space or work stations have a 24% higher chance of developing cancer as  evidence by 3000 lung cancer deaths pinned to passive smoking.

Further, she brings to mind that other risk factors associated with lung cancer are rare but combined with smoking, (passive or active) the risk of developing cancer is further compounded.  Evidence shows that Asbestos workers who smoke had a 50 to 90 times possibility of developing lung cancer in preference to the five times possibility accrued to non-smokers. The case is the same for workers exposed to radon gas and radioactive compounds.

Although there is insufficient evidence to support claims that genetic predisposition increase individuals vulnerability to developing lung cancer, the possibility cannot be totally ignored. Residents of air-polluted zones have contributed 1% of all lung cancer cases and clearly, cigarette smoking or passive smoking complicates the problem.  The US government has paid noteworthy attention to the increase of lung cancer deaths among Americans.

According to the National cancer institute, 213,389 new cases of lung cancer cases have so far been reported and out of those cases, 160,390 deaths have occurred in 2007 alone.  The magnitude of cancer problem is profound leading the government to respond investing a handsome chunk of money to cancer research each year.

The author of the article is a well-educated pathologist and she uses a lot of medical jargon in her article.  However, she makes efforts of clearly explaining important terms so that her audience can understand.  Her piece is well researched and developed giving it a smooth flow. She starts from the basics and develops the topics to complex aspects.

For instance, definition of lung cancer, commonality of the disease, causes, types of cancer, signs and symptoms, how it is diagnosed, treatment options, prognosis and prevention. However, for a nonprofessional some of the content may be confusing or too technical to understand.  Although she does try to explain in simple language, it is possible to get lost in the maze of medical terminology and information overload.  The argument does seem logical, supported by statistics from reliable sources.  She also builds her article from previous medical researches and from her own professional experience.

The author’s argument regarding smoking and its role in increasing risk of developing cancer among cancer prone population is well supported.  She mentions the various causal factors of lung cancer and relates them to smoking.  For instance, the fact that 12% of lung cancer deaths are attributable to radon gas exposure and concomitant smoking bringing the number to up to 15,000deaths per year.

I believe this article is most appropriate to Melissa’s target audience because it rolls out facts supported by statistics which I think makes the article believable and reliable.  It is unlikely that an individual, who smokes or is exposed to the risk factors mentioned in the article, would take the recommendations lightly.  Moreover, after reading her article, misconceptions about passive smoking are cleared.  The word that evoked a strong response in me is prognosis of lung cancer.

Prognosis of lung cancer refers to the chance of recovery from lung cancer.  Melissa sheds light on the possibility of recovery among lung cancer patients.  She submits that recovery is dependant on the localization and size of tumor type of cancer and overall health status of the patient.  This gets me thinking because; I always thought cancer was the same. She fills in the readers on the two types of lung cancers, which are the i.e. small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC).

SCLC is the most aggressive and survival time ranges from about 4 to 6 months after diagnosis, if untreated.  However, the SCLC is the most responsive to radiation and chemotherapy.  At this point, I feel enlightened.  Further, she points out treatments like surgical removal of tumors and local chemotherapy as the most effective treatment. Although there is, only 5%-10% chances of survival if lung cancer is untreated, good treatment can prolong cancer patient with SCLC types of lung cancer, to up to 5 times more than the untreated cases.

Overall I think the article is well researched and accurate and gives a clear take home message i.e. prevention is better than cure since prognosis of lung cancer is poor compared to other cancers.  Thus, smokers and passive smokers are best advised to avoid cigarette in order to minimize susceptibility to lung cancer.


Conrad M. S ed. Marks, J.W. Lung Cancer. Available at

Accessed on September 18, 2007


Free Essays

Nursing program

I have come to a point in life that many people have not.  I have made a firm decision to recommit myself to pursuing my dreams.  While there are those who believe that with an ounce of luck and a ton of persistence anything can be accomplished, I believe that there is no reason to expend so much energy and rely on luck.  I believe in taking hold of my destiny and carving out a future for myself based on the decisions that I make in life.  Life is simply too short and too precious to be left to luck alone.  This is why I have decided to apply at the National University Nursing Program to become a registered nurse.

I have always wanted to help change the world.  As a child, I believed that if everyone did their own little part in taking that extra step to help others, the world would be a much better place for everyone.  The stark reality of it all hit me not long after that but it did not lessen my resolve.  I figured that if so many people I knew did not want to do their part in changing the world then I would probably have to do their share.  This is where my motivation to pursue nursing comes from; the drive to go the extra mile just to make a difference in this world.

Early in life, I have always realized that my dream was to be able to help those less fortunate in life.  I have relentlessly pursued this dream and at present I am proud to say that I have had a lot of experience in the Nursing Field by acting as a private caregiver to the elderly in La Jolla.  I understand, however, that in order for me to turn these dreams into realities I need to get the training and proper experience necessary.  I see this as the first step in attaining my goals.  Eventually, I hope that my education with the National University over the next 2 years coupled with work in the neonatal intensive care unit as a registered nurse will allow me to live out my dreams.

I see my goal in life as similar to that of Nurse Leader Mary Breckenridge in that I know that nursing plays a very important role in the world today.  There are few jobs and professions that are as rewarding as nursing.  While other jobs may get more publicity, the role that nurses play in the health care industry is highly valued and appreciated.  My motivation has to do with the fact that nursing is one of the ways by which I am able to do something that I really want to do in my life and that is to care and help other people.  More importantly, I greatly feel that by taking up nursing I can become a productive member of society.

I remember vividly the first time that I had decided to become a registered nurse.  My Aunt had given birth prematurely and ended up losing her child.  She was only six months pregnant when this happened.  It was a traumatic and harrowing experience for all of us in the family.  Seeing her pain, I was determined to make sure that I would do all I could to help those in similar situations.  Much like my mother devoted her time to the less fortunate by completing her Masters in Special Education at the National University, I also plan to pattern my life after her example.  As such, I would also like to point out that I have continually improved my academic performance in school over the years.

This was the factor that set the field of nursing apart from the other careers in the medical field.  The human involvement that is critical in nursing makes it the ideal profession for me.  The remunerations that one can receive from being a nurse are only secondary to the feeling of fulfillment from knowing that one was able to provide support to those in need.  These experiences that I took with me during my time in the hospital shaped my future and opened my eyes to the benefits that a career in nursing can provide.

Pursuing my career in nursing is just the first step in my plan.  Much like Nurse Leader Mary Breckenridge has done, I too want to be just more than a nurse.  I would like to have the opportunity to take a bigger role in making the world a better place to live.  My main philosophy in life is to lead by setting an example. I cannot expect others to do what I myself would be willing to do but that does not mean that I cannot hope that others will see the example that I have shown them.

This philosophy is one of the many forces that drive me to pursue my dream of pursuing a career in nursing and of becoming so much more in life.  The chance to help those who are less fortunate in life, the chance to help others, the opportunity to be of service to humanity; these are the reasons why I have selected nursing as the profession that I will pursue; for, as Eleanor Roosevelt once said, “The future belongs to those who believe in the beauty of their dreams…”