Application of Concepts to Current Job
1. Health History
The information from health history is beneficial to both individuals and health care providers as the process of obtaining the data help in the establishment of trust and rapport between lay persons and medical professionals. The information also helps assist with development of diagnosis and in making treatment decisions as wells as determining an individual's baseline, or what is normal and expected for that person. The clinical interview is the most common method for obtaining a health history. When a person or a designated representative can communicate effectively, the clinical interview is a valuable means for obtaining information.
Obtaining a health history as part of admission process is very important to neonatal health. Maternal conditions such as hypertension, presence of sexual transmitted infection, pyrexia, use of medication during pregnancy, problems during pregnancy such as vomiting can affect the infants’ wellbeing during labor or at birth.
A maternal history of fever for example places the infants at risk for sepsis and many of the multiple organ dysfunction which ensue. Knowing this information preferable before the infant is born enable clinicians and nurses to plan appropriate care modalities that will assist infant in successful transition to extra uterine life. The information obtained in maternal health record, as well as admission history will also assist nurses and clinician in future cares of the infant because through experience and knowledge certain health issues in the neonatal period take a precise course.
2. Health Promotion
The concept is very useful in nursing as it shows that an individual health is determine by personal characteristic and personal history. Since health is determined also by lifestyle choices the importance of obtaining a thorough health history cannot be overemphasized. This part of nursing assessment will form the basis for developing and planning health promotional activities geared towards improving patient health status. Health promotion can be used for all individual and at any point on the health illness continuum. Health promotion is a fundamental role within the nursing profession, however a review of the literature highlights a gap in nursing knowledge about how and when to promote health and wellness.
Health promotion can take many forms. For example if a patient presented to the hospital post-myocardial infarction, nurses encourage the patient to exercise more frequently and eat more fruits and vegetables, reduce intake of food high in fats and cholesterol and information on programs to help them quit smoking is given.
In my experiences in nursing, promoting health comes without any deliberate efforts to neonatal nurses because it is a natural and automatic component of this special care unit. In the Neonatal Intensive Care Unit when an infant is admitted to the unit there are a number skills and knowledge they must master before an infant is discharge to the family. We call this the discharge checklist. One of the ways we promote health is that where relevant items on the list have to be checked and sign for by nurses indicating that a certain item was taught, return demonstration was given and that the family id competent at a certain skill. Another way we promote health of the child is that we ensure that the caregiver is ready and willing to care for the baby at home. We teach subjects sucking as management of a chocking infant, cardiopulmonary resuscitation (CPR) of the infants, sterilization of infants’ equipment, expression and storage of breast milk. We also make sure that an appointment for review is made within 48 –72 after the infant is discharge.
Health promotional activities can take various other forms. For example, one of the problems unique to the Saint Lucian culture it that it is customary the mothers would provide the daughters who have just delivered infants with some herbal mixture believed to cleanse their system of all illness and component of pregnancy. Older women believe that the body is unclean after birth and must be cleaned to prevent the just deliver mothers from becoming ill. In order to cleanse the body herbal remedies prepared and sold in local stores are taken by these new parents. However one of the detrimental effects of ingestion of certain substances is that these mothers continue to breast feed. Although some infants are able to withstand the transfer from breastmilk others are severely affected and exhibit multisystem organ failure. In order to prevent this devastating effects we educate mothers on the natural cleansing mechanism of the body and the multisystem effects ingredients in the remedies can have on the health of the infant. We ensure that each mother we come in contact with is abreast to that information.
The most common perceived barrier to promoting health in nursing practice is time, as well as education and training. Neonatal nurses know that health promotion works based on the number of admission with preventable illness we received. We believed as by evidence, that health promotion is an effective method for helping infants and families improve their health and prevent illness and complications. Nurses however have reported that patients can be barriers to health promotion activities because some patients are unwilling to accept information and frequently ignore advice given to them.
3. Self – Actualization
This concept is very useful in nursing profession. A self-actualized nurse is one who engages in the process of becoming true to herself and those with whom she goes through life’s experiences. Being self-actualized improve the nurse’s quality of care as she would place value in what she does within the nursing profession. The concepts teaches nurses to learn themselves and then know others. Values and meaning expressed by self-actualized nurses are internally generated and not externally imposed therefore more meaning is applied. They express these important values and manifest complementary behavior in both demeanor and action. Once self-actualization is experiences it becomes a continuous process of always striving to develop and achieve higher levels of excellence and gratification. Qualities such as confidence, competence emerge. The attitude of self-actualized nurses radiates to patients, families, co-workers and community. She is a locus for high quality care and patient satisfaction. By her mere presence makes a differences in the lives of everyone she encounters.
When nurses care for infants with chronic illness and continue to promote health, nurses are assisting the patients to be the best they can be with the diseases. By merely encouraging patients to continue living and take on new projects and activities can assist these patients to become self-actualized even with his present circumstances. For example, in a case where a man who suffered with paralysis after a vehicular accident, he becomes self-actualized because he leads an organization where people who has suffered from that same fate can openly converse and assist others in the transition of a new life.
4. Therapeutic relationship
A therapeutic relationship with clients is very important especially at the first encounter where information is needed from client to guide practice. In health assessment for example, because the nurse is usually the first point of contact with the health care environment a therapeutic relationship is necessary to encourage clients to provide necessary information to formulate nursing diagnoses and plan intervention.
For example a young mother who is HIV positive come to an obstetrical unit in labor and has decided to not to divulge information of her status because she has felt stigmatized in the past. However when the infants is born ill, prematurely and transferred to the Neonatal Intensive Care Unit she begun to form a trusting relationship with a particular neonatal nurse, and feels comfortable enough to provide this pertinent detail of her health status to that nurse. The neonatal staff provides her support and continue to provide the best of care to her baby and support to her. She feels so confident in the relationship that she has formed that she later shares with the staff details of her sexual relationship and the fact that the baby she has just given birth to is a result of sexual abuse by her step-father.
The importance of a therapeutic relationship with clients is paramount. Because infants are not able to communicate verbally, nurses are in constant interaction with the family members and therefore the establishment of a therapeutic relationship between the nurse and families of the infant promotes family centered care, a theme of this care environment. The kind of relationship which develops with the family of the newborn will determine the type of care infants received from their parents, how open parents are about divulging information, and how comfortable they are when visiting the unit. Because of the fragility of these set of patients, nurses are required to have special training and skills to offer support to families in their moments of weakness. NICU nurses are responsible for implementing care that vocalizes the physical mental and social development of the newborn. The nurse must be aware of certain boundaries which must not be crossed to keep this relationship with client as professional and be able to step back when the relationship is no longer therapeutic.
Highlighted in the care of newborn is the family participation on the care of newborns. Care must be individualized and focus on the development of the family and newborn. To achieve this the nurse must see the world according to the perspective of the family achieved from the development of a therapeutic relationship. However this relationship can only be developed if family is involved in the care of the baby. However as has been observed, some nurses feel that the presence of family members in the NICU hinders their performance and prefer the baby to be restricted to the incubators and tell parents that they will disturb the baby. This kind of attitude does not impact positively on the nurse client relationship.
5. Client Centered Care
The concept of client -centered care is not new to the nursing profession, however it is not readily practiced. One of the tool used by nurses which should help in the practice is the nursing process. The unique process provides a framework for nurses to follow and at each step it forces the nurses to explore the individual client. Nursing diagnoses have to be client focused and when it is not, it affects all the remaining components of the nursing process. Because patients’ needs are continually changing the nursing process call for continuous assessment and evaluation to ensure that individualized client center care is given. Person-centered care strengthens the patient- nurse relationship, promotes communication about things that matter, and helps patients know more about their health, which facilitates their involvement in their own care.
6. Critical thinking
Critical thinking helps in interpreting data which is a challenge in nursing because signs and symptoms needed to form nursing diagnoses are often overlapping because of the complex, unique and holistic responses of persons. Being able to think critically, benefits the nurse and patients as it improves work productivity. Accurate nursing diagnosis can be formulated reducing diagnostic errors and ensures that the right nursing interventions are plan and implemented. The concept forces the nurses to look beyond the obvious.
For example, a neonate is born at 33 weeks gestation and brought to the nursery for clinical management. During the first hour of life the infant started presenting with signs of severe respiratory distress evidence by tachypnea, moderate respiratory retractions, nasal flaring and grunting. The nurse replies to the situation by placing the infant on oxygen via nasal prongs and attributes the clinical deterioration as the infants normal transitioning. A nurse who is able to think critically would look beyond what is presented and normal and would analyze both the infant maternal history and realize that the infants was at risk for early onset sepsis secondary to maternal pyrexia. Competent critical thinking would indicate to the nurse that the infants is already showing signs of inability to fight infection because of prematurity as manifested by RDS and that more invasive form of ventilation would have been necessary as she would anticipate a further decline in respiratory status.
Critical thinking is a skill that must be worked on. To become competent at it I must gain knowledge and competence in health assessment findings, gain more experience in the job, accept correction and learn from my mistakes. Teaching more junior staff will also boost my confidence and will forces me to be abreast with my clinical skills and knowledge.
7. Patient Advocacy
Patient advocacy includes many interventions such as explaining healthcare options, instructing patients about different procedures and treatments, and clarifying healthcare goals. By providing patient advocacy, nurses establish trust within the nurse-patient relationship, recognize individual patient needs, and promote the patient’s active participation in healthcare decisions. Neonatal nurse are in active display of this role of nurses. Because infants are not able to communicate their needs, neonatal nurses are the voices of these set of patients and have the power to influence health care decision. The nurses’ role of advocacy in the nursery can been observe when nurse communicate to physician aspect of the care not beneficial of infants and family, decide on whether or not infants is ready for discharge, quarantine in born infants from more mature ones who have gone home and return for medical treatment, refusal to provide care that may do more harm than good to infants and family.
An example of patient advocacy can be seen in a neonatal nurse’s refusal to accept a 25 day old infants who had been discharge two days after birth who presented with whooping cough as well as pustule into the unit although there was a physician order to be admitted to the unit. Her refusal was based on the fact of unavailability of the required amount of space between individual infants in the unit although protocol suggested and that infants less than 28 days old should be care for in the unit. She protects the rest of the infants from what could have been an epidemic as the neonatal unit does not have negative pressures. She however makes arrangement with the physician for the infant to be cared for in the pediatric ward where mothers are allowed to sleep overnight. A practice not available in the Neonatal Intensive Care unit.
8. Delegating
Delegation directs care and determines the appropriate utilization of any assistant involved in providing direct patient care. Critical thinking and professional judgment are very important when following the Five Rights of Delegation, to be sure that the delegation or assignment is: 1.) the right task. 2.) Under the right circumstances. 3.) To the right person. 4.) With the right directions and communication and 5.) Under the right supervision and evaluation. The decision of whether or not to delegate or assign is based upon the nurse’s judgment concerning the condition of the patient, the competence of all members of the nursing team and the degree of supervision that will be required of the nurse if a task is delegated. The nurse must delegates only those tasks for which she or he believes the other health care worker has the knowledge and skill to perform, taking into consideration training, cultural competence, experience and facility/agency policies and procedures. The nurses’ individualizes communication regarding the delegation to the nursing assistive personnel and client situation and the communication should be clear, concise, correct and complete. The nurses must verify comprehension with the nursing assistive personnel and that the assistant accepts the delegation and the responsibility that accompanies it. Nursing assistive personnel should have the opportunity to ask questions and/or for clarification of expectations. Chief Nursing Officers are accountable for establishing systems to assess, monitor, verify and communicate ongoing competence requirements in areas related to delegation. In my experience with delegation I have observed that when it is done right charge nurses are better able to provide clinical care because they have the time to focus on other aspects of care. Delegating to family members also benefits the family as they feel like they can directly impact their loved ones health outcome.
9. Wellness
According to the National Wellness Institute, a professional can determine whether he or she practices within a wellness approach if he or she answers "yes" to the following 3 questions: "Does this help patients achieve their full potential? Does this recognize and address the whole patient? Does this affirm and mobilize positive qualities and strengths?" Wellness is a broad concepts. However nurses are in a critical position to promote the concept of optimal wellness during interactions with patients. Providing information however small can help a client in a significant way. For example, during a home visit to discuss newborn care, the nurse uses the opportunity to discuss the childhood vaccine schedule, recommended vitamin supplements or even the developmental milestones of an older sibling. Recognition of these subtle yet effective interactions is important in giving credit to the significance of nurses as health promoters.
In my personal experience however I have not achieved wellness in all dimension. As a professional we are so focused on the health and habits of persons in our lives and the patients we come into contact with, that we often neglect our own health. In order to improve on my social wellness which was one of the areas that posed the biggest issue for me, I have designated one day out of the month where I go out with friends and have a good time. I am also come to the realization that certain aspects of my marriage is not beneficial or healthy such as my total dependency of my husband for social and emotional needs. To address this problem I have engaged myself in activities which I once used to enjoy before I got married.
10. Pain
Nurse must be aware of the certain factors which can affect pain perception such as age, sociocultural factors. Establishing a positive nurse client relationship and teaching are essential when nurses are caring for patients treated with analgesia because its success is dependent of open communication and patient cooperation. The most success for pain management is the use of both pharmacological and non-pharmacological means. An important aspect of caring for patients with pain is reassessing the pain after interventions have been implemented. Nurse needs to consider other measures if intervention were ineffective. The presence of pain in the neonates have not been well understood by nurses and clinician in the unit. When various painful interventions are being implemented on these sets of patients it is not a usual practice to offer the infants some sort of comfort. One of the reason I think this is so because neonatal response to pain mimic response to other stimuli and therefore is frequently overlooked by many staff members. It is however a common practice with upper level staff to provide infants some comfort of pain relief during or after painful procedures by various intervention such as nonnutritive sucking, drops of dextrose 10% glucose on tongue, cuddles with mom, touching, and feeding.