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One of the complexities of 21st century medicine is the evolution of nursing care theories in combination with a changing need and expectation of the stakeholder population. Nurses must be advocates and communicators, but must balance these along with an overall philosophy of ethics while still remaining mindful of budgets and the need for the medical institution to be profitable. It seems as if these issues comprise a three-part template for nursing: respect for patient value & individuality, education of patients, and cognition and respect for the realities of contemporary medicine. In many ways, too, modern technology has advanced further than societal wisdom, especially when confronting the issue of death. The modern nurse's role is to create a nurse-patient culture that encourages the individual to take responsibility for their healthcare and, in partnership with the nurse, to be involved in their recovery. The modern complexities of healthcare, then, when combined, focus us towards a multidimensional template (combining at least psychology, biology and philosophy) (Beckstead and Beckstead, 2004).
Ethics and multidimensionality provide a way for the nurse to advocate for the patient. This is, of course, a gray area at times -- certain drugs or tests may have initial negative or painful effects, but in the long run, provide relief to the patient. However, while the nursing code of ethics echoes the Hippocratic Oath of "do no harm," the greater or long-term benefit to the patient may, at times, override brief discomfort in order to heal. For the modern nurse, theory is not an end, but part of the destination. It is part of a toolbox of techniques -- some from experience, some from an alternative point-of-view. We live in a global society, and as such, the "usage and development of [divergent] nursing theories should be a top priority" -- but only if those theories are used in a practical manner befitting of patient advocacy and clinical knowledge (Dudley-Brown, 1997, p.82).
However, more than just focusing on what we can do, the idea of ethics within the modern template of nursing has a duality: just because we can do something medically does not mean we should, and; more importantly, who should step up to ensure that those moral decisions are being made, or at least considered and discussed? Quality care is expected, and patient advocacy has always been a part of this paradigm. Watson used a more integrative approach to develop her theory -- a combination of Eastern and Western thought that looks at a more holistic approach to the healthcare model and the individual. This is not a new approach to nursing, but rather one in which there is a long historical tradition dating back to the Civil War and ideals of Florence Nightingale, through the interpersonal advocacy model of Hildegard Peplau, and finally, epitomized and continually advocated by Jean Watson.
Focus of the Model
Essentially, based on a number of theories, Jean Watson, for instance, modern nursing has an overall responsibility for advocacy and care. More often than not, nurses tend to act as the "moral agents" within the system because they are the locus of communication between the physician, the patient, and the family. The modern nurse leader must act with moral courage and conviction since "nursing leaders are responsible for creating cultures that support acts of courage in nursing… [because] these acts have the potential to increase nurse retention, promote patient comfort, relieve patient suffering, and enhance the reputation of the organization" (Edmonson, 2010).
Thus, there is a clear expectation for APN and RN professionals. For instance, within the culture of the healthcare industry, the moral development of the work group often impacts the way decisions are evaoluated and made. For this reason, the psychological imperative of the modern nurse requires having a toolbox of ethics and morals that can be expressed at the right time under the right circumstances. This power does not need to be coercive, but more a servant leadership style in which the nurse leaders is inspiring and can lead by example. This form of leadership assumes competition and conflict, which is not negative because it brings alternative viewpoints to light that may otherwise have been left uncovered. Research findings, in fact, show that moral identity contributes to leadership acument and vice versa. The identity of the expectations of the leader's role within the organization will shape the manner in which moral and ethical paradigms can be used to make decisions (Mayer, 2012, pp. 165-6).
Overview of Model and Concepts
A critical theoretical approach to patient advocacy, Jean Watson's Theory of Human Caring represents a dramatic paradigm shift, and as a result, it has been a source of considerable controversy since its introduction in 1979 with Nursing: The Philosophy and Science of Caring (revised 2008). To Jean Watson, nursing is both an art and a science, with the overall goal of preserving the worth of humankind through the process of caring. The core for nursing is caring -- and it must be more than a theoretical precept. "Caring...has to become a will, an intention, a commitment, and a conscious judgment that manifests itself in concrete acts. Human care, as a moral ideal, also transcends the act and goes beyond the act of an individual nurse and produces collective acts of the nursing profession that has important consequences for human civilization" (Watson, 1988, p. 32).
The caring experience is part of the human experience. Because humans are unique, Watson advocates the push towards transpersonal caring, finding that the nurse and client must both participate in the responsibility and eventual goal of complete (Watson, 1988, p. 70). Her concept of health is ironically eastern - harmony between mind, body and soul, with illness disharmony between mind, body, and soul. As well, integral to Watson's theory are the 10 carative factors that serve as a "framework for providing a structure and order for nursing phenomena" (Watson, 1997, p. 50). Watson's crucial ten carative factors are:
Humanistic-altruistic system of values
Sensitivity to self and others
Helping-trusting, human care relationship
Expressing positive and negative feelings
Creative problem-solving caring process
Supportive, protective, and/or corrective mental, physical, societal, and spiritual environment
Human needs assistance
Offshoots and Theories Generated
There are numerous leadership theories that have developed over the past half century -- some specific to healthcare, but most are applicable for any organization, they just need some refinement for the particular life-and-death challenges of healthcare. Most nursing theorists (e.g. Watson, Leninger, Peplau, etc.) emphasize servant and/or ethical leadership -- focusing on character, civility and community. "Leadership and management development therefore focuses on the enhancement of the personal attributes, qualities… knowledge and skills of individuals" (Edmonstone, 2011). Ethics and morals are culturally based; there are still several moral and ethical values that transcend time and geography. Much of the ideas of ethical leadership surround the basic premises of utilitarianism and deontology -- asking very critical questions of whether the needs of the many outweigh the needs of the few, and/or does the means to an end matter more than the end results. The true ethical leader, from leading within a profession to leading a community or large organization, seeks fundamental changes within their purview to ensure that justice and equality are part of the operating paradigm. This can happen through a number of leadership theories, all which tend to raise the bar for employees and the organization itself by developing a culture in which ethical practices become the norm (Mayer, et.al., 2012).
Watson's theoretical basis in more a logical offshoot of Peplau, in the sense of a combining of care, advocacy and communication as crucial to the needs of the patient. Peplau's most famous contribution to nursing literature was her 1952 publication Relations in Nursing. In this text, Peplau focused on the manner in which the foundation for any nursing theory must be the client-nurse relationship. This may seem quite logical today, but around World War II it was both reactionary and controversial because of the perceived correctness of the doctor-nurse relationship and the theory of patient care. Peplau believed that the partnership relationship between nurse and patient was essential to any means that would contribute to patient healing. The nurse, she said, should do far more than simply listen to the doctor and carry out medical orders. Instead, the nurse should develop a relationship with the patient in which the nurse actively listens to the needs and issues of the patient, communicates those needs up the chain of command, and acts as an advocate for patient well-being. The ratio of patients to doctors, reasoned Peplau, was such that the professional nurse had a critical responsibility in performing this advocacy role:
The authority and direction for designing nursing functions derive from situations in which professional workers collaborate to bring about health improvement. Any problem to be faced by an individual or a community suggests what is needed for its solution; health workers assess problematic situations and cooperate with individuals and communities in…[continue]
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