Nursing philosophy and professional role transition

¶ … Education is an important part in everyman's life and preparation. In most cases it offers a window of opportunity for the new road ahead and for the challenges facing us in life. This is why it is essential to take into account, to measure and analyze the impact and benefits each new course and lecture has to our life perspective.

From this point-of-view, the input nursing had on my academic evolution, both as an individual living in the society and as a future RN staff nurse, is indeed considerable. On the one hand, it made me change, adjust, and sometimes even correct my philosophy of nursing, as it made me completely aware of the immense importance treating the patient and his family has on the entire healing process. Secondly, through different thinking exercises, the course offered me the chance to question specific health care systems and reflect on each of their strengths and weaknesses in order to finally decide on a suitable and flexible system, one that would adapt to the needs of each patient. Thirdly, throughout my studies, I came to realize the existence of a rather difficult period of transition from being a student to actually taking part in the everyday life of a health care unit. It is very likely that few graduates actually grasp the extent to which theory differs from practice and the difficulty to adapting to a real environment; nonetheless, it becomes somewhat easier if there are certain elements to be considered before addressing this role transition period. Finally, learning and dealing with different aspects of nursing also prepares us for addressing controversial issues as well. The discussions held in class and the need to argue my own personal convictions on different matters up for debate enabled me to rethink my position on a rather sensitive issue which has raised a lot of controversy in our society. The right of individuals to exercise their own decisions on whether to withdraw or withhold life-sustaining therapy for themselves is in my view sacred both for the patient and for the doctor who is forced to respect it. However, this issue raises ethical, moral, and even legal problems, all of which I had the opportunity to explore during classes and thus to acquire new and relevant information for my future career as a RN staff nurse on an oncology unit.

It is often thought that in order to best achieve one's job, one must first and foremost identify the object of the respective job. Indeed, in recent discussions, the same question was put up for debate in regard to the common ground of nursing. It is considered that there are different areas of focus in the nursing activities; June Kikuchi and Helen Simmons point out that indeed, "until recently, nurses had sought common ground in nursing philosophy in the form of a single (common) philosophy of nursing that would guide the activities of all nurses (...) yet some of these nurses insist that we, in nursing, must identify the central concerns of nursing." (Kikuchi and Simmons, 7) Despite the fact that there are different ideas on the subject, there are certain undeniable truths which must not be disregarded when one sets up in his journey of becoming a nurse. They are usually set up in what came to be known as a nursing philosophy, which is "a set of ontological, epistemological and ethical claims that identify and define the basic units of the discipline. Two of these units are the nature of human beings and the focus of nursing practice. Moreover, the ethical claims must address the values that regulate nursing practice and at least minimally, the character of the person choosing to practice nursing." (Kikuchi and Simmons, 18)

As the subject of the first delimitation, moral constrictions include perceiving the human being as a living individual and being aware of the responsibility one has over the protection of his life. More concretely, the patient must be at the center of all the actions doctors and nurses alike undergo. Indeed there are financial benefits one might get, but first and foremost, the well being of the patient must be the primary concern, as "the human being ought to be respected simply for what they are and (...) nursing care ought to be carried out with consideration for human dignity." (Kikuchi and Simmons, 14)

There are other values as well which must be taken into consideration and must lay at the foundation and represent the motivation for every nurse dedicated to his job. On the one hand, one must be a caring individual, sensible to the suffering of those around him. This affirmation is based on my own personal experience, as I have come to realize that one must be completely dedicated to opening up to those in pain and at the same time to be ready to offer them support, both medical and moral support, as there are a multitude of dimensions of the healing process a nurse can explore. From one perspective a nurse can give medical support and insure that the doctor's work is carried out with success. From another perspective however, it is important to treat the patient not merely as a name on a hospital sheet, but rather as a man with a past, a personal history, and a particular individual. This cannot be achieved unless there is a vivid willingness to talk to the patient and to become, even if for a short period of time, a reliable presence. However, this raises the question of caring as moral and professional obligation or on the contrary as a trait of humanity and of the sense of human solidarity. The issue is addressed by Kkikuchi and Simmons as they ask themselves whether "the status of caring" is fundamental for the discipline. In the end, they agree that caring, aside from being a moral imperative, an interpersonal relationship, it is also a nursing intervention. (Kkikuchi and Simmons, 17)

There are indeed certain ethical matters which a nurse must take into account. Telling the truth and taking responsibility for one's own actions is a rather difficult thing to achieve even in everyday life, when there are not too many consequences that would follow an innocent lie, for instance. However, throughout the courses undergone, I was proven that no matter how hard and sensible the truth was, in regard to a patient's condition, it is always essential to tell it out loud, as the patient has the right to have a full compete and accurate image of his condition.

In applying such a line of judgment, there is yet another element that must be taken into account in the relationship with the patient and in clearly defining one's nursing philosophy. As a future nurse, I am a strong believer in each patient's right to have full control over the way in which he decides to spent his final days or the decision to follow or not a treatment that may or may not offer relief. I believe that although doctors are aware of any particular risks, the patient is most qualified to take a decision which impacts the course of his life.

The evolving society implies, aside from the obvious technological advancements, even a changing atmosphere in regard to the health care system. Even if it may seem of little relevance, it is important to take into account the changes that take place at the level of the medical infrastructure and legislative initiatives because the moves that occur influence the way medical assistance and nursing activities develop. Thus, the American health case system is the framework for the medical practices across the country.

Like everything else related to public policy, it was only natural that the American heath care system be the target of scrutiny and debate. It has been rather seriously argued that the system fails to provide adequate heath care for all the people. (Jarvis, 2001) The general policy has in sight mostly those who are very poor and lack the basic means to finance their medical care. For the rest of the common people, the state encourages the private system of medical insurances. This offers the people the possibility to contribute to their medical care expenses through the means of the private sector. These basic principles stir indeed rather big controversies and at the same time draw the attention on serious issues relating to the capabilities of the state to provide for a minimum of health care.

Malcolm Gladwell pointed out in one of his articles in the New Yorker the big difference health care makes by taking the particular example of dental problems which can become rather important should they be left untreated. (Gladwell, 2005) Although it is an essential part in the overall state of health, according to Gladwell, few actually allow themselves the luxury of having an annual check and in most cases they suffer silently until the situation worsens to such an extent that nothing can be done to save the teeth. Indeed, dental issues are a big problem, but in fact they are just the top of the iceberg which is the American medical system. Even if there have been serious attempts to reform the system and introduce a universal means of publicly financing medical care for all people, "Americans have fewer doctors per capita than most Western countries. We go to the doctor less than people in other Western countries. We get admitted to the hospital less frequently than people in other Western countries. We are less satisfied with our health care than our counterparts in other countries. American life expectancy is lower than the Western average. Childhood-immunization rates in the United States are lower than average." (Gladwell, 2005) Indeed, given the fact that the U.S. is considered to be the most advanced country in the world it is rather peculiar the lack of a reasonable medical care system, one that would provide assistance also for those with medium to low incomes in order to help them access more freely the hospital and clinical systems.

Attempts to reform the medical system have been made but rarely has the real issue been addressed. More often the legislature, no matter their political orientation, tried to resolve the under funding of the medical units by cutting the spending the state has with insuring staff in major hospitals or even by reducing the number of hospitals. Such initiatives have led to the current situation in which there are fewer hospitals operating with a more limited staff. This in turn forced the patient to either seek solutions for their treatment in the private sector or, more worryingly, to adopt a self-made home remedy. Eventually, there is no easy way out or a reasonable one. The reality today is that there is a reduction in hospital units and a shortage of nurse staff because of the policies undergone by all administrations from the late 60's on. (Reid, 2004)

From my point-of-view, I consider this situation rather unacceptable. I do feel that there should be a system set in place that would offer a minimum of medical assistance irrespective of the family or personal outcome. Indeed, it may encourage certain abuses, as the notion of "moral hazard" suggests insurance can change the behavior of the person being insured (Gladwell, 2005); at the same time, however, it may help some of those who cannot afford private medical insurance to get treatment because, according to different interviews taken, "almost every time we asked interviewees what their first priority would be if the president established universal health coverage tomorrow the immediate answer was 'my teeth.'"(Gladwell, 2005) therefore there is an acute need for public funding in this respect.

At the same time however, a satisfying solution could also be one that advocates a more intense public involvement in financing the medical system. More precisely, in order to have more funds to the budget, additional contributions by employees and employers should be made common and regular practice. In this way, there would be more significant financial resources to provide the medical care needed and one that would enable every person the access to a basic package of medical care.

The particular situation of the medical care system is just one of the issues a nurse must confront when entering the practice. Up to the point of graduation, there are more theoretical aspects rather than practical ones that are given increased attention. However, when dealing with real life and common situations, even if there had been discussed in class, they become important and in the beginning they represent a certain amount of difficulty. Dependent of such cases, there can be a smooth or less smooth transition from the state of graduate student to that of fulltime nurse. As Janice Ellis and Celia Hartley consider, "like most new nursing graduates, when you complete your studies, you will probably seek employment in an organization- a health care organization. This may be in an acute care hospital, a long-term care facility, an intermediate care facility, a clinic, an outpatient unit or a variety of other organizations that offer challenging opportunities. Accepting employment in a health care organization requires that you are knowledgeable about and become accustomed to the policies and procedures established by that organization. You will go through what we refer to as 'role transition', the process of assuming and developing a new role." (Ellis and Hartley, 455) The idea, seen from a more pragmatic and practical point-of-view, points out the fact that in order to adapt to an environment, one must necessarily get to know and adjust to the requirements of the respective care unit. At the same time however, there are certain aspects that can be applied to all situations in which a graduate student passes through the so called role transition period. For instance, as students, we only learn about the need to respect ethical percepts in our work; it is only when a difficult case appears that we fully grasp its importance. Similarly, the idea of impartial treatment of patient is yet another change we must adapt to. Even if in theory, it is rather easy to declare the fact that one would always treat patients equally and unbiased, it is hard to manage to make on the spot decisions over the priority of certain cases dependent of their seriousness. However, nursing is not fully engaged in on the spot decisions; still, the theoretical idea of impartiality cannot be fully respected because there are other issues such as personal preferences and sympathies that can intervene and thus interfere with the impartiality criteria.

Moreover, there are also issues of practical nature that focus on the financing of the medical care system. Once we enter the public sector, we come in contact with certain aspects of the budgetary life that we were either unaware of or we were not directly affected by it. Once we become to a certain extent dependent of them, budgetary allocation, the lack of financial sources or the exceeding funds begin to draw our attention and become an important part of our current reality. Therefore, we experience also a shift in interests and in matters affecting our everyday life. From this perspective, we can find ourselves engaged in serious discussions over the reform of the medical care system or the right of patients to be granted a minimal of medical insurance, issues that did not affect us to such a large extent before.

Another major issue that can change the focus of our attention once we become full time nurses will be, in my view, the moral and ethical debates surrounding different aspect of today's medical practices. One of these subjects has stirred a rather heated debate in recent years because it places in contrast several distinct moral and even legal issues. The right of a patient who is fighting a terminal illness to choose the way he wants to end or prolong his life has been the subject of debate and controversy.

On the one hand there are those who believe that the patient, existing in a serious state of pain and suffering, has the right to end his life, or more precisely to choose the way he wants to spend the remaining moments of it. The claim to such a right however must be seen through the perspective of the psychology a terminal patient begins to develop. Thus, according to Martin Lipp, the patient is in fact choosing how to die, being constantly aware of the imminent fact. He decides however the means because, unlike the rest of the health people, he does not have the time to experience the slow death which, again according to the author starts from the moment we are born. Thus, he justifies the behavior of terminal patients by arguing that "there are as many ways to die as there are to live. Sudden death is the exception rather than the rule; more often life continues as one is dying; thus, the issue is not how to die, but rather how to live with the knowledge that death is imminent." (Lipp, 94) Choosing to way in which to die is therefore spearing the person of time spent in suffering and pain.