al., 2010). Nursing and the ER

The Emergency Room is often one of the most visible parts of healthcare for political debate. It is also one of the most difficult environments for a modern nurse. It is interesting that one of the founders of modern nursing had emergency experience prior to developing her overall theories. Nightingale also looked at negatives and positives that are the conditions, which could help make people recover and reach their actual potential, as also noted by Maslow hierarchy of needs. She did not look or speak directly of the disease per se, but rather, looked at air, clean water, environment, and sanitation. She published her book in1860 with the title a "Notes on Nursing: What it Is and What it Is Not," connecting human beings and quality of human life, and comparing the stagnant sewage she saw in Scutari, as well as in London. She wrote, "I have met a strong stream of sewer coming up the back staircase of a grand London house from the sink as I have ever met in Scutari."? This is probably still true to date. She talked about the negative influences such as apprehension, uncertainty, waiting and expectation, and fear of surprise can have on patient. This could be compared to the current waiting in an emergency room not knowing how serious the injury was, or even having any information. The prominent example is that of the patient who died in the Emergency Room at Bellevue Hospital earlier this year while waiting to be seen by a doctor. Her most negative health determinants were stagnant water, second hand smoke, air pollution, isolation, and impoverished conditions. The positive determinants were caring and compassion, healthy literacy, sense of family, nurtured infancy, clean water, and excellent nursing care. (Beck, 2005, 142).

Further, emergency room nurses have varying degrees of experiences when at work, most of them highly stressful. One example is of vulnerable populations, those with some form of intellectual disability for instance; including the poor, homeless, or those disenfranchised individuals who are vulnerable. In a study of 23 emergency rooms, for instance, nurses perceived care for the ID patient to be difficult at best, primarily due to communication difficulties. Nurses felt that they had little time to be dealing with outside issues when their own task were so rigidly controlled. However, life expectancy and number of ID patients using ER services is increasing, pointing to a need for increased levels of training in communication with alternative populations (Fisher, et.al., 2009).

Nurses report that one of the biggest issues for them in an ER setting is the issue of patient centered care. Certainly, the modern healthcare professional's role is not limited to only assisting the doctor in procedures, however. Instead, the contemporary professional takes on a partnership role with both the doctor and patient as advocate caregiver, teacher, researcher, counselor, and case manager. The caregiver role includes those activities that assist the client physically, mentally, and emotionally, while still preserving the client's dignity. In order for one to be an effective caregiver, the patient must be treated in a holistic manner. Proper communication and advocacy is another role that the modern caregiver assumes when providing quality care. For the purposes of our essay, the two terms, advocacy and communication, are often interchangeable, since one is the result of the other, and vice versa (Kozier, Erb, & Blais, 1997).

At the heart of healthcare as an institution is, of course, the need to care for the sick and the injured. However, in the contemporary model of healthcare, effective communication during a crisis is not only important, but also vital. Communication by healthcare professionals takes the concern and worry out of the situation; offers a quicker resolution, makes better control of information possible, earns the trust of the public and individual families; and keeps the flow of information consistent and accurate, thus averting potential external problems. Technology has increased the ease and ability for adequate communication -- there are more translators, access to databases, etc. within the field, and certainly there is more information about healthcare available for the layperson. However, the manner in which modern medicine works -- the reality that it is the nurse as opposed to the doctor who tends to follow the patient throughout their care, lends greater credibility to the use of the modern nurse as a paradigm for successful communication and patient advocacy (Nemeth, 2008).

It is a given that the modern nurse will have a far greater exposure to new medical methods, pharmaceutical...

In fact, "the use of clinical judgment in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability, until death" is one of the definitions of modern nursing (Royal College of Nursing, 2003). In fact, with such a vast amount of clinical information needed, combined with the stress of a busy hospital, and the various insurance and legalities to be considered, many contemporary nurse managers find that it is helpful for the modern nurse to utilize a "medical checklist" to improve patient care (Hales, 2008).
In the contemporary world, it is important to note that a more holistic approach is preferable, seeing the patient as more than their disease, and advocating for that patient's proper care and assistance when they are unable (Kozier, Erb, & Blais, 1997). One of the more critical approaches to the rubric of patient care and advocacy is the Theory of Human Caring, by Jean Watson. This book represents a needed, but dramatic, shift in the modeling of patient care, and remains controversial still. Watson's theory formed the basis of modern nursing theory and some of the ideas she epitomizes have become part of other theories, among them Marilyn Ray's "Theory of Bureaucratic Caring for the Nursing Practice." Some of Watson's material came from a previous theoretical maxim, that of the "Self-Scare Deficit" based on the book Nursing: Concepts of Practice (Orem, 1971, 2001). Over the past three-four decades the very idea of patient centered nursing practice has evolved to be the standard in care -- advocacy, concern, communication, and the ability to treat patients with appropriate ethical standards. These same nurses see that a contemporary Emergency Department simply cannot function without the use of a model that addresses all needs -- patient, nurse, physician, healthcare institution, and societal model.

This model, the Health Psychology Model, has three key objectives: 1) to provide adequate and holistic care for the patient, 2) to provide communication and advocate solutions for the patient, and 3) to balance the necessary structure of cost control and ethics when dealing with modern issues in healthcare. It is this conglomeration of the tactical/strategic and holistic/advocate role that is the most ethical manner in which decisions can be made under the system of managed care, as well as the need to balance healthcare decisions with finite fiscal objectives. The nursing literature, particularly that on nursing in emergency and stressful units, about the way patient advocacy balances out the paradigm of nursing while still supporting cost-based care (Schroeter, 2000). Not everyone agrees that it can be quantified in the ER scenario though, since there are varying degrees of advocacy based on certain presumptions (Bennett, 1999). The nurse's role as a patient advocate is to "inform patients of their rights in a particular situation, to support patients in the decision they make, and to intercede when there is a need to protect the patient's rights" (AORN, 2003).

Client communication/advocacy is the application of skills, information, resources and action to speak out in favor of causes, ideas, or decisions to preserve and improve the quality of life for those who cannot effectively speak for themselves. Tyson (1999, p 64) defines patient advocacy as "the act of educating and supporting clients so they can make the best decisions possible for themselves. Nurses frequently encounter patients that feel emotionally powerless, vulnerable to the system, and unable to assert themselves. Thus, the role of the nurse as a client advocate is there to protect the rights of patients. Advocacy has become a concept in nursing practice that is misunderstood and often overlooked by nurses practicing in the role of the caregiver. Professional registered nurses have a duty to protect their patients and have an ethical obligation to act in any instance in which patients may be in danger. The aim of this analysis is to explore operational definitions of the theoretical concept of advocacy in the hospital setting, while retaining the ethical nature of the profession (Butts, et.al., 2007). Advocacy in communication combines two-way or three-way dialog for information dissemination and the proper manner of advocacy necessary.

Within contemporary nursing, particularly in Emergency Medicine, the realities of budgets and staffing may seem overwhelming. Nevertheless the primary goal of the ER nurse is to act as an advocate for the patient -- often because they are in…