Nursing Leadership Hospital Nurses

Question: Discuss about theNursing Leadershipfor Hospital Nurses. Answer: Introduction In Australia two categories of nurses are registered to practice, the first are registered nurses that are degree educated and the second are enrolled nurses that have a diploma/certificate in nursing. In the recent years nurses work in the health care settings has intensified due to patient keenness and decreased length of hospital stays. This intensification has blurred the skill boundaries of many health care roles. The recent administrative chart audits and databases have pointed towards an association between health care roles for patient outcomes, skill mix and workload division. Same goes for the work of a registered nurse and enrolled nurse but we are no where even close to consider that the enrolled nurses do the same work as the registered nurse. Now lets first understand the difference between a registered nurse and an enrolled nurse. According to the Nursing and Midwifery Board of Australia or (NMBA) registered nurses are accountable and responsible for supervision of the nursing activities of the enrolled nurses. An enrolled nurse is a second level nurse that provides care under the supervision of a registered nurse. This supervision can be indirect or direct which is according to the nature of the nursing care(Dwyer, 2011). Lets see how the work of a registered nurse is different than that of an enrolled nurse.( Jacob et al. 2012) The work of the registered nurse involves of thinking strategies in making decisions for quality care nursing. According to standard 1: thinks critically and analyses nursing practice of NMBA the registered nurse has to access and analyse various research findings in order to ensure a safe and quality care. Their practice develops through experiences, beliefs, knowledge and actions. Whereas the standard for enrolled nurses states that they have to reflect evidence based practice and show essential skills and knowledge. Standard 2: engages in therapeutic and professional relationships of the NMBA standards for registered nurses states that the registered nurse has to participate and lead a collaborative practice. This means that the enrolled nurses have to work alongside the registered nurses and demonstrate competence in delivering a person centered care. This person centered care is in accordance to the standard that entitles the registered nurse to foster a culture where health pro fessionals like enrolled nurses work towards helping a registered nurse to make health related decisions. According to the new standard for enrolled nurses they have to collaborate with the health care team members to achieve desired health outcomes. The registered nurses are regulated health professionals who are accountable for ensuring that they are always capable for practice. This is stated in the standard 3: Maintains the capability of practice of the NMBA which requires the registered nurse to self manage and respond for their professional contribution and development of others. They would help people in making decisions related to their health. They have to provide information that would enhance individuals control over his or her health. They have to possess a lifelong approach to learning in order to continue to develop professional development of self and others. They have to seek and respond to practice feedback and give reviews. The standard 4: Comprehensively conduct a ssessments of NMBA, a registered nurse has to conduct assessment that are culturally appropriate. The impact of colonization on Australia is significant which has contributed to the significant health inequality across the country. This standard ensures that the registered nurse should be able to recognize the diverse mixture of linguistic and cultural diversity in Australia. The standard 5: develops a plan for nursing practice of NMBA states that registered nurses have to develop plan in partnership with other heath care roles and is responsible for negotiating the time frame of engagement. The standard 6: provides safe, appropriate and responsive quality nursing practice of NMBA states that registered nurse has to appropriately delegate aspects of practice to enrolled nurses according to their scope of practice. Lastly the standard 7: Evaluate outcome to inform nursing practice states that registered nurses are responsible for the evaluation of other nursing practice (enrolled nur ses etc) by monitoring progress based on expected goals and the desired outcomes. They have the authority to revise the plan based on their evaluation. They have to document and communicate the revised goals to the relevant person. After closely evaluating all standards provided by NMBA for registered nurses, we can easily draw a conclusion that registered nurses are responsible for a lot more than any enrolled nurse. The role of an enrolled nurse is principle based and broad as they have to ensure that they are sufficiently dynamic for the health care settings. On 21st October, 2015 NMBA gave the Enrolled nurse standards of practice that states that an enrolled nurse has to work under the indirect or direct supervision of a registered nurse, they would be accountable for their actions and they would be accountable in providing delegated care. An enrolled nurse has to practice within their scope of practice and their own educational preparation. This proves that enrolled nurses contribute to care and planning but they do not act independently, as a registered nurse has to retain that responsibility. The national competency standards clearly gave the responsibility to the registered nurses as they have the auton omy in the practice decisions. Many researchers such as Duffield and his colleagues, Gibson and Heartfield conducted studies to determine about the activities of nurses in Australian hospitals (Duffield et al. 2005), (Duffield, Wise, 2003). A Comparison of Activities Undertaken by Enrolled and Registered Nurses on Medical Wards in Australia: An Observational Study was a study conducted by Wendy Chaboyer and his colleagues. This study was conducted on nursing staff that included enrolled nurses as well as the registered nurses that provided care, part time and full time care in the wards. In their results they found out that the enrolled nurses were performing almost double direct care than registered nurses (which included admission, assessment, patient hygiene medication, IV administration). The registered nurses were performing more indirect care activities (team meetings, patient rounds, verbal report handover, clinical pathways and care planning). This clearly supports the skill mix that the health care settin g is experiencing lately. We can see how assessment and admission which includes the physical assessment and vital signs monitoring is being completed by enrolled nurses. These findings are then interpreted by the registered nurses. Both registered and enrolled nurses were spending equal time in assisting patients with daily living and mobility. These findings along with the previous studies findings provide us the insight that models of care require teamwork. O Connell and his colleagues in the year 2006 suggested in his study that building good working relationships and exchanging knowledge among team members is crucial for team functioning in a healthcare setting (OConnell et al. 2006). The implications for patient care of enrolled nurses not working to their scope of practice can be huge. As we can highlight that there may be some similarities between the activities of the different nursing care roles but the education and experience that a registered and a enrolled nurse hold is quite different (Whitehead, Myers, 2016). Where a registered nurse is trained in the universities the enrolled nurses only have vocational training (Richardson, Cunliffe., 2003). The enrolled nurses are taught about nursing interventions and health assessment in their scope of practice but still they are expected to work under the supervision of a registered nurse. They should be only contributing to patient care not leading it any way. The registered nurses on the other hand should know about the impending complications and should intervene to prevent them. They are educated and skilled to perform these tasks. According to a study conducted by Aitken and colleagues the role of a registe red nurse should never be taken by an enrolled nurse (Aiken et al. 2002). The study conducted by Wendy Chaboyer and his colleagues showed how the enrolled nurses were performing almost double direct care than registered nurses (which included admission, assessment, patient hygiene medication, IV administration). Assessment and admission come in the observed direct care and in medical wards such as oncology etc where patients are usually admitted with chronic diseases. In many hospitals there are number of admissions where patients are old and mentally confused to properly describe their symptoms (Wiles et al. 2003). These situations need a critical decision making skills at the time of assessments. Without this critical decision making skills it is quite possible that the assessment that is made is not appropriate. It is crucial that considerate staffing is provided to ensure that adequate numbers of registered nurses are present to assess the data and also to analyse it (Pelletier, Duffield, Donoghue, 2005). It is quite possible that a enrolled nurse data can differ than the observation made by a registered nurse. Now lets take an example where both the registered nurse and enrolled nurse are performing wound dressings on a patient. Both are dressing similarly but the registered nurse is focusing more on central lines and complex incision wounds whereas the enrolled nurse is providing routine care. If the patient is from complicated surgery these dressings are of great importance for his recovery but if an enrolled nurse is caring for him, his recovery can take more time. The differences are crucial when assigning a pool or float staff and therefore staff activities should always be tailored (Spilsbury, Meyer, 2001). Another example from the study conducted by Wendy Chaboyer and his colleagues team meetings and patient rounds are an indirect care activity. But this planning requires a strong communication skills and knowledge base (Chaboyer et al.2008). Whe n planning the rosters and staffing, these characteristics in the staff should be kept in mind rather than just focusing on nurse abilities in the area. According to a recent study conducted by Aiken and colleagues with the title Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care he mentions how ensuring a good skill mix is increasing challenging for the health care systems (Aiken et al.2016 ),(Aiken et al, 2003). He states how technology and medical advancement will only increase nurse staffing requirements. According to his study the higher proportion of nurse assistants with limited training resulted in higher mortality rates. Similar results were observed in a study conducted in NHS where higher percentage of nurse assistants in comparison to registered nurses resulted in higher mortality rate. It was also seen that if there is a 10% increase in registered nurses numbers there was a 11% decrease in the patient deaths after a surgery. Each 10% decrease in registered nurse numbers increased the patient deaths by 12%. Their research suggested that su bstituting enrolled nurses, nurses assistants or any lower qualified health personnel resulted in preventable deaths or any other adverse effects on the patients.( Aiken et al. 2012) Studies like these supports the belief that hospital nursing skill mix should be cautiously monitored as this could result in life threatening or adversely affecting outcomes for the patients (Jennifer, 2014). By not implementing policies that can prevent this we are risking preventable deaths, but we need to understand that eroding the nursing skill mix can result in negative impact on the quality of care(Parker, 2004). There is a need for a respectful and collaborative partnership between the health care roles that results in a mutual trust and understanding relationship. Nurses should be competent to perform for the health needs of the people and should be accountable for the care of the people. They are accountable for their actions, behaviors, responsibilities and decisions. The nursing profession is about the human rights of the people and about the moral responsibility to safeguard the dignity of these people. Nurses should foster constructive and supportive relationships with their colleagues as they are the pillars in providing culturally and ethically competent care. References Aiken, L. H., Clarke, S. P., Cheung, R. B., Sloane, D. M., Silber, J. H., 2003. Educational Levels of Hospital Nurses and Surgical Patient Mortality. JAMA, 290 (12), 1617-1623. Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J. A., Busse, R., Clarke, H., Giovannetti, P., Hunt, J., Rafferty, A., Shamian, J., 2002. Nurses' reports on hospital care in five countries. Health Affairs, 20 (3), 43-53. Aiken, L., Sermeus, W., Van den Heede, K., Sloane, D., Busse, R., McKee, M., Bruyneel, L., Rafferty, A., Griffiths, P., Moreno-Casbas, M., Tishelman, C., Scott, A., Brzostek, T., Kinnunen, J., Schwendimann, R., Heinen, M., Zikos, D., Sjetne, I., Smith, H. and Kutney-Lee, A., 2012. Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States.BMJ, 344(mar20 2), pp.e1717-e1717. Aiken, L., Sloane, D., Griffiths, P., Rafferty, A., Bruyneel, L., McHugh, M., Maier, C., Moreno-Casbas, T., Ball, J., Ausserhofer, D. and Sermeus, W., 2016. Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care.BMJ Quality Safety, pp.bmjqs-2016-005567. Chaboyer, W., Wallis, M., Duffield, C., Courtney, M., Seaton, P., Holzhauser, K., Schluter, J. and Bost, N., 2008. A comparison of activities undertaken by enrolled and registered nurses on medical wards in Australia: An observational study.International Journal of Nursing Studies, 45(9), pp.1274-1284. Duffield, C., Forbes, J., Fallon, A., Roche, M., Wise, W., Merrick, E. T., 2005. Nursing skillmix and nursing time: The roles of registered nurses and clinical nurse specialists. Australian Journal of Advanced Nursing, 23 (2), 14-21. Duffield, C., Wise, W., 2003. Tell me what we do? Using work sampling to find the answer. Australian Journal of Advanced Nursing, 20 (3), 24-26. Dwyer, D., 2011. Experiences of registered nurses as managers and leaders in residential aged care facilities: a systematic review.International Journal of Evidence-Based Healthcare, 9(4), pp.388-402. Jacob, E., Sellick, K. and McKenna, L., 2012. Australian registered and enrolled nurses: Is there a difference?.International Journal of Nursing Practice, 18(3), pp.303-307 Jennifer, S., 2014. Skill mix, not numbers, is the most important issue, says chief nurse.Nursing Standard, 28(19), pp.9-9. Richardson, A. L, and Cunliffe., 2003. New horizons: the motives , diversity and future of nurse led care. Journal of Nursing Management, 11, 80- 84. Nursing and Midwifery Board of Australia. (2015) Supervision guidelines for nursing and midwifery. Retrieved 25 September 2015 OConnell, B., Duke, M., Bennett, P., Crawford, S., Korfiatis, V., 2006. The trials and tribulations of team-nursing. Collegian, 13 (3), 11-17. Parker, J. M., 2004. Nursing on the medical ward. Nursing Inquiry, 11 (4), 210-217. Pelletier, D., Duffield, C., Donoghue, J., 2005. Documentation and transfer of clinical information in two aged care settings. Australian Journal of Advanced Nursing, 22 (4), 40-45. Spilsbury, K., Meyer, J., 2001. Defining the nursing contribution to patient outcome: lessons from a review of the literature examining nursing outcomes, skill mix and changing roles. Journal of Clinical Nursing, 10 (1), 3-14. Whitehead, L. and Myers, H., 2016. The effect of hospital nurse staffing models on patient and staff-related outcomes.International Journal of Nursing Practice, 22(4), pp.330-332. Wiles, R., Postle, K., Striner, and Walsh, B., 2003. Nurse-led intermediate care: patients perceptions. International Journal of Nursing Studies, 40 61 71. The NMBA Competency Standards for Nurse Practitioners, Registered Nurses and Enrolled Nurses The NMBA National Framework for the Development of Decision-Making Tools for Nursing and Midwifery Practice