Analysis of Nursing Ideologies: Leg Ulcers and COPD Case

Professional Studies Essay

The aim of this essay is to address various professional nursing ideologies and how they can be applied to nursing practice. This will be undertaken in order to assess the author’s knowledge and understanding of the various themes of the Professional Studies module. In order to assess knowledge and understanding this essay will answer three questions, each pertaining to particular strands of professional studies. These include factors that can influence the promotion of evidence-based care, the philosophy of caring and managing the delivery of care. Examples of practice used in this assignment will be from published research. The answers given will be supported by research pertaining to the treatment of venous leg ulcers and chronic obstructive pulmonary disease (COPD).

It is suggested that evidence-based practice (EBP) or evidence-based care is a high point on political and professional agendas (Wright, 2001, p198) having gained popularity in health care following concerns over the continued use of practices based on tradition or habit, rather than evidence of their efficacy (Flaherty, 2001, p4). EBP contrasts with this in that it intends to promote treatment and care that is based on systematic evaluation of the evidence of the effectiveness of interventions. It is suggested that the Department of Health (1998, p17) has adopted the principles of EBP, changing the focus from individual staff seeking to identify the best course of action in given clinical situations to national initiatives to minimize variations in healthcare provision across regions, developing national standards of health care and debatably determining what is deemed the most effective use of finite NHS resources. However, it is argued that the implementation of the national standards of health care which are in the form of guidelines issued by organisations such as the National Institute for Clinical Excellence (NICE) are often delayed (Shannon, 2003, p1368). Debatably, this is a result of various factors such as lack of finances, time, inclination to change and lack of conviction that change will be beneficial. Having said that, it is important that nurses understand what theoretical knowledge is needed in accessing and selecting evidence for use in supporting practice.

It is recommended that nurses, who employ evidence-based care, recognize the distinction between EBP and research-based practice. EBP acknowledges that even where there is an absence of empirical research, evidence in the form of case studies or expert opinion might exist that can inform practice (Hewitt-Taylor, 2003b, p43). In addition, arguably not all research is of high quality, and practices may be described as “researched-based”, even where the research upon which they are based is not of a good standard, or not intended to be applied in a particular setting.

Theoretically, EBP is concerned with gathering all the available evidence, evaluating the evidence and deciding what would constitute the best approach to a particular aspect of care in a given clinical situation (Hewitt-Taylor, 2003b, p44). The evidence that can be used includes research, consensus expert opinion, cost and patient preferences (NICE 2003, p3). It is suggested that as well as taking into account a variety of sources of evidence, the use of EBP with health care involves the ability to evaluate the quality of all these forms of evidence and there application to certain clinical circumstances. Therefore, it is proposed that nurses need to be able to critically analyse all of the proposed evidence that is to be used before employing evidence-based care to practice.

It is also suggested that nurses need to have knowledge of the individual component skills of evidence based-practice. These include research and information technology skills, awareness of major information types and sources, as already mentioned, the ability to analyse critically evidence against set standards, dissemination of new ideas about care to colleagues and the ability to review own practice (Cranston, 2002, p39).

As previously mentioned, nurses need to have the knowledge and skills to be able to identify and analyse which evidence is most appropriate for a given clinical situation. Therefore when implementing EPB in a care situation it is important to understand that research evidence is only one part of the picture when considering clinical decision making. For instance, at present there is good quality research evidence which indicates that the most effective treatment for uncomplicated venous leg ulcers is the application of compression bandaging (RCN Institute, 1998, p7). It is suggested however that research evidence cannot yet point to the best type and method of bandaging to apply. Therefore, individual nurse clinical experience and the patient’s preference in terms of comfort of bandaging will come into play when making a decision about the best way to treat the leg ulcer. It is debated that it is essential for nurses to understand that arguably very few treatment interventions or nursing practices have a purely research evidence base from which to direct practice (Cranston, 2002, p40).

Therefore, it is argued that nurses must also be able to draw on all aspects of evidence, including patients’ and families’ perspectives, the results of research, and their own and colleagues’ expertise to reach the best holistic, person-centred care for each patient (Howitt & Armstrong, 1999, p1324). Apart from the importance of holistic care and person-centred care, the theory of caring is also a key issue relevant to the advancement of nursing.

It is proposed that in recent years several issues pertaining to the development of nursing knowledge have been addressed. Debatably, these include uncovering phenomena considered central to nursing and nursing theories and models that have emanated from them (Chinn & Kramer, 1995, p24). One important concept within nursing that is gaining increasing attention in nursing literature is that of caring (Kyle 1995, p506). A range of theories have been presented in nursing literature that have caring as a central concept and are based on a human science perspective. One of these theories is that of Simone Roach’s (1992) theory on caring. In her writings she discusses the uniqueness of caring, arguing that caring is not unique to nursing but it is unique in nursing. Furthermore, she presents the idea that this one concept includes the “essential characteristics of nursing as a helping discipline” (Roach, 1992, p12). The main concepts of this theory are the attributes of caring, or the five Cs. Roach perceived the five Cs as “a broad framework suggesting categories of human behaviour within which professional caring may be expressed” (Roach, 1992, p69). The five Cs are defined as compassion, competence, confidence, conscience and commitment (Roach, 1992, p19). It is acknowledged that it has been difficult to find any practical examples of Roach’s work. This could be due to the fact that it is not formally considered a theory for nursing.

Debatably, while the five Cs including are essential to caring within nursing, it is proposed that the third C, confidence is required to enable the nurse to deliver holistic care. (Roach, 1992, p63) defines confidence as “the quality which fosters trusting relationships”. In Roach’s writings she accentuates the need for a ‘caring confidence’ between the nurse and patient that promotes a trusting, truthful, equitable and respectful relationship that happens without any attached conditions, misrepresentations, anxiety or subjection (Roach, 1992, p64).

In a practice setting, it is suggested that if patients cannot feel that the staff are being truthful and candid in their contact with them they will not trust or believe in them. Debatably, at the center of patients’ making informed choices is that nurses are honest and give truthful information, therefore, if they do not perceive honesty the patients’ cannot be sure they are making the right decisions. It is essential that nurses trust in their own abilities and they need to possess confidence in their own skills and judgements and as well as knowing their limitations (Fry, 1989, p9, Pusari, 1998, p6).

With this in mind it is proposed that nurses could use the Johns’ Model of Structured Reflection (1994, pp71-75). Arguably, this model can help the nurse reflect on the above factors that constitute confidence in caring. The model asks questions that allow nurses to reflect on their abilities, actions and what they tried to achieve in a given clinical setting. It helps nurses to reflect on how they responded as they did in a care setting and if they could have dealt better with the situation. On reflection the model might help nurses to have the confidence to care in a holistic, person-centred, knowledgeable and reflective manner.

It is suggested that in order to manage the delivery of holistic, patient-centred care, that care needs to be of high quality and performed within current policy guidelines. Delivery of healthcare can be undertaken on three levels: primary, secondary and tertiary care (Royal College of Physicians (RCP), 2001, p292). It is proposed that the delivery of COPD care can be undertaken at all levels of care; however, it is argued that COPD care is normally managed within primary and secondary care settings. Patients suffering from COPD can access primary care from there General Practitioner (GP). Some GPs might have an interest and an expertise in the management of COPD and therefore could provide specialist nurse-led clinics within their surgeries. Secondary care for COPD sufferers is normally a hospital-based service whereby patients have accessed this level of care either from a referral from their GP of through Accident and Emergency. It is proposed that most district general hospitals have a highly trained respiratory medicine team (RCP, 2001, 292).

One example of managing the delivery of COPD within primary care is that of the introduction of Quality Outcome Framework (QOF) practitioners. Arguably, this is a major incentive to improve primary care COPD management and the QOF for COPD became part of the General medical Services Contract (Booker, 2005, p33). Debatably, the QOF targets can form the basis of good COPD management as in most cases; evidence-based rationales were used for the inclusion of particular targets such as smoking cessation advice. However, it appears that in some areas the QOF and the NICE guidelines disagree on the management of COPD care. The NICE guideline suggests that reversibility testing is not routinely necessary for initial diagnosis (NCCCC, 2004, p1), but the QOF requires spirometry testing plus reversibility testing as a premise for diagnosis. Evidence suggests that reversibility testing to a single, “acute” dose of bronchodilator is not reproducible and can be misleading. It is suggested that the majority of COPD cases can be accurately diagnosed from the clinical history and then confirmed with spirometry testing (Calverley, 2003, p659). Debatably, despite the disagreements between NICE guidelines and QOF, the QOF scheme is a good starting point and arguably, has served to increase the profile of COPD in primary care.

Nurses need to understand and become knowledgeable about professional nursing theories and ideologies. Person-centred holistic care is often based on clinical evidence and research. It is important therefore that nurses can appreciate the usefulness of evidence but also be conscious of the relevance of the evidence in everyday practice. Nurses need to be able to critically analyse any evidence-based research or guidelines for its effectiveness in practice. Knowledge of the theories of nursing can help enhance practice by understanding key concepts pertaining to care and delivery of care. Reflection as a concept within care is important for developing safe, quality, holistic, patient-centred care. In contemporary nursing managing the delivery of care is often guided by current policy. Nurses need to be aware of the current care guidelines that plan their care actions. It is important to note that clinical care guidelines can enhance patient care by providing rules on ethical, safe and quality care. However, it is important to note that guidelines are there for the safety of the healthcare profession as well as the patients.

References

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