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Nursing Ethical Law Employment
The aim of this assignment is to critically analyse the future roles of nurses as professional. Caulfield (2005) identifies four pillars that make up a framework of professional accountability, deriving from different types of authority in nursing practice; professional, ethical, law and employment.
Due to the word restrictions, the main focus of this assignment will be on the roles and professional accountabilities of registered mental health nurses also known as psychiatric nurses in relation to clause 2 of the Nursing and Midwifery Council (NMC) (2004) Code of Professional Conduct; `respect patient as an individual`. The reason for choosing the psychiatric nurses is a result of being a mental health student nurse.
Nursing has become increasingly professional with higher academic requirements and a growing evidence-base to support practice. At a fundamental level, professional practice is about the expectation of a nurse who is registered with a professional body; NMC and clearly no one can claim to be a professional without a body of knowledge established by the NMC (Jasper, 2006). Edwards (2005) claims that the primary aim of `Project 2000` was to promote nursing as a profession and nurses were expected to accept greater accountability for their actions. This indicates that the call for nursing to become a profession in its own right can be viewed as an attempt to give nursing a clearer identity, as it was traditionally viewed as to carry out doctors` orders or subordinate to doctors.
The Chief Nursing Officer (will be referred as CNO) of Department of Health (DOH, 2006) asserts that mental health nurses are acknowledged as the backbone of the statutory mental health services in England and it is important that the profession is supported and has a clear direction and sense of its future role. In addition, NHS careers (2008) claims that mental health nursing is one of the most complex and demanding areas of nursing and as many as one in three people are thought to suffer some form of mental health problems.
However, there has also been criticism regarding the roles of mental health nurses such as custodial role within in-patient services, for example, stopping patients from leaving the ward without approval (Gournay, 2005). Jones & Harborne (2005) argued that the traditional methods of delivering psychiatric care have often been criticised for the lack of attention to professional roles and expectations, for example, focusing mainly on the medical model. Despite the anecdotal accounts, the contribution of mental health nurses is greatly valued by service users (Morrissey, 2003).
Recently there has been an increased emphasis on the role of the mental health nurses gaining additional therapeutic or technical skills such as psychosocial interventions and nurse prescribing, a drive that appears to be interpreting nursing as an exclusively evidence-based profession (Till, 2007). Brimblecombe et al (2005) asserts that prescribing medication is just one of the ways that mental health nurses are extending their role and this will potentially improve services by allowing patients quicker and more effective access to medication.
Despite of increasing evidence that nurse prescribing is safe and effective, there are only 487 mental health nurse prescribers on the register out of a total of 37,683 nurse prescribers (Snowden, 2006). This indicates that psychiatric nurses have not yet found a systemic way of embracing nurse prescribing. Therefore, there is a need to maximise their contribution and meet the very real demands placed on the health care system, by societal, political and technological changes, if they are to respond to service users` and carers’ expectations (DOH, 2007).
Over the last few years there have been many opportunities for psychiatric nurses to take on new roles such as nurse consultant and modern matron and due to the changes in the mental health law, psychiatric nurses may take on roles previously held by other professionals to allow patients to have the most appropriate person involved, such as approved mental health professional similar to approved social workers (DOH, 2006).
Therefore, it can be argued that the roles of psychiatric nurses are changing as a result of government policies and initiatives, such as the CNO review of mental health nursing (2006), as this was carried out in order to answer the question, ‘How can mental health nursing best contribute to the care of service users in the future? To support this argument, Brimblecombe & Nolan (2008) emphasise that the CNO`s consultation provides a unique chance for psychiatric nurses to help shape the future of the profession and encourage nurses to take up this opportunity to provide ideas for developments in the future and highlight current examples of good practice. It implies that the roles of mental health nurse not only demand adherence to NMC (2004) codes of practice but also to national legislation and guidelines.
The NMC (2004) clearly states that registered nurses are personally accountable for their practice and actions regardless of advice or directions from other professionals. This indicates that although a nurse may delegate responsibilities to others, the accountability remains with that nurse and it puts clear responsibilities on nurses to justify their decision-making. Therefore, it is crucial for psychiatric nurses to rely on analytical principles to justify their professional decisions, as the nursing profession requires greater accountability and the use of evidence-based practice. NMC (2004, clause 2) states that a professional nurse must `respect patients as individuals`, by recognising and respecting the role of patients as partners in their care and to involve them in any decisions being made. This is a current ethos of modern mental health care set out in the National Service Frameworks for mental health (1999), which is concerned with working in partnership with patients and carers.
The aim to respect patients, as individuals will not be realised without effective communication skills. Research suggests that nurses have poor communication skills particularly when sharing information with mentally ill patients (Stickley & Freshwater, 2006). In addition to empathy, respect and non-judgemental approach, the application of Egan’s model; `sit squarely, open posture, lean forward, eye contact, relaxed and unhurried appearance`, (1998, cited in Smith, 2007 p 48) in mental health settings can help nurses to look attentive.
It appears that, this can encourage patients to disclose issues that they may normally find difficult to discuss. However, non-verbal communication can also be misinterpreted by patients with certain mental health problems, such as persecutory ideas (Dexter & Wash, 2001). Therefore, an awareness of verbal and non- verbal communication skills are paramount when interacting with mental health patients. Moreover, nurses not only need good communication skills but they also need to have an environment conductive to open communication as this can inhibit the application of communication skills.
Working in partnership is crucial for psychiatric nurses as Mitchell & Selmes (2007) claimed that over the course of a year about 75% of patients will discontinue prescribed antipsychotic medications, often coming to the decision themselves. Chaplin (2007) claims that enhancing patients` concordance with medication regimens is one of the challenges facing all mental health professionals.
However, Jasper (2006) emphasises that increased involvement by patients in their care and shared decision-making have the potential to improve concordance with treatment plans. Therefore, recognising the individuality of patients requires that the role of the patients as partners in their care must be respected in order to achieve a patients-led NHS and psychiatric nurses can achieve this by identifying with patients their preferences for care and respecting these within professional and legal limits, as there is widespread recognition that patients are experts about their own illness.
For example, discussing choice of pharmacological treatments with patients that best support their recovery goals. Providing meaningful choice is a core component of a therapeutic relationship, as many mental health patients are often excluded from shared decision-making (Hemingway, 2003). Moreover, the CNO (2006) recommends that service users should not only be involved in treatment decisions but also in the four key areas of the educational process for mental health nursing student: recruitment, curriculum planning, teaching and assessment.
For people with enduring mental health problems medication is not the sole focus of intervention (Till, 2007). It is crucial for mental health nurses to assist patients to improve their quality of life by providing information and support relevant to their health and social needs (NMC, 2004). This means working towards the aims that are meaningful to patients and promoting social inclusion, which can be seen as a mean of engaging with patients and also creating an environment of therapeutic trust and hope.
According to Harrison (2004) one approach towards maximising patient involvement is the use of advocacy and it is an essential feature of nurses` accountability. In the role of advocate, mental health nurses have a statutory duty for promoting patients` right, by facilitating patients to appeal against their detention under the Mental Health Act (1983). Conversely, psychiatric nurses also have the statutory power under the Mental Health Act (1983) to detain patients who are seeking to leave the hospital using the nurse’s holding power or to administer treatment under Part IV of the act (Norman & Ryrie, 2004).
Advocacy can also take place by representing patients` views and concerns in the ward rounds or in the care programme approach (CPA) meeting, where patients might find it difficult to express their concerns due to the presence of several professionals (Edwards, 2005). Being patients` advocate implies that nurses have a primary responsibility to protect patients` interests and to assist them in communicating their subjective experiences with others. This is reinforced by the NMC (2004) as nurses have the professional responsibility to act in the patients` best interests. However, one has to be careful when considering ‘best interests’, as there is a risk that this can lead to paternalism if one is operating from the traditional perspective of ‘we know best’ (Brimblecombe et al, 2005).
In order to achieve a person-centred care, mental health nurses should take a holistic approach, which must reflect patients` psychological, physical, social, cultural and spiritual needs (DOH, 2006). Nash (2005) claims that the physical health of people with mental illness is a current concern in mental health care. Therefore, this indicates that psychiatric nurses should also be reflective of physical care skills training and not only training linked to mental health care practice and the philosophy of holistic care in mental health must embrace physical and diversity needs just as it embraces psychological needs. Essence of Care benchmark for promoting health (2004) provides one useful tool to help psychiatric nurses to take a service user-focused and structured approach to share and compare practice, as it enables nurses to work together with patients and carers to identify best practice and to develop action plans to improve care.
According to the NMC (2004) nurses are expected to take a value free approach towards patients in promoting and protecting the interests and dignity of patients at all times irrespective of gender, age, race, ability, sexuality, economic status, lifestyle, culture and religious or political beliefs. This creates a rewarding environment for patients because they will be treated equally without any discrimination, as the function of NMC is to inform the public, other professions and employers of the standard of professional conduct that they can expect of a nurse, by maintaining a register of all eligible registrants to practice in the UK.
This indicates that the NMC (2004) Code of Professional Conduct outlines the professional accountabilities of registered practitioners and ensures that practitioners provide high standards of care to their patients. Moreover, it is evident that the NMC (2004) code of professional conduct is not simply a guide but a means of regulating the nursing profession.
The transition from being a student nurse to a newly qualified nurse can be very stressful and challenging (Wood, 2007). Therefore, an action plan is crucial to overcome any difficulties. As a newly qualified nurse it will be compulsory to adhere to the NMC (2004) codes of practice, national legislation and guidelines, in order to practice as a professional nurse.
As a mental health nurse, good communication skills will be paramount; this can be achieved by respecting patients` autonomy and by adopting a non-judgemental approach. In order to respect patients as individuals, it will be essential for me to involve them in the decision making process of their care and to achieve a person-centred care will require moving beyond the traditional focus on medication by providing information and support relevant to their health, cultural and social needs as a patient advocate.
Demonstration of my professional competence will be a crucial element of being a registered nurse. This will be achieved by compiling an ongoing portfolio to fulfil the NMC (2006) requirement for the post-registration education and practice (PREP), as it requires all practitioners on its live register to demonstrate their fitness to remain eligible to practice.
The portfolio will contain of attendance certificates of in-house and external training such as awareness of diversity and cultural needs, social inclusion and medication management, reflective reviews of what I have learnt and how this will inform my practice, such as communication skills with mental health patients, notes of clinical supervision meetings, appraisals and written critical incident analysis by maintaining confidentiality.
As NMC (2006) advocates continuing professional development as a method of improving patient care, the portfolio will also assist me in identifying the areas that need improvement for example, the implications of the new Mental Health Act 2007. Initiatives such as Knowledge and Skills Framework will assist me to make coherent plans for the future to improve personal development plans and this will facilitate me to move through the gateway of Agenda for Change. Moreover, I must recognise that development of relationships with other staff is fundamental to social and professional integration. Therefore, being part of a team is not just about patient care but also about support from other members of the team to develop new skills.
In conclusion, nurses can be seen as professionals, as all qualified nurses are personally accountable for their actions and must work within the NMC (2004) Code of Professional Conduct. Moreover, a nurse can be removed from the registration if there is a violation of the code of conduct. To meet the current and future challenges in nursing, the roles of psychiatric nurses are evolving, by recognising that each person has individual needs and taking such action is necessary to work in partnership with patients.
To meet the individual needs it requires specialist use of the professional nurse-patient relationship, incorporating skills of an interpersonal nature and dealing with the issues that may arise within such relations. Respecting patient as an individual is a core principle of the nursing profession and modern mental health services must be planned and delivered around the needs and aspirations of patients. Mental health nurses should be committed to their own personal and professional development as nursing practice is continually changing and expanding to meet complex needs. To ensure safe and effective practice, the NMC professional portfolio is designed to demonstrate that nurses are caring for patients safely and to the highest standards.
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