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Nurse, a multitask angel, is always caring for the sick, public, patients and their families , helping with the management stuff and assisting other health care providers in order to provide holistic quality care through teamwork and caring service. This eventually brings to confusion and conflicting opinions as the professional identity of nursing become unclear and the blurring of boundaries are existing inadvertently. Barber (2002) commended that the traditional professional identity of nursing might be lost in the context of the expanded role by the nurse. The nurse tends to pass the traditional nursing role to others junior staff or healthcare assistants whenever they extended their scope of practice which usually done by doctors.
As many others hospital setting, the problem in my working area are lack of doctors and the nurses appear to be the largest group in the health setting. The article( Star on line) (2010) reported that in Malaysia, the doctor and patient ratio is 1:940 in year 2009 and the nurse patient ratio is 1:645 in year 2009 and 1:375 in year 2010 as reported in The Star on line (2008). Thus, In the context of lacking of doctors, the nurses tend to takeover the expended role voluntarily as they are willing to learn and developing themselves.
The expanded role usually performed by the staff in my ward is cannulation, this happened whenever the doctors are busy covering a few wards during night duty. No doubt it actually greatly increased their burdens, but they do have their key role in coordinating patient’s care and look after them from the organizational turbulence. Rushforth & Mc Donald (2004) had done a survey on the expanded role of nurses on procedure such as IV admistration, Cannulation, ECG recording, Defibrillation and Prescibing, they found that on cannulation alone are performed by over 50% of the nurses in the respective area.
The female medical ward which has 35 beds is a busy ward and one of the highest admission rate in the hospital, the turnover rate is high as the number of admissions. The bed occupancy rate was xxx% and a total number of xx patients were admitted in 2009. The average length of stay was xx days, the ward has divided into five cubicles and 2 isolation rooms for the patient either receive chemotherapy and cases of Methicillin Resistant Staphylococcus aureus (MRSA) and Extended Spectrum Beta Lactamases ( ESBL).
The total number of nurses in my unit are 27 and eight out of them are senior staff nurses. Most of the patient admitted is due to hypertension, diabetes mellitus and anemia and they need the cannulation for the continuation of injection antibiotic, maintenance of fluid to prevent dehydration and blood transfusion purposes. In this paper, I will discuss the crossing boundary in the context of cannulation being done by nurses. Although the senior staffs are given the authority by doctors in performing the cannulation to the patients, sometime they are facing the situation of the role uncertainty and decision making in expending their role.
In the United Kingdom, the neonatal nurse are given the title of ” Advanced Neonatal Nurse Practitioner” after completed the course, they are able to perform the duty as the junior doctors competently and efficiently in handling the cases of the high risk infant as described by Dilon & George ( 1997). The diabetes specialist nurse provide the need of the patient relating to diet control, self monitoring and treatment as illustrated by Loveman et al ( 2003). Similarly in Malaysia, the diabetes nurse who are educating the diabetes patients and neonatal nurse who are taking care of the newborn infant are not given the title such as nurse practitioner, advanced nurse practitioner and clinical specialist nurse. Those nurses are undergone specialized post basic training and most of them are quite senior but always been referred as neonatal nurse, diabetes nurse, stoma nurse, critical care nurse and so on.
Nancarrow (2004) illustrated that increasing in the overlapping of the extended role is result from the growth of the interprofessional practice and training. It happened among nurses and others healthcare providers such as doctors, dietician, pharmacist and physiotherapist which has brings to the establishment of the new nursing roles. However, Cameron (2010) has found that the senior nurses felt empowered in expanding their role and appear to be more acceptable about flexible work and multi-skilling to improve continuity, efficiency and effectiveness of patient care compare to the junior staffs who felt more stressful in the expanded role. As a nurse, I think this is due to the complex situation because of time constrain, lacking resources available nor in the nursing curriculums or workplaces.
I am working as a staff nurse in a medical ward and have 18 years of experience. From my experience, I noticed that the senior staff frequently making recommendations regarding patient care and they do influence decision making by providing related information about the patient. This is always happened spontaneously during the interaction in between the nurses and the doctors.
In my practice setting, the ward are monopoly by doctors because of they are seen owing full professional status by having exclusive theoretical knowledge which enable them to control over nurses. However, the junior doctors are rotating every three month and they are relied on the senior nurses for guidance on the aspects of ward practice and the details of local protocols. For instance, in the treatment decision, they will seek for the nursing advice about drug dosages if they are unclear.
Jones (2007) has described boundaries can be known as ” Interfaces, clear dividing margins between different ownership’s areas or shared areas of contact” . The blurring boundaries that commonly happened in my ward is cannulation which is supposed to be performed by doctor but it is done by the senior nurses in the ward. It frequently happened during night duty, usually there are only one specialist on call, one medical official and one junior doctor on call, one senior staff nurse with post basic and two junior staff nurses are on duty. The junior doctor is responsibilities to cover a few medical wards included acute medical ward which has a few ill and ventilated patients. The problem arise whenever the nurses facing difficulties in getting the junior doctors to come to the ward to set cannula resulting the burden has increase to ward staff. The nurse must undertake the cannulation themselves either in providing the continuity of circulatory antibiotic levels or to ensure the maintenance of adequate fluid status for the patient. However, Tye and Ross (2000) has illustrate that an evaluation done by the key stakeholders within the organization indicates that the extended role of the nurses may culminate in uncertainty, individual variation and a perception of a blurring of role boundaries.
Hoder and Schenthal (2007) described that professional boundaries are defined as limit-lines protection in between the nurse and the patient. The demand for professional boundaries has increasing drastically in nursing profession, resulting the limitation must be set to ensure a safe, therapeutic connection among the nurse-client relationship. An essential component of competent and ethical nursing care is required in providing better services and reducing underlying conflict. It is the responsibilities of the nurses to establish and sustain the professional relationship through the guidance of code of ethics and professional standards.
Most of the nurses in my ward are facing with the challenges even though they are given the authority in setting the cannula, this is because they have to make difficult decisions and facing uncertainty whenever they are dealing with difficult situation. In minimizing the uncertainty, they are practicing a few routes to ensure the best services are delivered to the client.
First, through the documentation of evidence based practice on client preference, the nurse must get the consent or agreement from the client before delivering the services to him/her. Besides that, the NNIA ( National Nursing International Audit) are implemented to ensure the current practice did not increase infection and insertion site phlebitis, the audit is carried out by the nursing team in my practice area every twice yearly.
Secondly is the source through SOP( Standard Of Procedure) and protocol or guideline that is easily accessible for nurses as referral when need. The nurses are practicing the proper hand washing technique and performing the procedure under aseptic technique to avoid infection during performing the cannulation for client.
From a professional perspective, the Code of Professional Conduct for nurses (1998) states that individual nurses have a responsibilities to keep up with advances in health practice and maintain their competence in nursing knowledge and skills. Aveyard and Sharp (2009) illustrate that by performing the latest evidence based practice is able to protect the healthcare provider from any legal proceedings.
The third source is the intuitive knowledge that emerged from the past experience. Benner (1984) has described a nurse must passes through five stages that is from novice to expert. Although the contribution of knowledge has been acknowledge in clinical practice, most of the credibility is subjected to biasness. This is supported by Romyn et al (2003) said that credibility must base on knowledge that used to be critique and scrutinized.
In order to perform the task of decision making, Dowding and Thompson (2003) stipulated the nurses must aware that the impact of decision making are influence on nursing outcome and patient’s experience. Simpson and Courtney (2002) emphasized that the nurses must be able to think critically to provide best care at the same time dealing with the expansion role especially in the current health care system as it appears to be more complex over the last few decades.
As suggestion, Rushforth and McDonald (2004) recommended that a sense of balancing and safer policy is needed for the few senior nurses to expand their role without jeopardized to the nursing component. The nurses are fit to practice and accountable for the nursing care they provide.
Oermann(2007) suggested that evidence based practice in nursing can be searched in the web sites. By using the available research evidence and clinical expertise, the nurses are able to focus on nursing knowledge in minimizing the role uncertainty and developing a culture of lifelong learning.
A emergence training programme for cannulation and re-evaluation on regular interval is needed to ensure the standard is maintained accordingly. However, training alone is inadequate to bring a change in the behavior of the nurses to take on their expanded role in performing the advanced skills. The nurse’s perception and the support systems are some of the important factors to be address such as opportunity are provided on regular basis in maintaining one’s competencies and support from supervisors to facilitate and guide the senior nurses in the overlapping role.
Inevitably, there is far-reaching implication pending on how the nurses conduct themselves in their relationships. If the blurring boundaries always happened, the nurses will be confused as it bring into an ethical issue regarding their professional role. Barber (2002) suggested that all practitioners are responsible toward their action and have high awareness of legal implication of practice during performing their overlapping role.
However, Molyneux (2001) described that contribution of care from multidiscipline for the same patient through collaboration, knowledge and skills. Caldwell and Atwal (2003) found that different ideologies, unequal power, overlapping role and communication are the difficulties exist within the interprofessional practice. Therefore, a clear flow and structured at several level is needed for the interprofessional team to facilitate and guide their practice effectively.
As conclusion, no doubt the nursing blurring boundaries may against the professional rule, but it had bring benefit to patients especially during night time and the treatment are able to carry out on time. Nurses must understand the additional responsibility invariably probably may increase their burden. Therefore, by using evidence-based practice, critical thinking and updating knowledge in lifelong learning, the nurses are able to extend and cross the boundaries safely to meet client’s needs.
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