Research Korner: Nursing Case Studies

Assessing knowledge and attitude of nurses caringfor the terminally ill in Africa

ATTITUDE OF NURSES CARING FOR THE TERMINALLY ILL IN AFRICA         Medical professional including nurses have a critical control over the terminally ill patient, because it is a matter of life and death their expertise is required to be considered in this time of need. Nurses must exert their effort to play the part to prolong the patients hope to live and their expert advice to their immediate family to accept the facts that they cannot change. Their knowledge and attitude must not be question and total care must be met for their administrative function. Patients however may also require a solid attention not just on medical professional but also their family and colleague the best they can do is to support the patients to be beside them.       There are many cases in Africa that most patients died in this condition because of HIV, maternal problem and aids that is why family and local community has hoped for the impact of three palliative care interventions in their countries.  This program has been given priority and somehow became a success in health care, basically this method has been introduced to Malawi, Kenya and Uganda initiated by local nursing and medical authority with the help of the community in their respective places.       The truth is that nobody not even the greatest medical doctor can increase the life of a person but they can only do so is to hope for the best that is why this concern has been tested all throughout. Palliative care is concerned with practical and emotional intervention, spiritual deep care, and education. This requires a vital research and assessment based on good proper practices, nursing aid together with their patients must exemplify acceptance and faith to be cured.      In another point in time community support for patients to realize has been pre- assessed, they must take caution when dealing with patients this group are trained to speak only the things that can help them, and they cannot argue nor blame the patients for it will only weaken their conditions. They are given a series of information and sets of questions that they can use to ask for patients and medical professionals to make sure that the spirit of the patients will be uplifted, they usually end up in prayer before they leave and patients are very thankful about their home visit.   Poverty stricken community may lead to shortage of health workers has been the problem, they tend to resort into the private hospital to seek for their cure but financial problem arises, palliative care emerge successful because of combined approach and proper nursing symptom assessment and care. African Palliative Care Association are promoting palliative care in Africa knowing that people especially terminally ill patient has a needs and therefore must require this attention of hope therefore humanitarian in nature. There are various palliative health care programs available for although the APCA has only been limited to their services.       In Malawi Palliative health care has been introduced although there are little sponsors there were also nurses available for the sick and most of them are volunteers focusing on physical health and support. In Uganda they were able to establish faith based support program including the fisher folk and poverty stricken community who would like to volunteer to support the HIV patients even if they do not belong to their family. While in Kenya a well established Christian based hospital sponsored the palliative care program to help the patients.       The Mau Hospital serves about 700,000 community residences with various illnesses and terminally ill individual including aids, maternal problem and various cancers.  Mau Hospital has given hope for the poor not just their physical but also their spiritual needs. Palliative care more than medicine treatment and nursing of medical health workers addresses a combination of the best cure for physical, psychological and spiritual support for people who are suffering from dreadful disease.       Helping each other and caring for the people in needs with the help of health worker, medicine, and encouragement of their family, traditional methods of cure and its entirety equal to the community volunteerism and helpfulness to take away the pain. Their total cooperation works greatly and must be expanded as the needs may arise. Although poverty stricken communities from this three countries, the result has been effective. Terminally ill patients has been very thankful for the nursing support from various sectors including medical professional, sponsors and communities, furthermore they have regain their strength and dignity and if they have to die, they will die with respect and high spirit all this is because of the nursing effort of everyone.

Assessing knowledge and attitude of nurses caringfor the terminally ill in Africa

ATTITUDE OF NURSES CARING FOR THE TERMINALLY ILL IN AFRICA Medical professional including nurses have a critical control over t...

Exploring the role of the nurse in preventing and controlling risks factors in cardiovascular disease

Exploring the role of the nurse in preventing and controlling risks factors in cardiovascular disease Nurses are in a unique position to diagnose and treat human responses to actual or potential health problems. The nurse practitioner can have a positive impact on the prevention and management of cardiovascular disease through patient education and counseling.  Nurse Practitioners are oftentimes the first healthcare provider seen when there is a new patient.  The Nurse Practitioner conducts the initial evaluation and sets up the care plan which includes primary and secondary prevention strategies. The success of your patient teaching plan is measured through the patient’s compliance to the prescribed treatment plan.  Your teaching should be set up with goals that will enhance compliance. You need to make the assessment with the patient and family to focus on maximum compliance. Each visit should incorporate a review of the goals that were set and examples of how the patient is meeting or not meeting those goals. When you are following up during your visit to assess the success, if the patient has not followed the plan ask for the patient’s help to identify what is preventing him from being successful and revise the plan based on revised goals (Solomon, 2000). If the patient has even had small successes it is important to congratulate them and focus on those positives as you reformulate goals.  Provide the patient with resources to help support his plan. Remember that there are many references out there in the internet. Some are not so accurate, that may have just the opposite effect you and the patient are trying to achieve. By providing the patient with a take home list of resources you can be sure the information is the right information for the patient [http://nursesaregreat.com/articles/rrfh.htm].  The ICSI Health Care Guideline was designed to assist clinicians by providing an analytical framework for the evaluation and treatment of patients, and is not intended either to replace a clinician’s judgment or to establish a protocol for all patients with a particular condition.  The guideline outlines the existing evidence for the effectiveness of strategies and programs designed to help adults successfully make essential changes to achieve healthier lifestyles (increased physical activity, improved nutrition, decreased tobacco use and exposure, decreased hazardous and harmful drinking/alcohol use). It also outlines how these programs might be integrated into preventive services in health care systems, which traditionally have focused on early detection of disease or treatment of risk factors rather than preventing the onset of risk factors. Nearly all individuals would derive measurable benefits from healthier lifestyles; even small improvements across a large portion of the population would have a greater impact than focusing on a small portion of the population that is at the upper end of the risk distribution. Therefore, the target population for this guideline includes all adults (age 18 and older) in the community, irrespective of their utilization of the health care system. Although this guideline focuses on adults, adolescents and children may benefit from many of the components or recommendations in this guideline [http://www.icsi.org/chronic_disease_risk_factors__primary_prevention_of__guideline__23506/chronic_disease_risk_factors__primary_prevention_of__guideline__23508.html]. Nurse practitioners should follow these guidelines to create a successful educational plan for their patients.  They should teach the following four lifestyle behaviors – 1.    adequate physical activity 2.    a diet that emphasizes fruits and vegetables 3.    abstinence from tobacco and avoidance of tobacco smoke 4.    avoidance of hazardous and harmful drinking These are associated with a decade or more of increased life expectancy. Individuals, who adopt this lifestyle, at any age, have significantly lower total mortality rates [http://www.icsi.org/chronic_disease_risk_factors__primary_prevention_of__guideline__23506/chronic_disease_risk_factors__primary_prevention_of__guideline__23508.html]. After you begin your teaching plan it is important for compliance and success to evaluate where you are. This allows you and the patient to reset goals and stay on target. It will ensure greater success (Patient Teaching, 2001). Evaluation of lifestyle changes should be part of each visit to help the patient stay on track. Follow-up visits are planned based on patient needs. For example if you have a patient with elevated blood pressure and you are using lifestyle modification as an initial treatment plan you may want an every two week follow-up. For many patients a more realistic follow up is monthly. Evaluation and revision of the teaching plan is part of every visit [http://nursesaregreat.com/articles/rrfh.htm].

Exploring the role of the nurse in preventing and controlling risks factors in cardiovascular disease

E xploring the role of the nurse in preventing and controlling risks factors in cardiovascular disease Nurses are in a unique positi...

Nursing Case Study - Ethical Conflict

She has been in the hospital for 10 days and she is finally scheduled to be discharged today. She is very excited to go home. She was admitted in the hospital due to bowel obstruction which was spontaneously resolved.   I accidentally walk past her bedroom today and heard her vomiting. When she saw me, she begged me not to tell anyone because she really feels all right and she just don’t want that to stop her from going home. For one moment, I hesitated.   I was trained to serve for the best health interest of my patients. The dilemma begins when their interests aren’t really the best for their health. Though I, as a person, completely understand that they have their reasons for whatever their interests are, we, medical practitioners often find ourselves in crossroads between following the policies or believing the patients who feel themselves better.     Bowel Obstruction   According to the book "Small-bowel obstruction: optimizing radiologic investigation and nonsurgical management", Bowel obstruction is a mechanical or functional obstruction of the intestines, preventing the normal transit of the products of digestion. It can occur at any level distal to the duodenum of the small intestine and is a medical emergency. Although many cases are not treated surgically, it is a surgical problem. Symptoms of bowel obstruction depends on the intensity of the obstruction. It might trigger the patients abdominal pain, abdominal distension, vomiting, fecal vomiting, and constipation. It may be present within the bowel lumen, within the walls of the bowel, or outside the bowel (such as compression, entrapment or volvulus). (Maglinte et al., 2001) Moreover, bowel obstruction may also be accompanied with dehydration and electrolyte abnormalities due to vomiting; respiratory compromise from pressure on the diaphragm by a distended abdomen, or aspiration of vomitus; bowel ischaemia or perforation from prolonged distension or pressure from a foreign body. (Maglinte et al., 2001) The book also sited the difference of the small bowel obstruction and large bowel obstruction. In small bowel obstruction the pain tends to be colicky (cramping and intermittent) in nature, with spasms lasting a few minutes. The pain tends to be central and mid-abdominal. Vomiting occurs before constipation. While in large bowel obstruction the pain is felt lower in the abdomen and the spasms last longer. Constipation occurs earlier and vomiting may be less prominent. Proximal obstruction of the large bowel may present as small bowel obstruction. There are couple of ways to diagnose this illness. It is normally confirmed through blood tests, X-rays of the abdomen, CT scanning and/or ultrasound. If a presence of mass inside the abdomen is identified, biopsy is also one of the most common ways to measure the nature of the mass. Radiological signs of bowel obstruction include bowel distension and the presence of multiple (more than six) gas-fluid levels on supine and erect abdominal radiographs. (Maglinte et al., 2001) Contrast enema or small bowel series or CT scan can be used to define the level of obstruction, whether the obstruction is partial or complete, and to help define the cause of the obstruction. According to a meta-analysis of prospective studies by the Cochrane Collaboration, the appearance of water-soluble contrast in the cecum on an abdominal radiograph within 24 hours of oral administration predicts resolution of an adhesive small bowel obstruction with a pooled sensitivity of 96% and specificity of 96%. (Maglinte et al., 2001) Other diagnostic operations are colonoscopy, small bowel investigation with ingested camera or push endoscopy, and laparoscopy. Most cases of Bowel obstruction require operative treatments. Maglinte sited in his book that frequently, the surgical intervention and the treatment of the causative lesion are required. In malignant large bowel obstruction, endoscopically placed self-expanding metal stents may be used to temporarily relieve the obstruction as a bridge to surgery, or as palliation. However, there are some causes of the illness that resolve spontaneously. Patient’s condition She has been under medication for ten days. The illness was proven to resolve spontaneously, which, apparently, is the reason of her early discharge from the hospital. There has been no treatment which was mentioned to have been applied to the patient the whole time she was confined to the hospital. It is clear, that the bowel obstruction subsided on its own. However, the vomiting is, as mentioned earlier, a sign or a symptom that the illness have not resolved yet. Although, in most cased the patient itself claims to feel all right and well, a nurse, or a medical practitioner should always check the appropriate symptoms based on how he or she was trained as a medical practitioner, before yielding to whatever the patient wishes or says. The patients’ health is not his or her sole responsibility. It is a shared responsibility of the government and the medical practitioners. In a book written by Fleming, Health Promotion: Principles and Practice in the Australian Context, she defined public health in the Australian Context. “The Australian Public Health Association (1997) defines public health in a similar way to last as: … a combination of science, practical skills, and beliefs that is directed to the maintenance and improvement of the health of all people. It is one of the efforts organized by society to protect, promote and restore the people's health through collective or social actions.” (Fleming and Parker, 2001) The Australian Health Administration Act 1982 sec 22 or Disclosure of Information states that: If a person discloses any information obtained in connection with the administration or execution of this Act or any other Act conferring or imposing responsibilities or functions on the Minister, Department, Director-General, Corporation or Foundation and the disclosure is not made: (a) with the consent of the person from whom the information was obtained, (b) in connection with the administration or execution of this Act or any such other Act, (c) for the purposes of any legal proceedings arising out of this Act or any such other Act or of any report of any such proceedings, (d) with other lawful excuse, or (e) in any other prescribed circumstances, that person is guilty of an offence against this Act and, on conviction by a court of summary jurisdiction, liable to a penalty not exceeding 10 penalty units or to imprisonment for a term not exceeding 6 months.   In this case, concealing of information such as a symptom which is present on the patient for discharge is an act against the health department.   'Act always in such a manner as to promote and safeguard the interests and well-being of patients and clients' is the first and central statement of the nurse's Code of Professional Conduct and at first sight seems to embody what every nurse firmly believes in. (Hunt, 1994)   Let’s examine the possible outcome of this scenario if information such as this are concealed. Patients will go home untreated. Later on, complexities will arise. More or severe illness will follow, and in worst cases, death may even be the result of tolerating secrecy between patients and attending medical practitioners. The impact will both be devastating to the health department and to the patient’s or family’s patients as well.   As a medical practitioner, it is a duty to report every important detail of either the recovery or worsening of their patients.   This act will sure halt the scheduled discharge of the patient. However, decision may always be in favor of the patient’s health, but not might not sound as pleasing to them as it should be.   Ethical Concerns   The patient asked for a disclosure of the symptoms. The patient would like to keep that particular piece of detail, since according to her, that wouldn’t be a big problem nor would create a problem because she feels good to go.     The choice between right or wrong is always a tough one. Right and wrong is not a natural knowledge which we biologically inherited when we were born. It is mandated by the culture, and by the society we are brought up in.   “--cases that can be paradigms of either right or wrong conduct. In either instance, the case represents very strong and widely accepted judgments to the effect that this particular conduct in these particular circumstances is right or wrong. The idea here is that our notions of right or wrong grows out of actual experiences of exemplary conduct, and thus are not the result of theoretical speculations about the nature of ‘the good’ and ‘the right.’ While the paradigm case serves, then, as the objective source of our substantive notions of right or wrong, the judgment that the case elicits represents the moral sensibility that guides the professional casuist.” (Blake, 1992)     Utilitarianism can also be the grounds of deciphering the right act from the wrong. Most countries in the west were adapting utilitarianism, which is prescribed as “the greatest good for the greatest number”.   Since this would not apply to this situation, because the only interest we have is the patient and there is no “common good” given in the situation, let’s dig deeper to other kinds of utilitarianism. Because of the absence of the “common good”, we can now use the law of “lesser evil” or Negative utilitarianism (NU) requires us to promote the least amount of evil or harm, or to prevent the greatest amount of suffering for the greatest number.   Conclusion   Non-disclosure of the information will give the patient what she wishes. A time well-spent in the family. However, a few days later, the patient might still go through the same symptoms. Vomiting, constipation, abdominal pains and all the she would probably don’t want to feel again.   On the other hand, disclosure of the information will, the same way, add an amount of suffering for staying a few more days inside the hospital, and probably having to go through a more painful operation and dialysis in order to be treated. However, this would end the illness and will never let the patient have to go through all these again.   Both ways will inflict pain and suffering. Both will have to have the patient to be confined in the hospital. The only difference is time. The patient might be discharged today and will come back at a later time for the same reason, or the patient will not be discharged today but won’t come back in the later time.   But time is an important element in recovery. If the patient will not be treated today, possible complexities will arise. That will cause more suffering and pain to the patient. Therefore, it is best to disclose the information to the attending physician so he or she can decide the best way to cure the patient. It is at the same time what was mandated by law.   Physicians have special competence in many areas of social importance, from abortion and drug addiction to the psychiatric effects of military combat. The increasing tendency to view competent medical practice as necessarily dealing with the whole person, not simply with his damaged liver, heart, eyes, spleen, stomach, or kidneys, means that physicians must deal with ethical problems in relation to social situations. (Visscher, 1972) Books: Visscher, M.B. (1972) Humanistic Perspectives in Medical Ethics. New York: Prometheus Books.   Maglinte, D.D., Kelvin, F.M., Rowe, M.G., Bender, G.N. and Rouch, D.M. (2001). "Small-bowel obstruction: optimizing radiologic investigation and nonsurgical management". [Electronic Version] Radiology 218 (1): 39-46.   The Cochrane Collaboration. The Cochrane Manual Issue 1, 2008, section 2.2.5.4 COCHRANE LIBRARY FEEDBACK HOUSE RULES [updated 15 November 2007]. (http://www.cochrane.org/admin/manual.htm) (accessed 12th December 2007])   Hunt, Geoffrey. (1994) Ethical Issues in Nursing.  London and New York: Routledge.   Journal: Blake, D.C. (1992) The Hospital Ethics Committee: Health Care's Moral Conscience or White Elephant? The Hastings Center Report, Vol. 22.   Websites: www.austlii.edu.au/forms/search1.html

Nursing Case Study - Ethical Conflict

She has been in the hospital for 10 days and she is finally scheduled to be discharged today. She is very excited to go home. She was adm...

Advance Practice Nursing

A nurse is “the agent of a patient doing for a patient what he would do for himself if he were able” (Husted & Husted, 2001).Thus, nursing has always been regarded to as one of the professions with the most responsibilities and accountabilities and Gastmans (1998) states, “The nurse functions both as a professional and as a human being within a variety of contexts. These contexts influence directly or indirectly the way in which the nurse performs caring tasks.”  Nevertheless, the scope of nursing has continued to expand over the years to meet the demands of the growing public in matters of health concerns in general. One area of nursing that practically evolved is advanced practice nursing and its practice showed the multi-faceted world of the nursing profession.   Moreover, Advanced Practice Nursing refers to the whole ﬁeld, involving a variety of such roles and the environments in which they exist. Many barriers to realizing the full potential of these roles could be avoided through better planning and efforts to address environmental factors, structures, and resources that are necessary for advanced nursing practice to take place. (Brayant –Liusd, Dicensoa, Browneg & Pinellij ( 2004). In addition, Advanced Practice Nurse (APN) is nurse with a masters degree and it falls into 4 categories namely: Nurse Practitioners (NP) whose main function includes provision of basic care focused on a specific population or health need, including writing prescriptions and Certified Nurse Anesthetist (CRNA) whose job is to  administer anesthesia for all types of surgery. The other two categories of APN are Clinical Nurse Specialist (CNS)  and Certified Nurse Midwife (CNM) who provide specialist care in a number of areas: cardiology, oncology, neonatology, OB/GYN, pediatrics, neurology, and mental health and provide prenatal care, delivers babies, and provide postpartum care to normal healthy respectively.    Moreover, the evolution of APNs has been a major event in the history of nursing. While each of the four APN disciplines—clinical nurse specialist, nurse practitioner, certified nurse midwife, and nurse anesthetist—has a unique history and place within nursing, the commonalities have established a force within health care that has changed the way care is delivered and will continue to change the system. In fact, the commonalities provide a critical basis for forging an even more powerful coalition of APNs to tackle common challenges related to ensuring patients get the best care possible. The social contract that nurses have with the public is unique, and APNs have extended that contract to higher levels of service, decision-making, and accountability. (Stanley, 2005).   Furthermore, advanced practice nursing includes a variety of roles in which nurses function at an advanced level of practice (ANA 1995a, Brown 1998, RCNA 2000). In countries such as the United States, where legislation, regulatory mechanisms and protected titles for clinical nurse specialists, nurse midwives, nurse anaesthetists, and nurse practitioners exist, there is less difﬁculty distinguishing APN roles. However, most countries do not have protected titles and there is no international agreement about the use of titles to distinguish APN roles. Role confusion arises when the same title, such a nurse specialist is applied to different roles with varied purposes, educational preparation, and scopes of practice (Alcock 1996, Bamford & Gibson 2000, Whyte 2000). Role compe- tencies involving domains of advanced nursing practice related to clinical practice, education, research, organizational leadership, and professional development are better indicators of APN roles than role titles alone. There is mounting agreement that graduate education combined with practice experience is required for APN roles (ANA 1995a, CNA 2000, RCNA 2000, ICN 2003).   Health care restructuring in many countries has led to substantial increases in the different types and number of APN roles. (Brayant –Liusd, Dicensoa, Browneg & Pinellij ( 2004). This is imperative so that every client needs are catered appropriately. In Hongkong, nursing profession is practiced with the ultimate goal of providing its citizen the quality care they deserve. In fact, The College of Nursing, Hong Kong promotes the highest possible standards of professional nursing endeavor by determining and examining issues relevant to nursing practice and the health of the community; initiating and supporting research to seek solutions to nursing and health related problems; taking action on issues of significance to nursing and health; promoting and facilitating professional development in areas of clinical practice, management and education; disseminating information on issues of significance to nursing and health; advising and contributing to the formulation and implementation of nursing and health related policies; providing an advisory and consultative service to Government and other bodies on nursing and health related matters; promoting social and international links with nursing and other professional and educational establishments and securing the widest possible representation of the nursing profession in order to increase the effectiveness of its service to members and the profession. [The College of Nursing, Hongkong. Available at http://www.fmshk.com.hk/conhk/frame2.htm. (Accessed at 25/01/2008.]     Furthermore, the mission of the Nursing Council of Hongkong is to fulfill the statutory obligations as stipulated in the Nurses Registration Ordinance and to ensure the quality of nursing practice in Hong Kong meeting the rapidly changing health care needs of the society through the establishment of a registration system, provision of guidance and intervention with discipline. In addition to that, the then Nursing Board of Hong Kong formulated in 1986 a Code for Professional Conduct for Nurses in Hongkong. This is to keep pace with contemporary health care development commensurate with societal and cultural changes, the Nursing Council of Hong Kong which replaced the Nursing Board of Hong Kong in 1999 has now revised the code and also devised a Code of Ethics for an accurate representation of Nurses’ ethical responsibilities. The Code of Ethics is adapted largely from the “Code of Ethics for Nurses in the New Millennium” published in a Chinese nursing magazine with due regard to practices in the international community.   According to The Nursing Council of Hong Kong Code of Professional Conduct and Code of Ethics for Nurses in Hong Kong each nurse (registered or enrolled) is accountable for his/her practice. In the exercise of his/her professional responsibilities, each nurse has an obligation to uphold and adhere to the Code of Professional Conduct for Nurses in Hong Kong and  the code aims to make explicit the standards for professional conduct that nurses shall act at all times in their course of duty. It may also serve to provide the public with a basis for decisions regarding standards of professional conduct. Moreover, the Code of Professional Conduct for Nurses in Hong Kong highlights eight aspects of professional conduct that nurses are to comply with in discharging their professional duties and the explanatory statements provide guidelines regarding the way each aspect of professional conduct is to be enacted in practice situations.  [The Nursing Council of Hongkong Code of Professional Conduct and Code of Ethics for Nurses in Hongkong. Available at http://www.nchk.org.hk/conduct/conduct_eng.pdf (Accessed at 25/01/2008.)   It can then be summarized that to be able to practice the nursing profession in Hongkong, one should uphold upright moral values, discipline, empathy and most importantly sound decision making skills. Aside from these, advanced practice in Hong Kong includes clinical skills, education, research and consultancy (Wong, 2001). Meanwhile, decision-making is what which most characterizes advanced practice and underlying decision-making are clinical judgments, scholarly inquiry, and leadership. The work of the advanced nurse is practice, the product is patient care; therefore, leadership in the advanced practice role supports the scientific process by: interpreting the context of practice, demonstrating influences on care and leading changes in practice. (Erickson & Sheehy, 1998.)   Benner, Tanner, and Chelsa (1996) added, “The development of clinical expertise inherently demands the development of ethical expertise.” But if developed together will yield favorable outcome. Ethical reasoning and clinical judgment share a common process, and both serve to teach and inform the other. The importance, therefore, of attention to clinical practice, regardless of how far removed an APN is from the clinical setting, cannot be overemphasized (Solomon, et al., 1991.)   On the other hand, advance practice nursing has its share of legal and professional implications. Rapid advances in technology make many demands on the character, education, and abilities of the advanced nurse practitioner. The emphasis on scientific developments throughout the past several centuries has caused ethics to take a quantitative rather than a qualitative approach. Science has sought to separate itself from concerns about human values and values systems. (Callahan & Mannino, 1998.) That ethical decision-making skills are part of the core competencies of all APNS is a basic tenet and central to the definition of advanced nursing practice (Reigle, 1996). It is paramount also that the ethical aspects of her practice will be coupled  with the clinical aspects.   Husted & Husted ( 1998) stressed that an APN has come to a state of development wherein she can interweave the ethical and professional aspects of her practice. She may well have adopted some aspects of a practice-based ethic. Nothing does more to produce effective professional practice. She can master skill in ethical decision making by attending to what is important in her patient’s life. In doing this, she will establish pride in what she is and what she is doing. Thus, the Code of Ethics for Nurses in Hong Kong aims to make explicit the fundamental moral commitments of the profession; provide nurses with a basis for ethical practice, and to indicate to the community the values that nurses hold.   The Code of Ethics for Nurses in Hong Kong is organized around four broad value statements and seventeen provisions that represent the morals and ideals of the profession and are regarded as central to ethical nursing practice. The four broad value statements are: Respect life, and improve quality of life; Respect individual rights and dignity; Be responsive to society’s needs, and work towards a healthy community through partnership;  Strive for excellence, and assure quality of care.  The provisions articulated in each value statement are ethical responsibilities that nurses should act upon in order to enact the broad values in practice situations. For each of these statements, the scope of responsibilities identified extends beyond individuals to include families, communities and society. By upholding these values in practice, it is envisaged that nurses can improve their personal quality, provide quality nursing care and earn the trust of those under their care. [The Nursing Council of Hongkong Code of Professional Conduct and Code of Ethics for Nurses in Hongkong. Available at http://www.nchk.org.hk/conduct/conduct_eng.pdf (Accessed at 25/01/2008.)   Meanwhile, the Nursing Council's powers in this regard are as laid down in the Nurses Registration Ordinance, the Nurses (Registration and Disciplinary Procedure) Regulation and the Enrolled Nurses (Enrolment and Disciplinary Procedure) Regulation, Cap. 164, Laws of Hongkong and complaint against a registered nurse or an enrolled nurse for professional misconduct should be forwarded in writing to the Secretary who will then refer it to the Chairman of the Preliminary Investigation Committee (PIC) for consideration. It is the  PIC that will decide whether to dismiss the complaint or refer it to the Council for inquiry. The Council, at the conclusion of the inquiry, will exercise its powers in accordance with the Ordinance and make such disciplinary awards as it deems fit. [The Nursing Council of Hong Kong. Available at http://www.nchk.org.hk/council/index.htm. Accessed at (25/01/2008.) (Wong 1997) reiterates that much more work is still to be done to drive the role of nurse practitioners forward in Hongkong and ‘Not only after the NP position is recognized and legitimized, and that the education program meets the global credential criteria, that these NPs then have the power in the organization to make claims and to control work in their role and expertise. It is important that clients’ needs are carefully assessed ensuring that optimal level of care is rendered in a low cost setting. Evidence suggests that advance nursing practice provides cost effective care in terms of patient outcomes as well as the benefits of advanced nursing practice outweighing any costs of introducing such approaches to practice (Byers & Brunell, 1998; Schroeder, et al., 2000). Further research of advanced nursing practice in public health nursing suggests that although findings consistently demonstrate high levels of patient satisfaction, research needs to be extended to include patient groups with more complex health needs and chronic diseases (Horrocks, et al., 2002). Wong (1997) pointed out the global trend in advance practice nursing such as the increasing initiative of developing NP educational programs in various countries and a global interest in promoting the highest quality of educational preparation and she suggested that there should be a criteria or guideline of NP program education at the international level.   In conclusion, introduction and evaluation of APN roles warrant greater attention to the concept of advancement, other attributes of advanced nursing practice, and environmental factors that affect APN roles. Lack of clarity about the multi-dimensional nature and mandate of APN roles to improve patient health through innovation in nursing and health care delivery is a central barrier to the optimal utilization of APN roles. The ad hoc introduction of APN roles suggests the nursing profession and APN community must provide stronger leadership by: establishing consensus and communicating clearer messages about the purpose, scope and education of APN roles; providing organizations with guidance about the introduction of APN roles; and advocating for health polices that support APN role development. Advanced practice nursing roles interact across various clinical settings and inﬂuence change to improve patient health through clinical, educational, professional development, organizational, and research activities (Corner et al. 1995, Davies & Hughes 1995, Plant et al. 2000, Brooten et al. 2002, McGee & Castledine 2003). This broad vision of APN suggests the need for a systems approach to role introduction that recognizes the environments in which the roles operate. Of primary importance is identiﬁcation of social factors or patient health needs and stakeholder expectations for how the APN role will improve care delivery. Existing models of care delivery are deﬁned by health care provider roles and relationships, and are inﬂuenced by stakeholder values, beliefs, and experiences with APN (Dunn & Nicklin 1995, Beal et al. 1997, Woods 1998, Cameron & Masterson 2000). Role implementation is affected by the role acceptance and support of administrators and health care providers. These stakeholders must participate in the introduction of APN roles in order to promote role clarity, systems entry, and integration of roles within local environments. The value added component of APN roles involves maximizing health and quality of life through coordinated, holistic, patient-centred care (Watson 1995, Bredin et al. 1999, Brooten et al. 2002). The extent to which medically- driven and illness-oriented health systems permit these dimensions of care is a challenge for developing innovative APN roles. Therefore, the process of role introduction must include strategies to promote social change consistent with the fundamental values of APN. Many barriers to realizing the full potential of APN roles could be avoided with better planning and systematic efforts to develop and evaluate APN roles. (Brayant –Liusd, Dicensoa, Browneg & Pinellij ( 2004.)                                   BIBLIOGRAPHY   Alcock D.S. (1996) The clinical specialist, clinical nurse specialist/ nurse Practitioner and other titled nurse in Ontario.Canadian Journal of Nursing Administration Jan–Feb, 23-44   ANA (1995a) Standards of Clinical Practice and Scope of Practice for the Acute Care Nurse Practitioner. American Nurses Association. Washington, DC, USA   Barnes, D. M., & Boyle, J. S. (1995). Transcultural concepts in nursing case (ed.   2).Philadelphia: Lippincott.       Benner, P., Tanner, C. A., & Chelsa, C. A. (1996). Expertise in nursing practice. New York: Springer   Bryant-Lukosius, D. et al (2004). Advanced nursing practice role: development, implementation and evaluation.  Canada: Blackwell Publishing, Inc.   Byers, J.F. & Brunell, M.L. (1998). Demonstrating the value of the advanced practice nurse: an evaluation model. Advanced Practice in Acute and Critical Care, 9(2), 296-305   Callahan, L., & Mannino, M. J. (1998). Legal aspect of advanced nursing   practice. In Sheehy, C. M., & McCarthy, M. C. (Eds.), Advanced practice   nursing (pp. 281–302). Philadelphia: F.A. Davis.       Corner J., Plant H., A’Hern R. & Bailey C. (1996) Non-pharmacological   intervention for breathlessness in lung cancer. Palliative   Medicine 10, 299–305       Dunn K. & Nicklin W. (1995) The status of advanced nursing roles   in Canadian teaching hospitals. Canadian Journal of Nursing   Administration Jan–Feb, 111–135     Erickson, R., & Sheehy, C. M. (1998). Clinical research in the advanced practice   role. Philadelphia: F.A. Davis.       Gastmans, C. (1998). Challenges to nursing values in a changing nursing   environment.Nursing Ethics, 5, 236–245.       Horrocks, S., Anderson, E. & Salisbury, C. (2002). Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal, 324, 819-823.   Husted, G. L., & Husted, J. H. (2001). Ethical decision making in nursing and   health care: The symphonological approach (ed. 3). New York: Springer         Reigle, J. (1996). Ethical-decision making skills. In Hamric, A. B., Spross, J. A., &   HansonC. M. (Eds.), Advanced nursing practice: An integrative approach   (pp. 273–295).Philadelphia: Saunders   Stanley, J. M. (2005). Advanced Practice Nursing: Emphasizing Common Roles Edition 2. Philadelphia: F.A. Davis Company   Solomon, M. Z., Jennings, B., Guilfoy, V., Jackson, R., O’Donnell, L. Wolf, S. M., Nolan,K., Koch-Weser, D., & Donnelley, S. (1994). Toward an expanded vision of clinicalethics education: From individual to the institution. Kennedy Institute of Ethics Journal, 1,224–226   Styles M. & Lewis C. (2000) Conceptualizations of advanced nursing   practice. In Advanced Nursing Practice: An Integrative Approach   (Hamric A.B., Spross J.A. & Hanson C.M., eds), W.B. Saunders,   Philadelphia, pp. 33–51.         Watson J. (1995) Advanced nursing practice…and what might be.   Nursing & Health Care: Perspectives on Community 16, 78–83   Wong, F.K.Y. (2001). Senior clinical nurse specialist pilot position in Hong Kong. Clinical Nurse Specialist, 15(4), 169-176.   Wong, F. (2002). Development of advanced nursing practice in Hong   Kong: A celebration of ten years’ work. The Hong Kong Nursing   Journal.38(3), 25-29.

Advance Practice Nursing

A nurse is “the agent of a patient doing for a patient what he would do for himself if he were able” (Husted & Husted, 2001).Thus, nu...

Clinical Healthcare and the Challenges that lie Ahead

Introduction             Medicine is not all, or even mostly, about money. Science, caring, professionalism, and even religious concerns regarding birth and death can be more important than dollars.             Healthcare is among the world’s largest industries, accounting for 10 percent of gross world product, but only a tiny fraction of world trade.  Around the world, healthcare institutions are encountering growing pressures from governments, investors and the general public. Healthcare is indeed a more complex economic problem than bridge-building.             Like some other professions but unlike many other goods and even services, it is difficult for the consumer (the patient) to evaluate the quality of services received. Much depends on the self-control and reliability of the individual practitioner, the supplying group, and the medical profession as a whole, in ways that the ordinary patient cannot readily check whenever he/she needs to. These institutions must simultaneously improve the health and well being of the public, cut costs and remain competitive. To achieve these goals, many healthcare institutions have implemented total quality management (TQM). Evidence from hospital-based studies, however, suggests that the success of TQM is constrained by inadequate information systems and poor application of information technology.   Change appears to be a driving force in society today and the American healthcare system is no exception. In addition to the need for change in today's society, the importance of creativity in bringing about needed change must also be considered. An organization will quickly lose strategic advantages that it has worked hard to gain unless it invests in innovation and creativity, and consequently, change. According to some experts, the American Healthcare system is on the brink of failure. To support this assertion, experts point out signs of failure in the healthcare system. For one, Americans spend more than twice as much as Canadians on healthcare. And, there is a similar disparity between American and British spending. The Americans certainly don't get their money's worth, according to some experts. The US has roughly 43 million people with no insurance whatsoever, and among the rest, many are underinsured. That is, they have shrinking packages. This might be covered, but that won't be covered. What's more, experts argued that Americans are unhealthy. The life expectancy is shorter and infant mortality is higher. Childhood immunization rate is lower. The United States is considered to have the highest healthcare costs per capita in the world. The healthcare industry faces a lot of challenges at present and which can be reflective of what lies ahead. These includes health care costs, the growing diversity of health populations and their expectations, government support for healthcare, the increasing use of technology and yet its poor application, the decreasing quality of healthcare education and the growing shortage of healthcare professionals especially the nurses among many others. There is also a challenge on the kind of leadership and management that is present in the healthcare profession. Hospitals will be forced to shell out more on bioterrorism preparedness. Insurers will face rising demand for costly behavioral healthcare services. Vendors will have to scramble to supply new antibiotics. And physicians' pleas for better Medicare payments may fall on deaf ears as Congress remains focused on homeland security. Add to that the economic slowdown-which is leaving more Americans without health insurance and compelling states to squeeze their Medicaid budgets-and citizens have a perilous outlook for the coming year. The distribution of health is unequal and has a profound impact on economic well-being. Some people work productively for years and die contentedly with wealth and happiness in old age, while others struggle for a few months or decades in agony as they are relentlessly drawn down into premature mortality. In the situation depicted in the previous paragraph, the question is not whether the distribution of health is fair, or whether it determines or is determined by income, but whether it is amenable to change. The unequal distribution of healthcare is only one of the many challenges that the healthcare industry is facing and will continue to face in the next years. The question whether this could be change is answered by Yes. It is possible, provided the right measures and support are done.   Many health problems are usually concentrated in specific, underserved populations, usually ethnic minorities or areas of extreme poverty. Although tremendous resources are available for advanced experimental treatment, electronic scanning for diagnosis, and long-term rehabilitation, there is still a lack of primary care resources ensuring that every child is immunized, that all pregnant women receive adequate prenatal care and nutrition, and that every person has a primary physician to contact when in need of advice or care. In many ways, the American healthcare system faces the same problems of maldistribution and misallocation in the delivery of healthcare as other high-income and low-income countries. The American healthcare system is facing reform, which demands collaboration instead of competition, employment of a more diverse work force, and service to a larger number of uninsured individuals. Purpose of the study This paper aims to look into the American healthcare system and the challenges that lie ahead by using the qualitative method of research. By looking into the various challenges that the American healthcare system now faces and will be facing in the future, individuals will be more aware and vigilant regarding their health and healthcare. This paper also aims to provide recommended actions that can be taken in order to properly face and overcome these challenges.   Importance of the study             Healthcare is an indispensable part of people’s lives. Given the strong relationship between mortality and income, questions have arisen regarding the importance of healthcare, especially in increasing life expectancy of individuals. As a whole, the importance of healthcare is connected to increasing life expectancy of individuals.             One complication though is that more and better healthcare is usually associated with higher incomes. Along with that are the other various challenges that the American healthcare system is facing now.             Cows can get just as many diseases as humans do and we could put all the resources to saving cows, but we don’t. We are the ones paying the bills and therefore we put the resources for our own health.             What can be said of the future of health and healthcare over the next fifty years? It is relatively certain that clinical challenges will still be present. There will also be continued increases in longetivity, greater technological capacity to treat diseases, and continuous increases in expenditure among others.             By being aware of these healthcare challenges that the Americans are facing now and being aware of solutions and ways to solve them, there would be a higher chance of overcoming these challenges and provide a better quality of care for all the Americans.             Aside from awareness, Americans have to understand how various healthcare factors interact and affect the healthcare system. Like for instance, Americans might be wondering why healthcare costs so much. It is because health is so precious that its value exceeds that of the things that people possess. Scope of the study This study focuses on the various factors that interact in the provision of healthcare. We are all aware that the provision of healthcare is not without challenges. These factors in fact themselves provide a challenge for the American healthcare system. This study regarding the clinical challenges that the American healthcare system faces and is going to face in the future was undertaken to provide information about these various situations, and also to address specific recommendations on these problems that we face. This study summarizes some of the descriptive information, as well as information from the historical record, in an attempt to describe the challenges present within the American healthcare and their impact on whole quality of care for the Americans. Data will be collected from various healthcare professionals within the country. These are practicing professionals from any field of healthcare. Their opinions and ideas will be collected and used to further verify what has been observed by ordinary citizens and authors.   Rationale of the study               One of the main issues in the rationale for this study was the opportunity to study the interaction of healthcare factors and the challenges it brings to the American healthcare system.             As stated, the United States has one of the most expensive healthcare systems in the world. Moreover, the quality of care provided is more or less the same as that of other countries even with the higher healthcare cost. Thus, many Americans are still not being provided with adequate healthcare.             These are just some challenges that somehow make the American healthcare system less than perfect. Something has to be done so that there would be a proper provision and allocation of healthcare goods and services to all Americans.             This study can help support the consistency of what ordinary American citizens and various writers have already found about the challenges that the American healthcare system face. Added to that, this can also help healthcare organizations come up with solutions on how to face these challenges. Definition of the terms Balanced Scorecard - a performance metric used in strategic management to identify and improve various internal functions and their resulting external outcomes. The balanced scorecard attempts to measure and provide feedback to organizations in order to assist in implementing strategies and objectives. Bioterrorism - the use of biological agents, such as pathogenic organisms or agricultural pests, for terrorist purposes.   Charges – the amount appearing on the patient’s bill. Clinical Pathways – a protocol, or defined standard set of tests and procedures which are to be used in the diagnosis or treatment of a particular symptom or disease. Coinsurance – the amount of the bill not paid by insurance, but by the patient. A plan with 15% coinsurance means that the insurance company pays 85% and the person pays 15%. Consumer - one that consumes, especially one that acquires goods or services for direct use or ownership rather than for resale or use in production and manufacturing. Continuing Professional Development (CPD) - is the means by which members of professional associations maintain, improve and broaden their knowledge and skills and develop the personal qualities required in their professional lives. Disabled – a clear preference in referring to people having either physical or mental impairments, with the impairments themselves preferably termed disabilities. Efficacy – the ability to actually cure a disease; how well a treatment works in practice. Enrollee – a person covered by a health benefits plan. Entitlements – social insurance payments to which beneficiaries are entitled by law with little regard to actual contributions or premiums, or income qualifications (e.g. Medicare, Social Security).   Generic Drugs – drugs that are identical in chemical composition to a brand name pharmaceutical preparation, but produced by competitors after the firm’s patent expires. Grandfathering – approving those who are already in practice to continue even if they do not meet the new standards. Healthcare - the prevention, treatment, and management of illness and the preservation of mental and physical well-being through the services offered by the medical and allied health professions.   Homeopathy – an alternative form of health practice emphasizing natural remedies used in extreme dilute solutions.   Infant Mortality - the death rate during the first year of life.   Information System – is a technologically implemented medium for recording, storing, and disseminating linguistic expressions, as well as for drawing conclusions from such expressions. It is a business application of the computer. It is made up of the database, application programs and manual and machine procedures. It also encompasses the computer systems that do the processing.   Information Technology – the development, installation, and implementation of computer systems and applications.   Inpatient – services or goods which are provided within a hospital or within a nursing home.   Licensure – the establishment of legal restrictions specifying which individuals or firms have the rights to provide services or goods.   Life Expectancy - the number of years that an individual is expected to live as determined by statistics.   Long-Term Care – Nursing homes, visiting homes, home I.V. and other services provided to chronically ill or disabled persons.   Malpractice – the legal framework for failure to meet the required professional standards.   Managed Care – the use of a manager to control utilization of medical services and control costs.   Management – (a) the act, manner, or practice of managing; handling, supervision, or control: management of a crisis; management of factory workers; (b) the person or persons who control or direct a business or other enterprise; (c) skill in managing; executive ability.   Mandated Benefits – specific services (e.g. pregnancy, alcoholism detoxification) for which a state requires all health plans to provide coverage.   Medicaid - a program in the United States, jointly funded by the states and the federal government, that reimburses hospitals and physicians for providing care to qualifying people who cannot finance their own medical expenses.   Medicare - a program under the U.S. Social Security Administration that reimburses hospitals and physicians for medical care provided to qualifying people over 65 years old.   Medigap – a policy designed to pay coinsurance, deductibles, drugs, and other expenses not fully covered by Medicare.   Morbidity – illness or disability, especially when expressed as a rate.   Mortality – death, usually expressed as a rate per one hundred, thousand, or hundred-thousand.   Open Book Management – a management technique wherein the method is to give employees all relevant financial information about the company so they can make better decisions as workers. This information includes, but is not limited to, revenue, profit, cost of goods, cash flow and expenses.   Outpatient – services provided in a physicians’ office, clinic, or other ambulatory setting.   Outsourcing - the procuring of services or products, such as the parts used in manufacturing a motor vehicle, from an outside supplier or manufacturer in order to cut costs.   Out-of-Pocket – payments made by individuals or their family, rather than an insurance company, government, or other third party, for healthcare services.   Over-the-Counter – a drug that consumers can purchase without a prescription from a physician.   Primary Care – the basic medical attention provided by a physician to a patient seeking care, as distinct from referral services obtained from specialists, or tertiary care provided in technologically sophisticated hospitals.   Quality Adjusted Life Years (QALY) – a way of measuring the value of a medical intervention by the increase in life expectancy, adjusted for difference in disability and timing.   Strategic Partnerships - an alliance between two parties (frequently one corporation that provides engineering, manufacturing or product development services, and one smaller, entrepreneurial firm or inventor) to create a specialized new product.   Supply Chain Management (SCM) – the planning, scheduling and control of the supply chain, which is the sequence of organizations and functions that mine, make or assemble materials and products from manufacturer to wholesaler to retailer to consumer. The driving force behind supply chain management is to reduce inventory.   Tertiary Care – medical care delivered in technologically sophisticated and university hospitals.   Third-Party Transaction – an exchange which is indirect and often pools the funds of many individuals with money collected and disbursed by a third party such as an insurance company, voluntary non-profit organization, or government agency.   Total Quality Management (TQM) - an organizational undertaking to improve the quality of manufacturing and service. It focuses on obtaining continuous feedback for making improvements and refining existing processes over the long term.   Transformational Leadership – offer a purpose that transcends short-term goals and focuses on higher order intrinsic needs. The four dimensions of transformational leadership are: Charisma or idealized influence, Inspirational motivation, Intellectual stimulation, and Individualized consideration.   Universal Health Insurance – a national plan providing health insurance or services to all citizens, or to all residents. Overview of the study   A number of external and internal forces cause health care systems to consider the need for change. The process in changing governance and management had three critical elements: establishment of a vision and guiding principles for the change, development of support, and implementation of change in governance and management.   The healthcare professions all involve life and death situations. In these situations, quality is crucial and quantity is irrelevant. Clinical governance provides a framework for a coherent, local program of quality improvement and an opportunity to share best practice. For the healthcare professionals, clinical governance will be about building upon and linking together many of the activities that they are already involved in, which help to promote and improve standards of patient care.   The various challenges that the American healthcare system faces includes the high cost of medical care, challenges faced in health insurance, the advantages and disadvantages of technological advancements, the problems encountered in dealing with diverse populations (as the United States has citizens of many different cultures), the role of the government, what the consumers (patients) expect, the problem of deteriorating healthcare work environments, the need for further education and training of healthcare professionals, and the need for a better management.   Local government is a large portion of the overall health care safety net in the United States, providing direct-care services and funding such items as public hospitals, transportation, educational outreach, and housing subsidies. Whatever the government decides and implements can affect the whole healthcare system and the ordinary American citizens.   Healthcare costs are skyrocketing. Most people are frustrated and angry about the state of affairs, and they want something done to rectify the problem. The assortment of components of health care cost increases are not independent but interact.   Health insurance coverage is currently the primary means for access to medical services when unexpected medical crises arise and for everyday health concerns. The high costs of health insurance and medical services has led to reliance on (1) employer-provided health insurance coverage, and (2) federal- and state-funded Medicare and Medicaid programs.   Rapid advancements in science and technology, along with investor dollars, have created major advances in medical care. These emerging technologies in medicine, which were increasingly housed in hospitals and physicians' offices, not only laid the groundwork for the coming shift in the way health care was delivered, but also increased healthcare costs as well as new problems in their implementation and management.   The diverse American population also presents a challenge in clinical healthcare. Of particular importance are the elderly population who requires other special services and the non-English speaking patients who need translators in order to ensure that the right medical care is given.   Consumer expectations are fueling demand for health information that they can understand and services that they want. Consumers would want to know what their care options are and what health plans are available to them. By offering consumers a choice of healthcare services and plans, various healthcare organizations encourage the development of price competition among competitors.   The deterioration of healthcare work environments is a major problem of concern to the healthcare leaders or managers. It presents a challenge to the American healthcare system. A healthy work environment is necessary to bring about quality healthcare service to the population. An unhealthy work environment would create a devastating impact not only to the healthcare professionals and the clients but most importantly on the effectiveness of the entire healthcare system.   There is also a growing acknowledgement of the importance of continuing professional development (CPD) in order that the individual can continue to refine skills and keep up to date with current evidence for practice. CPD must encompass, among many other things, technical skills and attitudes towards patients, staff and the general population.   For this proposal, the authors will employ a combination of qualitative methods. The qualitative methodology that was employed in this research is appropriate since it seeks to interpret or illuminate the actions and/or subjective experiences of the healthcare professionals regarding their experiences in the American healthcare system. This kind of research can utilize the qualitative method.             For the particular study, the participants will be various healthcare professionals from different parts of the country. Basically, how the participants will be selected is only a matter of random.   Before the study will be conducted, an approval to perform the study will be obtained from the ethics committee. The researchers will employ an interview method of data collection in two forms: (1) a questionnaire which will be sent by mail or email (2) a narrative interview through the telephone.   Every participant in the study will be interviewed in the same manner and the data will all be collected in the same way. The timing of when the interviews will take place will also be within one timeframe – e.g. within a span of two weeks. The reason for this is because discrepancies in time could significantly affect the data collected.               Data analysis employed in the study will be carried out in steps. Every data form (audiotape-recorded or written and transcribed) will be carefully read in order to have an idea of the whole results concept. The text will then be read again and divided into meaningful units as the researchers see fit. Data will be condensed and formed into four syntheses which will be integrated to form the structure of the challenges of the American healthcare system.             The data gathered from the study will show the many challenges that clinical healthcare faces and will continue to face in the future. These are all ideas which healthcare professionals think of in the current situation that is being faced at the moment.             From these generalizations, various recommendations are put forth. These recommendations are focused on management, performance measurements, and improving skills and performance among others.   Most early leaders in healthcare management had a vision that stressed the primacy of patient care. The aim of management is to put the interest of the patient first, regardless of race, creed, or ability to pay, and to seek complete health rather than just to cure the ailment at hand. This is a critical moral commitment to the same core value as the caring professions. Any philosophy that puts management values contrary to the caring professions will be corrosively destructive.   Managers for their part regarding information technology and information systems, should plan, coordinate and implement information technologies that can improve quality and efficiency in all processes. For example, an organization should provide on-line medical records and other clinical information at multiple sites, such as laboratory results and imaging.   Improving performance of employees in the healthcare setting is also recommended. There are three main routes to improve performance in the health care setting: (1) prevention, (2) appropriateness of services, and (3) coordination of services. Formal organization and trained management will be essential to all three.             Leadership style that should be employed in healthcare settings is the effective leadership style and shared leadership. Effective leadership style is an integral part of creating an environment that nurtures the development of an empowered healthcare staff.   The professional accountabilities of the empowered healthcare professional includes having a sense of value about their work and willingness to provide the full scope of practice as well as ability to work as equal members of a comprehensive interdisciplinary team. In order to move into a fully empowered position, healthcare professionals need mentoring, education, awareness of political activism opportunities, and networking skills.   Shared leadership is a collaborative team process in which team members share key leadership roles. Shared leadership is empowering employees to act autonomously, be decisive at the point-of-service, and create a shared vision aligned with organizational goals.   Shared leadership development and autonomously practicing nurses appear to be the equation for success in delivering quality patient outcomes in today's organized health care delivery systems. Employees must develop or refine new behaviors and skills in empowerment, facilitation, negotiation, systems thinking, and accountability on behalf of patients.   It is increasingly recognized that formal preparation is necessary for healthcare staff so as to ensure true teamwork. We are moving away from the traditional, didactic teaching methods (e.g. lectures) to more student-centered enquiry or problem-based learning methods. These alternative approaches not only develop problem-solving skills and enhance critical thinking, but they may also provide a forum for the frank discussion of issues relating to deviance, difference and dilemmas in healthcare.   In an increasingly technological healthcare world, it is therefore apparent that in order to respond to the ever-changing and increasing diversity of skills required to participate effectively in a highly technological healthcare system, mechanisms for continuing skills acquisition are a necessity. Yet it is not solely technical skills that are required.   It is becoming increasingly important for healthcare staff to provide more holistic care which requires staff from differing professions to work effectively within a multidisciplinary team. These teams may be ward, acute care or primary care based, and may also require working across areas and with other voluntary and statutory organizations.               In this fast changing world, the American healthcare system is no exception the challenges that are present. The key to overcoming these challenges lies in the strategies that are used by healthcare organizations. But not only that, the government, private organizations and individual Americans all share the responsibility of overcoming these challenges.

Clinical Healthcare and the Challenges that lie Ahead

Introduction Medicine is not all, or even mostly, about money. Science, caring, professionalism, and even religious concerns...