Paradigm Shift In Nursing Curriculum And Administration

PARADIGM SHIFT IN NURSING CURRICULUM AND ADMINISTRATION I. PRE-WAR TO 1945 1. Concept of a hospital: The Hospital has a morbid image to the people at this period. When someone is brought to the hospital, people feel the patient is dying. • The hospital is for the sick and the dying 2. organizational structure and facilities • Highly centralized/ absence of electronic devices 3. Nursing service • No participation in operational planning • No managerial knowledge, managerial practice was gained by experience • Task-oriented, but ensures high quality and excellent bedside care • Multi-dimensional scope of responsibilities, e.g. Incharge of linen, housekeeping and dietary at times • Nurses were highly disciplined but very few takes up Nursing • Nurses lack theoretical knowledge to back-up their skills • Nursing administrator holds a very demanding job; she must be strong and clever. 4. Nursing education • A three-year Graduate Nursing program solely existed. • Conceptualization of BSN program and implementation in 1947 with the first graduate from UP College of Nursing in 1952 II. Professionalization Period of Nursing (1946-70s) 1. Hospital – the Hospital image gradual changed • It maintained curative and rehabilitative function; however, the preventive function was not emphasized • Electronic age started, e.g. chemotherapy for Tb and cancer, and radiation became available • The hospital was still highly centralized in terms of control 2. Nursing Service • Chief Nurses had no voice in Operation Planning; no emphasis on qualification, tenure was the basis of succession • Many registered nurses enrolled in supplemental programs • Maintained highly appreciated bed care • Exodus of nurses started in the 50s • In late 70s, Standards for Nursing Practice were formulated

3. Nursing Education • Nursing began to be recognized as a profession due to birth of the BSN Program. However, two (2) types of programs existed (GN and BSN) for some time • Abolition of GN Program came in the late 70s 4. Health Delivery System Came in Three Levels Three Levels are: • Primary • Secondary • Tertiary This concept is premised on self-sufficiency at the primary level with the development of Barangay Health Workers. It aimed to promote proper utilization of the secondary and tertiary facilities. 5. Technology • Computerization made some job easy • Electronic gadgets at the bedside became a necessity (e.g. cardiac monitors) • Faster communication system was a great support in the Health care institution III.

ERA OF CARE FRAGMENTATION (80's to 90's)

It is worthwhile to quote Dhorter Edwards, "While medical knowledge has rapidly expanded in recent years, but medical and nursing care has in certain ways deteriorated." This is highly evident in the Philippine setting. A. The Hospital • For the sick and the well – many people come to the hospital for executive check-up. There is awareness of the public for heath maintenance and health promotion • Emphasis on diagnostic programs • Decentralization – departments were well-organized and had autonomy in running their departments • Facilities are high tech! hospitals competed in their facilities • Highly specialized services came into reality (i.e. intensive care units) • B. Nursing Service • Exodus increased as USA, Canada, Australia, Middle East are all open

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Understaffing was felt and became a big headache for Nursing Admin. Public demand for quality care both in government and private hospitals are echoed Nursing care activities delegated to non-nursing personnel due to understaffing – thus contributing to poor quality of care rendered. Continuing education Units, a prerequisite to licensure, a requirement which had never proven its worth Birth of "manager" title with unclear job description is a fashion. Almost all hospitals changed the title of supervisor/head nurse to manager. Nevertheless, there was no corresponding change in the content of their job description Scarce local employment (in spite of the unemployment of nurses) Proliferation of health care workers/providers Specialization in nursing care with sophisticated equipment to support the nurses in their skills. To quote, Simon and Schuster: "fancy devices, new fangled diagnostic procedures, esoteric jargon machinery, buzzers and beepers, play an important role in the medical and nursing practice. These technological tools, innovations, and even miracles, while producing new hope for diagnosis and cure, tend to distance the caregiver from the patient." At this point in time Nursing Service became complicated to manage and thus;  Demand for better management of nursing service  Change in role expectations heightened calling for: o Business Management o Clinically oriented o Labor relation which demands for strong orientation to legal aspects of Nursing Administration o Educator of patients and staff o Nursing Management Systems that respects the major administrative principles of Planning, Organizing, Directing and Controlling. o Service coordinator with other departments o Operational planning was felt needed by some nursing administrators. o Budgetary planning is a must but barely done due to inadequacy in the technical know-how.

C. Environmental Factors affecting patient care and the Role of the Nursing Administrators  Socio-economic condition – Poor health condition in the midst of rising health care cost  Corporatization of Health care by the year 2000 is shaping up. Many hospitals are now run by corporations thus the profit orientation.

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Social disintegration of the society where Nursing Administration is not prepared to take care of the victims. Our health care agencies are not well-prepared for them. High tech; high cost of health facilities, thus the expectation for high quality service from all health care providers. Home Care (USA) due to high cost of hospitalization. Philippine setting – the hospital will remain as the biggest employer of nurses.

D. Technology  Work simplification, but weak clinical practice because every data needed is available in the computer.  Fast communication system, thus easy access to developments in Nursing in other countries.  Health – tremendous problems, communicable diseases and social disintegration are persistently rising. These have great impact in planning for patients service both in hospitals and in the community. IV. The 21st Century Nurse Executive: Some of the Mega Trends By John Naisbitt, (Famous Futurist) 1. Ten Directions, the Millenial Mega trends: Gateways to the 21st Century:  The blooming Global Economy of the 1990  A Renaissance in the Arts  The Emergence of the Free Market Socialism  Global lifestyles and cultural nationalism  The privatization of the welfare state  The rise of the Pacific Rim  The Decade of Women in Leadership (will nurses be on the lead?)  The Age of Biology  The Religious Revival of the Millenium  The Triumph of the Individual All these are on the way to reality particularly in the areas of global economy and age of Biology. Health Care industries and the nature of a Nurse Manager's job will definitely change. 2. Increase Corporatization of Health Care – thus the need for:  Nursing Administrators are grounded on two (2) domains • Nursing Science – Nursing as a science and an art must be rich in scientific knowledge in order to render high quality of care.

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• Business – for better understanding of her fiscal responsibility. For Nursing Administrators to have good clinical knowledge and business skills on how these two interact and yield a favorable outcome. Must know how to draw a line, when asked to describe between positive balance sheet and positive patient outcome.

It is imperative to note that Clinical knowledge in peso tied to a patient outcome will be the key to the survival of Nursing as a profession. The nurse executive must be prepared to manage Nursing's contribution as a business unit that is to treat nursing like any other profit-generating segment of the organization. Therefore the asst of the 21st Century is the advanced clinical degree and the MBA degree. 3. Preparation of Patients in the next millennium  Vision to create the great need for the care coordination and continuity  Many opportunities to focus in practice, thus nursing will even be more rewarding.  Increasing responsibilities for the clients, particularly those who are best prepared will have the most impact in nursing practice.  Calls for professional competence and self-direction in with major categories: 1. Clinical procedures 2. Leadership 3. Critical thinking 4. Continuous program improvement  New roles of Nursing Administrators • Supporter • Reinforcer • Facilitator  Ethical Dilemmas of Nursing Administrative Practice • Conflict between moral obligations of administrative practice and moral obligations of professional nursing practice and moral obligations of professional nursing practice. Situation: Shortage of staff – there are some items but the hospital administrators freeze hiring. How then can you provide quality care in this situation? 

Application of technology in administrative and technical nursing practice. We would want nurses to be able to make comprehensive Nursing care documentation, not just a checklist.

4. Nursing Administration Perspective  Cost and responsibilities • Assessing and planning appropriately

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Education and Training Collaborating with the staff and other health discipline Politically active in matter concerning violence in the organization for reforms Decision supports database • Determine nursing management decision support system, one that is: o User friendly o Flexible o Accessible and integrated with other institutional databases

Note that available database will enhance ability to evaluate changes in programs, personnel, policies, staffing, organizational and nursing culture  Prepare to lead in many areas such as: • Adopt technology-based conditionable data sets of nursing practice, articulate outcomes and accelerate pace of information flow, reengineer basic model of nursing practice.  Leadership attributes in a world of change • Inspires and encourage rather than control and convince • Use imagination rather than control and convince • Provocative, intuitive and innovative rather than conforming • Takes responsibility with pioneering spirit will arrive at new ways of meeting organizational goals Note: "Change is inevitable but choosing to grow is optional." By Kwamoto, Kristi 

US Setting – Year 2000, migrants, women, and minorities will account to 85% of the net growth in Labor force, with more than 25% comprising of people from the 3rd world countries, thus the need for Transcultural Nursing Administration in health care setting. • Transcultural Nursing Administration refers to the process of assessing, planning and making decision and policies that will facilitate the provisions of educational and clinical services that take into account the cultural caring values, beliefs, symbols, references and life ways of people of diverse and similar cultures for beneficial or satisfying outcomes.

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Real challenges to nursing in the new millennium 1. setting Standard of Care (Service and Education) 2. Ensure quality care by supporting research efforts to prove Nursing's real worth, that is the value of Quality Nursing 3. Develop awareness of Cost, Quality and Nursing

4. Shift to health promotion approach. This is cost-effective and consistent with Nursing values and concerns 5. Involvement in policy development in health care delivery system 6. To re-energize to answer the call of challenges of globalization 7. Learning Nursing thru the internet  

Turn-over and intermobility, a major factor in today's Nursing Administration This is inevitable and healthy, however, if it is too much, the results are: 1. Reduced productivity 2. Demoralized incumbent 3. Expensive 4. Quality Care suffers

If it is too little, the results are: 1. Stultifies employees ambition 2. Slow rate of separation of old hands 3. Slow rate of new blood results to moribund organization So, let us be very objective about this dilemma.  Transcultural perspective in Nursing Administration is essential for survival, growth, satisfaction and achievement of goals in the multicultural workplace. Nursing Administration Educators  Profound and structural – cultural changes require new knowledge and skills for nurses in administrative and leadership positions – thus changes in Nursing Administration curricula.  Proliferation of sophisticated information technology applicants where nurses a re the integrators of patient information management techniques including internet utilization  Focus must be in developing the student's analytic and decision-making skills and provide foundation in business skills, e.g. • Cost benefit analysis • Negotiation • People management skills with effective communication, management skills that increase productivity Self-development, like flexibility and adaptability – Leadership for the future • Provide shared leadership • Has Decision-making autonomy • Creates the vision and mission of Nursing service • Can bring about the best in the subordinates • Charisma • Promote individual growth

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Provides intellectual stimulation and do research Can transform problems into opportunities and challenges Has strong and visionary leadership who can elevate Nursing Management in the context of National Health System

The changing world of the Nurse on Administrative practice brings hopes, dreams and opportunities in the new millennium: 1. Reflection – looking at the map of Nursing Administration, there are more questions than answers because of the rapid rate of change. We must be prepared for this. 2. Thoughtful Action – how to achieve the purpose to fulfill the mission, purpose and vision of Health Care. Planning and implementing the mission leads to quality Health Care 3. Recognition of our Strength – People and Outcomes. Transitions from Nursing Services to Patient Services accountability got building collaborative relationships. The future of the Nursing Director needs to be more focused to patientcentered care and strategic innovations. There is a fast-growing competition, as many hospitals are coming up. Globalization (as some of these hospitals) have foreign funding and foreign partners in Asia's challenge to rise to world-class standards of efficiency, productivity and quality. The impact of globalization is not only on the management practice, but extends beyond to lifestyles and values of the people. It should be realized then, that Nursing Services will be serving the most demanding group of health care consumers in the world. In the simple illustration, please note the PARADIGM SHIFT in Nursing.

50's Period of Ideology "Humanistic Care"

60's 80's Professionalism marked decline in quality care

21st Century 90's 2000's Age of Technology the unknown "Mechanistic Caring" 1. reengineering processes and 2. realigning in the infrastructure to support changes.

Lastly, Nursing Administrator needs to turn around and face the challenges of transformational nature relative to her role and expectations to be visionary. One who can discover, redesign, and redirect their services and training activities to achieve organizational effectiveness in the 3 rd millennium. Who is that Nurse? The characteristics that she should possess are the characteristics of a Future Leader.