Before one can discuss nursing's contribution to the quality of care, one must discuss what kind of care one is talking about. Medical care and health care are often used as interchangeable terms. For instance, admission to a health care program of any type usually requires the approval of a physician. The payment mechanism for many health insurance plans recognizes only the physician as a health care provider. Nurses and other health care workers are frequently still referred to as "paramedical personnel." The underlying assumption of these ideas is that the health needs of people are the same as the medical needs and therefore such needs can only be directed and legitimized by a medical practitioner.
This assumption has been challenged and it is essential that we continue to provide the hard evidence that the health care of the public requires the attention of more than medicine. Nowhere is this more true than in the care of the older person who experiences many health problems which are not disease- related.
The operational model of health which I find most useful is the following:
An individual is healthy (that is, has attained or is in the state of condition known as health) if he is functioning adequately in a stated environment: and if while functioning in this environment he is subjected to some sort of stress, he is able to adapt to this stress within the range of normal functioning.
Conversely, an individual is not healthy if he is not functioning adequately in a stated environment; or if while functioning in this environment he is subjected to some sort of stress and does not adapt within the range of normal functioning.1
This definition focuses on the concepts of adequate functioning and the ability to adapt to stress in a stated environment. Because health is not defined simply as the absence of disease, it is possible to be considered healthy even though one may have only one leg or have a chronic disease or when needing some personal care by others.
In support of this definition, health care must refer to a broad set of services and include at least: health promotion (and health teaching); prevention of illness; health maintenance; many aspects of rehabilitation; personal care of an individual who is disabled in some way; and medical care. The implementation of these services requires the combined abilities of a variety of health care professionals who have both shared and specialized knowledge and skills to contribute to meeting the health needs of individuals and groups in our society.
Nursing's Contribution to Medical Care
Medical care refers to that part of health care which concerns itself primarily with the diagnosis and treatment of disease processes. It is, rightfully, the domain of physicians. They are frequently assisted in this task by other health care workers.
Nurses have a special place in this sphere because of their continuous contact with people in illness and periodic or continuous contact with people who are well in a variety of settings. Because of their educational preparation in medical sciences and because of their special abilities in communicating and relating to people, nurses are able to case-find, monitor illness states, and help individuals implement the medical treatment component of their health care.
This "medical assisting" function is a critical part of nursing's contribution to health Care and represents the shared knowledge and skill of medicine and nursing.
Nursing's Specialized Contribution
The major and specialized contribution of nursing to health care relates to a component different from medical care.
Nurses help people to deal with pressures in their lines that arise either because of their developmental level or because of factors in their life situations.
Demands created by the need to master mental tasks at specific intervals in one's life span are predictable events which occur with uniformity for all persons. Young children must learn to move away from the security of their families out into the social world of persons who are unrelated to them. New parents must learn how to raise their children. Elderly persons need to learn to live with a physical body which is in some sort of decline.
Situational changes are less predictable because of the variability in human experience and human nature. Illness represents one kind of situational change that leads to a multiplicity of demands. The elderly person with cardiovascular failure must learn how to: redirect his or her physical energies within the limits of remaining cardiac function; follow a medically prescribed regimen of treatment; adjust his self-image so that he may still see himself positively in spite of a loss in physical functioning; reorganize the roles he plays, both in his family and society, so that he may maintain a satisfying contribution; prepare for the possible event of his or her death. This he must do with the knowledge that there is no cure available.
Figure 1 depicts some of the stressful events that confront elderly persons and which create in them demands for responses.
It has been shown that the quality of the management of these stressful situations in a person's life is critical for the subsequent health status of an individual regardless of whether the crisis point is developmental or situational in origin.2 Older persons are confronted with a number of actual and potential crises situations and nurses are strategically placed in the health care system at points where help in adjusting to these crises can be activated and maintained.
What is it that nursing has to offer? I think that there are four classes of interventions that we use:
1. Intervention related to caring for and maintaining the biological organism;
EXAMPLES OF STRESSFUL EVENTS FACED BY ELDERLY PERSONS
2. Interventions used to modify a person's response pattern;
3. Interventions which are directed at modifying the forces impinging on a person;
4. Interventions designed to facilitate the medical management of disease processes.
Figure 2 shows some of the strategies that nursing utilizes under each of the kinds of interventions that I have mentioned. It should be stated clearly that when one uses a particular nursing action, i.e., giving a bed bath, one can accomplish all four types of intervention. Giving a bed bath is directed at personal care and biological maintenance. During that activity one expresses, both verbally and nonverbally, one's respect for the individual as a person. Health teaching, preventive care, and counseling can all be integrated into the interaction. Attaching a bell cord creates a safe environment. Observation and assessment of any disease state that may be present can be undertaken throughout the contact period.
NURSINGS CONTRIBUTION TO HEALTH CARE
Let me say that 1 believe that all health professionals could classify their activities under these headings but each tends to develop special expertise in one or more of them. What makes nursing different is that it uses all four types and often uses these simultaneously in a single nurse/patient interaction. Because of this diffuseness, we have difficulty in explaining to other people in the health care system just exactly what it is that we do. I believe that this diffuse breadth of activity comes from the fact that of all the health professionals we are the only ones who have preparation in both the behavioral and the medical sciences. We are able to use the "hardware" of sophisticated medical technology as well as the "software" of human relationship training; we focus on the whole person as well as his parts; and we are as concerned about a person's lifestyle as we are about his particular disease.
A Gase in Point
In the older person, what frequently starts out as a developmental crisis soon evokes a situational crisis. Such is the case of the person who, because of normal biological decline, is confronted with a deterioration of the learned skill of continence. The person has difficulty in managing either his urinary or fecal elimination in a socially approved manner. While there are some causes for this problem amenable to medical treatment (and nurses must be knowledgeable about this and appropriately interact with the physician to manage such instances), for many elderly persons this is not the case. Persons with this problem are usually emotionally distressed by this loss of control. They may exhibit behavioral characteristics such as withdrawal or disregard of the problem or anger. At times they are embarrassed and feel unjustifiable shame. One often sees that the person will restrict his or her interaction with others in order to avoid the occurrence of embarrassing incidents, resulting in a limiting of their social functioning. Effective management eludes them because they lack understanding and skill. If they are living at home, it is often the onset of this problem that creates enough family tension to necessitate admission to some type of institution. The institutionalization itself creates a further demand for coping. The individual and his family are in need of help; not because of an illness state but because of the effects of the situational crisis caused by the need to relocate a family member away from familiar surroundings.
In a situation such as the one described, how does nursing contribute to the quality of care? Personal care related to cleanliness and dryness becomes mandatory. Modifications can be made in clothing to facilitate rapid and easy access for toileting activities. Our care can be delivered with an understanding which conveys respect and inherent value for the person as well as compassion for the distress created. When appropriate, health teaching related to the reasons for the problem, as well as alternative methods of management, can be undertaken. Rehabilitation in the form of a bladder training program is instituted by many of you when you interact with these persons. Skin care and regular toileting times represent two preventive strategies. The willingness to let a person express their feelings goes a long way in making those feelings more tolerable. Moving a patient's room closer to a bathroom may well be the most useful modification of his physical world. Family ease and understanding can be facilitated by the same processés of health teaching, listening, and counseling which one provides for the individual. While often there is no medical therapy which is appropriate, one is always watchful for signs and symptoms which indicate that a pathological process is occurring.
Let me conclude by reaffirming that nursing does have a contribution to make. It may be that in the care of the elderly we make our greatest contribution to the health care needs of the population because the older person is at risk of developing a large number of nonmedical health problems amenable to nursing management.
- 1. Dolfman ML: Toward operational definitions of health. J of School Health 44:207, April 1974.
- 2. Aguilera DC et al: Crisis Intervention: Theory and Methodology. St. Louis, The CV Mosby Company, 1970, chapter one.