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1 ADVOCACY

2 PREVENTION

3 HEALTH TEACHING

4 SUPPORT AND COUNSELLING

5 THERAPEAUTIC ROLE

6 COORDINATION/COOPERATION

ADVOCACY

The evolving role of the nurse as patient advocate, building on GADOW’S frame work of “existential
advocacy’’ and COOPER’S description of conventional relationships. A new conception of advocacy
relevant to pediatric nursing is proposed , based not on protection of patient autonomy, but instead
emphasizing protection of patient autonomy of the child’s potential ‘determining self’ is accomplished
through the following nursing interventions

_Alleviation of pain and discomfort. THERAPEUTIC ROLE OF THE PEDIATRIC NURSE

_Thorough of preparation of the child for procedures.

_Carefull explanation to the child and family about what will happen, how it will feel, and how child and
family will be helped to cope.

_Inclusion prerogatives, this is where the nurse commitment to the mastery of technical skills, an
agreement to safeguard the patient, a promise to provide qualified care, and a promise to free the
patient from the fear of abandonment and unnecessary pain. It is argued that ethical practice in
pediatric nursing may at times require that the nurse fulfill all of these comittments. It is also
recognized, however, that certain organizational characteristics powerfully influence the ability of
pediatric nurses to act in this new advocacy role. Characteristics of practice settings which are thought
to facilitate or inhibit advocacy, such as staff nurse influence and nursing resources are described.

PREVENTION

The nurse today is not only concerned with those who are ill ,or who are in hospital but has an
important role to play in social activities of a childs life . The significant fact that four fifth of accidents to
children under the age of five years have been ascribed to errror’s of adults clearly indicates that the
young child’s accident problem lies primarily with the care taker’s. In handling this problem the p
ediatric nurse, who is more highly trained ,should logically set the pace for other responsible individuals
including not only parents, physicians, and teachers, but also scout masters, camp directors, and even
baby sitters. The position of the pediatric nurse is unique because the youngsters for whose welfare
she must answer are unlike the charges of the kindergarten or nursery school worker in that there is no
lower age limit.

The nurse’s duties have an infinite range. Whether she welcomes the newborn baby, regulates
the important environment of the premature infant, keeps tactful watch over the convalescing child
with cardiac disease, or checks the spread of communicable disease, her responsibility are constant. If
her services is with surgical patients the added requirements of sterilization, special dressings and
mechanical appliances must be met. Eye ,ear, and throat procedures similarly impose technical watch
fullness make exacting demands.

Under present conditions wards are usually understaffed and in this respect the nurse is in the
position of the teacher whose flock normally numbers twenty but who has the burden of sherperding
forty. For any unfavourable incident that transpires, the hospital itself is likely to be blamed, not always
judiciously.

Accidental deaths of young children occour in the home, where the kitchen, which serves as a
miniature industrial plant, rates as the most dangerous room in the house. In the first year, suffocation
unrelated to so called ‘asphyxia neonatrum’ is the foremost cause of accidental death.In the age period
from one to five years, burns and scalds, falls, poisoning are leading causes. Fortunately in a hospital
drownings and motor vehicle accidents need not to be kept in mind, but suffocation (from aspiration),
burns and scalds, falls, poisoning and fatal .tub submersions must all be considered. In the operating
room ,where inflammable or explosive anesthetics are used, the menace of defective electrical
connections and the hot cautery is never to be forgotten.

HEALTH EDUCATION

The WORLD HEALTH ORGANIZATION (WHO) defines the health promotion as a process of enabling
people to increase control over and to improve their health (WHO, 1986). To facilitate that process , we
must provide people with appropriate information. Nurses have a key role in providing that information
in the form of health teaching. Nurse are highly educated, experienced health professionals who are
accessible through many settings. Telehealth Ontrio is a great example of how anyone can access the
expertise of a nurse . Anyone can call in with a question, concern or health issue and gain information
while being adviced of a plan of action right over the phone . Tele health is not for resolving situations
that require immediate attention. Nurse can direct people to local resources and give out health and
wellness information.

When nurses are working within a health promotion model, every interaction with a client can be
an educational intervention (Rankin 2005). For example, while changing the dressing of a diabetic foot
ulcer, there is the opportunity to discuss blood sugar testing and diabetic control. When in a clinic or
doctors office, if a patient comes in with a cut, it’s the perfect time to check the chart for the last
tetanus booster. During a home visit to discuss new born care, it is the perfect time to discuss the child
hood vaccine schedule, recommended vitamin supplements or even the developmental mile stones of
an older siblings. Everyone will interact with a nurse at some point in their lives. I challenge you to make
the most of the expertise of a nurse. Nurse are high level thinkers with exceptional thinkers with
exceptional skills and considerable ability to communicate, negotiat , and collaborate in order to deliver
care (Sullivan,2004).

SUPPORT AND COUNSELLING

According to coincise oxford dictionary counseling is the process of assisting and guiding clients ,
especially by a trained person on a professional basis, to resolve especially personal, social, or
psychological problems and difficulties.

Councelling is:

The process that occurs when a client and a councellor set aside time in order to explore difficulties
which may include the stressfull or emotional feeling of the client.

The act of helping the client to see things more clearly, possibly from a different view point. This can
enable the client to focus on feelings, experiences or behavior, with a goal to facilitating positive change.

A relationship of trust .Confidentiality is paramount to successful councelling. Professional councellors

will usually explain their policy on confidentiality, they may , however it can be required by law to
disclose information if they believe that there is a risk to life.

COUNCELLING IS NOT

_Giving advice.

_Judgemental.

_Attempting to sort out the problems of clients.

_Expecting or encouraging a client to in a way in which the coucellor may have behaved when
confronted with a similar problem in their own life.

_Getting emotionally involved with the client.

_Looking at a clients problems from your own perspective, based on your own value system.

COUNSELLING SKILLS

1 Communication skills: are obviously of utmost importance to councellors.

2 Active listening.

3 Clarification.

4 Reflection.
5 Effective questioning skills.

The counselor will attempt to build acertain kind of rapport with the client, but not to an extent that
will allow them to become emotionally involved. Councellors need to be emphathetic, seeing things
from the clients point of view, rather than sympathetic (feeling sorry for the client). Empathy can help
the counsellor to help the appropriate questions and lead the client to positive conclusions.

THE ROLE OF SUPPORT AND COUNCELLING

The role of the counsellor is to enable the client to explore many aspects of their life and feelings, by
talking openly and freely. Talking such a way it is rarely possible with family friends, who are likely to be
emotionally involved and have opinion and biases that may be detrimental to the success of the
counseling. It is important that the counselor is not emotionally involved with the client and does not
become so during counseling sessions. The counselor neither judges, nor offers advice. The councellor
gives the client an opportunity to express difficult feelings such as anger, resentment, guilt, and fear in a
confidential environment.

THERAPEUTIC ROLE

Therapeutic role is defined as a helping relationship that is based on mutual trust and respect, the
nurturing of respect, the nurturing of faith and hope, being sensitive to self and others ,and assisting
with the gratification 0f your patients physical, emotional, and spiritual needs through your knowledge
and skill. In Peplau’s theory of interpersonal relations, these phases are therapeutic and focus on
interpersonal interactions through the following phases.

Orientation phase .

Identification phase.

Exploitation phase.

Resolution phase.

Termination phase.

ORIENTATION PHASE

The patient seeks help , and the nurse assist the patient to identify the problem and the extent of the
help needed. The nurse patient relationship requires unique communication skills. Every day people
communicate with those around them by listening, talking, sharing, laughing , reassuring and caring.
Nurses use these basic components of communication to establish a helping relationship. Although
different from the other relationships, and professional alliances relationship between nurse and
patients are still a connection between people. Particular communication skills are effective for nurses
when they begin these unique relationshios with patients.
 As described by Peplau, the relationship formerly begins during the orientation phase. The nurse
sets the tone for the relationship by greeting the patient properly. The tone and warmth of the words
during this exchange can promote connectedness between the nurse and the patient. Often a hand
shake is an appropriate component of the introduction, but this will vary by cultural setting and acuity of
the clinical situation. Patients are addressed by their formal names first and then asked what they prefer
to be called. Establishing rapport might begin with talking about clinically relevant topics, such as health
issues and concerns. Nurses foster trust by being consistent in both their words and actions. This
consistency conveys dependability and competence. The orientation phase is important in developing a
foundation for the therapeutic relationship.

Data collection also occurs during the orientation phase. Collecting data for the nursing assessment
requires active participation from the client to identify health status and functioning. The nurse needs
an open mind to understand the patient perception of the problems and need for treatment. What may
seem apparent to the nurse may not be the patient view of the situation. For example what brought you
to the hospital today? Or what kind of assistance can we provide for you? While more specific questions
on the nursing assessment might provide a focus for the initial data collection, it is important for the
nurse to take time to listen, really hear the patient needs and expectations. This prevents
disappointment during and at the end of the relationship if care did not proceed as the patient
anticipated. The nurse can correct misinformation and clarify the situation before actual intervention
begins.

The orientation phase ends with a therapeutic contract. While not usually a formal document, the
verbal contract explains the role of the nurse and patient and the goals of the relationship. An example
is the nurse can conclude the meeting by saying to the patient mother that hajiya Nafisa I will be with
you during the biopsy of your child until you go home. I will explain what will happen today, but before I
begin do you have any question.

IDENTIFICATION PHASE

The working segment of the relationship begins with the identification phase. The nurse and patient
work together to identification phase. The nurse and patient work together to identify problems and set
specific problem oriented goals. Health problems are identified during data collection, and appropriate
interventions are developed in the nursing care plan. Mutual goal setting allows patient to be active
participants in their care. Nurse can also help patients explore feelings about their situation, including
fear, anxiety, and helplessness, and direct their energies toward actions. Identification of personal
strengths and resources may help patients cope with the current health problems and actively
participate in their care. If a patient expresses fear about pain during a procedure, The nurse should say
or ask, are you concerned about pain during the procedure. I will also be with you during the procedure
or surgery. I will talk to the surgeon about your medications during the procedure. Since I will be with
you, you can ask me any questions or when you begin to feel uncomfortable.

EXPLOITATION PHASE
 During this phase the nurse assist the patient in using health services. Interventions appropriate to
the mutually planned goals are carried out with ongoing reassessment and reevaluation. Sometimes
even well planned interventions need to be reviewed, and new , more realistic goals need to be
established. The therapeutic relationship allows the nurse and patient to work together during this
phase. The patient patient uses identified strength and resources to regain control and develop
solutions.

RESOLUTION PHASE

Ending a therapeutic relationship requires a period of resolution that Peplau aptly named the
resolution phase. Some of the most satisfying parts of a nurse’s job are caring relationships with
patients. Often, very meaningful sharing has taken place between the patient and the nurse during
some challenging times. The relationship was originally established with a purpose and, frequently, a
time frame. For example, the perioperative nurse at an outpatient surgical center has a short time frame
for the relationship with a patient who is undergoing arthroscopy. In contrast, the oncology nurse has a
long term relationship with the patient with recurrent colon cancer that might end with patient dying.
Each relationship, both the short term and the long term partnership, requires preparation for the end
of resolution.

TERMINATION PHASE

Endings are a time for review and growth. The termination phase is often overlooked
because of emphasis in health care on diagnosis and treatment. The ending of therapeutic relationship,
no matter how brief, can be a valuable time for the patient and the nurse to examine the achievement
of their goals and review their time together. The nurse uses summarization skills to evaluate the
progress of the interventions towards the intended goals. This review can bring a sense of
accomplishment and closure for both parties.

Emotions are part of ending relationships. Caring attitudes and shared experiences, especially in
long term relationships, may result in sadness and ambivalence at the end of a nurse patient
relationship. Termination of a relationship can awaken feelings of loss from previous relationships.
Acknowledgement of the feelings that arise is helpful in dissipating sadness and learning healthy skills
for dealing with ending loss. The termination phase is also the time when unmet goals are identified by
the nurse and patient may require referral and follow up care.
 COORDINARION AND COOPERATION

DEFINITION OF CARE COORDINATION

Many health policy groups, professional organizations, regulatory agencies, and consumer advocacy
groups have been challenged to define care coordination. Examples of such groups include the Agency
for Healthcare Research and Quality (AHRQ), the center for Health Systems Change, and National
committee for Quality Assurance. Care coordination is conceptually intertwined with organizational
analysis. The NQF defines care coordination as “function that helps ensure that the patient’s needs and
preferences for health services and information sharing across people, functions, and sites are met over
time”(2006). The AHRQ defines care coordination as “the deliberate organization of patient care
activities between two or more participants (including the patient) involved in a patients care to
facilitate the appropriate delivery of health care services”( McDonald,et al., 2010.

THE NURSES ROLE

The care coordination process is one aspect of professional practice through which
registered nurses at every level regularly influence patient care. Nurse are central to coordinating the
patient experience, targeting both cost efficiencies and improved care outcomes for diverse patient
groups.

Children also receive demonstrated value from care coordination. Care coordination is
especially important and challenging for children who have complex chronic conditions that may be life
long and require special services. Coordination has resulted in improved quality and reduced cost.
Antonelli, Stille, and Antonelli (2008) conducted a study to quantify the activities, personnel cost, and
outcomes associated with care coordination for youth and children with special health care needs.