№ 14. Medical Education in Ukraine and in the World.

• Nurses are on the front lines of the health care delivery team. They independently assess and monitor patients, and taking a holistic approach, determine what patients need to attain and preserve their health. Nurses then provide care and, if needed, alert other health care professionals to assist. Thus, nurses coordinate care delivery by physicians, nurse practitioners, social workers, physical therapists and others. Nurses assess whether care is successful. If not, they create a different plan of action.

• Nursing: Nursing is the therapeutic relationship that enables the client to attain, maintain or regain optimal function by promoting the client’s health through assessing, providing care for and treating the client’s health conditions. This is achieved by supportive, preventive, therapeutic, palliative and rehabilitative means. The relationship with an individual client may be a direct practice role or it may be indirect, by means of management, education or research roles.

• One of the most important roles of the nurse is to be a patient advocate--to protect the interests of patients when the patients themselves cannot because of illness or inadequate health knowledge.

• Nurses are patient educators, responsible for explaining procedures and treatments. For instance, nurses teach patients and their families how to eat in a healthier way, take medicines, change wound dressings, and use health care equipment.

• Nurses empower patients, guiding them toward healthy behaviors and support them in time of need. When patients are able, nurses encourage and teach them how to care for themselves. Nurses provide physical care only when patients cannot do so for themselves.

• As patients near the end of their lives, nurses provide dignity in death by advocating for sufficient pain medication and the opportunity to die at home to allow them to spend meaningful time with family members in their final days.

• Skills, knowledge, and abilities required and used by Registered Nurses and Nurse Practitioners include:

• · Speaking - Talking to others to effectively convey information. • · Service Orientation - Actively looking for ways to help people. • · Social Perceptiveness - Being aware of others' reactions and

understanding why they react the way they do. • · Reading Comprehension - Understanding written sentences and

paragraphs in work related documents. • · Oral Comprehension - The ability to listen to and understand

information and ideas presented through spoken words and sentences. • · Judgment and Decision Making - Weighing the relative costs and

benefits of a potential action.

• Skills, knowledge, and abilities required and used by Registered Nurses and Nurse Practitioners include:

• · Speaking - Talking to others to effectively convey information. • · Service Orientation - Actively looking for ways to help people. • · Social Perceptiveness - Being aware of others' reactions and

understanding why they react the way they do. • · Reading Comprehension - Understanding written sentences and

paragraphs in work related documents. • · Oral Comprehension - The ability to listen to and understand

information and ideas presented through spoken words and sentences. • · Judgment and Decision Making - Weighing the relative costs and

benefits of a potential action.

• Medicine and Dentistry - Knowledge of the information and techniques needed to diagnose and treat injuries, diseases, and deformities. This includes symptoms, treatment alternatives, drug properties and interactions, and preventive health care measures.

• · Biology - Knowledge of plant and animal living tissue, cells, organisms, and entities, including their functions, interdependencies, and interactions with each other and the environment.

• · Customer and Personal Service - Knowledge of principles and processes for providing customer and personal services including needs assessment techniques, quality service standards, alternative delivery systems, and customer satisfaction evaluation techniques.

• · Chemistry - Knowledge of the composition, structure, and properties of substances and of the chemical processes and transformations that they undergo. This includes uses of chemicals and their interactions, danger signs, production techniques, and disposal methods.

• · Problem Sensitivity - The ability to tell when something is wrong or is likely to go wrong. It does not involve solving the problem, only recognizing there is a problem.

• · Critical Thinking - Using logic and analysis to identify the strengths and weaknesses of different approaches.

• Nurses generally fall into several main groups, depending on where they work: in hospitals, in private practice, in private homes, etc.

• Types of Nursing Careers• * AGENCY - Agency nursing is essentially where a nurse will register or sign up with

an agency or similar group and tell them what hours they are available to work. The nurses are then contacted and offered work on a shift to shift basis.

• Agency nurses are now in high demand, particularly, in the case of nurses with specialized training or experience.

• See also: Travel Nursing • * AMBULATORY CARE - Ambulatory care nurses care for patients whose stay in the

hospital or other facility will last for less than 24 hours. Ambulatory care nursing covers a broad range of specialties in the out-patient setting.

• o American Academy of Ambulatory Care Nursing • * ANESTHESIA - Nurse Anesthetists work with surgeons, dentists, podiatrists,

anesthesiologists, and other doctors to provide anesthesia to patients before, during, and after surgery or child birth.

• American Association of Nurse Anesthetists • * CARDIAC CARE - The Cardiac Care Nurse works with other members of the medical staff in

assessing, intervening, and implementing nursing care for the cardiac patient. • o American College of Cardiovascular Nursing • * CASE MANAGEMENT - Case management is a collaborative process of assessment, planning,

facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes.

• o American Case Management Association • * CRITICAL CARE - Critical Care nurses provide care for patients and families who are

experiencing actual or potential life-threatening illness. More specific fields that fit into the Critical Care category include Cardiac Care, Intensive Care, and Neurological and Cardiac Surgical Intensive Care.

• o American Association of Critical Care Nurses • * EMERGENCY - Emergency nurses assess patients, provide interventions and evaluate care in a

time limited and sometimes hectic environment. Emergency nurses work independently and interdependently with various health professionals in an attempt to support patients and their families as they experience illness, injury or crisis.

• Emergency Nurses Association • * FORENSICS - Forensic nurses provide medical care to victims of crime,

collect evidence after crimes occur, and provide medical care to patients within the prison system.

• o International Association of Forensic Nurses • * GASTROENTEROLOGY - Gastroenterology (GI) nurses provide care to

patients with known or suspected gastrointestinal problems who are undergoing diagnostic or therapeutic treatment and/or procedures. GI nurses practice in physician offices, inpatient and outpatient endoscopy departments, ambulatory endoscopy centers and inpatient hospital units.

• o Society of Gastroenterology Nurses Association • * GERIATRICS - Geriatric nurses care for elderly patients in a number of

settings which include the patients home, nursing homes, and hospitals. Geriatric nurses face constant challenges because their patients are often very ill, very complex, and very dependent on the nurses skills.

• American Geriatrics Society • * HOLISTIC - Holistic nurses provide medical care for patients while

honoring the individual's subjective opinions about health, health beliefs, and values. Holistic nursing requires nurses to integrate self-care, self-responsibility, spirituality, and reflection into their daily nursing care.

• o American Holistic Nurses Association • * HIV/AIDS - HIV/AIDS nurses provide healthcare for patients who are HIV

or AIDS positive. These nurses usually have specialized training in HIV/AIDS.

• o Association of Nurses in AIDS Care • * INFORMATICS - Nursing informatics is a broad field which combines

nursing knowledge with the use of computers. Jobs in this field could range from the implementation of a new computer network within a hospital to the sales of computer systems to hospitals by an outside computer company.

• American Nursing Informatics Association • * LEGAL NURSING - Legal nursing combines the use of the legal system with a

thorough knowledge of the nursing field. Legal nurses are usually seasoned veterans of the nursing field who work with attorneys to review medical documents and determine if medical negligence occurred.

• o American Association of Legal Nurse Consultants • * MIDWIFERY - Midwives are nurses that are specially trained to deal with childbirth

and providing prenatal and postpartum care. The midwife is qualified to deliver babies by themselves unless there are extenuating circumstances which require the midwife to consult with a physician.

• o American College of Nurse-Midwives • * MILITARY - Military nurses work in a variety of settings, ranging from family

practice at a local military base to providing emergency care for the wounded during war times.

• * NEONATAL - Neonatal nurses provide care for newborns by assessing the patient to ensure good health, providing preventative care to prevent illness, and caring for the babies which are sick. The neonatal nurse is responsible for anticipating, preventing, diagnosing and minimizing illness of newborns.

• Medical ethics is primarily a field of applied ethics, the study of moral values and judgments as they apply to medicine. As a scholarly discipline, medical ethics encompasses its practical application in clinical settings as well as work on its history, philosophy, theology, and sociology.

• Medical ethics tends to be understood narrowly as an applied professional ethics, whereas bioethics appears to have worked more expansive concerns, touching upon the philosophy of science and the critique of biotechnology. Still, the two fields often overlap and the distinction is more a matter of style than professional consensus. Medical ethics shares many principles with other branches of healthcare ethics, such as nursing ethics.

• There are various ethical guidelines. The Declaration of Helsinki is regarded as one of the most authoritative.

• By the 18th and 19th centuries, medical ethics emerged as a more self-conscious discourse. For instance, authors such as the British Doctor Thomas Percival (1740-1804) of Manchester wrote about "medical jurisprudence" and reportedly coined the phrase "medical ethics." Percival's guidelines related to physician consultations have been criticized as being excessively protective of the home physician's reputation. Jeffrey Berlant is one such critic who considers Percival's codes of physician consultations as being an early example of the anti-competitive, "guild"-like nature of the physician community. In 1847, the American Medical Association adopted its first code of ethics, with this being based in large part upon Percival's work. While the secularized field borrowed largely from Catholic medical ethics, in the 20th century a distinctively liberal Protestant approach was articulated by thinkers such as Joseph Fletcher. In the 1960s and 1970s, building upon liberal theory and procedural justice, much of the discourse of medical ethics went through a dramatic shift and largely reconfigured itself into bioethics.

• Since the 1970s, the growing influence of ethics in contemporary medicine can be seen in the increasing use of Institutional Review Boards to evaluate experiments on human subjects, the establishment of hospital ethics committees, the expansion of the role of clinician ethicists, and the integration of ethics into many medical school curricula.

• Values in medical ethics• In the United Kingdom, General Medical Council provides clear overall

modern guidance in the form of its 'Good Medical Practice' statement. Other organisations, such as the Medical Protection Society and a number of university departments, are often consulted by British doctors regarding issues relating to ethics.

• How does one ensure that appropriate ethical values are being applied within hospitals? Effective hospital accreditation requires that ethical considerations are taken into account, for example with respect to physician integrity, conflicts of interest, research ethics and organ transplantation ethics.

• Autonomy is a general indicator of health. Many diseases are characterised by loss of autonomy, in various manners. This makes autonomy an indicator for both personal well-being, and for the well-being of the profession. This has implications for the consideration of medical ethics: "is the aim of health care to do good, and benefit from it?"; or "is the aim of health care to do good to others, and have them, and society, benefit from this?". (Ethics - by definition - tries to find a beneficial balance between the activities of the individual and its effects on a collective.)

• By considering Autonomy as a gauge parameter for (self) health care, the medical and ethical perspective both benefit from the implied reference to Health.

• Beneficence• James Childress and Tom Beauchamp in Principle of Biomedical Ethics (1978) identify beneficence

as one of the core values of health care ethics. Some scholars, such as Edmund Pellegrino, argue that beneficence is the only fundamental principle of medical ethics. They argue that healing should be the sole purpose of medicine, and that endeavors like cosmetic surgery, contraception and euthanasia fall beyond its purview.

• Non-Maleficence• In practice, however, many treatments carry some risk of harm. In some circumstances, e.g. in

desperate situations where the outcome without treatment will be grave, risky treatments that stand a high chance of harming the patient will be justified, as the risk of not treating is also very likely to do harm. So the principle of non-maleficence is not absolute, and must be balanced against the principle of beneficence (doing good)

• Some American physicians interpret this principle to exclude the practice of euthanasia, though not all concur. Probably the most extreme example in recent history of the violation of the non-maleficence dictum was Dr. Jack Kevorkian, who was convicted of second-degree homicide in Michigan in 1998 after demonstrating active euthanasia on the TV news show, 60 Minutes.

• In some countries euthanasia is accepted as standard medical practice. Legal regulations assign this to the medical profession. In such nations, the aim is to alleviate the suffering of patients from diseases known to be incurable by the methods known in that culture. In that sense, the "Primum no Nocere" is based on the realisation that the inability of the medical expert to offer help, creates a known great and ongoing suffering in the patient. "Not acting" in those cases is believed to be more damaging than actively relieving the suffering of the patient. Evidently the ability to offer help depends on the limitation of what the practitioner can do. These limitations are characteristic for each different form of healing, and the legal system of the specific culture. The aim to "not do harm" is still the same. It gives the medical practitioner a responsibility to help the patient, in the intentional and active relief of suffering, in those cases where no cure can be offered.

• Nursing ethics is a branch of applied ethics that concerns itself with activities in the field of nursing. Nursing ethics shares many principles with medical ethics, such as beneficence, non-maleficence and respect for autonomy. It can be distinguished by its emphasis on relationships, maintaining dignity and collaborative care.

• Development of subject• The nature of nursing means that nursing ethics tends to examine the ethics of

caring rather than 'curing' by exploring the relationship between the nurse and the person in care. Early attempts to define ethics in nursing focused more on the virtues that would make a good nurse, rather than looking at what conduct is necessary to respect the human rights of the person in the nurse's care. However, in the modern era, the ethics of nursing has shifted more towards the nurse's obligation to respect these rights and this is reflected in a number of professional codes for nurses. For example, the importance of respecting human rights in nursing is made explicit in the latest code from the International Council of Nurses.

• Although much of nursing ethics can often appear similar to medical ethics, there are some factors that differentiate it. The focus of nursing ethics is on developing a caring relationship and this produces some differences. For example, a well established principle of traditional medical ethics is beneficence. Whereas, traditional medical ethics allows this to be expressed through paternalism, this approach would not be compatible with nursing ethics. This is because nursing theory seeks a collaborative relationship with the person in care. Themes that emphasizes respect for the autonomy and maintaining the dignity of the patient by promoting choice and control over their environment are commonly seen. This is in contrast to paternalistic practice where the health professional chooses what is in the best interests of the person from a perspective of wishing to cure them.

• The distinction can be examined from a different angle. Despite the move toward more deontological themes by some, there continues to be an interest in virtue ethics in nursing ethics and some support for an ethic of care. This is considered by its advocates to focus more on relationships than principles and therefore to reflect the caring relationship in nursing more accurately than other ethical views.

• Nursing seeks to defend the dignity of those in their care. In terms of mainstream ethical theory, this may be interpreted as having a respect for autonomy. People are then enabled to make decisions about their own treatment. Amongst other things this grounds the practice of informed consent that should be respected by the nurse. Although much of the debate lies in the discussion of cases where people are unable to make choices about their own treatment due to being incapacitated or having a mental illness that affects their judgement. A way to maintain autonomy is for the person to write an advance directive, outlining how they wish to be treated in the event of them not being able to make an informed choice, thus avoiding unwarranted paternalism.

• Another theme is confidentiality and this is an important principle in many nursing ethical codes. This is where information about the person is only shared with others after permission of the person, unless it is felt that the information must be shared to comply with a higher duty such as preserving life.