Chapter 1: Nursing Past & Present

Trends in Society

-Our historical roots strongly influence current nursing practice and will undoubtedly continue to do so -In addition, nursing is influenced by trends in the economy, the growing number of older adults, increased consumer knowledge, legislation, the women's movement, and collective bargaining

Benner's Model

-Patricia Benner (1984) described the process by which a nurse acquires clinical skills and judgment -Expertise is not merely demonstration of skilled application of knowledge, but rather a personal integration of knowledge that requires technical skill, thoughtful application, and insight; expertise requires thinking, doing, and caring -Benner's process occurs in stages -Benner's model deals with the development of clinical wisdom and competence -Nurses do not automatically move through the stages as they gain experience; instead, this model assumes that, to improve in skill and judgement, you must also be attuned to each clinical situation; this requires an ability to take in information from a variety of sources and to notice subtle variations -Although expertise (stage 5) is a goal, not everyone can achieve this level of skill

Where do Nurses Work?

-Hospitals -Extended care facilities -Ambulatory care -Home care -Community health

Benner's Model: Stage 4 - Proficient

-Proficient nurses are a resource for less experienced nurses -They are able to see the "big picture" and can coordinate services and forecast needs -They are much more flexible and fluent with their role and able to adapt to nuances of various patient situations -Proficient nurses plan intuitively as well as consciously

Hospitals

-Provide services to patients who require around-the-clock nursing care -This type of care is frequently referred to as *acute care* -Length of stay is limited to the amount of time that the client requires 24-hour observation

Florence Nightingale's Major Contributions

-The establishment of nursing as a distinct profession -Introduction of a broad-based liberal education for nurses -Major reform in the delivery of care in hospitals -The introduction of standards to control the spread of disease in hospitals -Major reforms in healthcare for the military

Importance of a Definition for Nursing

(1) Help the public understand the value of nursing (2) Describe what activities and roles belong to nursing versus other health professions (3) Help students and practicing nurses understand what is expected of them within their role as nurses

RN: Associate Degree

-Most associate degree (AD) programs are offered in community colleges -Although the nursing component typically lasts 2 years, students are required to take numerous other courses in liberal arts and the sciences -*ADN students are prepared to provide direct patient care*

Standards of Practice

-"Describe a competent level of nursing practice and professional performance common to all registered nurses...They are authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are expected to perform competently" (ANA, 2010, p. 2) -Standards are used by individual nurses, employers of nurses, professional organizations, and other professions -Practicing nurses use the standards to judge their own performance, develop an improvement plan, and understand what employers expect them -Employers incorporate the standards into annual evaluation tools at hospitals and health facilities -Professional organizations use the standards to educate the public about nursing, to plan for continuing education programs for nurses, and to guide their efforts at lobbying and other activities that advocate for nurses -Other professions read the standards of practice to examine the boundaries between nursing and other health professions

Interest in Interpersonal Collaboration

-*Collaboration* is the process of joint decision making among independent parties, involving joint ownership of decisions and collective responsibility for outcomes -However, in a relationship in which there is a power imbalance, true collaboration can occur only if the more powerful parties are willing -Physicians and nurses tend to have different values and to place different emphases on patient care; this may contribute to strained relationships and disagreements about a patient's plan of care, which may lead to undesired outcome for patients -True collaboration occurs when institutions state it as a goal and give recognition to those who practice it

Increased Use of Nursing Assistive Personnel

-*Nursing assistive personnel (NAP)* are healthcare providers who help nurses and physicians provide patient care -Common NAP roles include nurse aide, assistant, orderly, and technician -NAPs may perform simple nursing tasks (e.g., bathing, taking temperatures, or making beds) under the direction of the licensed nurse -Some institutions even train NAPs for more complex tasks traditionally reserved for licensed nurses (e.g., inserting urinary catheters, giving certain medications) -The nurse retains ultimate responsibility for the patient, yet may have to base important patient care decisions on information obtained by the NAP

Is Nursing a Profession, Discipline, or Occupation

-*Profession*: Starr (1982) said that a group must meet certain criteria to be considered a profession: --The knowledge of the group must be based on technical and scientific knowledge --The knowledge and competence of members of the group must be evaluated by a community of peers --The group must have a service orientation and a code of ethics -Nursing appears to meet all criteria of a profession as defined by Starr -*Discipline*: to be considered a discipline, a profession must have a domain of knowledge that has both theoretical and practical boundaries; the *theoretical boundaries* of a profession are the questions that arise from clinical practice and are then investigated through research; the *practical boundaries* are the current state of knowledge and research in the field--the facts that dictate safe practice *A case can be made that nursing is both a profession and a discipline*: -It is a scientifically based and self-governed profession that focuses on the ethical care of others -It is a discipline, driven by aspects of theory and practice. It demands mastery of both theoretical knowledge and clinical skills -*Occupation*: in spire of meeting criteria for both profession and discipline, nursing is often described as an occupation, or job -Most nurses are hourly wage earners; the employer, not the nurse, decides the conditions of practice and the nature of the work; nurse practice acts do not prevent nurses from functioning more autonomously, however

Collective Bargaining

-A form of negotiating that allows nurses to seek better wages and working conditions as a a group rather than individually -A union or organization that represents the nurses usually conducts collective bargaining -It has resulted in significant improvements in wages, benefits, and working conditions for nurses, as well as safer conditions for patients

The Growing Proportion of Older Adults in the United States

-A larger older adult population creates a need for more medical and nursing care; at the same time, there are fewer younger people to provide care

Problem-Solving

-A process by which nurses consider an issue and attempt to find a satisfactory solution to achieve the best outcome

Critical Thinking

-A reflective thinking process that involves collecting information, analyzing the adequacy and accuracy of the information, and carefully considering options for action -Nurses use critical thinking in every aspect of nursing care

The Military Disease: Nurses Fighting Disease

-A second military image portrays nurses as warriors in the fight against disease; this image is common in public awareness campaigns against infectious diseases -*Florence Nightingale's* contributions in public health and epidemiology (the study of the distribution and origins of disease) were among the first nursing efforts to fight disease; in her *Notes on Hospitals* (1863), she stated that air, light, nutrition, and adequate ventilation and space assist the patient to recuperate; the hospitals she designed to incorporate these ideas were associated with decreased mortality, decreased length of hospital stay, and decreased rate of *nosocomial infection* -*Lillian Wald and Mary Brewster* founded the Henry Street Settlement in New York to improve the health and social conditions of poor immigrants; this is considered the start of public health nursing in the U.S.; since then, nurses have played an important role in improving health and preventing illness by promoting safe drinking water, adequate sewage facilities, and proper sanitation measures in communities

Nursing Activités: Dependent

-Administering prescribed medication -Assisting with a diagnostic test (e.g., opening trays, handing instruments to the physician) -Administering IV fluids -Ensuring that the patient receives the prescribed diet

Divergence Between High-Tech and High-Touch

-Advances in clinical knowledge and technology have contributed to improved care for many patients who are critically ill (e.g., premature newborns and patients with advanced cardiovascular, pulmonary, or renal disease) -However, in prolong life, technology has created numerous legal and ethical dilemmas, particularly about end-of-life care -This trend is in contrast to the concurrent trend toward holism and high-touch therapies, which is often avoid technology

Ambulatory Care

-Also referred to as *outpatient care* -Clients live at home or in non hospital settings and come to the site for care -Ambulatory care sites include private health and medical offices; clinics; outpatient therapy centers; and walk-in clinics in shopping centers, pharmacies, and other retail sites -Typically they treat only common ailments are refer complex or serious illness to specialized physicians or emergency rooms

Nursing Organizations

-American Nurses Association (ANA)/Canadian Nurses Association (CNA) -National League for Nursing (NLN) -International Council of Nursing (ICN) -National Student Nurses Association (NSNA) -Sigman Theta Tau International (STTI) -Specialty Organizations

Expanded Variety of Settings for Care

-As the site of employment shifts away from the hospital, nurses must be prepared to function in these alternative settings -This change requires entry-level education programs to prepare nurses for this type of work -In the hospital, nurses have access to support personnel, ready access to equipment and diagnostic testing services, and increased access to the patient -In outpatient, community, or home settings, nurses must be prepared to function more autonomously and creatively, adapting care to the equipment available at the site

Benner's Model: Stage 1 - Novice

-Begins with the onset of education -The novice is typically receptive to education and is "learning the rules" of the profession

Increased Use of Complementary and Alternative Medicine

-CAM includes homeopathy, naturopathy, chiropractic, and traditional Chine medicine, as well as specific treatments -Many people have turned to CAM as a result of the rising costs of traditional care, concern about the safety of traditional care, concern about the safety of traditional healthcare, distrust of the role of insurance and managed care organizations in determining treatment options, and confusion over changing recommendations (e.g., how often to have a screening exam for breast cancer) -In addition, as the population becomes more culturally diverse, there is an accompanying exchange of information about therapies from different cultural traditions

Nursing: Formal Education

-Consists of completing the initial and continuing education required for licensure -To legally use the title nurse, a person must be a graduate of an accredited nursing education program and have successfully passed a licensure exam -Students may enter nursing through two paths: as a practical nurse or a register nurse

Changes in Healthcare Consumers

-Consumers are demanding greater choice decisions that affect their health, including legislation -Patients have access to vast amounts of health and medical information, particularly through the Internet (e.g., through Web sites such as WebMD) -Informed consumers tend to be active participants in discussions about their health problems and therapy options -Clients may request their healthcare providers to prescribe specific trade name therapies they have heard about in the media, so nurses need to be prepared to address the truthfulness of the advertisements, present balanced information to clients, and address the appropriateness of the advertised products and services for the individual person's needs

What Factors Influence Contemporary Nursing Practice?

-Contemporary nursing practice is influenced by factors outside the profession in society at large, and factors within nursing and healthcare

*Table 1-4*: Is Nursing a Profession?: Starr Criterion & Examples in Nursing

-Criterion: The knowledge of the group must be based on technical and scientific knowledge -Examples in Nursing: Entry-level nursing education requires coursework in basic and social sciences as well as humanities, arts, and general education; Nursing education and practice are increasingly based on research from nursing and related fields -Criterion: The knowledge and competence of members of the group must be evaluated by a community of peers -Examples in Nursing: State or provincial regulatory bodies have defined the criteria that nurses must meet to practice, and they monitor members for adherence to standards -Criterion: The group must have a service orientation and code of ethics -Examples in Nursing: Nursing is clearly focused on providing service to others; the major professional organizations have developed ethical guidelines to guide the practice of nursing

Registered Nursing Entry Education

-Currently, 5 educational pathways lead to licensure as a RN: diplomas, associate degree, baccalaureate degree, master's entry, and doctoral entry -Graduates of all these programs must successfully complete the NCLEX-RN exam to practice as RNs

Community Health

-Deals with care for community at large -Community health nurses provide to at-risk populations and devise strategies to improve the health status of the surrounding community -Examples: healthcare for the homeless and school-based programs designed to decrease the incidence of teen pregnancies

Nursing Activities: Independent

-Evaluating the patient's response to medication and withholding the next dose if the patient has a negative reaction -Teaching the patient what to expect from the diagnostic test; preparing the patient for the test (e.g., shaving a site); supporting the patient during the test -Evaluating the patient's response to treatment; monitoring the flow rate; evaluating the site for redness or leakage -Teaching a pregnant woman about additional nutrients needed in her diet

Benner's Model: Stage 5 - Expert

-Expert nurses are able to see what needs to be achieved and how to do it -They trust in and use their intuition while operating with a deep understanding of a situation -They have expert skills and are often consulted when others need advice or assistance

Illness Prevention

-Focuses on avoidance of disease, infection, and other comorbidities -Activities are targeted to decrease the risk of developing an illness or to minimize the risk of exposure to disease -For example: pneumonia affects society's most vulnerable: the very young, and the very ill -Some nursing activities to decrease the risk of pneumonia include: teaching the importance of hand hygiene to decrease the transmission of infection and advocating for and administering pneumonia immunizations to those at high risk

Health Restoration

-Fosters a return to health for those already ill -To restore health, the nurse provides direct care to ill individuals, groups, families, or communities -Direct care is what most people think of when they envision the nursing role -When you engage in health-restoration activities, your care should address each of these dimensions -For example: providing hygiene care, providing client teachings, and lobbying for health policy changes to improve access to care

Roles and Functions of the Nurse: *Client/Family Educator*

-Function: Assessing and diagnosing the teaching needs of the client, group, family, or community. Once the diagnosis is made, nurses plan how to meet these needs, implement the teaching plan, and evaluate its effectiveness -Examples: preoperative teaching, prenatal education for siblings, and community classes on nutrition

Roles and Functions of the Nurse: *Direct Care Provider*

-Function: addressing the physical, emotional, social, and spiritual needs of the client -Examples: assessing the client, giving medications, patient teaching

Roles and Functions of the Nurse: *Change Agent*

-Function: advocating for change on an individual, family, group, community, or societal level that enhances health. The nurse may use counseling, communication, and educator skills to accomplish this change -Example: working to improve the nutritional quality of the lunch program at a preschool

Roles and Functions of the Nurse: *Research Consumer*

-Function: applying evidence-based practice to provide the most appropriate care, to identify clinical problems that warrant research, and to protect the rights of research subjects -Examples: reading journal articles and attending continuing education; seeking additional education

Roles and Functions of the Nurse: *Manager*

-Function: coordinating and managing the activities of all members of the team -Examples: charge nurse on a hospital unit (e.g., assigns patients and work to staff nurses)

Roles and Functions of the Nurse: *Case Manager*

-Function: coordinating the care delivered to a client -Examples: coordinator of services for clients with tuberculosis

Roles and Functions of the Nurse: *Leader*

-Function: inspiring others by setting an example of positive health, assertive communication, and willingness to improve -Example: Florence Nightingale, Walt Whitman, and Harriet Tubman

Roles and Functions of the Nurse: *Client Advocate*

-Function: supporting clients' right to make healthcare decisions when they are unable to voice their opinions and protecting clients from harm when they are unable to make decisions -Examples: helping a client explain to his family that he does not want to have further chemotherapy

Roles and Functions of the Nurse: *Communicator*

-Function: using interpersonal and therapeutic communication skills to address the needs of the client, to facilitate communication in the healthcare team, and to advise the community about health promotion and disease prevention -Examples: counseling a client, discussing unit staffing needs at a meeting, providing pregnancy prevention education at a local school

Roles and Functions of the Nurse: *Counselor*

-Function: using therapeutic communication skills to advise clients about health-related issues -Examples: counseling a client on weight-loss strategies

RN: Graduate Nursing Education

-Graduate education prepares the RN for advanced practice, expanded roles, or research -*Master's degree programs* prepare RNs to function in a more independent role, for example, as advanced practice nurses (APNs) or educators -Programs typically last 2 years or longer -*Doctoral programs* in nursing offer professional degrees; typically the student has completed a BSN and master's degree before entry into a doctoral program; degrees awarded are usually the DNS (doctor of nursing science) or PhD (doctor of philosophy) -The DNS program prepares the nurse for advanced clinical practice -The PhD is a research degree

Caucasian Women

-Historically, images of nurses have been of Caucasian women -Rarely are there images of various ethnicity or men of any race -Men are a minority of the total nursing population worldwide -The trend in the U.S. now is toward a slightly more diverse workforce and the percentage will likely increase

The Women's Movement

-Historically, only unmarried women were allowed to practice nursing -As the women's movement gained momentum, women were no longer forced out of nursing if they chose to have a family However, the women's movement also opened up more career choices for women, and nursing has become just one of may options as opposed to a preferred career pathway -Societal views of nursing as a women's professions influence the decisions of men to enter nursing

Home Care

-Home healthcare is provided to clients who are homebound or unable to get ambulatory care centers for services -May also be used when the client or family prefers to receive care in the home---particularly when the client is terminally ill -Home care is also appropriate when a client still requires skilled care but is discharged from the hospital because his reimbursable length-of-stay has expired -Services are usually coordinated by a home health or visiting nurse service and include nursing care as well as various therapies and home assistance programs

Specialty Organizations

-Numerous specialty organizations have developed around clinical specialities, group identification, or similarly held values -*Clinical specialty*: Association of Operating Room Nurses (AORN); Association of Nurses in AIDS Care (ANAC); Emergency Nurses Association (ENA) -*Group identification*: National Organization for Associate Degree Nursing (NOADN); National Association of Hispanic Nurses (NAHN); American Assembly for Men in Nursing (AMN) -*Similar values*: Nurses Christian Fellowship (NCF); Nursing Ethics Network (NEN)

How is Nursing Practice Regulated?

-Nurse practice acts -Standards of practice

The Angel of Mercy

-Images of the angel-nurse are usually serene and content -The strong link between nursing and religious orders can be traced back to ancient cultures -Priests and priestesses treated the ill with a combination of physical care, prayer, and magic spells -In Asia, some of the earliest writings about a distinct nursing occupation are included in the Vedas, the ancient sacred books of the Hindu faith; the nurses included in these texts were always men who were part of a priestly order and who possessed knowledge of the preparation, compounding, and administration of drugs; wisdom; purity; and devotion to the patient -In late centuries, lay deacons and deaconesses in the early Christian church visited the sick in their homes and functioned as nurses until the first hospitals were established in the first century -In the U.S., all training programs for nurses were affiliated with religious orders until well after the Civil War -Today, many nursing programs, universities, colleges, and healthcare institutions are affiliated with religious groups (ex: University of Notre Dame) -Christianity gradually lost influence in general society over the 15th to the 19th centuries -Another reason for the association between nursing and spirituality is the inherent risks involved in patient care, especially in the recent past; before the development of microscopes and techniques for culturing microorganisms in the 19th century, people who entered nursing placed themselves at risk for exposure to diseases that were poorly understood and often could not be cured -The chief cause of mortality was infectious disease -Providing care in spite of these risks was considered self-sacrificing, much like the call to serve in religious life

American Nurses Association (ANA) Definition

-In 1980, the ANA defined nursing as "the diagnosis and treatment of human responses to actual and potential health problems" -Five characteristics of registered nursing: (1) Nursing practice is individualized (2) Nurses coordinate care by establishing partnerships (with persons, families, support systems, and other providers) (3) Caring is central to the practice of the registered nurse (4) Registered nurses use the nursing process to plan and provide individualized care to their healthcare consumers (5) A strong link exists between the professional work environment and the registered nurse's ability to provide quality health care and achieve optimal outcomes -The ANA now defines professional nursing as the following: *"The protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations"*

Trends in Nursing and Healthcare

-Increased use of complementary and alternative medicine -Expanded variety of settings for care -Interest in interpersonal collaboration -Increased use of advanced practice nurses -Increases use of nursing assistive personnel -Influence of nurses on healthcare policy -Divergence between high-tech and high-touch

Informal Education

-Involves a gradual progression in skill and clinical judgement that allows the nurse to advance in the profession -In addition to formal programs of study, education also requires socialization into the profession -*Socialization* is the informal education that occurs as you move into your new profession; it is the knowledge gained from direct experience, observation in the real world, and informal discussion with peers and colleagues -Professional socialization begins when you enter the educational program and continues as you gain expertise throughout your career -Informal education complements formal education to create clinical competence

Clinical Judgement

-Involves observing, comparing, contrasting, and evaluating the client's condition to determine whether change has occurred -It also involves careful consideration of the client's health status in light of what is expected based on the client's condition, medications, and treatment -These actions are intertwined with the nursing process stages of assessing, diagnosing, and evaluating

Nurse Practice Acts

-Laws that regulate nursing practice -In the U.S., each state enacts its own nurse practice act -The state board of nursing is the agency responsible for regulating nursing practice -Although there are minor variations, each board of nursing is responsible for the following: (1) Defining the practice of nursing (2) Establishing criteria that allow a person to be considered a RN or LPN/LVN (3) Determining activities that are in the scope of practice of nursing: that nurses may perform (and by implication, those they may not); and those that may be performed only by licensed nurses (4) Enforcing the rules that govern nursing -To practice nursing, an individual must be licensed as a nurse -Licenses are issued by the state -All states require graduation from an approved nursing program and successful completion of the NCLEX -To receive licensure in another state, the nurse simply applies for reciprocity

The Handmaiden

-Many activities that nurses now do independently were once performed only by physicians, including taking vital signs, performing physical assessments, and administering IV and other injectable medications -Physicians derive much of their power from legal and financial authority; early physicians from wealthy and dedicated classes wrote and lobbied for legislation that awarded them extensive power and ensured control of healthcare; now it is very difficult to change these laws to accommodate the expanded role of modern nurses -Without physicians, the institution does not generate income; most patients--or their insurers--directly pay the facility to provide care that is prescribed by the physician; in contrast, nurses, with the exception of advanced care nurses, are often employees of healthcare institutions--therefore, they are considered an expense because they cannot bill for the services they provide -In the past, not all nurses considered themselves to be subservient to physicians; the letters and writings of Florence Nightingale indicate that she considered nurses the colleagues of physicians rather than their servants; she stated that the standard description of nurses as "devoted and obedient...would do well for a porter" and "it might even do well for a horse" -Nightingale became a field nurse during the Crimean War, where she became known as "the Lady of the Lamp" because of her nighttime care to the wounded; upon her return to England, she used her experience in the Crimea to immediately lobby politicians and physicians about the importance of nursing and the need for public health reform -The employment status of the most nurses is another factor that must be considered when looking at the validity of the handmaiden image; if nurses have indeed been handmaidens, perhaps it has been to the institutions that employ them -Nurses are actively working to combat the handmaiden stereotype; for instance, they have formed unions to improve their working conditions and benefits and to advocate for patient safety -The increased number of advance practice nurses and nurse entrepreneurs further rebukes the validity of the handmaiden image -The increasing costs of healthcare, coupled with decreasing reimbursement for health services, appear to be driving these changes

Benner's Model: Stage 3 - Competence

-Nurses achieve competence after a few years of practice -Competent performers have gained additional experience and wrestle with more complex concerns -They are able to handle their patient load and prioritize situations -They are also more involved in their caregiving role and may be emotionally involved in the clinical choices made -Although competent nurses manage clinical care with mastery, they often do not fully grasp the overall scope and most important aspects

End-of-Life Care

-Nurses have been active in promoting the respectful care of those who are terminally ill or dying -Nursing activities for the dying are designed to promote comfort, maintain quality of life, provide culturally relevant spiritual care, and ease the emotional burden of death -Nurses work with dying individuals, their family members and support persons, and organizations that focus on the needs of the terminally ill

Full-Spectrum Nurse

-Nurses have often been shown actively caring for the patient--dressing wounds, bathing, giving medications--but the intellectual or thinking side of nursing is rarely portrayed -The angel of mercy and military stereotypes reinforce the idea that nursing is a duty and that nurses are carrying out orders; the naughty nurse, battle-ax, and handmaiden images suggest a woman who is quick to act but may not carefully consider her actions; in reality, a large portion of the nursing role involves thinking -*To be safe providers, nurses must carefully consider their actions and think carefully about the patient, the treatment plan, the healthcare environment, the patient's support system, the nurse's support system, resources, and safety* -Full-spectrum nursing involves clinical judgement, critical thinking, and problem-solving

What Are the Purposes of Nursing Care?

-Nurses provide care to achieve the goals of health promotion, illness prevention, health restoration, and end-of-life care -Together these aspects of care represent a range of services that cover the health spectrum from complete well-being to death

The Military Image

-Nursing imagery is often military, both in the general public and within the profession itself -Nurses involvement in the military dates from 27 BCE, as the Roman Empire began to consolidate its dominion; because the Roman Empire relied on the success of military excursions to extend its domain, the well-being of its soldiers was critical; thus, one of the great contributions of the Roman Empire was the development of the military hospital and the practice of providing first aid on the battlefield -During the Middle Ages, the two largest influences on nursing were the military and religion; these two threads fused in the Crusaders, soldiers who went to battle to conquer Islamic lands and spread Christianity throughout the world; among the Crusaders were *hospitalers*, specialized soldiers who at the end of battle returned to the outposts to care for the sick and injured -The hospitaler order known as the Knights of St. John of Jerusalem established men's and women's branches throughout Europe--one of which still exists in England as the Order of Malta -Nursing presence on the battlefield continued during the Civil War -The U.S. government established the Army Nursing Service in 1861, and its role was to organize nurses and hospitals and coordinate supplies for the soldiers; many trained nurses joined the Army Nursing Service from religious orders; thousands of laypersons also volunteered, including: Clara Barton, Harriet Tubman, Walt Whitman, Louisa May Alcott, and Dorothea Dix -*Clara Barton* and her volunteers provided care in tents and set up close to the fighting; she did not discriminate when giving care, nursing soldiers from both the North and the South, black and white; when the war was over, Barton continued this universal care through the establishment of the American Red Cross -Harriet Tubman helped slaves escape to freedom on the Underground Railroad -Dorothea Dix was the Union's superintendent of Female Nurses during the Civil War -Mary Mahoney was the first professionally trained African American nurse -In spite of the historical association of nursing with the military, currently only a small percentage of licenses U.S. nurses work in the armed services; similarly, despite the powerful image of the nurse fighting disease, only approximately 8% of nurses work in community and public health agencies, which includes school and public health departments

National League for Nursing (NLN)

-Originally founded as the American Society of Superintendents of Training Schools for nurses in 1893 -The first nursing organization with a goal to establish and maintain a universal standard of education -The NLN sets standards for and evaluates all types of nursing education programs, studies the nursing workforce, lobbies and participates with other major healthcare organizations to set policy for the nursing workforce, aids faculty development, funds research on nursing education, and publishes the journal "Nursing Education Perspectives"

Practical and Vocational Nursing Education

-Prepares nurses to provide bedside care to clients -Known as licensed practical nurses (LPNs) or licensed vocational nurses (LVNs) -Educational programs for LPN/LVNs offer both classroom and clinical teaching and usually last 1 year -After completing the practical nursing education program, the student must pass the NCLEX-PN exam -Practical nurses work under the direction of the RN or the primary care provider

Influence of Nurses on Healthcare Policy

-Professional nursing organizations are actively involved in local, state, and national politics -Nursing organizations sponsor legislation that promotes the interest of the profession and supports changes that positively influence health outcomes -Nurse-sponsored legislation has addressed safe staffing in hospitals, needle-exchange programs to decrease the transmission of HIV and the infectious diseases, and funding to increase nursing enrollment during times of nursing shortages -As individuals, nurses should vote, lobby their elected representatives, and run for political office

Extended Care Facilities

-Provide care for clients for an extended period of time--usually longer than 1 month -They include nursing homes, skilled nursing facilities (also known as convalescent hospitals), and rehabilitation facilities -The distinction among them is based primarily on whether they provide skilled or custodial care -*Skilled care* includes services of trained professionals that are needed for a limited period of time after an injury or illness -*Custodial care* consists of help with activities of daily living: bathing, dressing, eating, grooming, ambulation, toiling, and other are that people typically do for themselves (e.g., taking medications, monitoring blood glucose levels) -*A nursing home* provides custodial care for people who cannot live on their own but are not sick enough to require hospitalization; it provides a room, custodial care, and recreation -*A skilled nursing facility* primarily provides skilled nursing care for patients who can be expected to improve with treatment; for example, a patient who no longer needs hospitalization may transfer to a skilled nursing facility until she is able to return home

International Council of Nursing (ICN)

-Represents nursing on a global level -It is composed of a federation of national nursing organizations from more than 120 nations -The ICN aims to ensure quality nursing care for all, supports global health policies that advance nursing and improve worldwide health, and strives to improve working conditions for nurses throughout the world

National Student Nurses Association (NSNA)

-Represents nursing students in the U.S. -It is the student counterpart of the ANA -Like the ANA, this association is made up of elected volunteers who advocate on behalf of student nurses -The NSNA sponsors yearly conventions to address student concerns -Local chapters are usually organized at individual schools -The NSNA also publishes "Image," a journal dedicated to nursing student issues -In Canada, the Canadian University Student Nurses Association serves in the same capacity as the NSNA

How Can Nursing Improve the Recognition as a Profession?

-Standardizing the educational requirements for entry into practice -Enacting uniform continuing education requirements -Encouraging the participation of more nurses in professional organization -Educating the public about the true nature of nursing practice

RN: Baccalaureate Degree

-Students in BSN programs pursue a course of study like that of other undergraduate students -The course of study lasts at least 8 semesters -*Students are prepared to provide direct patient care, to work in community care, to use research, and to enter graduate education* -Many AD graduates enter RN-to-BSN programs -The length of time required to complete the BSN varies according to the program and the number of credits each student can transfer

Nursing Organization Guidelines

-The ANA and other organizations also help to continue to improve their practice (e.g., by setting standards and articulating nursing values) -For example, in the Code for Nurses, the ANA provides guidelines for nurses to conduct themselves in their day-to-day practice -These guidelines describe behaviors and values that help improve practice and participation in the profession

American Nurses Association (ANA)/Canadian Nurses Association (CNA)

-The ANA and the CNA are the official professional organizations for nurses in their respective countries -Both were formed in 1911 -Originally, these organizations focuses on establishing standards of nursing to promote high-quality care and work toward licensure as a means of ensuring adherence to the standards -Representatives are elected from the local branches of the state organizations to bring their concerns to the national level -They track healthcare legislation, serve as liaisons with national government representatives to inform them of her current and proposed legislation will affect nursing, and develop and sponsor legislation that will have a positive effect on nursing and on patient care -The ANA publishes educational materials on nursing news, issues, and standards

Common Images of Nurses

-The Angel of Mercy -The Handmaiden -The Battle-Ax -The Naughty Nurse -The Military Image -Caucasian Women

QSEN Commission and Quality Improvement

-The Quality and Safety Education for Nurses (QSEN) project and the Institute of Medicine (IOM) have identified quality and safety competencies for nurses -One important QSEN competency is *quality improvement (QI)* -QSEN defines that competence as the ability to "use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems"

Health Promotion

-The World Health Organization defined *health* as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity"; this inclusive definition can be applied to individuals, groups, families, or communities -Health promotion activities foster the recipient's highest state of well-being -For example, at the *individual* level you might counsel a pregnant client about the importance of adequate prenatal nutrition to promote health; *group* and family-level health promotion activities might include teaching about nutrition during pregnancy in family education programs; on a *community* level your activities would be focused on reaching a larger number of people, like posting signs in grocery stores recommending food sources for pregnant women and lobby for the labeling of substances that should be avoided in pregnancy

The National Economy

-The economy has a tremendous impact on nursing -In the U.S., health insurance coverage is linked to full-time employment with health insurance benefits (although that is changing with recent federal legislation); thus, when unemployment is high or businesses reduce their employee healthcare benefits, fewer people have insurance -Fearing the high cost of healthcare, many uninsured people delay seeking treatment -The effect is that they are often sicker when they enter the healthcare system; this taxes the system's resources and raises the level of nursing care required -The healthcare industry, even in a strong economy, is very expensive to operate -Downturns in the economy affect institutional investments and profits, and the amount of taxes the government can collect; these in turn limit the medications and services that are available in public-supported healthcare programs; similarly, the salaries of healthcare providers are influenced by national economic trends

The Battle-Ax

-The image of the nurse as a battle-ax is in direct opposition to the image of the angel of mercy, but these opposing images have coexisted for centuries -As science and philosophy grew more sophisticated and popular, religious orders for nursing became less common, and much of the devotion and knowledge of caring for the sick was lost -Municipal authorities took over hospitals and began to sentence criminals to care for the sick in the hospitals-to assume the nursing role; forced to care for large numbers of patients without training, supplies, assistance, or time off, these criminals often managed their workload by treating patients harshly and drinking alcohol while on duty; most patients who entered such hospitals died there and such practices persisted until the 1860s -Nurses give injections, clean and dress wounds, draw blood, and start IV lines that are designed to improve patient's health, but they cause significant pain, contributing to the persistence of the battle-ax image -To offset this image, nurses in pediatric units wear colorful uniforms to avoid frightening children who may associate "nurse" with "pain"

The Naughty Nurse

-The image of the sexy, risqué nurse arose in the early part of the 20th century with burlesque shows and persists in popular culture today -As trusted health professionals, nurses frequently provide care that involved exposing the patient's body, contact with bare skin, and discussion of intimate aspects of the client's life; in addition, hospitalized patients are in a weakened, vulnerable state, and the nurse may seem quite powerful by contrast -The "naughty nurse" stereotype may express a forbidden desire for intimate contact with a stranger in a position of power

Increased Use of Advanced Practice Nurses

-The increased use of advanced practice nurses (APNs) has resulted in greater public exposure for nurses -Professional and public reports demonstrate high patient satisfaction with APNs; comparable, and at times superior, patient outcomes over physician-provided care; better understanding of and compliance with treatment regimen; fewer hospitalizations and greater cost effectiveness when compared with physician providers -This positive exposure has resulted in creased acceptance and support for all nurses

Sigma Theta Tau International (STTI)

-The national honor society for nursing -Members are sought from the clinical, educator, and researcher nursing communities as well as from senior-level baccalaureate and graduate programs -The goal of this organization is to foster nursing scholarship, leadership, and research

Benner's Model: Stage 2 - Advanced Beginner

-The nurse functioning at this level begins to use more facts and is more sophisticated with use of the rules -A new graduate usually functions at this level

BOX 1-2: Nursing Values and Behaviors

-The nurse's primary concern is the good of the patient -Nurses ought to be competent -Nurses demonstrate a strong commitment to service -Nurses believe in the dignity and worth of each person -Nurses constantly strive to improve their profession -Nurses work collaboratively within the profession

RN: Master's Entry

-The typical student in these programs has a baccalaureate degree in another field and has entered nursing as a second career -Programs are completed in 3 years of full-time study -At the completion, the student is eligible to take the licensing exam and is awarded a masters degree in nursing

RN: Doctoral Entry

-This is the most unusual entry pathway into nursing -The nursing doctorate (ND) path parallels the pathway through which physicians enter the healthcare field -This entry has very limited enrollment

Other Forms of Formal Education

-To stay current with advances in healthcare after graduating, you must participate in ongoing education -*Continuing education* programs are intended to ensure that nurses keep up with current clinical knowledge -Theses programs are available at work sites, at colleges and universities, through privately operated educational groups, on the Internet, and in professional journals -In 23 states, renewal of the nursing license requires successful completion of a specified number of continuing education courses -When you receive your initial nursing license, your state board of nursing (SBN) will notify you about continuing education requirements, if any; thereafter, the SBN will notify you of any changes in the requirements--regulations change frequently -*Inservice education* is another form of ongoing education -It is offered at the work site, and usually does not count toward meeting the continuing education requirement for license renewal -For instance, inservice education might focus on the use of new equipment or the introduction of new policies in an institution, or it may resemble traditional continuing education programs

RN: Diploma

-Until the 1960s, diploma programs were the mainstay of nursing education -These programs are usually associated with a hospital -The typical program lasts 3 years and focuses on clinical experience in direct patient care -Since the 1960s the number of diploma programs has steadily decreased