nursing project and need a sample draft to help me learn.
In this paper, the goal is to apply ethical concepts previously learned to a specific ethical dilemma. Or, you may choose to do write an Opt-Ed paper.
First, you might want to google the word “monologue” for clear definition and description of the word.
Below are suggested topics for your ethical issues paper:
Artificial Intelligence in nursing
Ethical issues in research
Genetics in Nursing
Horizontal fashion incivility and vertical incivility
Incivility in the profession – Example: Expert RN towards Novice Nurses
Informatics in Nursing
Resources for Impaired Nurses
Robotics
Scholarship in Nursing by Boyer
The new competencies for BSN degree nurses
Violence – Example: “bullying”
The paper should be organized and systematic in manner. The content should:
be your original work
flow and be easy to read
be no more than 5 pages (including the cover page and the reference page)
https://www.nursingworld.org/practice-policy/nursi…
adhere to APA style Links to an external site. (includes introduction, body, conclusion) with correct grammar and spelling are expected
Requirements:
SIXTH EDITIONRole Development in Professional Nursing Practice
The PedagogyRole Development in Professional Nursing Practice, Sixth Edition drives comprehension through various strategies that meet the learning needs of students while also generating enthusiasm about the topic. This interactive approach addresses different learning styles, making this the ideal text to ensure mastery of key concepts. The pedagogical aids that appear in most chapters include the following:What is truth? Where do our ideas about truth originate? Why does truth matter? The four principal domains of nursingÑperson, envi-ronment, health, and nursingÑare the building blocks for all philoso-phies of nursing. As you are learning about these ideas, you are also learning that many nurses develop nursing theories or models. Think about it . . . nurses creating theory! Yet who better to describe our profession than professional nurses? All right, so maybe you are not that excited about this reality. Still, you have to admit that the ability to articulate nursing values and beliefs to guide us in our understand-ing of professional nursing is impressive. More than impressive, nurs-ing theory is necessary.In this chapter, we look more closely at nursing philosophy and its significance to professional nursing. We study the difference be-tween beliefs and values and investigate the importance of values clarification. Finally, we examine guidelines for creating a personal philosophy of nursing.Key Terms and Concepts ÈIdealism ÈParadigm ÈRealism ÈValues ÈValues clariÞcationAfter completing this chapter, the student should be able to:1. Identify various philosophical views of truth.2. Differentiate between values and beliefs.3. Discuss the process of value clariÞcation.4. Explain the major components of nursing philosophy.5. Articulate the purpose for having a personal philosophy of nursing.6. Begin the development of a personal philosophy of nursing.Learning ObjectivesPhilosophy of NursingMary W. Stewart109CHAPTER 3Learning Objectives These objectives provide instructors and students with a snapshot of the key information they will encounter in each chapter. They serve as a checklist to help guide and focus study.Key Terms and Concepts Found in a list at the beginning of each chapter, these terms will create an expanded vocabulary.
CASE STUDY 15-1 ■ DELEGATIONAs the nurse on the medical-surgical unit, you are responsible for the care of eight acute patients. You have two nursing assistants working with you on this shift. Both of the nursing assistants have worked on the unit for several years. To provide adequate care for all the patients under your care, it is necessary to delegate some of the nursing care to the nursing assistants working with you. You request that the first nursing assistant check the vi-tal signs for Mr. Martin and you request that the second nursing assistant assess Ms. SmithÕs level of pain because you have recently administered pain medication.Case Study Questions1. Is the delegation of the assignment to the first nursing assistant in the case study appropri-ate? Why or why not?2. Is the delegation of the assignment to the sec-ond nursing assistant in the case study ap-propriate? Why or why not?Classroom Activity 15-1A mock trial is a fun way to explore some of the concepts in this chapter. Assign roles to students and use a graduation gown for the judge to increase the realism. Make up your own case or use one already prepared, such as the excellent mock trial presented in Nurse Educator by Haidinyak (2006).ReferencesAlder, S. (2017). HIPAA compliance guide. https://www.mahima.org/wp-content/uploads/HIPAAJournal -com-HIPAA-Compliance-Guide2017.pdfAmerican Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Essentials-2021.pdfAmerican Medical Association. (2007). Informed consent. Author.American Nurses Association. (2010). Social policy statement: The essence of the profession. Author.American Nurses Association. (2012a). The essential guide to nursing practice: Applying ANAÕs scope and standards in practice and education. Author.American Nurses Association. (2012b). Principles for delegation [Brochure]. https://www.nursingworld .org/~4af4f2/globalassets/docs/ana/ethics/principlesofdelegation.pdfAmerican Nurses Association. (2015a). Code of ethics for nurses with interpretive statements. Author.American Nurses Association. (2015b). Nursing: Scope and standards of practice (3rd ed.). Author.American Nurses Association & National Council of State Boards of Nursing. (2019). National guidelines for nursing delegation. https://www.nursingworld.org/~4962ca/globalassets/practiceandpolicy/nursing -excellence/ana-position-statements/nursing-practice/ana-ncsbn-joint-statement-on-delegation.pdfArizona Superior Court. (n.d.). Civil case flow. https://www.sc.pima.gov/default.aspx?tabid=180Canterbury v. Spence, 464 F.2d 772 (D.C. Cir. 1972).Clevette, A., Erbin-Rosenmann, M., & Kelly, C. (2007). Nursing licensure: An examination of the relationship between criminal convictions and disciplinary actions. Journal of Nursing Law, 11(1), 5Ð8.Finkelman, A. W. (2006). Leadership and management in nursing. Pearson Prentice Hall.CHAPTER 15 Law and Professional Nursing Practice464Although our individual philosophies vary, there are similarities that link us in our universal philosophy as a profession. As a whole, we are kept on track by continually evaluating our at-titudes, beliefs, and values. We can evaluate our efforts by reflecting on our philosophies. In the process of personal and professional reflection, we are challenged to reach global relevancy and to begin the development of a global nursing philoso-phy (Henry, 1998).ConclusionIn this chapter, we have discussed one of the most ambiguous concepts in professional disciplinesÑnursing philosophy. The history of philosophy helps us to see that asking questions about humans, environment, health, and nursing is a continual process that leads to a better understanding of truth in our profession. Our own values and beliefs must be clarified so that we can authentically respond to the healthcare needs of our patients and to society as a whole. Along the way, our philosophies are changing. Therefore, we must constantly question the values of our profession, our society, and ourselvesÑaiming to better the health of all people worldwide.Hegel, an early philosopher, said, ÒHistory is the spirit seeking freedom.Ó On this path of searching for truth, we ask the same ques-tion but in different contexts and with distinct experiences. The an-swers for one person do not provide the same satisfaction for another person. Through our individual and collective searching, we become truth knowers. Habermas, the supporter of dialogue, would suggest that the journey does not end with communication and question-ing alone. When truth is revealed, oppressive forces are acknowl-edged, and the truth knowers are then responsible to move to action. Through that action comes a change in the social structure and the hope of rightness in the world.CRITICAL THINKING QUESTIONS✶Do I believe in health care for everyone? Does health care for everyone have value to me as a person? Does it have value to me as a nurse? What value does universal health care have to my patients?✶CRITICAL THINKING QUESTIONS✶How does my personal philosophy fit with the context of nursing? Does it fit? What ar-eas, if any, need assessing?✶KEY COMPETENCY 3-2Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesProfessionalism:Knowledge (K8a) Under-stands responsibilities inherent in being a member of the nursing professionSkills (S8a) Understands the history and philosophy of the nursing professionAttitudes/Behaviors (A8b) Values and upholds altruistic and humanistic principlesMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. https://www.mass.edu/nahi /documents/nofrncompetencies_updated _march2016.pdfClassroom Activity 3-1Take about 15 minutes after the class discus-sion related to developing a philosophy of nursing to begin answering the questions in Box 3-2. Jot down answers to the questions in Box 3-2. Ask questions as necessary while still in the classroom. This simple activity will make it easier when actually writing a per-sonal philosophy of nursing.Conclusion123Case Studies Case studies encourage active learning and promote critical thinking skills in learners. Students can read about real-life scenarios and then analyze the situation they are presented with.Critical Thinking Questions Review key concepts with these questions in each chapter.practice role continue to challenge the nurse education and healthcare systems around the world as the primary healthcare needs of popula-tions compete with acute care for scarce resources. A global commu-nity demands that nurses remain committed to cultural sensitivity in care delivery. The history of health care and nursing provides ample examples of the wisdom of our forebears in the advocacy of nursing in challenging settings in an unknown future. By considering the les-sons of our past, as well as the experiences during the unprecedented time of the COVID-19 pandemic, the nursing profession is posi-tioned to lead the way in the provision of a full range of high-quality, cost-effective services required to care for patients in this century.Classroom Activity 1-1There are many theories about NightingaleÕs chronic illness, which caused her to be an in-valid for most of her adult life. Many people have interpreted this as hypochondriacal, something of a melodrama of the Victorian times. Nightingale was rich and could take to her bed. She became ill during the Crimean War in May 1855 and was diagnosed with a severe case of Crimean fever. Today Crimean fever is recognized as Mediterranean fever and is categorized as brucellosis. She developed spondylitis, or inflammation of the spine. For the next 34 years, she managed to continue her writing and advocacy, often predicting her imminent death. Others have claimed that Nightingale suffered from bipolar disorder, causing her to experience long periods of de-pression alternating with remarkable bursts of productivity. Read about the various theories of her chronic disabling condition and reflect on your own conclusions about her mysteri-ous illness. With supporting evidence, what are your conclusions about NightingaleÕs health condition?Data from Dossey, B. (2000). Florence Nightingale: Mys-tic, visionary, healer. Lippincott Williams & Wilkins; Aus-tralian Nursing Federation. (2004). Nightingale suffered bipolar disorder. Australian Nursing Journal, 12(2), 33.Classroom Activity 1-2Create a rŽsumŽ or curriculum vitae based on what you know about the life and work of Florence Nightingale.Check out NightingaleÕs curriculum vitae at www.countryjoe.com/nightingale/cv.htmReferencesAbel, E. K. (1997). Take the cure to the poor: PatientsÕ responses to New York CityÕs tuberculosis program, 1894Ð1918. American Journal of Public Health, 87, 11.American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Essentials-2021.pdfCHAPTER 1 A History of Health Care and Nursing48Classroom Activities Each chapter includes classroom activities that focus on how the information in the text applies to everyday practice. Students can answer questions in a group or as individuals.
SIXTH EDITIONRole Development in Professional Nursing PracticeKathleen Masters, DNS, RNProfessorCollege of Nursing and Health ProfessionsUniversity of Southern MississippiHattiesburg, Mississippi
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DedicationThis book is dedicated to my Heavenly Father and to my loving family: my husband, Eddie; my two daughters, Rebecca and Rachel; their husbands Trevor and Grant; and my precious grandsons, Jasper and Josiah. Words cannot express my appreciation for the ongoing encouragement and support of my family throughout my career.
CONTENTSPreface xiiiContributors xviUNIT I: FOUNDATIONS OF PROFESSIONAL NURSING PRACTICE 1 1 A History of Health Care and Nursing 3Karen Saucier Lundy and Kathleen MastersClassical Era 3Middle Ages 7The Renaissance 8The Dark Period of Nursing 9The Industrial Revolution 11And Then There Was Nightingale . . . 13Continued Development of Professional Nursing in the United Kingdom 24The Development of Professional Nursing in Canada 24The Development of Professional Nursing in Australia 27Early Nursing Education and Organization in the United States 29The Evolution of Nursing in the United States: The First Century of Professional Nursing 30The New Century 44International Council of Nurses 46Conclusion 47References 48 2 Frameworks for Professional Nursing Practice 53Kathleen MastersOverview of Selected Nursing Theories 55Overview of Selected Nonnursing Theories 98Relationship of Theory to Professional Nursing Practice 99
Conclusion 100References 103 3 Philosophy of Nursing 109Mary W. StewartPhilosophy 110Early Philosophy 111Paradigms 113Beliefs 114Values 116Developing a Personal Philosophy of Nursing 121Conclusion 123References 125 4 Competencies for Professional Nursing Practice 127Kathleen Masters and Jill RushingOverview 127Nursing Competencies 128Critical Thinking, Clinical Judgment, and Clinical Reasoning in Nursing Practice 134Thinking Like a Nurse 150Conclusion 153References 155 5 Education and Formation in Professional Nursing 157Kathleen Masters and Melanie GilmoreProfessional Nursing Roles and Values 158The Formation Process 160Facilitating the Transition to Professional Practice 165Conclusion 168References 169 6 Advancing and Managing Your Professional Nursing Career 171Mary Louise Coyne and Cynthia ChathamNursing: A Job or a Career? 171Trends That Affect Nursing Career Decisions 173Showcasing Your Professional Self 176Mentoring 179Education and Lifelong or Career-Long Learning 181Professional Engagement 185Expectations for Your Performance 186Taking Care of Self 187Conclusion 189References 190CONTENTSix
7 Social Context and the Future of Professional Nursing 193Mary W. Stewart, Katherine E. Nugent, and Kathleen MastersNursingÕs Social Contract with Society 194Public Image of Nursing 194The Gender Gap 199Changing Demographics and Cultural Competence 202Access to Health Care 204Societal Trends 206Trends in Nursing 212Conclusion 221References 221UNIT II: PROFESSIONAL NURSING PRACTICE AND THE MANAGEMENT OF PATIENT CARE 227 8 Safety and Quality Improvement in Professional Nursing Practice 229Kathleen MastersPatient Safety 229Quality Improvement in Health Care 240Quality Improvement Measurement and Process 242The Role of the Nurse in Quality Improvement 252Conclusion 255References 257 9 Evidence-Based Professional Nursing Practice 261Kathleen MastersEvidence-Based Practice: What Is It? 261Barriers to Evidence-Based Practice 263Promoting Evidence-Based Practice 264Searching for Evidence 265Evaluating the Evidence 268Implementation Models for Evidence-Based Practice 272Conclusion 275References 277 10 Patient Education and Patient-Centered Care in Professional Nursing Practice 279Kathleen MastersDimensions of Patient-Centered Care 280Communication as a Strategy to Support Patient-Centered Care 284Patient Education as a Strategy to Support Patient-Centered Care 288Evaluation of Patient-Centered Care 303Conclusion 304References 305CONTENTSx
11 Informatics in Professional Nursing Practice 309Kathleen Masters and Cathy K. HughesInformatics: What Is It? 309The Effect of Legislation on Health Informatics 310Nursing Informatics Competencies 312Basic Computer Competencies 315Information Literacy 319Information Management 323Current and Future Trends 329Conclusion 331References 331 12 Leadership and Systems-Based Professional Nursing Practice 335Kathleen Masters and Sharon VincentHealthcare Delivery System 336Organizational Theory 337Healthcare Organizations and Systems 339Nursing Leadership in a Complex Healthcare System 341Leadership Theories 342Principles of Successful Nursing Leadership 345Leadership Competencies 347Nursing Models of Patient Care Delivery 354Roles of the Professional Nurse 359Conclusion 365References 365 13 Teamwork, Collaboration, and Communication in Professional Nursing Practice 369Kathleen MastersInterprofessional Teams and Healthcare Quality and Safety 369Interprofessional Collaborative Practice Domain 373Interprofessional Team Performance and Communication 375Conclusion 381References 382 14 Ethics in Professional Nursing Practice 385Janie B. Butts and Karen L. RichEthics 386Ethical Theories and Approaches 390Professional Ethics and Codes 395Ethical Analysis and Decision Making in Nursing 398Relationships in Professional Practice 405Moral Rights and Autonomy 411Social Justice 413CONTENTSxi
Death and End-of-Life Care 419Conclusion 430References 432 15 Law and Professional Nursing Practice 435Kathleen Driscoll and Kathleen MastersThe Sources of Law 436Classification and Enforcement of the Law 438Nursing Scope and Standards 441Malpractice and Negligence 444Nursing Licensure 448Professional Accountability 455Conclusion 463References 464Appendix A Provisions of Code of Ethics for Nurses 467Appendix B The ICN Code of Ethics for Nurses 468Glossary 470Index 489CONTENTSxii
PREFACEAlthough the process of professional development is a lifelong journey, it is a journey that begins in earnest during the time of initial academic preparation. The goal of this book is to provide nursing students with a road map to help guide them along the professional nursing journey.This book is organized into two units. The chapters in the first unit focus on the foundational concepts that are essential to the development of the individual professional nurse. The chapters in Unit II address is-sues related to professional nursing practice and the management of patient care, specifically in the context of quality and safety. In the Sixth Edition, the chapter content is conceptualized, when applicable, around nursing competencies, professional standards, and recommen-dations from national groups, such as Institute of Medicine reports. All chapters have been updated and several chapters have been expanded. The chapters included in Unit I provide the student nurse with a basic foundation in such areas as nursing history, theory, philosophy, social-ization into the nursing role, professional development, the social con-text of nursing, and professional nursing competencies. The chapters in Unit II are more directly related to patient care management and, as stated previously, are presented in the context of quality and safety. Chapter topics include the role of the nurse in patient safety and qual-ity improvement, evidence-based nursing practice, the role of the nurse in patient education and patient-centered care, informatics in nursing practice, the role of the nurse related to teamwork and collaboration, systems-based practice and leadership, ethics in nursing practice, and the law as it relates to patient care and nursing.The Sixth Edition incorporates the revised Nurse of the Future: Nursing Core Competencies: Registered Nurse throughout each chap-ter. The 10 essential competencies that are intended to guide nursing curricula and practice emanate from the central core of the model that represents nursing knowledge (Massachusetts Department of Higher
Education, 2016) and are based on the American Association of Col-leges of Nursing (AACN) Essentials of Baccalaureate Education for Professional Nursing Practice, National League for Nursing Council of Associate Degree Nursing competencies, Institute of Medicine recom-mendations, Quality and Safety Education for Nurses (QSEN) compe-tencies, and American Nurses Association standards, as well as other professional organization standards and recommendations. The 10 competencies included in the model are patient-centered care, profes-sionalism, informatics and technology, evidence-based practice, lead-ership, systems-based practice, safety, communication, teamwork and collaboration, and quality improvement. Essential knowledge, skills, and attitudes (KSAs) reflecting cognitive, psychomotor, and affective learning domains are specified for each competency. The KSAs identi-fied in the model reflect the expectations for initial nursing practice following the completion of a prelicensure professional nursing educa-tion program (Massachusetts Department of Higher Education, 2016).This new edition has key competencies integrated throughout the chapters that link examples of the Nurse of the Future: Nursing Core Competencies KSAs that are appropriate to the chapter content. The competency model is explained in detail in Chapter 4 and is available in its entirety online at https://www.mass.edu/nahi/documents/nofrn competencies_updated_march2016.pdf. The Sixth Edition also incor-porates some of the applicable sub-competencies from re-envisioned AACN Essentials as key outcomes throughout each chapter to assist faculty with the alignment and tracking of curricular content. While not all inclusive, the key competencies and key outcomes incorporated throughout the chapters also demonstrate for students the link between expectations reflected in the competency model, the competencies em-bodied in the essentials document, and the chapter content. A brief overview of the re-envisioned, competency-focused AACN (2021) es-sentials document, The Essentials: Core Competencies for Professional Nursing Education, is included in Chapter 4.This new edition continues to use case studies, congruent with Benner et al.Õs (2010) Carnegie Report recommendations that nursing educators teach for Òsituated cognitionÓ using narrative strategies to lead to Òsituated action,Ó thus increasing the clinical connection in our teaching or that we teach for Òclinical salience.Ó In addition, critical thinking questions are included throughout each chapter to promote student reflection on the chapter concepts. Classroom activities are also provided based on chapter content.Although the topics included in this textbook are not inclusive of all that could be discussed in relationship to the broad theme of role development in professional nursing practice, it is my prayer that the subjects herein make a contribution to the profession of nursing by PREFACExiv
providing the student with a solid foundation and a desire to grow as a professional nurse throughout the journey that we call a professional nursing career. Let the journey begin.ÑKathleen MastersReferencesAmerican Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing .org/Portals/42/AcademicNursing/pdf/Essentials-2021.pdfBenner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. Jossey-Bass.Massachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. https://www.mass.edu/nahi /documents/nofrncompetencies_updated_march2016.pdfPREFACExv
CONTRIBUTORSJanie B. Butts, PhD, RNProfessor (Retired)University of Southern MississippiCollege of Nursing and Health ProfessionsHattiesburg, MississippiCynthia Chatham, DSN, RNAssociate Professor (Retired)University of Southern MississippiCollege of Nursing and Health ProfessionsLong Beach, MississippiMary Louise Coyne, DNSc, RNProfessor (Retired)University of Southern MississippiCollege of Nursing and Health ProfessionsLong Beach, MississippiKathleen Driscoll, JD, MS, RNUniversity of CincinnatiCollege of NursingCincinnati, OhioMelanie Gilmore, PhD, RNAssociate Professor (Retired)University of Southern MississippiCollege of NursingHattiesburg, MississippiCathy K. Hughes, DNP, RNTeaching Assistant Professor (Retired)University of Southern MississippiCollege of Nursing and Health ProfessionsHattiesburg, MississippiKaren Saucier Lundy, PhD, RN, FAANProfessor EmeritusUniversity of Southern MississippiCollege of NursingHattiesburg, MississippiKatherine E. Nugent, PhD, RNProfessor and Dean (Retired)University of Southern MississippiCollege of NursingHattiesburg, MississippiKaren L. Rich, PhD, RNAssociate Professor (Retired)University of Southern MississippiCollege of Nursing and Health ProfessionsLong Beach, MississippiJill Rushing, MSN, PhD(c), RNLecturerUniversity of Southern MississippiCollege of Nursing and Health ProfessionsHattiesburg, MississippiMary W. Stewart, PhD, RNProfessor and Director of PhD ProgramUniversity of Mississippi Medical CenterSchool of NursingJackson, MississippiSharon Vincent, DNP, RN, CNORUniversity of North CarolinaCollege of NursingCharlotte, North CarolinaEditorKathleen Masters, DNS, RNProfessorCollege of Nursing and Health ProfessionsUniversity of Southern MississippiHattiesburg, Mississippi
Foundations of Professional Nursing Practiceunit i© Nuu Jeed/Shutterstock
Key Terms and Concepts ÈAmerican Journal of Nursing (AJN) ÈAmerican Nurses Association (ANA) ÈAnnie Goodrich ÈBrown Report ÈChadwick Report ÈClara Barton ÈDeaconesses ÈDorothea Lynde Dix ÈElizabeth Tyler ÈEthel Fenwick ÈFlorence Nightingale ÈFrances Payne Bolton ÈFrontier Nursing Service ÈGoldmark Report ÈGreek era After completing this chapter, the student should be able to:1. Identify social, political, and economic inßuences on the development of profes-sional nursing practice.2. Identify important leaders and events that have signiÞcantly affected the develop-ment of professional nursing practice.Learning ObjectivesA History of Health Care and Nursing1 Karen Saucier Lundy and Kathleen Masters1 Note: This chapter is from Lundy, K. S., & Bender, K. W. (2009). History of community health and public health nursing. In K. S. Lundy & S. Janes (Eds.), Community health nurs-ing: Caring for the publicÕs health (2nd ed., pp. 62Ð99). Jones & Bartlett Learning.Although no specialized nurse role per se developed in early civiliza-tions, human cultures recognized the need for nursing care. The truly sick person was weak and helpless and could not fulfill the duties that were normally expected of a member of the community. In such cases, someone had to watch over the patient, nurse the patient, and provide care. In most societies, this nurse role was filled by a family member, usually female. As in most cultures, the childbearing woman had special needs that often resulted in a specialized role for the care-giver. Every society since the dawn of time had someone to nurse and take care of the mother and infant around the childbearing events. In whatever form the nurse took, the role was associated with compas-sion, health promotion, and kindness (Bullough & Bullough, 1978).Classical EraMore than 4,000 years ago, Egyptian physicians and nurses used an abundant pharmacologic repertoire to cure the ill and injured. CHAPTER 1© Nuu Jeed/Shutterstock3
The Ebers Papyrus lists more than 700 remedies for ailments rang-ing from snakebites to puerperal fever (Kalisch & Kalisch, 1986). Healing appeared in the Egyptian culture as the successful result of a contest between invisible beings of good and evil (Shryock, 1959). Around 1000 b.c., the Egyptians constructed elaborate drainage systems, developed pharmaceutical herbs and preparations, and embalmed the dead. The Hebrews formulated an elaborate hygiene code that dealt with laws governing both personal and community hygiene, such as contagion, disinfection, and sanitation through the preparation of food and water. The Jewish contribution to health is greater in sanitation than in their concept of disease. Garbage and excreta were disposed of outside the city or camp, infectious diseases were quarantined, spitting was outlawed as unhygienic, and bodily cleanliness became a prerequisite for moral purity. Although many of the Hebrew ideas about hygiene were Egyptian in origin, the He-brews were the first to codify them and link them with spiritual god-liness (Bullough & Bullough, 1978).Disease and disability in the Mesopotamian area were considered a great curse, a divine punishment for grievous acts against the gods. Experiencing illness as punishment for a sin linked the sick person to anything even remotely deviant. Not only was the person suffering from the illness but was also branded by society as having deserved it. Those who obeyed GodÕs law lived in health and happiness, and those who transgressed the law were punished with illness and suffer-ing. The sick person then had to make atonement for the sins, enlist a priest or other spiritual healer to lift the curse, or live with the illness to its ultimate outcome (Bullough & Bullough, 1978). Nursing care by a family member or relative would be needed, regardless of the outcome of the sin, curse, disease-atonement-recovery, or death cycle. This logic became the basis for explanation of why some people Òget sick and some donÕtÓ for many centuries and still persists to some de-gree in most cultures today.The Greeks and HealthIn Greek mythology, the god of medicine, Asclepius, cured disease. One of his daughters, Hygieia, from whom we derive the word hy-giene, was the goddess of preventive health and protected humans from disease. Panacea, AsclepiusÕ other daughter, was known as the all-healing Òuniversal remedy,Ó and today her name is used to describe any ultimate cure-all in medicine. She was known as the ÒlightÓ of the day, and her name was invoked and shrines built to her during times of epidemics (Brooke, 1997).During the Greek era, Hippocrates of Cos emphasized the rational treatment of sickness as a natural rather than a god-inflicted phenom-enon. Hippocrates (460Ð370 b.c.) is considered the father of medicine ÈHenry Street Settlement ÈInternational Coun-cil of Nurses (ICN) ÈIsabel Hampton Robb ÈJane A. Delano ÈJeanne Mance ÈJessie Sleet Scales ÈLavinia Lloyd Dock ÈLillian Wald ÈMargaret Sanger ÈMary Agnes Snively ÈMary Breckinridge ÈMary Brewster ÈMary D. Osborne ÈReformation ÈRoman era ÈShattuck Report ÈWilliam Rathbone CHAPTER 1 A History of Health Care and Nursing4
because of his arrangements of the oral and written remedies and dis-eases, which had long been secrets held by priests and religious heal-ers, into a textbook of medicine that was used for centuries (Bullough & Bullough, 1978).In Greek society, health was considered to result from a bal-ance between mind and body. Hippocrates wrote a most important book, Air, Water, and Places, which detailed the relationship between humans and the environment. This is considered a milestone in the eventual development of the science of epidemiology as the first such treatise on the connectedness of the web of life. This topic of the re-lationship between humans and their environment did not recur until the development of bacteriology in the late 1800s (Rosen, 1958).Perhaps the idea that most damaged the practice and scientific theory of medicine and health for centuries was the doctrine of the four humors, first spoken of by Empedocles of Acragas (493Ð433 b.c.). Empedocles was a philosopher and a physician, and as a result he synthesized his cosmologic ideas with his medical theory. He be-lieved that the same four elements that made up the universe were found in humans and in all animate beings (Bullough & Bullough, 1978). Empedocles believed that man [sic] was a microcosm, a small world within the macrocosm, or external environment. The four hu-mors of the body (blood, bile, phlegm, and black bile) corresponded to the four elements of the larger world (fire, air, water, and earth) (Kalisch & Kalisch, 1986). Depending on the prevailing humor, a person was sanguine, choleric, phlegmatic, or melancholic. Because of this strongly held and persistent belief in the connection between the balance of the four humors and health status, treatment was aimed at restoring the appropriate balance of the four humors through the control of their corresponding elements. Through manipulating the two sets of opposite qualitiesÑhot and cold, wet and dryÑbalance was the goal of the intervention. Fire was hot and dry, air was hot and wet, water was cold and wet, and earth was cold and dry. For exam-ple, if a person had a fever, cold compresses would be prescribed; for a chill, the person would be warmed. Such doctrine gave rise to faulty and ineffective treatment of disease that influenced medical education for many years (Taylor, 1922).Plato, in The Republic, details the importance of recreation, a bal-anced mind and body, nutrition, and exercise. A distinction was made among gender, class, and health as early as the Greek era; only males of the aristocracy could afford the luxury of maintaining a healthful lifestyle (Rosen, 1958).In The Iliad, a poem about the attempts to capture Troy and res-cue Helen from her lover, Paris, 140 different wounds are described. The mortality rate averaged 77.6%, the highest as a result of sword and spear thrusts and the lowest from superficial arrow wounds. There was considerable need for nursing care, and Achilles, Patroclus, Classical Era5
and other princes often acted as nurses to the injured. The early stages of Greek medicine reflected the influences of Egyptian, Babylonian, and Hebrew medicine. Therefore, good medical and nursing tech-niques were used to treat these war wounds: The arrow was drawn or cut out, the wound washed, soothing herbs applied, and the wound bandaged. However, in sickness in which no wound occurred, an evil spirit was considered the cause. The Greeks applied rational causes and cures to external injuries, whereas internal ailments continued to be linked to spiritual maladies (Bullough & Bullough, 1978).Roman EraDuring the rise and the fall of the Roman era (31 b.c.Ða.d. 476), Greek culture continued to be a strong influence. The Romans easily adopted Greek culture and expanded the GreeksÕ accomplishments, especially in the fields of engineering, law, and government. For Ro-mans, the government had an obligation to protect its citizens not only from outside aggression, such as warring neighbors, but also from inside the civilization, in the form of health laws. According to Bullough and Bullough (1978), Rome was essentially a ÒGreek cul-tural colonyÓ (p. 20).Galen of Pergamum (a.d. 129Ð199), often known as the greatest Greek physician after Hippocrates, left for Rome after studying medi-cine in Greece and Egypt and gained great fame as a medical prac-titioner, lecturer, and experimenter. In his lifetime, medicine evolved into a science; he submitted traditional healing practices to experi-mentation and was possibly the greatest medical researcher before the 1600s (Bullough & Bullough, 1978). He was considered the last of the great physicians of antiquity (Kalisch & Kalisch, 1986).The Greek physicians and healers certainly made the most contri-butions to medicine, but the Romans surpassed the Greeks in promot-ing the evolution of nursing. Roman armies developed the notion of a mobile war nursing unit because their battles took them far from home where they could be cared for by wives and family. This por-table hospital was a series of tents arranged in corridors; as battles wore on, these tents gave way to buildings that became permanent convalescent camps at the battle sites (Rosen, 1958). Many of these early military hospitals have been excavated by archaeologists along the banks of the Rhine and Danube rivers. They had wards, recreation areas, baths, pharmacies, and even rooms for officers who needed a Òrest cureÓ (Bullough & Bullough, 1978). Coexisting were the Greek dispensary forms of temples, or the iatreia, which started out as a type of physician waiting room. These eventually developed into a primi-tive type of hospital, places for surgical clients to stay until they could be taken home by their families. Although nurses during the Roman era were usually family members, servants, or slaves, nursing had CHAPTER 1 A History of Health Care and Nursing6
strengthened its position in medical care and emerged during the Ro-man era as a separate and distinct specialty.The Romans developed massive aqueducts, bathhouses, and sewer systems during this era. At the height of the Roman Empire, Rome provided 40 gallons of water per person per day to its 1 million inhabitants, which is comparable to our rates of consumption today (Rosen, 1958).Middle AgesMany of the advancements of the Greco-Roman era were reversed during the Middle Ages (a.d. 476Ð1453) after the decline of the Roman Empire. The Middle Ages, or the medieval era, served as a transition between ancient and modern civilizations. Once again, myth, magic, and religion were explanations and cures for illness and health problems. The medieval world was the result of a fusion of three streams of thought, actions, and ways of lifeÑGreco-Roman, Germanic, and Christian (Donahue, 1985). Nursing was most influ-enced by Christianity with the beginning of deaconesses, or female servants, doing the work of God by ministering to the needs of oth-ers. Deacons in the early Christian churches were apparently avail-able only to care for men, whereas deaconesses cared for the needs of women. The role of deaconesses in the church was considered a forward step in the development of nursing and in the 1800s would strongly influence the young Florence Nightingale. During this era, Roman military hospitals were replaced by civilian ones. In early Christianity, the Diakonia, a kind of combination outpatient and welfare office, was managed by deacons and deaconesses and served as the equivalent of a hospital. Jesus served as the example of charity and compassion for the poor and marginal of society.Communicable diseases were rampant during the Middle Ages, primarily because of the walled cities that emerged in response to the paranoia and isolation of the populations. Infection was next to impossible to control. Physicians had little to offer, deferring to the church for management of disease. Nursing roles were carried out primarily by religious orders. The oldest hospital (other than military hospitals in the Roman era) in Europe was most likely the H™tel-Dieu in Lyon, France, founded about 542 by Childebert I, king of Paris. The H™tel-Dieu in Paris was founded around 652 by Saint Landry, bishop of Paris. During the Middle Ages, charitable institutions, hos-pitals, and medical schools increased in number, with the religious leaders as caregivers. The word hospital, which is derived from the Latin word hospitalis, meaning Òservice of guests,Ó was most likely more of a shelter for travelers and other pilgrims as well as the occa-sional person who needed extra care (Kalisch & Kalisch, 1986). Early European hospitals were more like hospices or homes for the aged, Middle Ages7
sick pilgrims, or orphans. Nurses in these early hospitals were reli-gious deaconesses who chose to care for others in a life of servitude and spiritual sacrifice.Black DeathDuring the Middle Ages, a series of horrible epidemics, including the Black Death or bubonic plague, ravaged the civilized world (Diamond, 1997). In the 1300s, Europe, Asia, and Africa saw nearly half their pop-ulations lost to the bubonic plague. Worldwide, more than 60 million deaths were attributed to this horrible plague. In some parts of Europe, only one-fourth of the population survived, with some places having too few survivors alive to bury the dead. Families abandoned sick chil-dren, and the sick were often left to die alone (Cartwright, 1972).Nurses and physicians were powerless to avert the disease. Black spots and tumors on the skin appeared, and petechiae and hemor-rhages gave the skin a darkened appearance. There was also acute in-flammation of the lungs, burning sensations, unquenchable thirst, and inflammation of the entire body. Hardly anyone afflicted survived the third day of the attack. So great was the fear of contagion that ships carrying bodies of infected persons were set to sail without a crew to drift from port to port through the North, Black, and Mediterranean seas with their dead passengers (Cohen, 1989).Medieval people knew that this disease was in some way commu-nicable, but they were unsure of the mode of transmission (Diamond, 1997); hence the avoidance of victims and a reliance on isolation tech-niques. During this time, the practice of quarantine in city ports was developed as a preventive measure that is still used today (Bullough & Bullough, 1978; Kalisch & Kalisch, 1986).The RenaissanceDuring the rebirth of Europe, political, social, and economic advances occurred along with a tremendous revival of learning. Donahue (1985) contends that the Renaissance has been Òviewed as both a blessing and a curseÓ (p. 188). There was a renewed interest in the arts and sci-ences, which helped advance medical science (Boorstin, 1985; Bullough & Bullough, 1978). Columbus and other explorers discovered new worlds, and belief in a sun-centered rather than an Earth-centered uni-verse was promoted by Copernicus (1473Ð1543). Sir Isaac NewtonÕs (1642Ð1727) theory of gravity changed the world forever. Gunpow-der was introduced, and social and religious upheavals resulted in the American and French revolutions at the end of the 1700s. In the arts and sciences, Leonardo da Vinci, known as one of the greatest geniuses of all time, made a number of anatomic drawings based on dissection experiences. These drawings have become classics in the progression of CHAPTER 1 A History of Health Care and Nursing8
knowledge about the human anatomy. Many artists of this time left an indelible mark and continue to exert influence today, including Michel-angelo, Raphael, and Titian (Donahue, 1985).The ReformationReligious changes during the Renaissance influenced nursing perhaps more than any other aspect of society. Particularly important was the rise of Protestantism as a result of the reform movements of Martin Luther (1483Ð1546) in Germany and John Calvin (1509Ð1564) in France and Switzerland. Although the various sects were numerous in the Protestant movement, the agreement among the leaders was al-most unanimous on the abolition of the monastic or cloistered career. The effects on nursing were drastic: Monastic-affiliated institutions, including hospitals and schools, were closed, and orders of nuns, in-cluding nurses, were dissolved. Even in countries where Catholicism flourished, royal leaders seized monasteries frequently.Religious leaders, such as Martin Luther, who led the Reformation in 1517, were well aware of the lack of adequate nursing care as a result of these sweeping changes. Luther advocated that each town establish something akin to a Òcommunity chestÓ to raise funds for hospitals and nurse visitors for the poor (Dietz & Lehozky, 1963). Thus, the closures of the monasteries eventually resulted in the cre-ation of public hospitals where laywomen performed nursing care. It was difficult to find laywomen who were willing to work in these hos-pitals to care for the sick, so judges began giving prostitutes, publicly intoxicated women, and poverty-stricken women the option of going to jail, going to the poorhouse, or working in the public hospital. Un-like the sick wards in monasteries, which were generally considered to be clean and well managed, the public hospitals were filthy, disorga-nized buildings where people went to die while being cared for by lay-women who were not trained, motivated, or qualified to care for the sick (Sitzman & Judd, 2014a).In England, where there had been at least 450 charitable founda-tions before the Reformation, only a few survived the reign of Henry VIII, who closed most of the monastic hospitals (Donahue, 1985). Eventually, Henry VIIIÕs son, Edward VI, who reigned from 1547 to 1553, endowed some hospitals, namely, St. Bartholomew Hospital and St. Thomas Hospital, which would eventually house the Nightingale School of Nursing in the later 1800s (Bullough & Bullough, 1978).The Dark Period of NursingThe last half of the period between 1500 and 1860 is widely regarded as Òthe dark period of nursingÓ because nursing conditions were at their worst (Donahue, 1985). Education for girls, which had been The Dark Period of Nursing9
provided by the nuns in religious schools, was lost. Because of the elimination of hospitals and schools, there was no one to pass on knowledge about caring for the sick. As a result, the hospitals were managed and staffed by municipal authorities; women entering nurs-ing service often came from illiterate classes, and even then, there were too few to serve (Dietz & Lehozky, 1963). The lay attendants who filled the nursing role were illiterate, rough, inconsiderate, and often immoral and alcoholic. Intelligent women and men could not be persuaded to accept such a degraded and low-status position in the offensive municipal hospitals of London. Nursing slipped back into a role of servitude as menial, low-status work. According to Donahue (1985), when a woman could no longer make it as a gambler, prosti-tute, or thief, she might become a nurse. Eventually, women serving jail sentences for such crimes as prostitution and stealing were or-dered to care for the sick in the hospitals instead of serving their sen-tences in the city jail (Dietz & Lehozky, 1963). The nurses of this era took bribes from clients, became inappropriately involved with them, and survived the best way they could, often at the expense of their as-signed clients.Nursing had, during this era, virtually no social standing or or-ganization. Even Catholic sisters of the religious orders throughout Europe Òcame to a complete standstillÓ professionally because of the intolerance of society (Donahue, 1985, p. 231). Charles Dickens, in Martin Chuzzlewit (1844), created the enduring characters of Sairey Gamp and Betsy Prig. Sairey Gamp was a visiting nurse based on an actual hired attendant whom Dickens had met in a friendÕs home. Sairey Gamp was hired to care for sick family members but was in-stead cruel to her clients, stole from them, and ate their rations; she was an alcoholic and has been immortalized forever as a reminder of the world in which Florence Nightingale came of age (Donahue, 1985). The first hospital in the Americas, the Hospital de la Pur’sima Concepci—n, was founded some time before 1524 by Hernando Cor-tez, the conqueror of Mexico. The first hospital in the continental United States was erected in Manhattan in 1658 for the care of sick soldiers and slaves. In 1717, a hospital for infectious diseases was built in Boston; the first hospital established by a private gift was the Charity Hospital in New Orleans. A sailor, Jean Louis, donated the endowment for the hospitalÕs founding (Bullough & Bullough, 1978).During the 1600s and 1700s, colonial hospitals with little resem-blance to modern hospitals were often used to house the poor and downtrodden. Hospitals called ÒpesthousesÓ were created to care for clients with contagious diseases; their primary purpose was to protect the public at large rather than to treat and care for the clients. Con-tagious diseases were rampant during the early years of the American colonies, often being spread by the large number of immigrants who brought these diseases with them on their long journey to America. CHAPTER 1 A History of Health Care and Nursing10
Medicine was not as developed as in Europe, and nursing remained in the hands of the uneducated. By 1720, average life expectancy at birth was only around 35 years. Plagues were a constant nightmare, with outbreaks of smallpox and yellow fever. In 1751, the first true hospital in the new colonies, Pennsylvania Hospital, was erected in Philadelphia on the recommendation of Benjamin Franklin (Kalisch & Kalisch, 1986).By todayÕs standards, hospitals in the 1800s were disgraceful, dirty, unventilated, and contaminated by infections; to be a client in a hospital actually increased oneÕs risk of dying. As in England, nursing was considered an inferior occupation. After the sweeping changes of the Reformation, educated religious health workers were replaced with laypeople who were Òdown and outersÓ in prison or had no op-tion left but to work with the sick (Kalisch & Kalisch, 1986).The Industrial RevolutionDuring the mid-1700s in England, capitalism emerged as an economic system based on profit. This emerging system resulted in mass produc-tion, as contrasted with the previous system of individual workers and craftsmen. In the simplest terms, the Industrial Revolution was the application of machine power to processes formerly done by hand. Machinery was invented during this era and ultimately standard-ized quality; individual craftsmen were forced to give up their crafts and lands and become factory laborers for the capitalist owners. All types of industries were affected; this newfound efficiency produced profit for owners of the means of production. Because of this, the era of invention flourished, factories grew, and people moved in record numbers to work in the cities. Urban areas grew, tenement housing projects emerged, and overcrowding in cities seriously threatened in-dividualsÕ well-being (Donahue, 1985).Workers were forced to go to the machines, not the other way around. Such relocations meant giving up not only farming but also a way of life that had existed for centuries. The emphasis on profit over people led to child labor, frequent layoffs, and long workdays filled with stressful, tedious, unfamiliar work. Labor unions did not exist, and neither was there any legal protection against exploitation of workers, including children (Donahue, 1985). All these rapid changes and often threatening conditions created the world of Charles Dickens, where, as in his book Oliver Twist, children worked as adults without question.According to Donahue (1985), urban life, trade, and industrial-ization contributed to these overwhelming health hazards, and the situation was confounded by the lack of an adequate means of social control. Reforms were desperately needed, and the social reform movement emerged in response to the unhealthy by-products of the Industrial Revolution. It was in this world of the 1800s that such The Industrial Revolution11
reformers as John Stuart Mill (1806Ð1873) emerged. Although the Industrial Revolution began in England, it quickly spread to the rest of Europe and to the United States (Bullough & Bullough, 1978). The reform movement is critical to understanding the emerging health concerns that were later addressed by Florence Nightingale. Mill championed popular education, the emancipation of women, trade unions, and religious toleration. Other reform issues of the era included the abolition of slavery and, most important for nursing, more humane care of the sick, the poor, and the wounded (Bullough & Bullough, 1978). There was a renewed energy in the religious com-munity with the reemergence of new religious orders in the Catholic Church that provided service to the sick and disenfranchised.Epidemics had ravaged Europe for centuries, but they became even more serious with urbanization. Industrialization brought people to cities, where they worked in close quarters (as compared with the isolation of the farm) and contributed to the social decay of the sec-ond half of the 1800s. Sanitation was poor or nonexistent, sewage disposal from the growing population was lacking, cities were filthy, public laws were weak or nonexistent, and congestion of the cities inevitably brought pests in the form of rats, lice, and bedbugs, which transmitted many pathogens. Communicable diseases continued to plague the population, especially those who lived in these unsanitary environments. For example, during the mid-1700s, typhus and ty-phoid fever claimed twice as many lives each year as did the Battle of Waterloo (Hanlon & Pickett, 1984). Through foreign trade and immi-gration, infectious diseases were spread to all of Europe and eventu-ally to the growing United States.The Chadwick ReportEdwin Chadwick became a major figure in the development of the field of public health in Great Britain by drawing attention to the cost of the unsanitary conditions that shortened the life span of the labor-ing class and threatened the wealth of Britain. Although the first sani-tation legislation, which established a National Vaccination Board, was passed in 1837, Chadwick found in his classic study, Report on an Inquiry into the Sanitary Conditions of the Labouring Population of Great Britain, that death rates were high in large industrial cities, such as Liverpool. A more startling finding, from what is often re-ferred to simply as the Chadwick Report, was that more than half the children of labor-class workers died by age 5, indicating poor living conditions that affected the health of the most vulnerable. Laborers lived only half as long as the upper classes.One consequence of the report was the establishment in 1848 of the first board of health, the General Board of Health for England (Richardson, 1887). More legislation followed that initiated social CHAPTER 1 A History of Health Care and Nursing12
reform in the areas of child welfare, elder care, the sick, mentally ill persons, factory health, and education. Soon sewers and fireplugs, based on an available water supply, appeared as indicators that the public health linkages from the Chadwick Report had an effect.The Shattuck ReportIn the United States during the 1800s, waves of epidemics of yel-low fever, smallpox, cholera, typhoid fever, and typhus continued to plague the population as in England and the rest of the world. As cities continued to grow in the industrialized young nation, poor workers crowded into larger cities and suffered from illnesses caused by the unsanitary living conditions (Hanlon & Pickett, 1984). Similar to ChadwickÕs classic study in England, Lemuel Shattuck, a Boston bookseller and publisher who had an interest in public health, orga-nized the American Statistical Society in 1839 and issued a census of Boston in 1845. ShattuckÕs census revealed high infant mortality rates and high overall population mortality rates. In 1850, in his Report of the Massachusetts Sanitary Commission, Shattuck not only outlined his findings on the unsanitary conditions but also made recommen-dations for public health reform that included the bookkeeping of population statistics and development of a monitoring system that would provide information to the public about environmental, food, and drug safety and infectious disease control (Rosen, 1958). He also called for services for well-child care, school-age childrenÕs health, immunizations, mental health, health education for all, and health planning. The Shattuck Report was revolutionary in its scope and vi-sion for public health, but it was virtually ignored during ShattuckÕs lifetime. Nineteen years later, in 1869, the first state board of health was formed (Kalisch & Kalisch, 1986).And Then There Was Nightingale . . .Florence Nightingale (Figure 1-1) was named one of the 100 most influential persons of the last millennium by Life magazine (ÒThe 100 People Who Made the Millennium,Ó 1997). She was one of only eight women identified as such. Of those eight women, including Joan of Arc, Helen Keller, and Elizabeth I, Nightingale was identified as a true Òangel of mercy,Ó having reformed military health care in the Crimean War and used her political savvy to forever change the way society views the health of the vulnerable, the poor, and the forgotten. She is probably one of the most written about women in history (Bullough & Bullough, 1978). Florence Nightingale has become synonymous with modern nursing.Born on May 12, 1820, in her namesake city, Florence, Italy, Flor-ence Nightingale was the second child in the wealthy English family of And Then There Was Nightingale . . .13
William and Frances Nightingale. As a young child, Florence displayed incredible curiosity and intellectual abilities not common to female children of the Victorian age. She mastered the fundamentals of Greek and Latin, and she studied history, art, mathematics, and philosophy. To her familyÕs dismay, she believed that God had called her to be a nurse. Nightingale was keenly aware of the suffering that industrialization cre-ated; she became obsessed with the plight of the miserable and suffering people. Conditions of general starvation accompanied the Industrial Revolution, prisons and workhouses overflowed, and persons in all sections of British life were displaced. She wrote in the spring of 1842, ÒMy mind is absorbed with the sufferings of man; it besets me behind and before. . . . All that the poets sing of the glories of this world seem to me untrue. All the people that I see are eaten up with care or poverty or diseaseÓ (Woodham-Smith, 1951, p. 31).Figure 1-1 Engraving from 1873 featuring the English reformer and founder of modern nursing, Florence Nightingale.© Traveler1116/Digital Vision Vectors/Getty Images.CHAPTER 1 A History of Health Care and Nursing14
NightingaleÕs entire life would be haunted by this conflict be-tween the opulent life of gaiety that she enjoyed and the misery of the world, which she was unable to alleviate. She was, in essence, an Òalien spirit in the rich and aristocratic social sphere of Victorian EnglandÓ (Palmer, 1977, p. 14). Nightingale remained unmarried, and at the age of 25, she expressed a desire to be trained as a nurse in an English hospital. Her parents emphatically denied her request, and for the next 7 years, she made repeated attempts to change their minds and allow her to enter nurse training. She wrote, ÒI crave for some regular occupation, for something worth doing instead of frit-tering my time away on useless triflesÓ (Woodham-Smith, 1951, p. 162). During this time, she continued her education through the study of math and science and spent 5 years collecting data about public health and hospitals (Dietz & Lehozky, 1963). During a tour of Egypt in 1849 with family and friends, Nightingale spent her 30th year in Alexandria with the Sisters of Charity of St. Vincent de Paul, where her conviction to study nursing was only reinforced (Tooley, 1910). While in Egypt, Nightingale studied Egyptian, Platonic, and Hermetic philosophy; Christian scripture; and the works of poets, mystics, and missionaries in her efforts to understand the nature of God and her ÒcallingÓ as it fit into the divine plan (Calabria, 1996; Dossey, 2000).The next spring, Nightingale traveled unaccompanied to the Kaiserswerth Institute in Germany and stayed there for 2 weeks, vowing to return to train as a nurse. In June 1851, Nightingale took her future into her own hands and announced to her family that she planned to return to Kaiserswerth and study nursing. Accord-ing to Dietz and Lehozky (1963, p. 42), her mother had ÒhystericsÓ and scene followed scene. Her father Òretreated into the shadows,Ó and her sister, Parthe, expressed that the family name was forever disgraced (Cook, 1913). In 1851, at the age of 31, Nightingale was finally permitted to go to Kaiserswerth, and she studied there for 3 months with Pastor Fliedner. Her family insisted that she tell no one outside the family of her whereabouts, and her mother forbade her to write any letters from Kaiserswerth. While there, Nightingale learned about the care of the sick and the importance of discipline and com-mitment of oneself to God (Donahue, 1985). She returned to England and cared for her then ailing father, from whom she finally gained some support for her intent to become a nurseÑher lifelong dream.In 1852, Nightingale wrote the essay ÒCassandra,Ó which stands today as a classic feminist treatise against the idleness of Victorian women. Through her voluminous journal writings, Nightingale re-veals her inner struggle throughout her adulthood with what was expected of a woman and what she could accomplish with her life. The life expected of an aristocratic woman in her day was one she grew to loathe, and she expressed this detestation throughout her writings (Nightingale, 1979). In ÒCassandra,Ó Nightingale put her And Then There Was Nightingale . . .15
thoughts to paper, and many scholars believe that her eventual intent was to extend the essay to a novel. She wrote in ÒCassandra,Ó ÒWhy have women passion, intellect, moral activityÑthese threeÑin a place in society where no one of the three can be exercised?Ó (Nightingale, 1979, p. 37). Although uncertain about the meaning of the name Cas-sandra, many scholars believe that it came from the Greek goddess Cassandra, who was cursed by Apollo and doomed to see and speak the truth but never to be believed. Nightingale saw the conventional life of women as a waste of time and abilities. After receiving a gener-ous yearly endowment from her father, Nightingale moved to London and worked briefly as the superintendent of the Establishment for Gentlewomen During Illness hospital, finally realizing her dream of working as a nurse (Cook, 1913).The Crimean Experience: ÒI Can Stand Out the War with Any ManÓNightingaleÕs opportunity for greatness came when she was offered the position of superintendent of the female nursing establishment of the English General Hospitals in Turkey by the secretary of war, Sir Sidney Herbert. Soon after the outbreak of the Crimean War, stories of the inadequate care and lack of medical resources for the soldiers became widely known throughout England (Woodham-Smith, 1951). The country was appalled at the conditions so vividly portrayed in the London Times. Pressure increased on Sir Sidney to react. He knew of one woman who was capable of bringing order out of the chaos and wrote a letter to Nightingale on October 15, 1854, as a plea for her service. Nightingale accepted the challenge and set sail with 38 self-proclaimed nurses with varied training and experiences, of whom 24 were Catholic and Anglican nuns. Their journey to Crimea took a month, and on November 4, 1854, the brave nurses arrived at Is-tanbul and were taken to Scutari the same day. Faced with 3,000 to 4,000 wounded men in a hospital designed to accommodate 1,700, the nurses went to work (Kalisch & Kalisch, 1986). They found 4 miles of beds 18 inches apart. Most soldiers were lying naked with no bedding or blanket. There were no kitchen or laundry facilities. The little light present took the form of candles in beer bottles. The hospi-tal was literally floating on an open sewage lagoon filled with rats and other vermin (Donahue, 1985).By taking the newly arrived medical equipment and setting up kitchens, laundries, recreation rooms, reading rooms, and a canteen, Nightingale and her team of nurses proceeded to clean the barracks of lice and filth. Nightingale was in her element. She set out not only to provide humane health care for the soldiers but also to essentially overhaul the administrative structure of the military health services (Williams, 1961).CHAPTER 1 A History of Health Care and Nursing16
Florence Nightingale and SanitationAlthough Nightingale never accepted the germ theory, she demanded clean dressings; clean bedding; well-cooked, edible, and appealing food; proper sanitation; and fresh air. After the other nurses were asleep, Nightingale made her famous solitary rounds with a lamp or lantern to check on the soldiers. Nightingale had a lifelong pattern of sleeping few hours, spending many nights writing, developing elabo-rate plans, and evaluating implemented changes. She seldom believed in the ÒhopelessÓ soldier, only one who needed extra attention. Night-ingale was convinced that most of the maladies that the soldiers suf-fered and died from were preventable (Williams, 1961).Before NightingaleÕs arrival and her radical and well-documented interventions based on sound public health principles, the mortality rate from the Crimean War was estimated to be from 42% to 73%. Nightingale is credited with reducing that rate to 2% within 6 months of her arrival at Scutari. She did this through careful, scientific epide-miologic research (Dietz & Lehozky, 1963). Upon arriving at Scutari, NightingaleÕs first act was to order 200 scrubbing brushes. The death rate fell dramatically once Nightingale discovered that the hospital was built literally over an open sewage lagoon (Andrews, 2003).According to Palmer (1982), Nightingale possessed the qualities of a good researcher: insatiable curiosity, command of her subject, familiarity with methods of inquiry, a good background of statistics, and the ability to discriminate and abstract. She used these skills to maintain detailed and copious notes and to codify observations. Nightingale relied on statistics and attention to detail to back up her conclusions about sanitation, management of care, and disease causation. Her now-famous Òcox combsÓ are a hallmark of military health services management by which she diagrammed deaths in the army from wounds and from other diseases and compared them with deaths that occurred in similar populations in England (Palmer, 1977).Nightingale was first and foremost an administrator: She be-lieved in a hierarchical administrative structure with ultimate control lodged in one person to whom all subordinates and offices reported. Within a matter of weeks of her arrival in the Crimea, Nightingale was the acknowledged administrator and organizer of a mammoth humanitarian effort. From her Crimean experience on, Nightingale involved herself primarily in organizational activities and health plan-ning administration. Palmer contends that Nightingale Òperceived the Crimean venture, which was set up as an experiment, as a golden opportunity to demonstrate the efficacy of female nursingÓ (Palmer, 1982, p. 4). Although Nightingale faced initial resistance from the unconvinced and oppositional medical officers and surgeons, she boldly defied convention and remained steadfastly focused on her mission to create a sanitary and highly structured environment for And Then There Was Nightingale . . .17
her ÒchildrenÓÑthe British soldiers who dedicated their lives to the defense of Great Britain. Because of her insistence on absolute author-ity regarding nursing and the hospital environment, Nightingale was known to send nurses home to England from the Crimea for suspi-cious alcohol use and character weakness.It was through this success at Scutari that she began a long ca-reer of influence on the publicÕs health through social activism and reform, health policy, and the reformation of career nursing. Using her well-publicized successful ÒexperimentÓ and supportive evidence from the Crimea, Nightingale effectively argued the case for the reform and creation of military health care that would serve as the model for peo-ple in uniform to the present (DÕAntonio, 2002). NightingaleÕs ideas about proper hospital architecture and administration influenced a generation of medical doctors and the entire world, in both military and civilian service. Her work in Notes on Hospitals, published in 1860, provided the template for the organization of military health care in the Union Army when the U.S. Civil War erupted in 1861. Her vision for health care of soldiers and the responsibility of the govern-ments that send them to war continues today; her influence can be seen throughout the previous century and into this century as health care for the women and men who serve their country is a vital part of the well-being not only of the soldiers but also of society in general (DÕAntonio, 2002).Returning Home a Heroine: The Political ReformerWhen Nightingale returned to London, she found that her efforts to provide comfort and health to the British soldier succeeded in making heroes of both herself and the soldiers (Woodham-Smith, 1951). Both had suffered from negative stereotypes: The soldier was often por-trayed as a drunken oaf with little ambition or honor, and the nurse as a tipsy, self-serving, illiterate, promiscuous loser. After the Crimean War and the efforts of Nightingale and her nurses, both returned with honor and dignity, never again downtrodden and disrespected.After her return from Crimea, Nightingale never made a public appearance, never attended a public function, and never issued a public statement (Bullough & Bullough, 1978). She single-handedly raised nursing from, as she put it, Òthe sink it wasÓ into a respected and noble profession (Palmer, 1977). As an avid scholar and student of the Greek writer Plato, Nightingale believed that she had a moral obligation to work primarily for the good of the community. Because she believed that education formed character, she insisted that nurs-ing must go beyond care for the sick; the mission of the trained nurse must include social reform to promote the good. This dual mission of nursingÑcaregiver and political reformerÑhas shaped the profession CHAPTER 1 A History of Health Care and Nursing18
as we know it today. LeVasseur (1998) contends that NightingaleÕs in-sistence on nursingÕs involvement in a larger political ideal is the his-toric foundation of the field and distinguishes us from other scientific disciplines, such as medicine.How did Nightingale accomplish this? She effected change through her wide command of acquaintances: Queen Victoria was a significant admirer of her intellect and ability to effect change, and Nightingale used her position as national heroine to get the attention of elected officials in Parliament. She was tireless and had an amaz-ing capacity for work. She used people. Her brother-in-law, Sir Harry Verney, was a member of Parliament and often delivered her Òmes-sagesÓ in the form of legislation. When she wanted the public incited, she turned to the press, writing letters to the London Times and hav-ing others of influence write articles. She was not above threats to Ògo publicÓ by certain dates if an elected official refused to establish a commission or appoint a committee. And when those commissions were formed, Nightingale was ready with her list of selected people for appointment (Palmer, 1982).Nightingale and Military ReformsThe first real test of NightingaleÕs military reforms came in the United States during the Civil War. Nightingale was asked by the Union to advise on the organization of hospitals and care of the sick and wounded. She sent recommendations back to the United States based on her experiences and analysis in Crimea, and her advisement and influence gained wide publicity. Following her recommendations, the Union set up a sanitary commission and provided for regular inspec-tion of camps. She also expressed a desire to help with the Confeder-ate military, but unfortunately had no channel of communication with them (Bullough & Bullough, 1978).The Nightingale School of Nursing at St. Thomas: The Birth of Professional NursingThe British public honored Nightingale by endowing 50,000 pounds sterling in her name upon her return to England from Crimea. The money had been raised from the soldiers under her care and donations from the public. This Nightingale Fund eventually was used to create the Nightingale School of Nursing at St. Thomas, which was to be the beginning of professional nursing (Donahue, 1985). Nightingale, at the age of 40, decided that St. Thomas Hospital was the place for her training school for nurses. While the negotiations for the school went forward, she spent her time writing Notes on Nursing: What It Is and What It Is Not (Nightingale, 1860). The small book of 77 pages, written for the British mother, was an instant success. An expanded And Then There Was Nightingale . . .19
library edition was written for nurses and used as the textbook for the students at St. Thomas. The book has since been translated into many languages, although it is believed that Nightingale refused all royal-ties earned from the publication of the book (Cook, 1913; Tooley, 1910). The nursing students chosen for the new training school were handpicked; they had to be of good moral character, sober, and honest. Nightingale believed that the strong emphasis on morals was critical to gaining respect for the new ÒNightingale nurse,Ó with no possible ties to the disgraceful association of past nurses. Nursing students were monitored throughout their 1-year program both on and off the hospital grounds; their activities were carefully watched for character weaknesses, and discipline was severe and swift for violators. Accounts from NightingaleÕs journals and notes reveal instant dismissal of nurs-ing students for such behaviors as Òflirtation, using the eyes unpleas-antly, and being in the company of unsavory persons.Ó Nightingale contended that Òthe future of nursing depends on how these young women behave themselvesÓ (Smith, 1934, p. 234). She knew that the experiment at St. Thomas to educate nurses and raise nursing to a moral and professional calling was a drastic departure from the past images of nurses and would take extraordinary women of high moral character and intelligence. Nightingale knew every nursing student, or probationer, personally, often having the students at her house for weekend visits. She devised a system of daily journal keeping for the probationers; Nightingale herself read the journals monthly to evalu-ate their character and work habits. Every nursing student admitted to St. Thomas had to submit an acceptable Òletter of good character,Ó and Nightingale herself placed graduate nurses in approved nursing positions.One of the most important features of the Nightingale School was its relative autonomy. Both the school and the hospital nursing service were organized under the head matron. This was especially significant because it meant that nursing service began independently of the med-ical staff in selecting, retaining, and disciplining students and nurses (Bullough & Bullough, 1978). Nightingale was opposed to the use of a standardized government examination and the movement for licen-sure of trained nurses. She believed that schools of nursing would lose control of educational standards with the advent of national licen-sure, most notably those related to moral character. Nightingale led a staunch opposition to the movement by the Royal British NursesÕ Association (RBNA) for licensure of trained nurses, one the RBNA believed critical to protecting the publicÕs safety by ensuring the qualification of nurses by licensure exam. Nightingale was convinced that qualifying a nurse by examination tested only the acquisition of technical skills, not the equally important evaluation of character (Nutting & Dock, 1907; Woodham-Smith, 1951).CHAPTER 1 A History of Health Care and Nursing20
Taking Health Care to the Community: Nightingale and WellnessEarly efforts to distinguish hospital from community health nursing are evidence of NightingaleÕs views on Òhealth nursing,Ó which she distinguished from Òsick nursing.Ó She wrote two influential papers, one in 1893, ÒSick-Nursing and Health-NursingÓ (Nightingale, 1893), which was read in the United States at the Chicago Exposition, and the second, ÒHealth Teaching in Towns and VillagesÓ in 1894 (Monteiro, 1985). Both papers praised the success of prevention- based nursing practice. Winslow (1946) acknowledged NightingaleÕs influence in the United States by being one of the first in the field of public health to recognize the importance of taking responsibility for oneÕs health. According to Palmer (1982), Nightingale was a leader in the wellness movement long before the concept was identified. Nightingale saw the nurse as the key figure in establishing a healthy so-ciety. She saw a logical extension of nursing in acute hospital settings to the community. Clearly, through her Notes on Nursing, she visual-ized the nurse as Òthe nationÕs first bulwark in health maintenance, the promotion of wellness, and the prevention of diseaseÓ (Palmer, 1982, p. 6).William Rathbone, a wealthy ship owner and philanthropist, is credited with the establishment of the first visiting nurse service, which eventually evolved into district nursing in the community. He was so impressed with the private duty nursing care that his sick wife had received at home that he set out to develop a Òdistrict nurs-ing serviceÓ in Liverpool, England. At his own expense, in 1859, he developed a corps of nurses trained to care for the sick poor in their homes (Bullough & Bullough, 1978). He divided the community into 16 districts; each was assigned a nurse and a social worker that provided nursing and health education. His experiment in district nursing was so successful that he was unable to find enough nurses to work in the districts. Rathbone contacted Nightingale for as-sistance. Her recommendation was to train more nurses, and she advised Rathbone to approach the Royal Liverpool Infirmary with a proposal for opening another training school for nurses (Rathbone, 1890; Tooley, 1910). The infirmary agreed to RathboneÕs proposal, and district nursing soon spread throughout England as successful health nursing in the community for the sick poor through voluntary agencies (Rosen, 1958). Ever the visionary, Nightingale contended that the goal is to care for the sick in their own homes (Attewell, 1996). A similar service, health visiting, began in Manchester, Eng-land, in 1862 by the Manchester and Salford Sanitary Association. The purpose of placing health visitors in the home was to provide health information and instruction to families. Eventually, health And Then There Was Nightingale . . .21
visitors evolved to provide preventive health education and district nurses to care for the sick at home (Bullough & Bullough, 1978).Although Nightingale is best known for her reform of hospitals and the military, she was a great believer in the future of health care, which she anticipated should be preventive in nature and would more than likely take place in the home and community. Her accomplishments in the field of Òsanitary nursingÓ extended beyond the walls of the hospital to include workhouse reform and commu-nity sanitation reform. In 1864, Nightingale and William Rathbone once again worked together to lead the reform of the Liverpool Workhouse Infirmary, where more than 1,200 sick paupers were crowded into unsanitary and unsafe conditions. Under the Brit-ish Poor Laws, the most desperately poor of the large cities were gathered into large workhouses. When sick, they were sent to the workhouse infirmary. Trained nursing care was all but nonexistent. Through legislative pressure and a well-designed public campaign describing the horrors of the workhouse infirmary, reform of the workhouse system was accomplished by 1867. Although not as complete as Nightingale had wanted, nurses were in place and be-ing paid a salary (Seymer, 1954).The Legacy of NightingaleA great deal has been written about NightingaleÑan almost mythic figure in history. She truly was a beloved legend throughout Great Britain by the time she left Crimea in July 1856, just four months after the war. Longfellow immortalized this ÒLady with the LampÓ in his poem ÒSanta FilomenaÓ (Longfellow, 1857). However, when Nightingale returned to London after the Crimean War, she remained haunted by her experiences related to the soldiers dying of prevent-able diseases. She was troubled by nightmares and had difficulty sleeping in the years that followed (Woodham-Smith, 1983). Night-ingale became a prolific writer and a staunch defender of the causes of the British soldier, sanitation in England and India, and trained nursing.As a woman, she was not able to hold an official government post, nor could she vote. Historians have had varied opinions about the exact nature of the disability that kept her homebound for the remainder of her life. Recent scholars have speculated that she experienced posttraumatic stress disorder (PTSD) from her experiences in Crimea; there is also considerable evidence that she suffered from the painful disease brucellosis (Barker, 1989; Young, 1995). She exerted incredible influence through friends and acquaintances, directing from her sick room sanitation and poor law reform. Her mission to ÒcleanseÓ spread from the military to the British Empire; her fight for improved sanitation both at home CHAPTER 1 A History of Health Care and Nursing22
and in India consumed her energies for the remainder of her life (Vicinus & Nergaard, 1990).According to Monteiro (1985), two recurrent themes are found throughout NightingaleÕs writings about disease prevention and wellness outside the hospital. The most persistent theme is that nurses must be trained differently and instructed specifically in dis-trict and instructive nursing. She consistently wrote that the Òhealth nurseÓ must be trained in the nature of poverty and its influence on health, something she referred to as the ÒpauperizationÓ of the poor. She also believed that above all, health nurses must be good teachers about hygiene and helping families learn to better care for themselves (Nightingale, 1893). She insisted that untrained, Ògood intended womenÓ could not substitute for nursing care in the home. Nightingale pushed for an extensive orientation and additional train-ing, including prior hospital experience, before one was hired as a dis-trict nurse. She outlined the qualifications in her paper ÒOn Trained Nursing for the Sick Poor,Ó in which she called for a monthÕs ÒtrialÓ in district nursing, a yearÕs training in hospital nursing, and 3 to 6 months training in district nursing (Monteiro, 1985).The second theme that emerged from her writings was the fo-cus on the role of the nurse. She clearly distinguished the role of the health nurse in promoting what we today call self-care. In the past, philanthropic visitors in the form of Christian charity would visit the homes of the poor and offer them relief (Monteiro, 1985). Nightingale believed that such activities did little to teach the poor to care for themselves and further ÒpauperizedÓ themÑdependent and vulnerableÑkeeping them unhealthy, prone to disease, and reli-ant on others to keep them healthy. The nurse then must help the families at home manage a healthy environment for themselves, and Nightingale saw a trained nurse as being the only person who could pull off such a feat.By 1901, Nightingale lived in a world without sight or sound, leav-ing her unable to write. Over the next 5 years, Nightingale lost her ability to communicate and most days existed in a state of unconsciousness. In November 1907, Nightingale was honored with the Order of Merit by King Edward VII, the first time it was ever given to a woman. After 50 years, in May 1910, the Nightingale Training School of Nursing at St. Thomas celebrated its jubilee. There were now more than 1,000 training schools for nurses in the United States alone (Cook, 1913; Tooley, 1910).Nightingale died in her sleep around noon on August 13, 1910, and was buried quietly and without pomp near the familyÕs home at Embley, her coffin carried by six sergeants of the British Army. Only a small cross marks her grave at her request: ÒFN. Born 1820. Died 1910Ó (Brown, 1988). The family refused a national funeral and burial at Westminster Abbey out of respect for NightingaleÕs last wishes. She had lived for 90 years and 3 months.And Then There Was Nightingale . . .23
Continued Development of Professional Nursing in the United KingdomAlthough Florence Nightingale opposed registration, based on the belief that the essential qualities of a nurse could not be taught, ex-amined, or regulated, registration in the United Kingdom began in the 1880s. The Hospitals Association maintained a voluntary regis-try that was an administrative list. In an effort to protect the public led by Ethel Fenwick, the Royal British NursesÕ Association (RBNA) was formed in 1887, with its charter granted in 1893 to unite British nurses and to provide registration as evidence of systematic training. Finally, in 1919, nurse registration became law. It took 30 years and the tireless efforts of Fenwick, who was supported by other nursing leaders such as Isla Stewart, Lucy Osbourne, and Mary Cochrane, to achieve mandated registration (Royal College of Nursing, n.d.).Another milestone in British nursing history was the founding in 1916 of the College of Nursing as the professional organization for trained nurses. Known now as the Royal College of Nursing, the organization has focused for over a century on professional stan-dards for nurses in their education, practice, and working conditions. Although the principles of a professional organization and those of a trade union have not always fit together easily, the Royal College of Nursing has pursued its role as both the professional organization for nurses and the trade union for nurses (McGann et al., 2009). Today the Royal College of Nursing is recognized as the voice of nursing by the government and the public in the United Kingdom (Royal College of Nursing, n.d.).The Development of Professional Nursing in CanadaMarie Rollet Hebert, the wife of a surgeon-apothecary, is credited by many with being the first person in present-day Canada to provide nursing care to the sick as she assisted her husband after arriving in Quebec in 1617; however, the first trained nurses arrived in Quebec to care for the sick in 1639. These nurses were Augustinian nuns who traveled to Canada to establish a medical mission to care for the physical and spiritual needs of their patients, and they established the first hospital in North America, the H™tel-Dieu de QuŽbec. These nuns also established the first apprenticeship program for nursing in North America. Jeanne Mance came from France to the French colony of Montreal in 1642 and founded the H™tel Dieu de MontrŽal in 1645 (Canadian Museum of History, n.d.).CHAPTER 1 A History of Health Care and Nursing24
The hospital of the early 19th century did not appeal to the Cana-dian public. They were primarily homes for the poor and were staffed by those of a similar class rather than by nurses (Mansell, 2004). The decades of the 1830s and 1840s in Canada were characterized by an influx of immigrants and outbreaks of diseases, such as cholera. There is evidence that it was difficult, especially in times of outbreak, to find sufficient people to care for the sick. Little is known of the hospital ÒnursesÓ of this era, but the descriptions are unflattering and work-ing in the hospital environment was difficult. Early midwives did have some standing in the community and were employed by individuals, although there is record of charitable organizations also employing midwives (Young, 2010).During the Crimean War and American Civil War, nurses were extremely effective in providing treatment and comfort not only to battlefield casualties but also to individuals who fell victim to accidents and infectious disease; however, it was in the North-West Rebellion of 1885 that Canadian nurses performed military service for the first time. At first, the nursing needs identified were for such duties as making bandages and preparing supplies. It soon became apparent that more direct participation by nurses was needed if the military was to provide effective medical field treatment. Seven nurses, under the direction of Reverend Mother Hannah Grier Coome, served in Moose Jaw and Sas-katoon, Saskatchewan. Although their tour of duty lasted only 4 weeks, these women proved that nursing could, and should in the future, play a vital role in providing treatment to wounded soldiers. In 1899, the Canadian Army Medical Department was formed, followed by the creation of the Canadian Army Nursing Service. Nurses received the relative rank, pay, and allowances of an army lieutenant. Nursing sisters served thereafter in every military force sent out from Canada, from the South African War to the Korean War (Veterans Affairs Canada, n.d.). In 1896, Lady Ishbel Aberdeen, wife of the governor-general of Canada, visited Vancouver. During this visit, she heard vivid accounts of the hardship and illness affecting women and children in rural areas. Later that same year at the National Council of Women, amid similar stories, a resolution was passed asking Lady Aberdeen to found an order of vis-iting nurses in Canada. The order was to be a memorial to the 60th an-niversary of Queen VictoriaÕs ascent to the throne of the British Empire; it received a royal charter in 1897. The first Victorian Order of Nurses (VON) sites were organized in the cities of Ottawa, Montreal, Toronto, Halifax, Vancouver, and Kingston. Today the VON delivers over 75 dif-ferent programs and services, such as prenatal education, mental health services, palliative care services, and visiting nursing, through 52 local sites staffed by 4,500 healthcare workers and over 9,016 volunteers (VON, n.d.).By the mid to late 19th century, despite previous negativity, nursing came to be viewed as necessary to progressive medical interventions. The Development of Professional Nursing in Canada25
To make the work of the nurse acceptable, changes had to be made to the prevailing view of nursing. In the 1870s, the ideas of Florence Nightingale were introduced in Canada. Dr. Theophilus Mack imported nurses who had worked with Nightingale and founded the first train-ing school for nurses in Canada at St. CatharineÕs General Hospital in 1873. Many hospitals appeared across Canada from 1890 to 1910, and many of them developed training schools for nurses. By 1909, there were 70 hospital-based training schools in Canada (Mansell, 2004).In 1908, Mary Agnes Snively, along with 16 representatives from organized nursing bodies, met in Ottawa to form the Canadian Na-tional Association of Trained Nurses (CNATN). By 1924, each of the nine provinces had a provincial nursing organization with member-ship in the CNATN. In 1924, the name of the CNATN was changed to the Canadian Nurses Association (CNA). CNA is currently a feder-ation of 11 provincial and territorial nursing associations and colleges representing nearly 150,000 registered nurses (CNA, n.d.).In 1944, the CNA approved the principle of collective bargain-ing. In 1946, the Registered Nurses Association of British Columbia became the first provincial nursing association to be certified as a bar-gaining agent. By the 1970s, other provincial nursing organizations gained this right. Between 1973 and 1987, nursing unions were cre-ated. Today each of the 10 provinces has a nursing union in addition to a professional association (Ontario NursesÕ Association, n.d.). One of the best known of these professional associations is the Registered NursesÕ Association of Ontario (RNAO). Established in 1925 to ad-vocate for health public policy, promote excellence in nursing practice, increase nursingÕs contribution to shaping the healthcare system, and influence decisions that affect nurses and the public they serve, the RNAO is the professional association representing registered nurses, nurse practitioners (NPs), and nursing students in Ontario (RNAO, n.d.). Through the RNAO, nurses in Canada have led the world in systematic implementation of evidence-based practice and have made their best practice guidelines available to all nurses to promote safe and effective care of patients.As Canadians entered the decade of the 1960s, there was serious concern about the healthcare system. In 1961, all Canadian provinces signed on to the Hospital Insurance and Diagnostic Services Act. This legislation created a national universal health insurance system. The same year, the Royal Commission on Health Services was established and presented four recommendations. One of the recommendations was to examine nursing education. Prior to this, the CNA had re-quested a survey of nursing schools across Canada with the goal of assessing how prepared the schools were for a national system of ac-creditation. The findings of this survey, paired with the commissionÕs recommendation, led to the establishment of the Canadian Nurses Foundation (CNF) in 1962. The CNF (2014) provides funding for CHAPTER 1 A History of Health Care and Nursing26
nurses to further their education and for research related to nursing care. The Canadian Association of Schools of Nursing (n.d.) is the orga-nization that promotes national nursing education standards and is the national accrediting agency for university nursing programs in Canada.Canadian nursing associations agreed that starting in the year 2000, the basic educational preparation for the registered nurse would be the baccalaureate degree, and all provinces and territories launched a campaign known as EP 2000, which later became EP 2005. The baccalaureate degree earned from a university is the ac-cepted entry level into nursing practice in Canada (Mansell, 2004).Nursing in Canada transformed itself to meet the needs of a changing Canadian society and in doing so was responsible for a shift from nursing as a spiritual vocation to a secular but indispensable profession. NursesÕ willingness to respond in times of need, whether economic crisis, epidemic, or war, contributed to their importance in the healthcare system (Mansell, 2004). Currently in Canada there are three regulated nursing groups that include the registered nurse (RN), the licensed practical nurse (LPN) or registered practical nurse, and the registered psychiatric nurse (RPN) (National Nursing Assessment Services, 2021).The Development of Professional Nursing in AustraliaIn the earliest days of the colony, the care of the sick was performed by untrained convicts. Male attendants undertook the supervision of male patients, and female attendants undertook duties with the female patients. Attention to hygiene standards was almost nonexistent. In 1885, the poor health and living conditions of disadvantaged sick per-sons in Melbourne prompted a group of concerned citizens to meet and form the Melbourne District Nursing Society. This society was formed to look after sick poor persons at home to prevent unneces-sary hospitalization. Home visiting services also have a long history in Australia, with Victoria being the first state to introduce a district nursing service in 1885, followed by South Australia in 1894, Tas-mania in 1896, New South Wales in 1900, Queensland in 1904, and Western Australia in 1905 (Australian Bureau of Statistics, 1985).Australian nurses were involved in military nursing as civilian volunteers as early as the 1880s (University of Melbourne, 2015); however, involvement of Australian women as nurses in war began in 1898 with the formation of the Australian Nursing Service of New South Wales, which was composed of 1 superintendent and 24 nurses. Based on the performance of the nurses, the Australian Army Nursing Service was formed in 1903 under the control of the federal govern-ment. The Royal Australian Army Nursing Corps had its beginnings The Development of Professional Nursing in Australia27
in the Australian Army Nursing Service (Australian Government De-partment of Veterans Affairs, n.d.). Since that time, Australian nurses have dealt with war, the sick, the wounded, and the dead. They have served in Australia, in war zones around the world, in field hospi-tals, on hospital ships anchored offshore near battlefields, and on transports (Australian War Memorial, n.d.; Biedermann et al., 2001). Other military opportunities for nurses include the Royal Australian Navy and the Royal Australian Air Force.Nursing registration in Australia began in 1920 as a state-based system. Prior to 1920, nurses received certificates from the hospi-tals where they trained, the Australian Trained NursesÕ Association (ATNA), or the Royal British NursesÕ Association in order to practice. Today nurses and midwives are registered through the Nursing and Midwifery Board of Australia (NMBA), which is made up of member state and territorial boards of nursing and supported by the Aus-tralian Health Practitioner Regulation Agency. State and territorial boards are responsible for making registration and notification deci-sions related to individual nurses or midwives (NMBA, n.d.).Around the turn of the 20th century, to create a formal means of supporting their role and to improve nursing standards and educa-tion, the nurses of South Australia formed the South Australian branch of ATNA. From this organization the Australian Nursing and Mid-wifery Federation in South Australia (ANMFSA) evolved (ANMFSA, 2012). The Australian Nursing and Midwifery Accreditation Council (ANMAC) is now the independent accrediting authority for nursing and midwifery under AustraliaÕs National Registration and Accredita-tion Scheme. The ANMAC is responsible for protecting and promoting the safety of the Australian community by promoting high standards of nursing and midwifery education through the development of accredi-tation standards, accreditation of programs, and assessment of interna-tionally qualified nurses and midwives for migration (ANMAC, 2016).In the late 1920s, two nurses, Evelyn Nowland and a Miss Clancy, began working separately on the idea of a union for nurses and were brought together by Jessie Street, who saw the improvement of nursesÕ wages and conditions as a feminist cause. What is now the New South Wales Nurses and MidwivesÕ Association (NSWNMA) was registered as a trade union in 1931 (NSWNMA, 2014). Through the amalgama-tion of various organizations, there is now one national organization to represent registered nurses, enrolled nurses, midwives, and assistants doing nursing work in every state and territory throughout Australia: the Australian Nursing and Midwifery Federation (ANMF). The orga-nization was established in 1924 and serves as a union for nurses with an ultimate goal of improving patient care. The ANMF is now com-posed of eight branches: the Australian Nursing and Midwifery Federa-tion (South Australia branch), the NSWNMA, the Australian Nursing and Midwifery Federation Victorian Branch, the Queensland Nurses CHAPTER 1 A History of Health Care and Nursing28
Union, the Australian Nursing and Midwifery Federation Tasmanian Branch, the Australian Nursing and Midwifery Federation Australian Capital Territory, the Australian Nursing and Midwifery Federation Northern Territory, and the Australian Nursing and Midwifery Federa-tion Western Australia Branch (ANMF, 2015).Early Nursing Education and Organization in the United StatesFormal nursing education in the United States did not begin until 1862, when Dr. Marie Zakrzewska opened the New England Hospital for Women and Children, which had its own nurse training program (Sitzman & Judd, 2014b). Many of the first training schools for nurs-ing were modeled after the Nightingale School of Nursing at St. Thomas in London. They included the Bellevue Training School for Nurses in New York City; the Connecticut Training School for Nurses in New Haven, Connecticut; and the Boston Training School for Nurses at Massachusetts General Hospital (Christy, 1975; Nutting & Dock, 1907). Based on the Victorian belief in the natural abilities of women to be sen-sitive, possess high morals, and be caregivers, early nursing training re-quired that applicants be female. Sensitivity, high moral character, purity of character, subservience, and ÒladylikeÓ behavior became the associated traits of a Ògood nurse,Ó thus setting the Òfeminization of nursingÓ as the ideal standard for a good nurse. These historical roots of gender- and race-based caregiving continued to exclude males and minorities from the nursing profession for many years and still influence career choices for men and women today. These early training schools provided a stable, subservient, White female workforce because student nurses served as the primary nursing staff for these early hospitals. Minority nurses found limited educational opportunities in this climate. The first Black nursing school graduate in the United States was Mary P. Mahoney. She gradu-ated from the New England Hospital for Women and Children in 1879 (Sitzman & Judd, 2014b).Nursing education in the newly formed schools was based on accepted practices that had not been validated by research. During this time, nurses primarily relied on tradition to guide practice rather than engaging in research to test interventions; however, scientific advances did help to improve nursing practice as nurses altered interventions based on knowledge generated by scientists and physicians. During this time, a nurse, Clara Maass, gave her life as a volunteer subject in the research of yellow fever (Sitzman & Judd, 2014b).CRITICAL THINKING QUESTIONS✶Some nurses believe that Florence Nightin-gale holds nursing back and represents the negative and backward elements of nursing. This view cites as evidence that Nightingale supported the subordination of nurses to physicians, opposed registration of nurses, and did not see mental health nurses as part of the profession. After reading this chapter, what do you think? Is Nightingale relevant in the 21st century to the nursing profes-sion? Why or why not?✶Early Nursing Education and Organization in the United States29
A significant report, known simply as the Goldmark Report, Nurs-ing and Nursing Education in the United States, was released in 1922 and advocated for the establishment of university schools of nursing to train nursing leaders. The report, initiated by Nutting in 1918, was an exhaustive and comprehensive investigation into the state of nursing education and training resulting in a 500-page document. Josephine Goldmark, social worker and author of the pioneering re-search of nursing preparation in the United States, stated,From our field study of the nurse in public health nursing, in private duty, and as instructor and supervisor in hospitals, it is clear that there is need of a basic undergraduate training for all nurses alike, which should lead to a nursing diploma. (Goldmark, 1923, p. 35)The first university school of nursing was developed at the Uni-versity of Minnesota in 1909. Although the new nurse training school was under the college of medicine and offered only a 3-year diploma, the Minnesota program was nevertheless a significant leap forward in nursing education. Nursing for the Future, or the Brown Report, au-thored by Esther Lucille Brown in 1948 and sponsored by the Russell Sage Foundation, was critical of the quality and structure of nursing schools in the United States. The Brown Report became the catalyst for the implementation of educational nursing program accreditation through the National League for Nursing (Brown, 1936, 1948). As a result of the postÐWorld War II nursing shortage, an associate degree in nursing was established by Dr. Mildred Montag in 1952 as a 2-year program for registered nurses (Montag, 1959). In 1950, nursing be-came the first profession for which the same licensure exam, the State Board Test Pool, was used throughout the nation to license registered nurses. This increased mobility for the registered nurse resulted in a significant advantage for the relatively new profession of nursing (ÒState Board Test Pool Examination,Ó 1952).The Evolution of Nursing in the United States: The First Century of Professional NursingThe Profession of Nursing Is Born in the United StatesEarly nurse leaders of the 20th century included Isabel Hampton Robb, who in 1896 founded the NursesÕ Associated Alumnae, which in 1911 officially became known as the American Nurses Association (ANA); and Lavinia Lloyd Dock, who became a militant suffragist linking womenÕs CHAPTER 1 A History of Health Care and Nursing30
roles as nurses to the emerging womenÕs movement in the United States. Mary Adelaide Nutting, Lavinia L. Dock, Sophia Palmer, and Mary E. Davis were instrumental in developing the first nursing jour-nal, the American Journal of Nursing (AJN) in October 1900. Through the ANA and the AJN, nurses then had a professional organization and a national journal with which to communicate with one another (Ka-lisch & Kalisch, 1986).State licensure of trained nurses began in 1903 with the enact-ment of North CarolinaÕs licensure law for nursing. Shortly thereafter, New Jersey, New York, and Virginia passed similar licensure laws for nursing. Over the next several years, professional nursing was well on its way to public recognition of practice and educational standards as state after state passed similar legislation.Margaret Sanger worked as a nurse on the Lower East Side of New York City in 1912 with immigrant families. She was astonished to find widespread ignorance among these families about concep-tion, pregnancy, and childbirth. After a horrifying experience with the death of a woman from a failed self-induced abortion, Sanger devoted her life to teaching women about birth control. A staunch activist in the early family planning movement, Sanger is credited with founding Planned Parenthood of America (Sanger, 1928).By 1917, the emerging new profession saw two significant events that propelled the need for additional trained nurses in the United States: World War I and the influenza epidemic. Nightingale and the devastation of the Civil War had well established the need for nurs-ing care in wartime. Mary Adelaide Nutting, now professor of nurs-ing and health at Columbia University, chaired the newly established Committee on Nursing in response to the need for nurses as the United States entered the war in Europe. Nurses in the United States realized early that World War I was unlike previous wars. It was a global conflict that involved coalitions of nations against nations and vast amounts of supplies and demanded the organization of all the nationsÕ resources for military purposes (Kalisch & Kalisch, 1986). Along with Lillian Wald and Jane A. Delano, director of nursing in the American Red Cross, Nutting initiated a national publicity cam-paign to recruit young women to enter nursesÕ training. The Army School of Nursing, headed by Annie Goodrich as dean, and the Vas-sar Training Camp for Nurses prepared nurses for the war as well as home nursing and hygiene nursing through the Red Cross (Dock & Stewart, 1931). The committee estimated that there were at most about 200,000 active ÒnursesÓ in the United States, both trained and untrained, which was inadequate for the military effort abroad (Kalisch & Kalisch, 1986).At home, the influenza epidemic of 1917 to 1919 led to increased public awareness of the need for public health nursing and public edu-cation about hygiene and disease prevention. The successful campaign The Evolution of Nursing in the United States: The First Century of Professional Nursing 31
to attract nursing students focused heavily on patriotism, which ushered in the new era for nursing as a profession. By 1918, nursing school enrollments were up by 25%. In 1920, Congress passed a bill that provided nurses with military rank (Dock & Stewart, 1931). Fol-lowing close behind, the passage of the Nineteenth Amendment to the U.S. Constitution granted women the right to vote.Lillian Wald, Public Health Nursing, and Community ActivismThe pattern for health visiting and district nursing practice outside the hospital was similar in the United States to that in England (Roberts, 1954). American cities were besieged by overcrowding and epidemics after the Civil War. The need for trained nurses evolved as in England, and schools throughout the United States developed along the Night-ingale model. Visiting nurses were first sent to philanthropic organiza-tions in New York City (1877), Boston (1886), Buffalo (1885), and Philadelphia (1886) to care for the sick at home. By the end of the century, most large cities had some form of visiting nursing program, and some headway was being made even in smaller towns (Heinrich, 1983). Industrial or occupational health nursing was first started in Vermont in 1895 by a marble company interested in the health and welfare of its workers and their families. Tuberculosis (TB) was a leading cause of death in the 1800s; nurses visited patients bedridden from TB and instructed persons in all settings about prevention of the disease (Abel, 1997).Lillian Wald (Figure 1-2), a wealthy young woman with a great social conscience, graduated from the New York Hospital School of Nursing in 1891 and is credited with creating the title Òpublic health nurse.Ó After a year working in a mental institution, Wald entered medical school at WomenÕs Medical College in New York. While in medical school, she was asked to visit immigrant mothers on New YorkÕs Lower East Side and instruct them on health matters. Wald was appalled by the conditions there. During one now famous home visit, a small child asked Wald to visit her sick mother. And the rest, as they say, is history (Box 1-1). What Wald found changed her life forever and secured a place for her in American nursing history. Wald (1915) said, ÒAll the maladjustments of our social and economic relations seemed epitomized in this brief journeyÓ (p. 6). Wald was profoundly affected by her observations; she and her colleague, Mary Brewster, quickly established the Henry Street Settlement in this same neighbor-hood in 1893. She quit medical school and devoted the remainder of her life to Òvisions of a better worldÓ for the publicÕs health. Ac-cording to Wald, ÒNursing is love in action, and there is no finer manifestation of it than the care of the poor and disabled in their own homesÓ (Wald, 1915, p. 14).CHAPTER 1 A History of Health Care and Nursing32
Figure 1-2 A photo of Lillian Wald, taken by Harris and Ewing during the first half of the 20th century.Courtesy of Library of Congress, Prints & Photographs Division, photograph by Harris & Ewing, LC-DIG-hec-19537.BOX 1-1 LILLIAN WALD TAKES A WALKFrom the schoolroom where I had been giving a lesson in bed- making, a little girl led me one drizzling March morning. She had told me of her sick mother and gathering from her incoherent ac-count that a child had been born, I caught up the paraphernalia of the bed-making lesson and carried it with me.The child led me over broken roadways . . . between tall, reeking houses whose laden fire-escapes, useless for their appointed purpose, bulged with household goods of every description. The rain added to the dismal appearance of the streets and to the discomfort of the crowds which thronged them, intensifying the odors, which as-sailed me from every side. Through Hester and Division Streets we went to the end of Ludlow; past odorous fish-stands, for the streets (continues)The Evolution of Nursing in the United States: The First Century of Professional Nursing 33
The Henry Street Settlement was an independent nursing ser-vice where Wald lived and worked. This later became the Visiting Nurse Association of New York City, which laid the foundation for the establishment of public health nursing in the United States. The were a market-place, unregulated, unsupervised, unclean; past evil-smelling, uncovered garbage cans. . . .All the maladjustments of our social and economic relations seemed epitomized in this brief journey and what was found at the end of it. The family to which the child led me was neither criminal nor vicious. Although the husband was a cripple, one of those who stand on street corners exhibiting deformities to enlist compassion, and masking the begging of alms by a pretense of selling; although the family of seven shared their two rooms with boardersÑwho were literally boarders, since a piece of timber was placed over the floor for them to sleep onÑand although the sick woman lay on a wretched, unclean bed, soiled with a hemorrhage two days old, they were not degraded human beings, judged by any measure of moral values.In fact, it was very plain that they were sensitive to their condi-tion, and when, at the end of my ministrations, they kissed my hands (those who have undergone similar experiences will, I am sure, un-derstand), it would have been some solace if by any conviction of the moral unworthiness of the family I could have defended myself as a part of a society which permitted such conditions to exist. Indeed, my subsequent acquaintance with them revealed the fact that miser-able as their state was, they were not without ideals for the family life, and for society, of which they were so unloved and unlovely a part.That morningÕs experience was a baptism of fire. Deserted were the laboratory and the academic work of the college. I never re-turned to them. On my way from the sick-room to my comfortable student quarters, my mind was intent on my own responsibility. To my inexperience it seemed certain that conditions such as these were allowed because people did not know, and for me there was a chal-lenge to know and to tell. When early morning found me still awake, my naive conviction remained that, if people knew thingsÑand ÒthingsÓ meant everything implied in the condition of this familyÑsuch horrors would cease to exist, and I rejoiced that I had a training in the care of the sick that in itself would give me an organic rela-tionship to the neighborhood in which this awakening had come.Wald, L. D. (1915). The House on Henry Street. Henry Holt.BOX 1-1 LILLIAN WALD TAKES A WALK (continued)CHAPTER 1 A History of Health Care and Nursing34
health needs of the population were met through addressing social, economic, and environmental determinants of health, in a pattern after Nightingale. These nurses helped educate families about disease transmission and emphasized the importance of good hygiene. They provided preventive, acute, and long-term care. As such, Henry Street went far beyond the care of the sick and the prevention of illness. It aimed at rectifying those causes that led to the poverty and misery. Wald was a tireless social activist for legislative reforms that would provide a more just distribution of services for the marginal and dis-advantaged in the United States (Donahue, 1985). Wald began with 10 nurses in 1893, which grew to 250 nurses serving 1,300 clients a day by 1916. During this same period, the budget grew from nothing to more than $600,000 a year, all from private donations.Wald hired Black nurse Elizabeth Tyler in 1906 as evidence of her commitment to cultural diversity. Although unable to visit White cli-ents, Tyler made her own way by ÒfindingÓ Black families who needed her service. In 3 months, Tyler had so many Black families within her caseload that Wald hired a second Black nurse, Edith Carter. Carter remained at Henry Street for 28 years until her retirement (Carnegie, 1991). During her tenure at Henry Street, Wald demonstrated her commitment to racial and cultural diversity by employing 25 Black nurses over the years, and she paid them salaries equal to White nurses and provided identical benefits and recognition to minority nurses (Carnegie, 1991). This was exceptional during the early part of the 1900s, a time when Black nurses were often denied admission to White schools of nursing and membership in professional organiza-tions and were denied opportunities for employment in most settings. Because hospitals of this era often set quotas for Black clients, those nurses who managed to graduate from nursing schools found them-selves with few clients who needed or could afford their services. Black nurses struggled for the right to take the registration examina-tion available for White nurses.Wald submitted a proposal to the city of New York after learning of a childÕs dismissal from a New York City school for a skin condi-tion. Her proposal was for one of the Henry Street Settlement nurses to serve free for 1 month in a New York school. The results of her experiment were so convincing that salaries were approved for 12 school nurses. From this, school nursing was born in the United States and became one of many community specialties credited to Wald (Dietz & Lehozky, 1963). In 1909, Wald proposed a program to the Metropolitan Life Insurance Company to provide nursing visits to their industrial policyholders. Statistics kept by the company docu-mented the lowered mortality rates of policyholders attributed to the nursesÕ public health practice and clinical expertise. The program demonstrated savings for the company and was so successful that it lasted until 1953 (Hamilton, 1988).The Evolution of Nursing in the United States: The First Century of Professional Nursing 35
WaldÕs other significant accomplishments include the establish-ment of the ChildrenÕs Bureau, set up in 1912 as part of the U.S. Department of Labor. She also was an enthusiastic supporter of and participant in womenÕs suffrage, lobbied for inspections of the work-place, and supported her employee, Margaret Sanger, in her efforts to give women the right to birth control. She was active in the American Red Cross and International Red Cross and helped form the WomenÕs Trade Union League to protect women from sweatshop conditions.Wald first coined the phrase Òpublic health nursingÓ (Figure 1-3) and transformed the field of community health nursing from the nar-row role of home visiting to the population focus of todayÕs commu-nity health nurse (Robinson, 1946). According to Dock and Stewart (1931), the title of public health nurse was purposeful: The role designation was designed to link the publicÕs health to governmental responsibility, not private funding. As state departments of health Figure 1-3 Photo of town and country rural public health nurse carrying the black bag typical of public health nurses in the early 20th century.CHAPTER 1 A History of Health Care and Nursing36
and local governments began to employ more and more public health nurses, their role increasingly focused on prevention of illness in the entire community. Discrimination developed between the visiting nurse, who was employed by the voluntary agencies primarily to provide home care to the sick, and the public health nurse, who con-centrated on preventive measures (see Figure 1-3) (Brainard, 1922).Early public health nurses came closer than hospital-based nurses to the autonomy and professionalism that Nightingale advocated. Their work was conducted in the unconfined setting of the home and com-munity, they were independent, and they enjoyed recognition as special-ists in preventive health (Buhler-Wilkerson, 1985). Public health nurses from the beginning were much more holistic in their practice than their hospital counterparts. They were involved with the health of industrial workers, immigrants, and their families and were concerned about ex-ploitation of women and children. These nurses also played a part in prison reform and care of the mentally ill (Heinrich, 1983).Considered the first Black public health nurse, Jessie Sleet Scales was hired in 1902 by the Charity Organization Society, a philan-thropic organization, to visit Black families infected by TB. Scales provided district nursing care to New York CityÕs Black families and is credited with paving the way for Black nurses in the practice of community health (Mosley, 1996).Dorothea Lynde DixDorothea Lynde Dix, a Boston schoolteacher, became aware of the hor-rendous conditions in prisons and mental institutions when asked to do a Sunday school class at the House of Correction in Cambridge, Massachusetts. She was appalled at what she saw and went about studying whether the conditions were isolated or widespread; she took 2 years off to visit every jail and almshouse from Cape Cod to Berkshire (Tiffany, 1890). Her report was devastating. Boston was scandalized by the reality that the most progressive state in the Union was now associated with such appalling conditions. The shocked legislature voted to allocate funds to build hospitals. For the rest of her life, Dorothea Dix stood out as a tireless zealot for the humane treatment of the insane and imprisoned. She had exceptional savvy in dealing with legislators. She acquainted herself with the legislators and their records and displayed the Òspirit of a crusader.Ó For her contributions, Dix is recognized as one of the pioneers of the reform movement for mental health in the United States, and her efforts are felt worldwide to the present day (Dietz & Lehozky, 1963).Dix was also known for her work in the Civil War, having been appointed superintendent of the female nurses of the army by the secretary of war in 1861. Her tireless efforts led to the recruitment of more than 2,000 women to serve in the army during the Civil War. The Evolution of Nursing in the United States: The First Century of Professional Nursing 37
Officials had consulted with Nightingale concerning military hospitals and were determined not to make the same mistakes. Dix enjoyed far more sweeping powers than Nightingale in that she had the author-ity to organize hospitals, to appoint nurses, and to manage supplies for the wounded (Brockett & Vaughan, 1867). Among her most well-known nurses during the Civil War were the poet Walt Whitman and the author Louisa May Alcott (Donahue, 1985).Clara BartonThe idea for the International Red Cross was the brainchild of a Swiss banker, J. Henri Dunant, who proposed the formation of a neutral international relief society that could be activated in time of war. The International Red Cross was ratified by the Geneva Convention on August 22, 1864. Clara Barton, through her work in the Civil War, had come to believe that such an organization was desperately needed in the United States. However, it was not until 1882 that Barton was able to convince Congress to ratify the Treaty of Geneva, thus becom-ing the founder of the American Red Cross (Kalisch & Kalisch, 1986). Barton also played a leadership role in the Spanish-American War in Cuba, where she led a group of nurses to provide care for both U.S. and Cuban soldiers and Cuban civilians. At the age of 76, Barton went to President McKinley and offered the help of the Red Cross in Cuba. The president agreed to allow Barton to go with Red Cross nurses but only to care for the Cuban citizens. Once in Cuba, the U.S. military saw what Barton and her nurses were able to accomplish with the Cuban military, and American soldiers pressured military of-ficials to allow BartonÕs help. Along with battling yellow fever, Barton was able to provide care to both Cuban and U.S. military personnel and eventually expanded that care to Cuban citizens in Santiago. One of BartonÕs most famous clients was young Colonel Teddy Roosevelt, who led his Rough Riders and who later became the president of the United States. Barton became an instant heroine both in Cuba and in the United States for her bravery and tenaciousness and for organizing services for the military and civilians torn apart by war. On August 13, 1898, the Spanish-American War came to an end. The grateful people of Santiago, Cuba, built a statue to honor Clara Barton in the town square, where it stands to this day. The work of Barton and her Red Cross nurses spread through the newspapers of the United States and in the schools of nursing. A congressional committee investigating the work of BartonÕs Red Cross staff applauded these nurses and recom-mended that the U.S. Army Medical Department create a permanent reserve corps of trained nurses. These reserve nurses became the Army Nurse Corps in 1901. Clara Barton will always be remembered both as the founder of the American Red Cross and as the driving force be-hind the creation of the Army Nurse Corps (Frantz, 1998).CHAPTER 1 A History of Health Care and Nursing38
Birth of the Midwife in the United StatesWomen have always assisted other women in the birth of babies. These Òlay midwivesÓ were considered by communities to possess special skills and somewhat of a Òcalling.Ó With the advent of professional nursing in England, registered nurses became associated with safer and more predictable childbirth practices. In England and in other countries where Nightingale nurses were prevalent, most registered nurses were also trained as midwives with a 6-month specialized training period. In the United States, the training of registered nurses in the practice of midwifery was prevented primarily by physicians. U.S. physicians saw midwives as a threat and intrusion into medical practice. Such resis-tance indirectly led to the proliferation of Ògranny wivesÓ who were ignorant of modern practices, were untrained, and were associated with high maternal morbidity (Donahue, 1985).The first organized midwifery service in the United States was the Frontier Nursing Service founded in 1925 by Mary Breckinridge. Breckinridge graduated from St. Luke Hospital Training School in New York in 1910 and received her midwifery certificate from the British Hospital for Mothers and Babies in London in 1925. She had extensive experience in the delivery of babies and midwifery systems in New Zealand and Australia. In rural Appalachia, babies had been delivered for decades by granny midwives, who relied mainly on tradition, myths, and superstition as the bases of their practice. For example, they might use ashes for medication and place a sharp axe, blade up, under the bed of a laboring woman to ÒcutÓ the pain. The people of Appalachia were isolated because of the terrain of the hol-lows and mountains, and roads were limited to most families. They had one of the highest birth rates in the United States. Breckinridge believed that if a midwifery service could work under these condi-tions, it could work anywhere (Donahue, 1985).Breckinridge had to use English midwives for many years and began training her own midwives only in 1939 when she started the Frontier Graduate School of Nurse Midwifery in Hyden, Kentucky, with the advent of World War II. The nurse midwives accessed many of their families on horseback. In 1935, a small 12-bed hospital was built at Hyden and provided delivery services. Under the direction of Breckinridge, the nurse midwives were successful in lowering the highest maternal mortality rate in the United States (in Leslie County, Kentucky) to substantially below the national average. These nurses, as at Henry Street Settlement, provided health care for everyone in the district for a small annual fee. A delivery had an additional small fee. Nurse midwives provided primary care, prenatal care, and postnatal care, with an emphasis on prevention (Wertz & Wertz, 1977).Armed with the right to vote, in the Roaring Twenties American women found the new freedom of the Òflapper eraÓÑshrinking dress The Evolution of Nursing in the United States: The First Century of Professional Nursing 39
hemlines, shortened hairstyles, and the increased use of cosmetics. Hospitals were used by greater numbers of people, and the scientific basis of medicine became well established because most surgical pro-cedures were done in hospitals. Penicillin was discovered in 1928, creating a revolution in the prevention of infectious disease deaths (Donahue, 1985; Kalisch & Kalisch, 1986). The previously mentioned Goldmark Report recommended the establishment of college- and university-based nursing programs.Mary D. Osborne, who functioned as supervisor of public health nursing for the state of Mississippi from 1921 to 1946, had a vision for a collaboration with community nurses and granny midwives, who delivered 80% of the Black babies in Mississippi. The infant and maternal mortality rates were both exceptionally high among Black families, and these granny midwives, who were also Black, were un-trained and had little education.Osborne took a creative approach to improving maternal and infant health among Black women. She developed a collaborative network of public health nurses and granny midwives; the nurses implemented training programs for the midwives, and the midwives in turn assisted the nurses in providing a higher standard of safe ma-ternal and infant health care. The public health nurses used OsborneÕs book, Manual for Midwives, which contained guidelines for care and was used in the state until the 1970s. They taught good hygiene, in-fection prevention, and compliance with state regulations. OsborneÕs innovative program is credited with reducing the maternal and infant mortality rates in Mississippi and in other states where her program structure was adopted (Sabin, 1998).The Nursing Profession Responds to the Great Depression and World War IIWith the stock market crash of 1929 came the Great Depression, re-sulting in widespread unemployment of private-duty nurses and the closing of nursing schools with a simultaneous increase in the need for charity health services for the population. Nursing students who had previously been the primary source to staff hospitals declined in number. Unemployed graduate nurses were hired to replace them for minimal wages, a trend that was to influence the profession for years to come (MacEachern, 1932).Other nurses found themselves accompanying troops to Europe when the United States entered World War II. Military nurses pro-vided care aboard hospital ships and were a critical presence at the invasion of Normandy in 1944 as well as in military operations in North Africa, Italy, France, and the Philippines. More than 100,000 nurses volunteered and were certified for military service in the Army and Navy Nurse Corps. The resulting severe shortage of nurses CHAPTER 1 A History of Health Care and Nursing40
on the home front resulted in the development of the Cadet Nurse Corps. Frances Payne Bolton, congressional representative from Ohio, is credited with the founding of the Cadet Nurse Corps through the Bolton Act of 1945. By the end of the war, more than 180,000 nurs-ing students had been trained through this act, and advanced practice graduate nurses in psychiatry and public health nursing had received graduate education to increase the numbers of nurse educators (Do-nahue, 1985; Kalisch & Kalisch, 1986).Amid the Depression, many nurses found the expansion and ad-vances in aviation as a new field for nurses. In efforts to increase the publicÕs confidence in the safety of transcontinental air travel, nurses were hired in the promising new role of Ònurse-stewardessÓ (Kalisch & Kalisch, 1986). Congress created an additional relief program, the Civil Works Administration, in 1933 that provided jobs to the un-employed, including placing nurses in schools, public hospitals and clinics, public health departments, and public health education com-munity surveys and campaigns. The Social Security Act of 1935 was passed by Congress to provide old-age benefits, rehabilitation services, unemployment compensation administration, aid to depen-dent and/or disabled children and adults, and monies to state and local health services. The Social Security Act included Title VI, which authorized the use of federal funds for the training of public health personnel. This led to the placement of public health nurses in state health departments and to the expansion of public health nursing as a viable career path.While nursing was forging new paths for itself in various fields, during the 1930s Hollywood began featuring nurses in films. The only feature-length films to ever focus entirely on the nursing pro-fession were released during this decade. War Nurse (1930), Night Nurse (1931), Once to Every Woman (1934), The White Parade (1934 Academy Award nominee for Best Picture), Four Girls in White (1939), The White Angel (1936), and Doctor and Nurse (1937) all used nurses as major characters. During the bleak years of the economic depression, young women found these nurse hero-ines who promoted idealism, self-sacrifice, and the profession of nursing over personal desires particularly appealing. No longer were nurses depicted as subservient handmaidens who worked as nurses only as a temporary pastime before marriage (Kalisch & Kalisch, 1986).During the 1930s, the Association of Collegiate Schools of Nurs-ing was formed to advance nursing education and to promote re-search related to educational criteria in nursing. Goals were aimed at changing the professional level of the nurse with a focus on preparing nurses in the academic setting and thus preparing nurses for special-ized roles, such as faculty, administrators of schools of nursing, and supervisors (Judd, 2014).The Evolution of Nursing in the United States: The First Century of Professional Nursing 41
Science and Health Care, 1945Ð1960: Decades of ChangeDramatic technologic and scientific changes characterized the decades following World War II, including the discovery of sulfa drugs, new cardiac drugs, surgeries, and treatment for ventricular fibrillation (Howell, 1996). The Hill-Burton Act, passed in 1946, provided funds to increase the construction of new hospitals. A significant change in the healthcare system was the expansion of private health insurance coverage and the dramatic increase in the birth rate, called the Òbaby boomÓ generation. Clinical research, both in medicine and in nursing, became an expectation of health providers, and more nurses sought advanced degrees. The first ANA Code of Ethics for Nurses was ad-opted in 1950, and in 1953 the International Council of Nurses (ICN) adopted an international Code of Ethics for Nurses. In 1952, the first scholarly journal, Journal of Nursing Research, was published in the United States (Kalisch & Kalisch, 2004).As a result of increased numbers of hospital beds, additional financial resources for health care, and the postÐWorld War II eco-nomic resurgence, nursing faced an acute shortage and nurses con-fronted increasingly stressful working conditions. Nurses began showing signs of the strain through debates about strikes and collec-tive bargaining demands.The ANA accepted Black nurses for membership, consequently ending racial discrimination in the dominant nursing organizations. The National Association of Colored Graduate Nurses was disbanded in 1951. Males entered nursing schools in record number, often as a result of previous military experience as medics. Prior to the 1950s and 1960s, male nurses also suffered minority status and were dis-couraged from nursing as a career. A fact seemingly forgotten by modern society, including Florence Nightingale and early U.S. nursing leaders, is that during medieval times more than one-half of the nurses were male. The Knights Hospitallers, Teutonic Knights, Franciscans, and many other male nursing orders had provided excellent nursing care for their societies. Saint Vincent de Paul had first conceived of the idea of social service. Pastor Theodor Fliedner, teacher and mentor of Florence Nightingale at Kaiserswerth in Germany; Ben Franklin; and Walt Whitman during the Civil War all either served as nurses or were strong advocates for male nurses (Kalisch & Kalisch, 1986).Years of Revolution, Protest, and the New Order, 1961Ð2000During the social upheaval of the 1960s, nursing was influenced by many changes in society, such as the womenÕs movement, organized protest against the Vietnam conflict, civil rights movement, President CHAPTER 1 A History of Health Care and Nursing42
Lyndon JohnsonÕs ÒGreat SocietyÓ social reforms, and increased con-sumer involvement in health care. Specialization in nursing, such as cardiac intensive care unit, nurse anesthetist training, and the clinical specialist role for nursing, became trends that affected both educa-tion and practice in the healthcare system. Medicare and Medicaid, enacted in 1965 under Title XVIII of the Social Security Act, provided access to health care for older adults, poor persons, and people with disabilities. The ANA took a courageous and controversial stand in that same year (1965) by approving its first position paper on nursing education, advocating for all nursing education for professional prac-tice to take place in colleges and universities (ANA, 1965). Nurses re-turning from Vietnam faced emotional challenges in the form of PTSD that affected their postwar lives.With increased specialization in medicine, the demand for pri-mary care healthcare providers exceeded the supply (Christman, 1971). As a response to this need for general practitioners, Dr. Henry Silver, MD, and Dr. Loretta Ford, RN, collaborated to develop the first NP program in the United States at the University of Colorado (Ford & Silver, 1967). NPs were initially prepared in pediatrics, with advanced role preparation in common childhood illness manage-ment and well-child care (Figure 1-4). Ford and Silver (1967) found that NPs could manage as much as 75% of the pediatric patients in community clinics, leading to the widespread use of and educational Figure 1-4 The nurse with advanced preparation and certification as a nurse practitioner is able to diagnose and treat patients.© Jose Luis Pelaez Inc/DigitalVision/Getty Images.The Evolution of Nursing in the United States: The First Century of Professional Nursing 43
programs for NPs. The first state in 1971 to recognize diagnosis and treatment as part of the legal scope of practice for NPs was Idaho. Alaska and North Carolina were among the first states to expand the NP role to include prescriptive authority (Ford, 1979). By the turn of the century, NP programs were offered at the masters of science in nursing level in family nursing; gerontology; and adult, neonatal, mental health, and maternal-child areas and have expanded to in-clude the acute care practitioner as well (Huch, 2001). Currently, the preferred educational preparation for advanced practice nurse is the doctor of nursing practice. Certification of NPs now occurs at the na-tional level through the ANA and several specialty organizations. NPs are licensed throughout the United States by state boards of nursing.In the late 1980s, escalating healthcare costs resulting from the explosion of advanced technology and the increased life span of Americans led to the demand for healthcare reform. The nursing pro-fession heralded healthcare reform with an unprecedented collabora-tion of more than 75 nursing associations, led by the ANA and the National League for Nursing, in the publication of NursingÕs Agenda for Health Care Reform. In this document, the challenge of managed care was addressed in the context of cost containment and quality as-surance of healthcare service for the nursing profession (ANA, 1991).The New CenturyThe new century began with a renewed focus on quality and safety in patient care. The landmark publication from the Institute of Medicine (IOM) published in November 1999, To Err Is Human, was the launching pad from which this movement began in earnest. This report is best known for drawing attention to the scope of er-rors in health care; for the conclusion that most errors are related to faulty systems, processes, and conditions that allow error rather than to individual recklessness; and for the recommendation to de-sign healthcare systems at all levels to make it more difficult to make errors. Subsequent reports followed focusing on quality through healthcare redesign and health professions education redesign (IOM, 2001, 2003).With the roles of nurses in the healthcare system expected to continue to expand in the future, the focus is placed on raising the educational levels and competencies of nurses and fostering interdisci-plinary collaboration to increase access, safety, and quality of patient care. For example, the latest IOM report, The Future of Nursing: Leading Change, Advancing Health (2011), specifically calls for inter-disciplinary education, decreasing barriers to nursesÕ scope of prac-tice, and increasing the educational levels of nurses. The Robert Wood Johnson Foundation sponsored the Quality and Safety Education for Nurses (QSEN) initiative with the overall goal of Òpreparing future KEY OUTCOME 1-1Example of Domain 1 subcompetency for entry-level professional nursing education.1.1c Understand the historical foundation of nursing as the relationship developed between the individual and the nurse (p. 26).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education.https://www.aacnnursing .org/Portals/42/AcademicNursing/pdf /Essentials-2021.pdfCHAPTER 1 A History of Health Care and Nursing44
nurses who will have the knowledge, skills and attitudes (KSAs) neces-sary to continuously improve the quality and safety of the healthcare systems within which they workÓ (QSEN, 2018). The focus of QSEN is to develop the competencies of future nursing graduates in six key areas: patient-centered care, evidence-based practice, quality improve-ment, teamwork and collaboration, safety, and informatics.In 2006, the Massachusetts Department of Higher Education (MDHE) and the Massachusetts Organization of Nurse Execu-tives convened a working session of stakeholders titled Creativity and Connections: Building the Framework for the Future of Nurs-ing Education and Practice. From this beginning, the Nurse of the Future: Nursing Core Competencies (MDHE, 2010) was developed in response to the goals of creating a seamless progression through all levels of nursing education and development of consensus on the minimum competency expectations for all nurses upon completion of prelicensure nursing education. In 2016, the Nurse of the Future: Nursing Core Competencies was revised to ensure that the competen-cies reflect the changes that have occurred in health care and nursing practice since the previous edition (MDHE, 2016). This movement to facilitate creation of a core set of entry-level nursing competencies and seamless transition in nursing education is not singular and re-flects the current focus in the profession to increase the access, safety, and quality of health care.U.S. healthcare system reform continues to be the topic of politi-cal debate, with the primary focus on federal coverage, access, and control of healthcare costs. Healthcare organizations in a managed care environment see economic and quality outcome benefits of car-ing for patients and managing their care over a continuum of settings and needs. Patients are followed more closely within the system, dur-ing both illness and wellness. Hospital stays are shorter, and more healthcare services are provided in outpatient facilities and through community-based settings.The Patient Protection and Affordable Care Act (PPACA) was signed into law on March 23, 2010, and was upheld as constitutional by the U.S. Supreme Court on June 28, 2012. The purpose of the PPACA is to provide affordable health care for all Americans, and overall, access to health care increased under the PPACA. The law included provisions for preventive care, such as cancer screenings and flu shots without cost sharing, and protections for consumers that included ending preexisting exclusions for children, ending lifetime limits, and preventing companies from arbitrarily dropping coverage (Shi & Singh, 2019). It was predicted that this legislation would have results through 2029, and its implementation would increase insur-ance coverage to 32 million additional uninsured people. In December 2017, a tax bill was passed with an effective date of 2019 that repeals the individual insurance mandate, one of the key elements of the KEY COMPETENCY 1-1Examples of applicable Nurse of the Future: Nursing Core CompetenciesProfessionalism:Knowledge (K8a) Understands the respon-sibilities inherent in being a member of the nursing professionSkills (S8a) Understands the history and philosophy of the nursing professionAttitudes/Behaviors (A8a) Recognizes the need for personal and professional behaviors that promote the profession of nursingMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi/documents /NOFRNCompetencies_updated_March2016 .pdfKEY OUTCOME 1-2Example of Domain 9 sub-competency for entry-level professional nursing education.9.3a Engage in advocacy that promotes the best interest of the individual, community, and profession (p. 53).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing .org/Portals/42/AcademicNursing/pdf /Essentials-2021.pdfThe New Century45
PPACA, but leaves most of the other components of what has become known as Obamacare intact (Qiu, 2017).As advocates for the public and in response to presidential cam-paign promises to repeal the PPACA, in December 2016, ANA deliv-ered a letter to then President-elect Trump outlining ANAÕs Principles for Health System Transformation. The principles outline system requirements, including that the system must (1) ensure universal access to a standard package of essential healthcare services for all citizens and residents; (2) optimize primary, community-based, and preventive services while supporting the cost-effective use of innova-tive, technology-driven, acute, hospital-based services; (3) encourage mechanisms to stimulate the economical use of healthcare services while supporting those who do not have the means to share costs; and (4) ensure a sufficient supply of a skilled workforce dedicated to pro-viding high-quality healthcare services (ANA, 2016).Across the globe, during the COVID-19 pandemic, nurses again answered the call to advocate for and serve their communities during a time of crisis. Nurses continued to care for patients during times when personal protective equipment was scarce and had to be reused beyond manufacturersÕ recommendations. Nurses continued to care for patients when staffing was far below recommendations due to high patient volume and acuity and due to colleagues being in quar-antine or out sick themselves. Nurses continued to care for patients when they were emotionally and physically exhausted. But from these stories of sacrifice, nurses saw the media and the public rally around the profession and begin to express understanding related to the im-portance of nurses in the healthcare system. The public began to show appreciation for nursing and other healthcare professionals by identi-fying them as heroes. The media, recognizing the enormous problems in the healthcare system and personal sacrifices of so many healthcare professionals during the pandemic drew attention to the issues and became advocates for the profession of nursing. The long-term out-comes of the pandemic and the professionÕs response to the resultant healthcare crisis remain to be seen.International Council of NursesA review of nursing history would not be complete without some dis-cussion of the contributions of the International Council of Nurses (ICN). The ICN was founded in 1899 by women whose names are familiar to the student of nursing historyÑsuch names as Ethel Fenwick of Great Britain, Lavinia Dock of the United States, Mary Agnes Snively of Canada, and Agnes Karll of GermanyÑwho believed in the link between womenÕs rights and professional nursing. They advocated for the creation of national nursing organizations that would allow women to self-govern the profession, and these early leaders from the KEY OUTCOME 1-3Example of Domain 9 sub-competency for entry-level professional nursing education.9.4a Advocate for policies that promote health and prevent harm (p. 54).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing .org/Portals/42/AcademicNursing/pdf /Essentials-2021.pdfCHAPTER 1 A History of Health Care and Nursing46
United Kingdom, Canada, the United States, Germany, the Nether-lands, and Scandinavia banded together in the ICN to encourage one another as they continued to build stronger national associations in their respective nations (Brush & Lynaugh, 1999).World Wars I and II presented threats to the organization, but the ICN emerged with greater participation from nurses in nations that had not previously participated in the organization. New members af-ter World War I included China, Palestine, Brazil, and the Philippines. After World War II, there was again an influx of new membership that included nations from Africa, Asia, and South America. With an increasingly diverse membership, the ICN implemented a more global agenda. During the time of the Cold War when Russia, China, and na-tions in Eastern Europe did not participate, the ICN still defined the work of nurses worldwide and claimed the right to speak for nursing. During the decades that followed, the ICN forged closer links with the World Health Organization, added to its agenda the delivery of primary health care to people around the world, and actively sup-ported the rights of nurses to fair employment and freedom from ex-ploitation (Brush & Lynaugh, 1999).Currently located in Geneva, Switzerland, the ICN has grown into a federation of more than 130 national nurse associations, rep-resenting the more than 16 million nurses worldwide. ICN is the worldÕs first and widest reaching international organization for health professionals, working to ensure high-quality nursing care for all, sound health policies globally, the advancement of nursing knowl-edge, and the presence worldwide of a respected nursing profession and a competent and satisfied nursing workforce (ICN, n.d.).ConclusionContemplating the progression of nursing as a profession, it becomes evident from the preceding pages that similar issues, barriers, chal-lenges, and opportunities were simultaneously present in locations around the globe. In each circumstance, nursing leaders arose to initiate change; whether related to nurse registration, standards for nursing education, or safe work environments, their ultimate goal was the provision of high-quality patient care. The history of professional nursing began with efforts to reach that goal, and we continue in this quest as our nursing organizations endeavor to develop and revise accreditation standards for pro-grams of nursing, examine practice competencies, and review criteria for licensure.Consensus regarding basic education and the entry level of registered nurses has not occurred in the United States, although progress has been made in neighboring Canada. Changes in the advanced KEY COMPETENCY 1-2Examples of applicable Nurse of the Future: Nurs-ing Core Competencies:Leadership:Knowledge (K8) Under-stands how healthcare issues are identiÞed, how healthcare policy is both developed and changedSkills (S8) Participates as a nursing professional in po-litical processes and grass-roots legislative efforts to inßuence healthcare policyAttitudes/Behaviors (A8) Recognizes how the healthcare process can be inßuenced through the efforts of nurses and other healthcare professionals, as well as lay and special advocacy groupsMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi/documents /NOFRNCompetencies_updated_March2016 .pdfCRITICAL THINKING QUESTION✶What do you think would be the response of such historical nursing leaders as Florence Nightingale, Lillian Wald, and Mary Breck-inridge if they could see what the profession of nursing looks like today?✶Conclusion47
practice role continue to challenge the nurse education and healthcare systems around the world as the primary healthcare needs of popula-tions compete with acute care for scarce resources. A global commu-nity demands that nurses remain committed to cultural sensitivity in care delivery. The history of health care and nursing provides ample examples of the wisdom of our forebears in the advocacy of nursing in challenging settings in an unknown future. By considering the les-sons of our past, as well as the experiences during the unprecedented time of the COVID-19 pandemic, the nursing profession is posi-tioned to lead the way in the provision of a full range of high-quality, cost-effective services required to care for patients in this century.Classroom Activity 1-1There are many theories about NightingaleÕs chronic illness, which caused her to be an in-valid for most of her adult life. Many people have interpreted this as hypochondriacal, something of a melodrama of the Victorian times. Nightingale was rich and could take to her bed. She became ill during the Crimean War in May 1855 and was diagnosed with a severe case of Crimean fever. Today Crimean fever is recognized as Mediterranean fever and is categorized as brucellosis. She developed spondylitis, or inflammation of the spine. For the next 34 years, she managed to continue her writing and advocacy, often predicting her imminent death. Others have claimed that Nightingale suffered from bipolar disorder, causing her to experience long periods of de-pression alternating with remarkable bursts of productivity. Read about the various theories of her chronic disabling condition and reflect on your own conclusions about her mysteri-ous illness. With supporting evidence, what are your conclusions about NightingaleÕs health condition?Data from Dossey, B. (2000). Florence Nightingale: Mys-tic, visionary, healer. Lippincott Williams & Wilkins; Aus-tralian Nursing Federation. (2004). Nightingale suffered bipolar disorder. Australian Nursing Journal, 12(2), 33.Classroom Activity 1-2Create a rŽsumŽ or curriculum vitae based on what you know about the life and work of Florence Nightingale.Check out NightingaleÕs curriculum vitae at www.countryjoe.com/nightingale/cv.htmReferencesAbel, E. K. (1997). Take the cure to the poor: PatientsÕ responses to New York CityÕs tuberculosis program, 1894Ð1918. American Journal of Public Health, 87, 11.American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Essentials-2021.pdfCHAPTER 1 A History of Health Care and Nursing48
American Nurses Association. (1965). Educational preparation for nurse practitioners and assistants to nurses: A position paper. Author.American Nurses Association. (1991). NursingÕs agenda for health care reform: Executive summary. Author.American Nurses Association. (2016). ANAÕs principles for health system transformation 2016. http://www.nursingworld.org/healthcarereformAndrews, G. (2003). NightingaleÕs geography. Nursing Inquiry, 10(4), 270Ð274.Attewell, A. (1996). Florence NightingaleÕs health-at-home visitors. Health Visitor, 6.9(10), 406.Australian Bureau of Statistics. (1985). Year book Australia, 1985. http://www.abs.gov.au/ausstats/abs@ .nsf/featurearticlesbytitle/911B5AF72F818795CA2569DE0024ED5A?OpenDocumentAustralian Government Department of Veterans Affairs. (n.d.). Sharing AustraliaÕs military and service history through the experiences of our veterans. https://anzacportal.dva.gov.au/wars-and-missions /ww1/military-organisation/australian-imperial-force/australian-army-nursing-serviceAustralian Nursing and Midwifery Accreditation Council. (2016). ANMAC: About. https://www.anmac .org.au/about-anmac/aboutAustralian Nursing and Midwifery Federation. (2015). About the ANMF. http://anmf.org.au/pages /about-the-anmfAustralian Nursing and Midwifery Federation (SA Branch). (2012). Our history. https://www.anmfvic.asn .au/about-us/historyAustralian Nursing Federation. (2004). Nightingale suffered bipolar disorder. Australian Nursing Journal, 12(2), 33.Australian War Memorial. (n.d.). Great war nurses. https://www.awm.gov.au/visit/exhibitions/nurses/ww1Barker, E. R. (1989). Care givers as casualties. Western Journal of Nursing Research, 11(5), 628Ð631.Biedermann, N., Usher, K., Williams, A., & Hayes, B. (2001). The wartime experience of Australian Army nurses in Vietnam, 1967Ð1971. Journal of Advanced Nursing, 35(4), 543Ð549.Boorstin, D. J. (1985). The discoverers: A history of manÕs search to know his world and himself. Vintage.Brainard, A. M. (1922). The evolution of public health nursing. Saunders.Brockett, L. P., & Vaughan, M. C. (1867). WomenÕs work in the Civil War: A record of heroism: Patriotism and patience. Seigler McCurdy.Brooke, E. (1997). Medicine women: A pictorial history of women healers. Quest Books.Brown, E. L. (1936). Nursing as a profession. Russell Sage Foundation.Brown, E. L. (1948). Nursing for the future. Russell Sage Foundation.Brown, P. (1988). Florence Nightingale. Exley.Brush, B. L., & Lynaugh, J. E. (1999). About this history. In B. L. Brush & J. E. Lynaugh (Eds.), Nurses of all nations: A history of the International Council of Nurses, 1899Ð1999 (pp. xiÐxvii). Lippincott Williams & Wilkins.Buhler-Wilkerson, K. (1985). Public health nursing: In sickness or in health? American Journal of Public Health, 75, 1155Ð1156.Bullough, V. L., & Bullough, B. (1978). The care of the sick: The emergence of modern nursing. Prodist.Calabria, M. D. (1996). Florence Nightingale in Egypt and Greece: Her diary and visions. State University of New York Press.Canadian Association of Schools of Nursing. (n.d.). CASN/ACESI mission. http://www.casn.ca/about-casn /casnacesi-mission/Canadian Museum of History. (n.d.). Canadian nursing history collection: A brief history of nursing in Canada from establishment of New France to present. http://www.historymuseum.ca/cmc/exhibitions /tresors/nursing/nchis01e.shtmlCanadian Nurses Association. (n.d.). History. https://cna-aiic.ca/en/about-us/historyCanadian Nurses Foundation. (2014). Our history. https://cnf-fiic.ca/who-we-are/our-stories/our-history/Carnegie, M. E. (1991). The path we tread: Blades in nursing 1854Ð1990 (2nd ed.). National League for Nursing Press.References49
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McGann, S., Crowther, A., & Dougall, R. (2009). A history of the Royal College of Nursing 1916Ð1990: A voice for nurses. Manchester University Press.Montag, M. L. (1959). Community college education for nursing: An experiment in technical education for nursing. McGraw-Hill.Monteiro, L. A. (1985). Florence Nightingale on public health nursing. American Journal of Public Health, 75(2), 181Ð185.Mosley, M. O. P. (1996). Satisfied to carry the bag: Three black community health nursesÕ contribution to health care reform, 1900Ð1937. Nursing History Review, 4, 65Ð82.National Nursing Assessment Services (2021). RN, RPN and LPN requirements in Canada. https://www .nnas.ca/nursing-requirements-in-canada/New South Wales Nurses and MidwivesÕ Association. (2014). History. http://www.nswnma.asn.au /about-us/history/Nightingale, F. (1860). Notes on nursing: What it is and what it is not. Harrison.Nightingale, F. (1893). Sick-nursing and health-nursing. In B. Burdett-Coutts (Ed.), WomenÕs mission (pp. 184Ð205). Sampson, Law, Marston.Nightingale, F. (1979). Cassandra. In M. Stark (Ed.), Florence NightingaleÕs Cassandra. Feminist Press.Nursing and Midwifery Board of Australia. (n.d.). State and territory nursing and midwifery board members. https://www.nursingmidwiferyboard.gov.au/about/state-and-territory-nursing-and-midwifery -board-members.aspxNutting, M. A., & Dock, L. L. (1907). A history of nursing: The evolution of nursing systems from the earliest times to the foundation of the first English and American training schools for nurses. G. P. PutnamÕs Sons.Ontario NursesÕ Association. (n.d.). Our history and milestones. https://www.ona.org/about-ona/our-vision-mission-and-history/Palmer, I. S. (1977). Florence Nightingale: Reformer, reactionary, researcher. Nursing Research, 26(2), 13Ð18.Palmer, I. S. (1982). Through a glass darkly: From Nightingale to now. American Association of Colleges of Nursing.Qiu, L. (2017, December 29). Trump falsely claims to have Òrepealed Obamacare.Ó New York Times. https://www.nytimes.com/2017/12/29/us/politics/fact-check-trump-interview.htmlQuality and Safety Education for Nurses. (2018). Quality and safety competencies. https://qsen.org /competencies/pre-licensure-ksas/Rathbone, W. (1890). A history of nursing in the homes of the poor. Introduction by Florence Nightingale. Macmillan.Registered NursesÕ Association of Ontario. (n.d.). About RNAO. http://rnao.ca/aboutRichardson, B. I. W. (1887). The health of nations: A review of the works of Edwin Chadwick (Vol. 2). Longmans, Green.Roberts, M. (1954). American nursing: History and interpretation. Macmillan.Robinson, V. (1946). White caps: The story of nursing. Lippincott.Rosen, G. (1958). A history of public health. M. D. Publications.Royal College of Nursing. (n.d.). Our history. https://www.rcn.org.uk/about-us/our-historySabin, L. (1998). Struggles and triumphs: The story of Mississippi nurses 1800Ð1950. Mississippi Hospital Association Health, Research and Educational Foundation.Sanger, M. (1928). Motherhood in bondage. BrentanoÕs.Seymer, L. (1954). Selected writings of Florence Nightingale. Macmillan.Shi, L., & Singh, D. A. (2019). Delivering health care in America: A systems approach (7th ed.). Jones & Bartlett Learning.Shryock, R. H. (1959). The history of nursing: An interpretation of the social and medical factors involved. Saunders.Sitzman, K., & Judd, D. (2014a). Nursing in the American colonies from the 1600s to the 1700s: The influence of past ideas, traditions, and trends. In D. Judd & K. Sitzman (Eds.), A history of American nursing: Trends and eras (2nd ed., pp. 49Ð62). Jones & Bartlett Learning.References51
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Although the beginning of nursing theory development can be traced to Florence Nightingale, it was not until the second half of the 1900s that nursing theory caught the attention of nursing as a discipline. During the decades of the 1960s and 1970s, theory development was a major topic of discussion and publication. During the 1970s, much of the discussion was related to the development of one global theory for nursing. However, in the 1980s, attention turned from the devel-opment of a global theory for nursing as scholars began to recognize multiple approaches to theory development in nursing.Because of the plurality in nursing theory, this information must be organized to be meaningful for practice, research, and further knowledge development. The goal of this chapter is to present an or-ganized and practical overview of the major concepts, models, philos-ophies, and theories that are essential in professional nursing practice.Key Terms and Concepts ÈAssumptions ÈConcept ÈConceptual model ÈEnvironment ÈHealth ÈMetaparadigm ÈNursing ÈNursing process ÈPerson ÈPhilosophies ÈPropositions ÈTheory After completing this chapter, the student should be able to:1. Identify the four metaparadigm concepts of nursing.2. Explain several theoretical works in nursing.3. Discuss components of several theoreti-cal works in nursing in the context of the nursing process.4. Describe several nonnursing theories im-portant to the discipline of nursing.5. Begin the process of identifying theoreti-cal frameworks of nursing that are consis-tent with a personal belief system.Learning Objectives1 Note: Excerpts from Masters, K. (2015). Nursing theories: A framework for profes-sional practice (2nd ed.). Jones & Bartlett Learning appear in this chapter.Frameworks for Professional Nursing Practice1Kathleen MastersCHAPTER 2© Nuu Jeed/Shutterstock53
It can be helpful to define some terms that might be unfamiliar. A concept is a term or label that describes a phenomenon (Meleis, 2004). The phenomenon described by a concept can be either empiri-cal or abstract. An empirical concept is one that can be either ob-served or experienced through the senses. An abstract concept is one that is not observable, such as hope or caring (Hickman, 2002).A conceptual model is defined as a set of concepts and statements that integrates the concepts into a meaningful configuration (Lippitt, 1973; as cited in Fawcett, 1994). Propositions are statements that describe relationships among events, situations, or actions (Meleis, 2004). Assumptions also describe concepts or connect two concepts and represent values, beliefs, or goals. When assumptions are chal-lenged, they become propositions (Meleis, 2004). Conceptual models are composed of abstract and general concepts and propositions that provide a frame of reference for members of a discipline. This frame of reference determines how the world is viewed by members of a dis-cipline and guides the members as they propose questions and make observations relevant to the discipline (Fawcett, 1994).A theory Òis an organized, coherent, and systematic articulation of a set of statements related to significant questions in a discipline that are communicated in a meaningful wholeÓ (Meleis, 2007, p. 37). The primary distinction between a conceptual model and a theory is the level of abstraction and specificity. A conceptual model is a highly abstract system of global concepts and linking statements. A theory, in contrast, deals with one or more specific, concrete concepts and propositions (Fawcett, 1994).A metaparadigm is the most global perspective of a discipline and Òacts as an encapsulating unit, or framework, within which the more restricted . . . structures developÓ (Eckberg & Hill, 1979, p. 927). Each discipline singles out phenomena of interest that it will deal with in a unique manner. The concepts and propositions that identify and interrelate these phenomena are even more abstract than those in the conceptual models. These are the concepts that comprise the metapar-adigm of the discipline (Fawcett, 1994).The conceptual models and theories of nursing represent various paradigms derived from the metaparadigm of the discipline of nurs-ing. Therefore, although each of the conceptual models might link and define the four metaparadigm concepts differently, the four metapara-digm concepts are present in each of the models.The central concepts of the discipline of nursing are person, environment, health, and nursing. These four concepts of the metapar-adigm of nursing are more specifically Òthe person receiving the nursing, the environment within which the person exits, the healthÐillness continuum within which the person falls at the time of the interaction with the nurse, and, finally, nursing actions themselvesÓ (Flaskerud & Holloran, 1980, cited in Fawcett, 1994, p. 5).KEY OUTCOME 2-1Example of Domain 1 sub-competency for entry-level professional nursing education.1.1d Articulate nursingÕs distinct perspective to practice (p. 27).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing .org/Portals/42/AcademicNursing/pdf /Essentials-2021.pdfCHAPTER 2 Frameworks for Professional Nursing Practice54
Because concepts are so abstract at the metaparadigm level, many conceptual models have been developed from the metaparadigm of nursing. Subsequently, multiple theories have been derived from conceptual models in an effort to describe, explain, interpret, and predict the experiences, observations, and relationships observed in nursing practice.Overview of Selected Nursing TheoriesTo apply nursing theory in practice, the nurse must have some knowledge of the theoretical works of the nursing profession. This chapter is not intended to provide an in-depth analysis of each of the theoretical works in nursing but rather to provide an introductory overview of selected theoretical works to give you a launching point for further reflection and study as you begin your journey into professional nursing practice.Theoretical works in nursing are generally categorized as either philosophies, conceptual models or grand theories, middle-range theories, or practice theories (which may also be referred to as situation-specific theories) depending on the level of abstraction. We begin with the most abstract of these theoretical works, the philoso-phies of nursing.Selected Philosophies of NursingPhilosophies set forth the general meaning of nursing and nursing phenomena through reasoning and the logical presentation of ideas. Philosophies are broad and address general ideas about nursing. Because of their breadth, nursing philosophies contribute to the dis-cipline by providing direction, clarifying values, and forming a foun-dation for theory development (Alligood, 2006).NightingaleÕs Environmental TheoryNightingaleÕs philosophy includes the four metaparadigm concepts of nursing (Table 2-1), but the focus is primarily on the patient and the environment, with the nurse manipulating the environment to enhance patient recovery. Nursing interventions using NightingaleÕs philosophy are centered on the 13 canons, which follow (Nightingale, 1860/1969):¥ Ventilation and warming: The interventions subsumed in this canon include keeping the patient and the patientÕs room warm and keeping the patientÕs room well ventilated and free of odors. Specific instructions included Òkeep the air within as pure as the air withoutÓ (Nightingale, 1860/1969, p. 10).CRITICAL THINKING QUESTION✶What are the specific competencies for nurses in relation to theoretical knowledge?✶Overview of Selected Nursing Theories55
¥ Health of houses: This canon includes the five essentials of pure air, pure water, efficient drainage, cleanliness, and light.¥ Petty management: Continuity of care for the patient when the nurse is absent is the essence of this canon.¥ Noise: Instructions include the avoidance of sudden noises that startle or awaken patients and keeping noise in general to a minimum.¥ Variety: This canon refers to an attempt at variety in the patientÕs room to avoid boredom and depression.¥ Taking food: Interventions include the documentation of the amount of food and liquids that the patient ingests.¥ What food? Instructions include trying to include patient food preferences.¥ Bed and bedding: The interventions in this canon include comfort measures related to keeping the bed dry and wrinkle free.¥ Light: The instructions contained in this canon relate to adequate light in the patientÕs room.¥ Cleanliness of rooms and walls: This canon focuses on keeping the environment clean.¥ Personal cleanliness: This canon includes such measures as keeping the patient clean and dry.¥ Chattering hopes and advices: Instructions in this canon include the avoidance of talking without reason or giving advice that is without fact.¥ Observation of the sick: This canon includes instructions related to making observations and documenting observations.The 13 canons are central to NightingaleÕs theory but are not all inclusive. Nightingale believed that nursing was a calling and that the recipients of nursing care were holistic individuals with a spiritual dimension; thus, the nurse was expected to care for the spiritual needs of the patients in spiritual distress. Nightingale also believed that nurses should be involved in health promotion and health teaching with the sick and with those who were well (Bolton, 2006).TABLE 2-1 Metaparadigm Concepts as DeÞned in NightingaleÕs ModelPersonRecipient of nursing care.EnvironmentExternal (temperature, bedding, ventilation) and internal (food, water, and medications).HealthHealth is Ònot only to be well, but to be able to use well every power we have to useÓ (Nightingale, 1860/1969, p. 24).NursingAlter or manage the environment to implement the natural laws of health.CHAPTER 2 Frameworks for Professional Nursing Practice56
The nursing process as it is now understood did not exist during the lifetime of Nightingale; however, an overview of the environmen-tal theory can be illustrated in the context of the nursing process. See Figure 2-1.Although NightingaleÕs theory was developed long ago in re-sponse to a need for environmental reform, the nursing principles are still relevant today. Even as some of NightingaleÕs rationales have been modified or disproved by advances in medicine and science, many of the concepts in her theory not only have endured but also have been used to provide general guidelines for nurses for more than 150 years (Pfettscher, 2006).Virginia Henderson: DeÞnition of Nursing and 14 Components of Basic Nursing CareHenderson made such significant contributions to the discipline of nursing during her 60-plus-year career as a nurse, teacher, author, and researcher that some refer to her as the Florence Nightingale of the 20th century (Tomey, 2006). She is perhaps best known for her definition of nursing, which was first published in 1955 (Harmer & Henderson, 1955) and then published in 1966 with minor revisions. According to Henderson (1966), the role of the nurse involves assist-ing the patient to perform activities that contribute to health, recov-ery, or a peaceful death, which the patient would perform without assistance if the patient possessed Òthe necessary strength, will, or knowledgeÓ and to do so in a way that helps the patient gain indepen-dence rather than remain dependent on the nurse (p. 15). In her work, Henderson emphasized the art of nursing as well as empathetic un-derstanding, stating that the nurse must Òget inside the skin of each of her patients in order to know what he needsÓ (Henderson, 1964, p. 63). ¥ Questioning about patient preferences¥ Observation focused on effects of environment on the patientAssessment andplanningEvaluationImplementation¥ Manipulation of environmental factors¥ Documentation of observed effects of changes in environmental factors on patientÕs healthFigure 2-1 The nursing process and NightingaleÕs environmental model of nursing.Overview of Selected Nursing Theories57
She believed that Òthe beauty of medicine and nursing is the combina-tion of your heart, your head and your hands and where you separate them, you diminish themÓ (McBride, 1997).Henderson identified 14 basic needs on which nursing care is based. These 14 needs are also referred to as the 14 components of basic nursing care. These needs include the following:¥ Breathe normally.¥ Eat and drink adequately.¥ Eliminate bodily wastes.¥ Move and maintain desirable postures.¥ Sleep and rest.¥ Select suitable clothes; dress and undress.¥ Maintain body temperature within normal range by adjusting clothing and modifying the environment.¥ Keep the body clean and well groomed and protect the integument.¥ Avoid dangers in the environment and avoid injuring others.¥ Communicate with others in expressing emotions, needs, fears, or opinions.¥ Worship according to oneÕs faith.¥ Work in such a way that there is a sense of accomplishment.¥ Play or participate in various forms of recreation.¥ Learn, discover, or satisfy the curiosity that leads to normal development and health and use the available health facilities (Henderson, 1966, 1991).Although Henderson did not consider her work a theory of nursing and did not explicitly state assumptions or define each of the domains of nursing, her work includes the metaparadigm concepts of nursing (Table 2-2) (Furukawa & Howe, 2002). In recent years many have TABLE 2-2 Metaparadigm Concepts as DeÞned in HendersonÕs Philosophy and Art of NursingPersonRecipient of nursing care who is composed of biological, psychological, so-ciological, and spiritual components.EnvironmentExternal environment (temperature, dangers in environment); some discus-sion of impact of community on the individual and family.HealthBased upon the patientÕs ability to function independently (as outlined in 14 components of basic nursing care).NursingAssist the person, sick or well, in performance of activities (14 components of basic nursing care) and help the person gain independence as rapidly as possible (Henderson, 1966, p. 15).CHAPTER 2 Frameworks for Professional Nursing Practice58
begun to refer to the 14 components of basic nursing care as Virginia HendersonÕs need theory (Ahtisham & Jacoline, 2015). Figure 2-2 provides an overview of HendersonÕs 14 components of nursing care in the context of the nursing process.Jean Watson: Philosophy and Science of CaringAccording to WatsonÕs theory (1996), the goal of nursing is to help persons attain a higher level of harmony within the mindÐbodyÐspirit. Attainment of that goal can potentiate healing and health (Table 2-3). This goal is pursued through transpersonal caring guided by carative factors and corresponding caritas processes.WatsonÕs theory for nursing practice is based on 10 carative factors (Watson, 1979). As WatsonÕs work evolved, she renamed these carative factors into what she termed clinical caritas processes (Fawcett, 2005). Caritas means to cherish, to appreciate, and to give ¥ Design a plan to meet identified deficits¥ Includes helping the patient gain independence¥ Patient assessed relative to the 14 basic needs¥ Assist the patient to perform activities to maintain health, recover from illness, or achieve a peaceful death¥ Based upon ability of patient to meet needs without or with decreasing assistance of the nursePlanningEvaluationAssessmentImplementationFigure 2-2 The nursing process and HendersonÕs 14 components of nursing care.TABLE 2-3 Metaparadigm Concepts as DeÞned in WatsonÕs Philosophy and Science of CaringPerson (human)A Òunity of mindÐbodyÐspirit/natureÓ (Watson, 1996, p. 147); embodied spirit (Watson, 1989).Healing space and environmentA nonphysical energetic environment; a vibrational field integral with the person where the nurse is not only in the environment but also Òthe nurse IS the environmentÓ (Watson, 2008, p. 26).Health (healing)Harmony, wholeness, and comfort.NursingReciprocal transpersonal relationship in caring moments guided by cara-tive factors and caritas processes.Overview of Selected Nursing Theories59
special attention. It conveys the concept of love (Watson, 2001). The 10 caritas processes are summarized here:¥ Practice of loving kindness and equanimity for oneself and other¥ Being authentically present and enabling and sustaining the deep belief system and subjective life world of self and the one being cared for¥ Cultivating oneÕs own spiritual practices; going beyond the ego self; deepening of self-awareness¥ Developing and sustaining a helpingÐtrusting, authentic caring relationship¥ Being present to, and supportive of, the expression of positive and negative feelings as a connection with a deeper spirit of oneself and the one being cared for¥ Creatively using oneself and all ways of knowing as part of the car-ing process and engagement in artistry of caringÐhealing practices¥ Engaging in a genuine teachingÐlearning experience within the context of a caring relationship while attending to the whole per-son and subjective meaning; attempting to stay within the otherÕs frame of reference¥ Creating a healing environment at all levels, subtle environment of energy and consciousness whereby wholeness, beauty, comfort, dignity, and peace are potentiated¥ Assisting with basic needs, with an intentional caring consciousness; administering human care essentials, which potentiate alignment of the mindÐbodyÐspirit, wholeness, and unity of being in all aspects of care; attending to both embodied spirit and evolving emergence¥ Opening and attending to spiritual, mysterious, and unknown exis-tential dimensions of life, death, suffering; Òallowing for a miracleÓ Data from Watson, J. (2001). Jean Watson: Theory of human caring. In M. E. Parker (Ed.), Nursing theories and nursing practice (pp. 343Ð354). F. A. DavisWatson (2001) refers to the clinical caritas processes as the ÒcoreÓ of nursing, which is grounded in the philosophy, science, and art of caring. She contrasts the core of nursing with what she terms the Òtrim,Ó a term she uses to refer to the practice setting, procedures, functional tasks, clinical disease focus, technology, and techniques of nursing. The trim, Watson explains, is not expendable, but it cannot be the center of professional nursing practice (Watson, 1997).Regarding the value system that is blended with the 10 carative factors, Watson (1985) states:Human care requires high regard and reverence for a person and human life. . . . There is high value on the subjectiveÐinternal world of the experiencing person and how the person (both patient and nurse) is perceiving and experienc-ing healthÐillness conditions. An emphasis is placed upon helping a person gain more self-knowledge, self-control, and readiness for self-healing. (pp. 34, 35)CHAPTER 2 Frameworks for Professional Nursing Practice60
The carative factors described by Watson provide guidelines for nurseÐpatient interactions; however, the theory does not furnish instructions about what to do to achieve authentic caringÐhealing relationships. WatsonÕs theory is more about being than doing, but it provides a useful framework for the delivery of patient-centered nurs-ing care (Neil & Tomey, 2006).While the nursing process is not explicitly incorporated into WatsonÕs theory, the phases of the process can be identified. Figure 2-3 provides an overview of WatsonÕs theory in the context of the nursing process.Patricia BennerÕs Clinical Wisdom in Nursing PracticeBennerÕs work has focused on the understanding of perceptual acu-ity, clinical judgment, skilled know-how, ethical comportment, and ongoing experiential learning (Brykczynski, 2010). Also important in BennerÕs philosophy is an understanding of ethical comportment. Ac-cording to Day and Benner (2002), good conduct is a product of an individual relationship with the patient that involves engagement in a situation combined with a sense of membership in a profession where professional conduct is socially embedded, lived, and embodied in the practices, ways of being, and responses to clinical situations and where clinical and ethical judgments are inseparable.BennerÕs original domains and competencies of nursing prac-tice were derived inductively from clinical situation interviews and observations of nurses in actual practice. From these interviews and observations, 31 competencies and 7 domains were identified and described. The domains are the helping role, the teaching-coaching ¥ Discussion and establishment of goals¥ Mutual engagement¥ Identification of problems¥ Analysis and diagnosis¥ Caritas process interactions that require intention, will, relationship, and actions¥ Based upon achieving goals¥ Process enhanced through mutual reflectionPlanningEvaluationAssessmentImplementationFigure 2-3 The nursing process and WatsonÕs philosophy and theory of transpersonal caring.Overview of Selected Nursing Theories61
function, the diagnostic and patient monitoring function, effective management of rapidly changing situations, administering and moni-toring therapeutic interventions and regimens, monitoring and ensur-ing the quality of healthcare practices, and organizational work role competencies (Benner, 1984/2001). Along with the identification of the competencies and domains of nursing, Benner identified five stages of skill acquisition based on the Dreyfus model of skill acquisition as applied to nursing along with characteristics of each stage. The stages identified included novice, advanced beginner, competent, proficient, and expert (Benner, 1984/2001).Later, in an extension of her original work, Benner and her col-leagues identified nine domains of critical care nursing. These domains are diagnosing and managing life-sustaining physiologic functions in unstable patients, using skilled know-how to manage a crisis, providing comfort measures for the critically ill, caring for patientsÕ families, pre-venting hazards in a technologic environment, and facing death including end-of-life care and decision making, communicating and negotiating multiple perspectives, monitoring quality and managing breakdown, using the skilled know-how of clinical leadership, and coaching and mentoring others (Benner et al., 1999). In addition, the nine domains of critical care nursing practice are used as broad themes in data interpreta-tion for the identification and description of six aspects of clinical judg-ment and skilled comportment. These six aspects are as follows:¥ Reasoning-in-transition: Practical reasoning in an ongoing clinical situation¥ Skilled know-how: Also known as embodied intelligent perfor-mance; knowing what to do, when to do it, and how to do it¥ Response-based practice: Adapting interventions to meet the changing needs and expectations of patients¥ Agency: OneÕs sense of and ability to act on or influence a situation¥ Perceptual acuity and the skill of involvement: The ability to tune into a situation and hone in on the salient issues by engaging with the problem and the person¥ Links between clinical and ethical reasoning: The understanding that good clinical practice cannot be separated from ethical no-tions of good outcomes for patients and familiesData from Benner, P., Hooper-Kyriakidis, P., & Stannard, D. (1999). Clinical wisdom and interventions in critical care: A thinking-in-action approach. Saunders.Benner identifies and defines the four metaparadigm concepts of nursing in addition to the concepts previously discussed. The concepts of person, environment, health, and nursing as defined by Benner are summarized in Table 2-4. While not specifically addressed by Benner, the nursing process is easily incorporated when using BennerÕs phi-losophy. Figure 2-4 provides an overview of BennerÕs philosophy in the context of the nursing process.CHAPTER 2 Frameworks for Professional Nursing Practice62
Selected Conceptual Models and Grand Theories of NursingConceptual models provide a comprehensive view and guide for nurs-ing practice. They are organizing frameworks that guide the reasoning process in professional nursing practice (Alligood, 2006). At the level of the conceptual model, each metaparadigm concept is defined and described in a manner unique to the model, with the model providing an alternative way to view the concepts considered important to the discipline (Fawcett, 2005).Martha RogersÕs Science of Unitary Human BeingsAccording to Rogers (1994), nursing is a learned profession that is both a science and an art. The art of nursing is the creative use of the science of nursing for human betterment.RogersÕs theory asserts that human beings are dynamic energy fields that are integrated with environmental energy fields so that the TABLE 2-4 Metaparadigm Concepts as DeÞned in BennerÕs PhilosophyPersonEmbodied person living in the world who is a Òself-interpreting being, that is, the person does not come into the world pre-defined but gets defined in the course of living a lifeÓ (Benner & Wrubel, 1989, p. 41).Environment (situation)A social environment with social definition and meaningfulness.HealthThe human experience of health or wholeness.NursingA caring relationship that includes the care and study of the lived experience of health, illness, and disease.¥ Assessment of patient in context of patient-related domains¥ Nurse and patient jointly plan for care based upon assessment¥ Occurs via domains of nursing practice in the context of six aspects of clinical judgment and skilled comportment¥ Based upon patient outcomes and the interpretation of outcomes in patientÕs unique situationImplementationEvaluationAssessment andplanningFigure 2-4 The nursing process and BennerÕs clinical wisdom in nursing practice.Overview of Selected Nursing Theories63
person and the environment form a single unit. Both human energy fields and environmental fields are open systems, pandimensional in nature and in a constant state of change. Pattern is the identifying characteristic of energy fields (Table 2-5).Rogers identified the principles of helicy, resonancy, and integral-ity to describe the nature of change within human and environmental energy fields. Together, these principles are known as the principle of homeodynamics. The helicy principle describes the unpredictable but continuous, nonlinear evolution of energy fields, as evidenced by a spiral development that is a continuous, nonrepeating, and innovative patterning that reflects the nature of change. Resonancy is depicted as a wave frequency and an energy field pattern evolution from lower to higher frequency wave patterns and is reflective of the continuous variability of the human energy field as it changes. The principle of integrality emphasizes the continuous mutual process of person and environment (Rogers, 1970, 1992).Rogers used two widely recognized toys to illustrate her theory and constant interaction of the humanÐenvironment process. The Slinky illustrates the openness, rhythm, motion, balance, and expand-ing nature of the human life process, which is continuously evolving (Rogers, 1970). The kaleidoscope illustrates the changing patterns that appear to be infinitely different (Johnson & Webber, 2010).Rogers (1970) identified five assumptions that support and con-nect the concepts in her conceptual model:¥ Man is a unified whole possessing his own integrity and manifest-ing characteristics more than and different from the sum of his parts (p. 47).¥ Man and environment are continuously exchanging matter and energy with one another (p. 54).TABLE 2-5 Metaparadigm Concepts as DeÞned in RogersÕs TheoryPersonAn irreducible, irreversible, pandimensional, negentropic energy field identi-fied by pattern; a unitary human being develops through three principles: helicy, resonancy, and integrality (Rogers, 1992).EnvironmentAn irreducible, pandimensional, negentropic energy field, identified by pat-tern and manifesting characteristics different from those of the parts and encompassing all that is other than any given human field (Rogers, 1992).HealthHealth and illness as part of a continuum (Rogers, 1970).NursingSeeks to promote symphonic interaction between human and environmen-tal fields, to strengthen the integrity of the human field, and to direct and redirect patterning of the human and environmental fields for realization of maximum health potential (Rogers, 1970).CHAPTER 2 Frameworks for Professional Nursing Practice64
¥ The life process evolves irreversibly and unidirectionally along the spaceÐtime continuum (p. 59).¥ Pattern and organization identify man and reflect his innovative wholeness (p. 65).¥ Man is characterized by the capacity for abstraction and imagery, language and thought, sensation, and emotion (p. 73).RogersÕs model is an abstract system of ideas but is applicable to practice, with nursing care focused on pattern appraisal and pattern-ing activities. Pattern appraisal involves a comprehensive assessment of environmental field patterns and human field patterns of communi-cation, exchange, rhythms, dissonance, and harmony through the use of cognitive input, sensory input, intuition, and language. Patterning activities can include such interventions as meditation, imagery, journ-aling, or modifying surroundings. Evaluation is ongoing and requires a repetition of the appraisal process (Gunther, 2006). This process of pattern appraisal continues as long as the nurseÐpatient relationship continues (Gunther, 2010). An overview of RogersÕs science of unitary human beings is presented in the context of the nursing process in Figure 2-5.Dorothea OremÕs Self-Care DeÞcit Theory of NursingOrem describes her theory as a general theory that is made up of three related theories: the theory of self-care, the theory of self-care deficit, and the theory of nursing systems. The theory of self-care describes why and how people care for themselves. The theory of self-care deficit describes and explains why people can be helped through nursing. The theory of nursing systems describes and explains relationships that must exist and be maintained for nursing to occur. These three theories in relationship constitute OremÕs general theory ¥ Pattern appraisal¥ Consensus regarding pattern appraisal and plan patterning process¥ Mutual patterning of the human- environmental field to promote symphonic rhythms¥ Ongoing and consists of a repetition of the appraisal processPlanningEvaluationAssessmentImplementationFigure 2-5 The nursing process and RogersÕs science of unitary human beings.Overview of Selected Nursing Theories65
of nursing known as the self-care deficit theory of nursing (Berbiglia, 2010; Orem, 1990; Taylor, 2006).Theory of Self-CareThe theory of self-care describes why and how people care for them-selves and suggests that nursing is required in case of inability to perform self-care as a result of limitations. This theory includes the concepts of self-care agency, therapeutic self-care demand, and basic conditioning factors.Self-care agency is an acquired ability of mature and matur-ing persons to know and meet their requirements for deliberate and purposive action to regulate their own human functioning and de-velopment (Orem, 2001). The concept of self-care agency has three dimensions: development, operability, and adequacy. According to Orem (2001), therapeutic self-care demand consists of the summa-tion of care measures necessary to meet all of an individualÕs known self-care requisites. Basic conditioning factors refer to those factors that affect the value of the therapeutic self-care demand or self-care agency of an individual. Ten factors are identified: age, gender, de-velopmental state, health state, pattern of living, healthcare system factors, family system factors, sociocultural factors, availability of re-sources, and external environmental factors (Orem, 2001).Orem identifies three types of self-care requisites that are in-tegrated into the theory of self-care and that provide the basis for self-care. These include universal self-care requisites, developmental self-care requisites, and health deviation self-care requisites.Universal self-care requisites are those found in all human beings and are associated with life processes. These requisites include main-tenance of sufficient intake of air, water, and food as well adequate elimination processes, maintenance of a balance of activity verses rest, and a balance of solitude verses social interaction. Requisites also in-clude prevention in relation to hazards and health promotion (Orem, 1985, pp. 90Ð91).Developmental self-care requisites are related to different stages in the human life cycle and might include such events as attending college, marriage, and retirement. Broadly speaking, the development self-care requisites include the maintenance of conditions that pro-mote the processes of development and the provision of care to either prevent adverse effects of conditions that affect human development or overcome the effects of these conditions (Orem, 1985, p. 96)Health-deviation self-care requisites are related to deviations in structure or function of a human being. The six categories of health-deviation requisites include securing appropriate medical assistance, acknowledging the potential consequences of illness states, perform-ing prescribed treatments, recognizing possible side effects of treat-ment, modification of self-concept to accept oneself in current health CHAPTER 2 Frameworks for Professional Nursing Practice66
condition, and living with the effects of illness and treatment (Orem, 1985, pp. 99Ð100).Theory of Self-Care DeÞcitThe theory of self-care deficit explains that maturing or mature adults deliberately learn and perform actions to direct their survival, quality of life, and well-being; put more simply, it explains why people can be helped through nursing. According to Orem, nurses use five methods to help meet the self-care needs of patients:¥ Acting for or doing for another¥ Guiding and directing¥ Providing physical or psychological support¥ Providing and maintaining an environment that supports personal development¥ Teaching (Johnson & Webber, 2010; Orem, 1995, 2001)Orem designed a version of the nursing process known as the Òpractice methodologyÓ for the self-care framework. The framework includes four operations: diagnostic operations, prescriptive opera-tions, regulatory operations, and control operations (Orem, 2001). These operations are comparable to the phases of the nursing process. Figure 2-6 provides an overview of OremÕs self-care deficit theory and the nursing process.Theory of Nursing SystemsThe theory of nursing systems describes and explains relationships that must exist and be maintained for the product (nursing) to occur ¥ Identification of therapeutic self-care demands¥ Assessment of conditioning factors, self-care agency, self-care requisites, self-care actions result in diagnosis¥ Determine the ideal therapeutic self-care demand for the patient and plan actions to meet self-care demands¥ Regulatory nursing system develops with emphasis on the development of self-care agency¥ Patient outcomes review related to functioning, developmental change, and adaptation to changes in level of self-care¥ Review of regulatory operationsPrescriptiveoperations(planning)Controloperations(evaluation)Diagnosticoperations(assessment)Regulatoryoperations(implementation)Figure 2-6 The nursing process and OremÕs self-care deficit nursing theory.Overview of Selected Nursing Theories67
(Berbiglia, 2010; Taylor, 2006). Three systems can be used to meet the self-requisites of the patient: the wholly compensatory system, the partially compensatory system, and the supportive-educative system.¥ In the wholly compensatory system, the patient is unable to per-form any self-care activities and relies on the nurse to perform care.¥ In the partially compensatory system, both the patient and the nurse participate in the patientÕs self-care activities, with the re-sponsibility for care shifting from the nurse to the patient as the self-care demand changes.¥ In the supportive-educative system, the patient has the ability for self-care but requires assistance from the nurse in decision making, knowledge, or skill acquisition. The nurseÕs role is to promote the patient as a self-care agent.The system selected depends on the nurseÕs assessment of the patientÕs ability to perform self-care activities and self-care demands (Johnson & Webber, 2010; Orem, 1995, 2001). There are eight general propositions for the self-care deficit theory of nursing (although each of the three in-dividual theories also has its own set of propositions) (Meleis, 2004):¥ Human beings have capabilities to provide their own self-care or care for dependents. These capabilities are learned and can be recalled.¥ Self-care abilities are impacted by factors such as age, developmen-tal level, life experiences, and sociocultural background.¥ Self-care deficits ought to balance between self-care demands and self-care capabilities.¥ Self-care is influenced by age, developmental stage, life experience, sociocultural factors, health, and resources.¥ The actions of nurses and the patient impact achievement of thera-peutic self-care.¥ Nurses assess the potential for patients to meet their self-care needs. ¥ Nurses choose processes, technologies, or actions to assist in meet-ing self-care needs.¥ Therapeutic self-care are categorized as wholly compensatory, partly compensatory, and supportive-educative.In addition to these other concepts, the four metaparadigm con-cepts of nursing are identified in OremÕs theory (Table 2-6). OremÕs theory clearly differentiates the focus of nursing and is one of the nursing theories that is most commonly used in practice.Callista RoyÕs Adaptation ModelThe Roy adaptation model presents the person as an adaptive system in constant interaction with the internal and external environments. CHAPTER 2 Frameworks for Professional Nursing Practice68
The main task of the human system is to maintain integrity in the face of environmental stimuli (Phillips, 2006). The goal of nursing is to foster successful adaptation (Table 2-7).According to Roy and Andrews (1999), adaptation refers to Òthe process and outcome whereby thinking and feeling persons, as indi-viduals or in groups, use conscious awareness and choice to create human and environmental integrationÓ (p. 54). Adaptation leads to optimum health and well-being, to quality of life, and to death with dignity (Andrews & Roy, 1991). The adaptation level represents the condition of the life processes. Roy describes three levels: integrated, compensatory, and compromised life processes. An integrated life process can change to a compensatory process, which attempts to re-establish adaptation. If the compensatory processes are not adequate, compromised processes result (Roy, 2009).TABLE 2-6 Metaparadigm Concepts as DeÞned in OremÕs TheoryPerson (patient)A person under the care of a nurse; a total being with universal, developmental needs and capable of self-care.EnvironmentPhysical, chemical, biologic, and social contexts within which human beings exist; environmental components include environmental factors, environmental elements, environmental conditions, and developmental environment (Orem, 1985).HealthÒA state characterized by soundness or wholeness of developed human structures and of bodily and mental functioningÓ (Orem, 1995, p. 101).NursingTherapeutic self-care designed to supplement self-care requisites. Nursing actions fall into one of three categories: wholly compensatory, partly compensatory, or supportiveÐeducative system (Orem, 1985).TABLE 2-7 Metaparadigm Concepts as DeÞned in RoyÕs ModelPersonÒAn adaptive system with cognator and regulator subsystems acting to maintain adaptation in the four adaptive modesÓ (Roy, 2009, p. 12).EnvironmentÒAll conditions, circumstances, and influences surrounding and affecting the development and behavior of persons and groups, with particular consideration of mutuality of person and earth resourcesÓ (Roy, 2009, p. 12).HealthÒA state and process of being and becoming an integrated and whole that reflects person and environment mutualityÓ (Roy, 2009, p. 12).NursingThe goal of nursing is Òto promote adaptation for individuals and groups in the four adaptive modes, thus contributing to health, quality of life, and dying with dignity by assessing behavior and factors that influence adaptive abilities and to enhance environmental factorsÓ (Roy, 2009, p. 12).Overview of Selected Nursing Theories69
The processes for coping in the Roy adaptation model are cat-egorized as Òthe regulator and cognator subsystems as they apply to individuals, and the stabilizer and innovator subsystems as applied to groupsÓ (Roy, 2009, p. 33). A basic type of adaptive process, the regu-lator subsystem responds through neural, chemical, and endocrine coping channels. Stimuli from the internal and external environments act as inputs through the senses to the nervous system, thereby affect-ing the fluid, electrolyte, and acidÐbase balance as well as the endo-crine system. This information is all channeled automatically, with the body producing an automatic, unconscious response to it.The second adaptive process, the cognator subsystem, responds through four cognitive-emotional channels: perceptual and informa-tion processing, learning, judgment, and emotion. Perceptual and in-formation processing includes activities of selective attention, coding, and memory. Learning involves imitation, reinforcement, and insight. Judgment includes problem solving and decision making. Defenses are used to seek relief from anxiety and to make affective appraisal and attachments through the emotions (Roy, 2009).The cognatorÐregulator and stabilizerÐinnovator subsystems func-tion to maintain integrated life processes. These life processesÑwhether integrated, compensatory, or compromisedÑare manifested in behav-iors of the individual or group. Behavior is viewed as an output of the human system and takes the form of either adaptive responses or inef-fective responses. These responses serve as feedback to the system, with the human system using this information to decide whether to increase or decrease its efforts to cope with the stimuli (Roy, 2009).Behaviors can be observed in four categories, or adaptive modes: physiologic-physical mode, self-conceptÐgroup identity mode, role function mode, and interdependence mode. Behavior in the physiologic-physical mode is the manifestation of the physiologic ac-tivities of all cells, tissues, organs, and systems making up the body. The self-conceptÐgroup identity mode includes the components of the physical self, including body sensation and body image, and the personal self, including self-consistency, self-ideal, and moral-ethical- spiritual self. The role function mode focuses on the roles of the per-son in society and the roles within a group, and the interdependence mode is a category of behavior related to interdependent relation-ships. This mode focuses on interactions related to the giving and re-ceiving of love, respect, and value (Roy, 2009).In the Roy adaptation model, three classes of stimuli form the environment: the focal stimulus (internal or external stimulus most immediately in the awareness of the individual or group), contextual stimuli (all other stimuli present in the situation that contribute to the effect of the focal stimulus), and residual stimuli (environmental fac-tors within or outside human systems, the effects of which are unclear in the situation) (Roy, 2009).CHAPTER 2 Frameworks for Professional Nursing Practice70
The propositions of RoyÕs theory include the following:¥ Nursing actions promote a personÕs adaptive responses.¥ Nursing actions can decrease a personÕs ineffective adaptive responses.¥ People interact with the changing environment in an attempt to achieve adaptation and health.¥ Nursing actions enhance the interaction of persons with the environment.¥ Enhanced interactions of persons with the environment promote adaptation (Roy, 2009).The Roy adaptation model is commonly used in nursing practice. To use the model in practice, the nurse follows RoyÕs six-step nursing process, which is as follows (Phillips, 2006):¥ Assessing the behaviors manifested from the four adaptive modes (physiologic-physical mode, self-conceptÐgroup identity mode, role function mode, and interdependence mode)¥ Assessing and categorizing the stimuli for those behaviors¥ Making a nursing diagnosis based on the personÕs adaptive state¥ Setting goals to promote adaptation¥ Implementing interventions aimed at managing stimuli to promote adaptation¥ Evaluating achievement of adaptive goalsData from Phillips, K. D. (2006). Sister Callista Roy: Adaptation model. In A. M. Tomey & M. R. Alligood (Eds.), Nursing theorists and their work (6th ed., pp. 355Ð385). Mosby.Andrews and Roy (1986) point out that by manipulating the stimuli rather than the patient, the nurse enhances Òthe interaction of the person with their environment, thereby promoting healthÓ (p. 51). Roy specifically addresses incorporation of a six-step nursing process stressing that the steps are discussed separated for clarity, but in practice they are ongoing and simultaneous (Roy, 2009, p. 57). An overview of the Roy adaptation model in the context of the nursing process is illustrated in Figure 2-7.Betty NeumanÕs Systems ModelThe Neuman systems model is a wellness model based on general systems theory in which the client system is exposed to stressors from within and without the system. The focus of the model is on the cli-ent system in relationship to stressors. The client system is a compos-ite of interacting variables that include the physiologic variable, the psychological variable, the sociocultural variable, the developmental variable, and the spiritual variable (Neuman, 2002). Stressors are clas-sified as intrapersonal, interpersonal, or extrapersonal depending on their relationship to the client system.Overview of Selected Nursing Theories71
The client system is represented structurally in the model as a series of concentric rings or circles surrounding a basic structure. These flexible concentric circles represent normal lines of defense and lines of resistance that function to preserve client system integrity by acting as protective mechanisms for the basic structure. The basic structure or central core consists of basic survival factors common to the species, innate or genetic features, and strengths and weaknesses of the system. The flexible line of defense forms the outer boundary of the defined client system; it protects the normal line of defense. The normal line of defense represents what the client has become or the usual wellness state. Adjustment of the five client system variables to environmental stressors determines its level of stability. The concentric broken circles surrounding the basic structure are known as lines of resistance. They become activated following invasion of the normal line of defense by environmental stressors (Neuman, 2002). The greater the quality of the client systemÕs health, the greater protection is provided by the various lines of defense (Geib, 2006). In addition to these concepts, the four metaparadigm concepts of nursing are identi-fied in NeumanÕs theory (Table 2-8).Basic assumptions of the Neuman systems model include the fol-lowing (Meleis, 2004; Neuman, 1995):¥ Nursing clients have both unique and universal characteristics and are constantly exchanging energy with the environment.¥ The relationships among client variables influence a clientÕs pro-tective mechanisms and determine the clientÕs response.¥ Clients present a normal range of responses to the environment that represent wellness and stability.¥ Assess behavior in the context of four adaptive modes and categorize stimuli¥ Analysis of data as nursing diagnosis reflecting adaptive state¥ Statement of behavioral outcomes of nursing care that will promote adaptation¥ Interventions chosen to promote adaptation through either changing stimuli or strengthening adaptive processes¥ Nurse uses observation, intuition, measurement and interviewing skills to determine if adaptive goals have been metPlanningEvaluationAssessmentImplementationFigure 2-7 The nursing process and the Roy adaptation model.CHAPTER 2 Frameworks for Professional Nursing Practice72
¥ Stressors attack flexible lines of defense and then normal lines of defense.¥ NursesÕ actions are focused on primary, secondary, and tertiary prevention.The Neuman systems model is health oriented, with an emphasis on prevention as intervention, and has been used in a wide variety of settings. Perhaps one of the greatest attractions to this model is the ease with which it can be used for families, groups, and communi-ties as well as the individual client. The use of the model in practice requires only moderate adaptation of the nursing process with a focus on assessment of stressors and client system perceptions. An overview of the Neuman systems model in the context of the nursing process is illustrated in Figure 2-8.TABLE 2-8 Metaparadigm Concepts as DeÞned in NeumanÕs ModelPerson (client system)A composite of physiologic, psychological, sociocultural, developmental, and spiritual variables in interaction with the internal and external envi-ronment; represented by central structure, lines of defense, and lines of resistance (Neuman, 2002).EnvironmentAll internal and external factors of influences surrounding the client system; three relevant environments identified are the internal environment, the ex-ternal environment, and the created environment (Neuman, 2002, p. 18).HealthA continuum of wellness to illness; equated with optimal system stability (Neuman, 2002, p. 23).NursingPrevention as intervention; concerned with all potential stressors.¥ Variances from wellness are identified and diagnoses are identified and prioritized¥ Goals and interventions are developed in partnership with the client to promote optimal client system stability¥ Implements prevention-as- intervention modalities and working in partnership with the client modifies interventions as necessary based upon client system stabilityNursing goals(planning andImplementation)Nursing diagnosiscategory(assessment)Nursing outcomes(implementation andevaluation)Figure 2-8 The nursing process and the Neuman systems model.Overview of Selected Nursing Theories73
Imogene KingÕs Interacting Systems Framework and Theory of Goal AttainmentKing, in her interacting systems framework, conceptualizes three lev-els of dynamic interacting systems that include personal systems (indi-viduals), interpersonal systems (groups), and social systems (society). Individuals exist within personal systems, and concepts relevant to this system include body image, growth and development, perception, self, space, and time. Interpersonal systems are formed when two or more individuals interact. The concepts important to understand-ing this system include communication, interaction, role, stress, and transaction. Examples of social systems include religious systems, educational systems, and healthcare systems. Concepts important to understanding the social system include authority, decision making, organization, power, and status (King, 1981; Sieloff, 2006).KingÕs theory of goal attainment was derived from her interacting systems framework (Sieloff, 2006) and addresses nursing as a process of human interaction (Norris & Frey, 2006). The theory focuses on the interpersonal system interactions in the nurseÐclient relation-ship (Table 2-9). During the nursing process, the nurse and the client perceive each other, make judgments, and take action that results in reaction. Interaction results, and if perceptual congruence exists, transactions occur (Sieloff, 2006). Outcomes are defined in terms of goals obtained. If the goals are related to patient behaviors, they become the criteria by which the effectiveness of nursing care can be measured (King, 1989).The propositions of KingÕs theory of goal attainment focus on transactions, interactions, and goals. For example, according to TABLE 2-9 Metaparadigm Concepts as DeÞned in KingÕs TheoryPerson (human being)A personal system that interacts with interpersonal and social systems.EnvironmentCan be both external and internal. The external environment is the context Òwithin which human beings grow, develop, and perform daily activitiesÓ (King, 1981, p. 18); the internal environment of hu-man beings transforms energy to enable them to adjust to continuous external environmental changes (King, 1981, p. 5).HealthÒDynamic life experiences of a human being, which implies con-tinuous adjustment to stressors in the internal and external environ-ment through optimum use of oneÕs resources to achieve maximum potential for daily livingÓ (King, 1981, p. 5).NursingA process of human interaction, the goal of nursing is to help pa-tients achieve their goals.CHAPTER 2 Frameworks for Professional Nursing Practice74
King (1981), transactions will occur if there is perceptual accuracy in the nurse-client interaction and if role expectations are congru-ent between the nurse and the client. If the nurse and client make transactions goals will be achieved and growth and development will be enhanced. Furthermore, if goals are attained, satisfactions and effective nursing care will occur. Nurses communicate appropriate information to clients which leads to mutual goal setting and goal attainment.KingÕs theory can be implemented in practice using the nursing process where assessment focuses on the perceptions of the nurse and client, communication of the nurse and client, and interaction of the nurse and client. Planning involves deciding on goals and agreeing on how to attain goals. Implementation focuses on transactions made, and evaluation focuses on goals attained using KingÕs theory (King, 1992). An overview of KingÕs theory in the context of the nursing pro-cess is illustrated in Figure 2-9.JohnsonÕs Behavioral System ModelDorothy JohnsonÕs model for nursing presents the client as a living open system that is a collection of behavioral subsystems that inter-relate to form a behavioral system (Table 2-10). The seven subsystems of behavior proposed by Johnson include achievement, affiliative, ag-gressive, dependence, sexual, eliminative, and ingestive. Motivational drives direct the activities of the subsystems that are constantly chang-ing because of maturation, experience, and learning (Johnson, 1980).The achievement subsystem functions to control or master an aspect of self or environment to achieve a standard. This subsystem ¥ Communication including gathering information, validating perceptions and concerns, and establishing trust¥ Synthesis, interpretation, and analysis of data¥ Mutual goal setting with decisions related to actions to meet goals¥ Assess attainment of goals and if goals are not attained, determine why¥ Reactions to actions lead to interactions between nurse and patient that lead to transactions¥ Transactions reflect shared commitmentDecision making,exploration,agreement(planning)Goal attainment(evaluation)Perception,communication,interaction(assessment)Transaction(implementation)Figure 2-9 The nursing process and the King interacting systems framework and theory of goal attainment.Overview of Selected Nursing Theories75
encompasses intellectual, physical, creative, mechanical, and social skills. The affiliative or attachment subsystem forms the basis for social organization. Its consequences are social inclusion, intimacy, and the formation and maintenance of strong social bonds. The ag-gressive or protective subsystem functions to protect and preserve the system. The dependency subsystem promotes helping or nurturing behaviors.The consequences include approval, recognition, and physical as-sistance. The sexual subsystem has the function of procreation and gratification and includes development of gender role identity and gender role behaviors. The eliminative subsystem addresses Òwhen, how, and under what conditions we eliminate,Ó whereas the ingestive subsystem Òhas to do with when, how, what, how much, and under what conditions we eatÓ (Johnson, 1980, p. 213).The nursing process for the behavioral system model is known as JohnsonÕs nursing diagnostic and treatment process. The components of the process include the determination of the existence of a problem, diagnosis and classification of problems, management of problems, and evaluation of behavioral system balance and stability. When us-ing JohnsonÕs model in practice, the focus of the assessment process is obtaining information to evaluate current behavior in terms of past patterns, determining the effect of the current illness on behavioral patterns, and establishing the maximum level of health. The assess-ment is specifically related to gathering information pertaining to the structure and function of the seven behavioral subsystems as well as the environmental factors that affect the behavioral subsystems (Holaday, 2006). The ultimate goals of nursing using the model are to maintain or restore behavioral system balance (Johnson, 1980). An overview of JohnsonÕs model in the context of the nursing process is illustrated in Figure 2-10.TABLE 2-10 Metaparadigm Concepts as DeÞned in JohnsonÕs ModelPerson (human being)A biopsychosocial being who is a behavioral system with seven sub-systems of behavior.EnvironmentIncludes internal and external environment.HealthEfficient and effective functioning of system; behavioral system bal-ance and stability.NursingAn external regulatory force that acts to preserve the organization and integrity of the patientÕs behavior at an optimal level under those conditions in which the behavior constitutes a threat to physical or social health or in which illness is found (Johnson, 1980, p. 214).CHAPTER 2 Frameworks for Professional Nursing Practice76
Selected Theories and Middle-Range Theories of NursingMiddle-range theory may be derived from a grand theory or a concep-tual model or may originate from practice perspectives. Middle-range theories are narrower in scope than grand theories and include con-cepts that are less abstract and therefore more amenable to testing in research and use in nursing practice.Rosemarie ParseÕs Humanbecoming TheoryParseÕs theory was originally called man-living-health (Parse, 1981). In 1992, Parse changed the name to human becoming and then in 2007 again changed the name to humanbecoming (Mitchell & Bournes, 2010) to coincide with ParseÕs evolution of thought. The humanbecoming the-ory consists of three major themes: meaning, rhythmicity, and transcen-dence (Parse, 1998). Meaning is the linguistic and imagined content of something and the interpretation that one gives to something. Rhythmic-ity is the cadent, paradoxical patterning of the humanÐuniverse mutual process. Transcendence is defined as reaching beyond with possibles or the Òhopes and dreams envisioned in multidimensional experiences pow-ering the originating of transformingÓ (Parse, 1998, p. 29). The three major principles of the humanbecoming theory flow from these themes.The first principle of the humanbecoming theory states, ÒStruc-turing meaning multidimensionally is cocreating reality through the languaging of valuing and imagingÓ (Parse, 1998, p. 35). This principle proposes that persons structure or choose the meaning of their realities and that the choosing occurs at levels that are not always known explic-itly (Mitchell, 2006). This means that one person cannot decide the sig-nificance of something for another person and does not even understand ¥ Behavioral system structure, balance, and stability data collected to assess organization, interaction, and integration of subsystems¥ Goal to restore, maintain, or attain behavioral system balance and stability¥ Nurse compares behavior after treatment to indices of system balance and stabilityImplementationEvaluationAssessment andplanningFigure 2-10 The nursing process and the Johnson behavioral system model.Overview of Selected Nursing Theories77
the meaning of the event unless that person shares the meaning through the expression of his or her views, concerns, and dreams.The second principle states, ÒCocreating rhythmical patterns of relating is living the paradoxical unity of revealingÑconcealing and enablingÑlimiting while connectingÑseparatingÓ (Parse, 1998, p. 42). This principle means that persons create patterns in life, and these patterns tell about personal meanings and values. The patterns of relating that persons create involve complex engagements and disengagements with other persons, ideas, and preferences (Mitchell, 2006). According to Parse (1998), persons change their patterns when they integrate new priorities, ideas, hopes, and dreams.The third principle of the humanbecoming theory states, ÒCotran-scending with the possibles is powering unique ways of originating in the process of transformingÓ (Parse, 1998, p. 46). This principle means that persons are always engaging with and choosing from infi-nite possibilities. The choices reflect the personÕs ways of moving and changing in the process of becoming (Mitchell, 2006).Three processes for practice have been developed from the con-cepts and principles in the humanbecoming theory, including the fol-lowing (Parse, 1998, pp. 69, 70):¥ Illuminating meaning is explicating what was, is, and will be. Ex-plicating is making clear what is appearing now through language.¥ Synchronizing rhythms is dwelling with the pitch, yaw, and roll of the humanÐuniverse process. Dwelling with is immersing with the flow of connectingÐseparating.¥ Mobilizing transcendence is moving beyond the meaning moment with what is not yet. Moving beyond is propelling with envisioned possibles of transforming.In practice, nurses guided by the humanbecoming theory prepare to be truly present (Table 2-11) with others through focused attentive-ness on the moment at hand through immersion (Parse, 1998). An overview of ParseÕs theory in the context of the nursing process is il-lustrated in Figure 2-11.TABLE 2-11 Metaparadigm Concepts as DeÞned in ParseÕs TheoryPersonAn open being, more than and different from the sum of parts in mutual simultaneous interchange with the environment who chooses from options and bears responsibility for choices (Parse, 1987, p. 160).EnvironmentCoexists in mutual process with the person.HealthContinuously changing process of becoming.NursingA learned discipline, the nurse uses true presence to facilitate the becoming of the participant.CHAPTER 2 Frameworks for Professional Nursing Practice78
Madeleine LeiningerÕs Cultural Diversity and Universality TheoryLeininger (1995) defined transcultural nursing as both an area of study and an area of nursing practice. The main features of the cul-tural diversity and universality theory focus on Òcomparative cultural care (caring) values, beliefs, and practicesÓ (p. 58) for either individu-als or groups of people with similar or different cultures. The goal of transcultural nursing is the provision of nursing care that is culture specific to either promote health or to assist individuals facing sick-ness or death Òin culturally meaningful waysÓ (p. 58). Consistent with the focus of her theory, Leininger defined the metaparadigm concepts of nursing in a manner that causes the nurse to specifically consider culture in the delivery of competent nursing care (Table 2-12).According to Leininger (2001), three modalities guide nursing judgments, decisions, and actions to provide culturally congruent care that is beneficial, satisfying, and meaningful to the persons the nurse serves. These three modes include cultural care preservation or main-tenance, cultural care accommodation or negotiation, and cultural care repatterning or restructuring. Cultural care preservation or main-tenance refers to those assistive, supportive, facilitative, or enabling professional actions and decisions that help people of a specific cul-ture to maintain meaningful care values for their well-being, recover from illness, or deal with a handicap or dying. Cultural care accom-modation or negotiation refers to those assistive, supportive, facilita-tive, or enabling professional actions and decisions that help people of a specific culture or subculture adapt to or negotiate with others for meaningful, beneficial, and congruent health outcomes. Cultural ¥ Nurse is present as the person explores the situation and considers options¥ Information is explored from perspective of the person by asking questions¥ Nurse provides care according to best clinical practice but skill-based care does not detract from nursing practice in relationship with persons¥ Focuses on the outcomes from the perspective of the personImplementationEvaluationAssessment andplanningFigure 2-11 The nursing process and ParseÕs theory of humanbecoming.Overview of Selected Nursing Theories79
TABLE 2-12 Metaparadigm Concepts as DeÞned in LeiningerÕs TheoryPersonHuman being, family, group, community, or institution.EnvironmentTotality of an event, situation, or experience that gives meaning to human expressions, interpretations, and social interactions in physical, ecological, sociopolitical, and/or cultural settings (Leininger, 1991).HealthA state of well-being that is culturally defined, valued, and practiced (Leininger, 1991, p. 46).NursingActivities directed toward assisting, supporting, or enabling with needs in ways that are congruent with the cultural values, beliefs, and lifeways of the recipient of care (Leininger, 1995).¥ Participation, observation, and interviews in the culture to discover worldview¥ Nurse analyzes information to discover patterns and themes¥ Nurse develops plan of care and presents it to patient for review and modification¥ Nurse implements plan to promote health and well- being using concepts of maintenance, negotiation, and restructuring¥ Nurse observes if the process has resulted in culturally congruent nursing carePlanningEvaluationAssessmentImplementationFigure 2-12 The nursing process and LeiningerÕs theory of culture care and diversity.care repatterning or restructuring refers to the assistive, supportive, facilitative, or enabling professional actions and decisions that help patients reorder, change, or modify their lifeways for new, different, and beneficial health outcomes (Leininger & McFarland, 2006).The nurse using LeiningerÕs theory plans and makes decisions with clients with respect to these three modes of action. All three care modalities require coparticipation of the nurse and client working together to identify, plan, implement, and evaluate nursing care with respect to the cultural congruence of the care (Leininger, 2001). An overview of LeiningerÕs theory in the context of the nursing process is illustrated in Figure 2-12.Leininger developed the sunrise model, which she revised in 2004. She labeled this model as Òan enabler,Ó to clarify that although it de-picts the essential components of the cultural diversity and universal-ity theory, it is a visual guide for exploration of cultures.CHAPTER 2 Frameworks for Professional Nursing Practice80
Hildegard PeplauÕs Theory of Interpersonal RelationsIn her theory, Peplau addresses all of nursingÕs metaparadigm con-cepts (Table 2-13), but she is primarily concerned with one aspect of nursing: how persons relate to one another. According to Peplau, the nurseÐpatient relationship is the center of nursing (Young et al., 2001).Peplau (1952) originally described four phases in nurseÐpatient relationships that overlap and occur over the time of the relationship: orientation, identification, exploitation, and resolution. In 1997, Pe-plau combined the phase of identification and exploitation, resulting in three phases: orientation, working, and termination. Nevertheless, most other theorists still consider the phases of identification and ex-ploitation to be subphases of the working phase. During the orienta-tion phase, a health problem has emerged that results in a Òfelt need,Ó and professional assistance is sought (p. 18).In the working phase, the patient identifies those who can help, and the nurse permits exploration of feelings by the patient. During this phase, the nurse can begin to focus the patient on the achieve-ment of new goals. The resolution (termination) phase is the time when the patient gradually adopts new goals and frees oneself from identification with the nurse (Peplau, 1952, 1997).Peplau (1952) also describes six nursing roles that emerge during the phases of the nurseÐpatient relationship: the role of the stranger, the role of the resource person, the teaching role, the leadership role, the surrogate role, and the counseling role. Over the course of Pep-lauÕs career, the nursing roles were refined to include teacher, resource, counselor, leader, technical expert, and surrogate. As a teacher, the nurse provides knowledge about a need or problem. In the role of resource, the nurse provides information to understand a problem. In the role of counselor, the nurse helps recognize, face, accept, and resolve problems. As a leader, the nurse initiates and maintains group goals through interaction. As a technical expert, the nurse provides TABLE 2-13 Metaparadigm Concepts as DeÞned in PeplauÕs TheoryPersonEncompasses the patient (one who has problems for which expert nursing services are needed or sought) and the nurse (a professional with particular expertise) (Peplau, 1992, p. 14).EnvironmentForces outside the organism within the context of culture (Peplau, 1952, p. 163).HealthÒImplies forward movement of personality and other ongoing human pro-cesses in the direction of creative, constructive, productive, personal, and community livingÓ (Peplau, 1992, p. 12).NursingThe therapeutic, interpersonal process between the nurse and the patient.Overview of Selected Nursing Theories81
physical care using clinical skills. As a surrogate, the nurse may take the place of another (Johnson & Webber, 2010, p. 125).In addition, Peplau (1952) described four psychobiologic experi-ences: needs, frustration, conflict, and anxiety. According to Peplau, these experiences Òall provide energy that is transformed into some form of actionÓ (p. 71) as well as a basis for goal formation and nurs-ing interventions (Howk, 2002). Nursing process is not explicitly described in PeplauÕs theory, but phases of the nursing process can be identified. An overview of PeplauÕs theory in the context of the nurs-ing process is illustrated in Figure 2-13.Peplau, as one of the first theorists since Nightingale to present a theory for nursing, is considered a pioneer in the area of theory development in nursing. Prior to PeplauÕs work, nursing practice involved acting on, to, or for the patient such that the patient was considered an object of nursing actions. PeplauÕs work was the force behind the conceptualization of the patient as a partner in the nursing process (Howk, 2002). Although PeplauÕs book was first published in 1952, her model continues to be used extensively by clinicians and to provide direction to educators and researchers (Howk, 2002).Nola PenderÕs Health Promotion ModelThe health promotion model is an attempt to portray the multidimen-sionality of persons interacting with their interpersonal and physical environments as they pursue health while integrating constructs from expectancy-value theory and social cognitive theory with a nursing perspective of holistic human functioning (Pender, 1996). A summary of the metaparadigm concepts of nursing as defined by Pender is pre-sented in Table 2-14.¥ Establish relationship and identify actual or potential problems¥ Working phase begins as the nurse and patient begin planning to address identified problems¥ Nurse-patient partnership is clarified¥ Nurse responsible for setting goals that move patient toward independence¥ Based patient achievement of goals¥ Termination occurs when patientÕs problem is resolved and patient is ready for independencePlanningEvaluationAssessmentImplementationFigure 2-13 The nursing process and PeplauÕs theory of interpersonal relations.CHAPTER 2 Frameworks for Professional Nursing Practice82
There are three major categories to consider in PenderÕs health promotion model: (1) individual characteristics and experiences, (2) behavior-specific cognitions and affect, and (3) behavioral out-come. Personal factors include personal biological factors, such as age, body mass index, pubertal status, menopausal status, aerobic capacity, strength, agility, or balance. Personal psychological factors include self-esteem, self-motivation, and perceived health status; personal sociocultural factors include race, ethnicity, acculturation, education, and socioeconomic status. Some personal factors are amenable to change, whereas others cannot be changed (Pender et al., 2006, 2011).Behavior-specific cognitions and affect are behavior-specific variables within the health promotion model. Such variables are con-sidered to have motivational significance. In the health promotion model, these variables are the target of nursing intervention because they are amenable to change. The behavior-specific cognitions and affect identified in the health promotion model include (1) perceived benefits of action, (2) perceived barriers to action, (3) perceived self-efficacy, and (4) activity-related affect. Perceived benefits of action are the anticipated positive outcomes resulting from health behavior. Per-ceived barriers to action are the anticipated, imagined, or real blocks or personal costs of a behavior. Perceived self-efficacy refers to the judgment of personal capability to organize and execute a health-pro-moting behavior. It influences the perceived barriers to actions such that higher efficacy results in lower perceptions of barriers. Activity-related affect refers to the subjective positive or negative feelings that occur before, during, and following behavior based on the stimulus properties of the behavior. Activity-related affect influences perceived self-efficacy such that the more positive the subjective feeling, the greater the perceived efficacy (Pender et al., 2006, 2011; Sakraida, 2010, 2014).TABLE 2-14 Metaparadigm Concepts as DeÞned in PenderÕs ModelPersonThe individual, who is the primary focus of the model.EnvironmentThe physical, interpersonal, and economic circumstances in which persons live.HealthA positive high-level state.NursingThe role of the nurse includes raising consciousness related to health- promoting behaviors, promoting self-efficacy, enhancing the benefits of change, controlling the environment to support behavior change, and man-aging barriers to change.Overview of Selected Nursing Theories83
Commitment to a plan of action marks the beginning of a be-havioral event. Interventions in the health promotion model focus on raising consciousness related to health-promoting behaviors, promot-ing self-efficacy, enhancing the benefits of change, controlling the en-vironment to support behavior change, and managing the barriers to change. Health-promoting behavior, which is ultimately directed to-ward attaining positive health outcomes, is the product of the health promotion model (Pender et al., 2006, 2011, 2015).The nursing process is not described as a part of PenderÕs theory, but various phases of the nursing process can be easily identified. An overview of PenderÕs theory in the context of the nursing theory is il-lustrated in Figure 2-14.Afaf Ibrahim MeleisÕs Transitions TheoryTransitions are a central concept of interest to nursing (Meleis, 2007). Nurses interact with individuals experiencing transitions if those transitions relate to health, well-being, or self-care ability. Nurses also interact with individuals within environments that support or hamper personal, communal, familial, or population transitions (Meleis, 2010).Transition is a process triggered by a change that represents a passage from a fairly stable state to another fairly stable state (Meleis, 2010). Transitions can be described in terms of types and patterns of transitions, properties of transition experiences, transition conditions, process indicators, outcome indicators, and nursing therapeutics (Meleis et al., 2000).Types of transitions include developmental, health and illness, sit-uational, and organizational. Developmental transitions may include such events as the transition from childhood to adolescence or from adulthood to old age. Health and illness transitions may include such ¥ Nurse gathers data related to prior behavior, personal factors, patient perceptions, and competing demands¥ Nurse and patient work together to develop a health promotion plan¥ Patient commits to the plan of action¥ Incorporation of the health-promoting behavior into patientÕs routine¥ Based upon actual incorporation of the health-promoting behavior into the patientÕs lifePlanningEvaluationAssessmentImplementationFigure 2-14 The nursing process and PenderÕs health promotion model.CHAPTER 2 Frameworks for Professional Nursing Practice84
events as diagnosis of chronic illness. Birth and death are examples of events that may lead to situational transitions. Patterns of transitions reflect the experience of multiple simultaneous transitions in the lives of individuals rather than single, sequential transition events (Meleis et al., 2000).Essential and interrelated properties of transition experiences have been identified that include awareness, engagement, change and difference, time span, and critical points and events (Meleis et al., 2000). Awareness is related to perception, knowledge, and recogni-tion of the transition experience; it is often reflected in the congruency between what is known about the process and responses and what the expected perceptions and responses of individuals in similar transi-tions are. Engagement is related to the involvement of the individual in the transition process, which may be manifested by such activities as seeking information. Change and difference are properties of tran-sitions that are similar but not interchangeable. Either change may be the result of transition or the transition may result in change. All transitions involve change, but not all change is related to transition (Meleis et al., 2000). Confronting difference in the context of transi-tions refers to Òunmet or divergent expectations, feeling different, be-ing perceived as different, or seeing the work and others in different waysÓ (Meleis et al., 2000, p. 20). Time span refers to the flow and movement over time that occurs with all transitions. Individuals ex-periencing long-term transitions do not necessarily constantly experi-ence a state of flux; however, such a state Òmay periodically surface, reactivating a latent transition experienceÓ (Meleis et al., 2000, pp. 20Ð21). Thus, it is important to consider the possibility of variability over time and to reassess outcomes.Most transitions include critical points or marker events, such as birth, death, or diagnosis with an illness. Critical points are often associ-ated with awareness of change or difference or increased engagement in the transition experience and may represent periods of heightened vulner-ability. During the period of uncertainty, a number of critical points may occur depending on the nature of the transition. Final critical points are characterized by a sense of stabilization (Meleis et al., 2000).Transition conditions include facilitators and inhibitors or the perceptions of and meanings attached to health and illness situations that facilitate or hinder progress toward achieving a healthy transition (Schumacher & Meleis, 1994). Perceptions and meanings are influenced by and in turn influence the conditions in which transitions occur. These facilitators and inhibitors include personal, community, or soci-etal conditions. Personal conditions include meanings, cultural beliefs and attitudes, socioeconomic status, and preparation and knowledge. Community conditions may include community resources, support from family, and role models. Societal conditions may include stigmati-zation, marginalization, and cultural attitudes (Meleis et al., 2000).Overview of Selected Nursing Theories85
Patterns of response include process indicators and outcome in-dicators. Because transitions occur over time, process indicators that direct individuals toward health or toward vulnerability and risk may be identified through early assessment to promote health outcomes. Assessment of outcome indicators may be used to ascertain whether a transition process is healthy and may include efforts to determine whether the individual is feeling connected, interacting, being situated, and developing confidence and coping (Meleis et al., 2000). Outcome indicators include mastery and development of identity. Mastery of new skills required to manage a transition and the development of a new fluid and integrative identity reflect a healthy outcome of the transition process.Nursing therapeutics are conceptualized as measures applicable to therapeutic intervention during transitions. The first nursing thera-peutic is an assessment of readiness; it includes an assessment of each transition condition to determine readiness and allows clinicians to determine patterns of the transition experience. Preparation for transi-tion is the second nursing therapeutic. It includes education to gener-ate the best condition for transition. The third nursing therapeutic is role supplementation (Schumacher & Meleis, 1994), a deliberative process that is applied when role insufficiency or potential role in-sufficiency is identified. In this process, the conditions and strategies of role clarification and role taking are used to develop preventive or therapeutic measures to decrease, improve, or prevent role insuf-ficiency (Meleis, 2010). The metaparadigm concepts of nursing as defined by Meleis are summarized in Table 2-15. An overview of MeleisÕs transitions theory in the context of the nursing process is il-lustrated in Figure 2-15.TABLE 2-15 Metaparadigm Concepts as DeÞned in MeleisÕs Transitions TheoryPersonActive beings who experience fundamental life patterns and who have percep-tions of and attach meaning to transition experiences (Meleis et al., 2000, p. 21).EnvironmentEnvironmental conditions expose persons to potential damage, problematic recovery, or delayed or unhealthy coping, contributing to vulnerability re-lated to transitions.HealthConsists of complex and multidimensional transitions that are characterized by flow and movement over time; healthy outcomes are defined in terms of the transition process.NursingBeing the primary caregiver for individuals and their families during the transition process and applying nursing therapeutics during transitions to promote healthy outcomes.CHAPTER 2 Frameworks for Professional Nursing Practice86
Kristen SwansonÕs Theory of CaringSwansonÕs theory of caring (1991, 1993, 1999a, 1999b) offers an explanation of what it means to practice nursing in a caring manner. In this theory, caring is defined as a Ònurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibilityÓ (Swanson, 1991, p. 162). Swanson (1993) posits that caring for a personÕs biopsychosocial and spiritual well-being is a fundamental and universal component of good nursing care.Five additional concepts are integral to SwansonÕs theory of car-ing and represent the five basic processes of caring: maintaining belief, knowing, being with, doing for, and enabling.¥ The concept of maintaining belief is sustaining faith in the otherÕs capacity to get through an event or transition and to face a future with meaning. This includes believing in the otherÕs capacity and holding the other in high esteem, maintaining a hope-filled at-titude, offering realistic optimism, helping to find meaning, and standing by the one cared for, no matter what the situation.¥ The concept of knowing refers to striving to understand the mean-ing of an event in the life of the other, avoiding assumptions, focusing on the person cared for, seeking cues, assessing meticu-lously, and engaging both the one caring and the one cared for in the process of knowing.¥ The concept of being with refers to being emotionally present to the other. It includes being present in person, conveying availabil-ity, and sharing feelings without burdening the one cared for.¥ The concept of doing for refers to doing for others what one would do for oneself, including anticipating needs, comforting, performing skillfully and competently, and protecting the one cared for while preserving his or her dignity.¥ Assess readiness through assessment of each transition condition to determine patterns of the transition experienceAssessment andplanningEvaluationImplementation¥ Preventative role supplementation¥ Therapeutic role supplementation¥ Based upon effectiveness of nursing therapeutics and the healthy outcome of the transition processFigure 2-15 The nursing process and MeleisÕs transitions theory.Overview of Selected Nursing Theories87
¥ The concept of enabling refers to facilitating the otherÕs passage through life transitions and unfamiliar events by focusing on the event, informing, explaining, supporting, validating feelings, gener-ating alternatives, thinking things through, and giving feedback.Data from Swanson, K. M. (1991). Empirical development of a middle range the-ory of caring. Nursing Research, 40(3), 161Ð166.These caring processes are sequential and overlapping. In fact, they might not exist separate from one another because each is an integral component of the overarching structure of caring (Wojnar, 2010). According to Swanson (1999b), knowing, being with, doing for, enabling, and maintaining belief are essential components of the nurseÐclient relationship, regardless of the context. A summary of the metaparadigm concepts of nursing as defined by Swanson is included in Table 2-16. An overview of SwansonÕs theory of caring in the con-text of the nursing process is illustrated in Figure 2-16.TABLE 2-16 Metaparadigm Concepts as DeÞned in SwansonÕs Theory of CaringPersonÒUnique beings who are in the midst of becoming and whose wholeness is made manifest in thoughts, feelings, and behaviorsÓ (Swanson, 1993, p. 352).EnvironmentÒAny context that influences or is influenced by the designated clientÓ (Swanson, 1993, p. 353).HealthHealth and well-being is Òto live the subjective, meaning-filled experience of wholeness. Wholeness involves a sense of integration and becoming wherein all facets of being are free to be expressedÓ (Swanson, 1993, p. 353).NursingInformed caring for the well-being of others (Swanson, 1991, 1993).¥ NurseÕs role is to maintain belief¥ Nurse engages in understanding or knowingAssessment andplanningEvaluationImplementation¥ Nurse conveys to client that he or she is emotionally present¥ Nurse engages in doing for and enabling¥ Intended client outcome is referred to as the consequences of caring, which refers to client well-being or wholenessFigure 2-16 The nursing process and SwansonÕs theory of caring.CHAPTER 2 Frameworks for Professional Nursing Practice88
Katharine KolcabaÕs Theory of ComfortComfort, as described in KolcabaÕs (2004) theory of comfort, is the immediate experience of being strengthened by having needs for relief, ease, and transcendence addressed in four contextsÑphysical, psycho-spiritual, sociocultural, and environmental; it is much more than sim-ply the absence of pain or other physical discomfort. Physical comfort pertains to bodily sensations and homeostatic mechanisms. Psycho-spiritual comfort pertains to the internal awareness of self, including esteem, sexuality, meaning in oneÕs life, and oneÕs relationship to a higher order or being. Sociocultural comfort pertains to interpersonal, family, societal relationships, and cultural traditions. Environmental comfort pertains to the external background of the human experience, which includes light, noise, color, temperature, ambience, and natural versus synthetic elements (Kolcaba, 2004).According to Kolcaba, comfort care encompasses three compo-nents: an appropriate and timely intervention to meet the comfort needs of patients, a mode of delivery that projects caring and empathy, and the intent to comfort. Comfort needs include patientsÕ or familiesÕ desire for or deficit in relief, ease, or transcendence in the physical, psychospiritual, sociocultural, or environmental contexts of human ex-perience. Comfort measures refer to interventions that are intentionally designed to enhance patientsÕ or familiesÕ comfort (Kolcaba, 2004).The theory of comfort also addresses intervening variablesÑ negative or positive factors over which nurses and institutions have little control but that affect the direction and success of comfort care plans. Examples of intervening variables are the presence or absence of social support, poverty, prognosis, concurrent medical or psycho-logical conditions, and health habits (Kolcaba, 2004).An additional concept within the theory comprises the health-seeking behaviors of patients and families. Health-seeking behaviors are those behaviors that patients and families engage in either consciously or unconsciously while moving toward well-being. Health-seeking behaviors can be either internal or external and can include dying peacefully. It is posited that enhanced comfort results in engagement in health-seeking behaviors (Kolcaba, 2004). The metaparadigm concepts of nursing as defined by Kolcaba are sum-marized in Table 2-17. An overview of KolcabaÕs theory of comfort in the context of the nursing process is illustrated in Figure 2-17.Pamela ReedÕs Self-Transcendence TheoryThree major concepts are central to the theory of self-transcendence: self-transcendence, well-being, and vulnerability. Self-transcendence is the capacity to expand self-boundaries intrapersonally, interperson-ally, temporally, and transpersonally (Reed, 2008, 2014). The capacity to expand self-boundaries intrapersonally refers to a greater aware-ness of oneÕs philosophy, values, and dreams. The capacity to expand Overview of Selected Nursing Theories89
interpersonally relates to others and oneÕs environment. The capacity to expand temporally refers to integration of oneÕs past and future in a way that has meaning for the present. Finally, the capacity to ex-pand transpersonally refers to the capacity to connect with dimensions beyond the typically discernible world. Self-transcendence is a char-acteristic of developmental maturity that is congruent with enhanced awareness of the environment and a broadened perspective on life. Self-transcendence is expressed through behaviors, such as sharing wisdom with others, integrating physical changes of aging, accepting death as a part of life, and finding spiritual meaning in life (Reed, 2008).Well-being is the second major concept of ReedÕs theory. Well-being is a sense of feeling whole and healthy, according to oneÕs own criteria for wholeness and health. The definition of well-being TABLE 2-17 Metaparadigm Concepts as DeÞned in KolcabaÕs Theory of ComfortPersonRecipients of care may be individuals, families, institutions, or communities in need of health care (Kolcaba et al., 2006).EnvironmentThe environment includes any aspect of the patient, family, or institutional setting that can be manipulated by the nurse, a loved one, or the institution to enhance comfort (Dowd, 2010, p. 711).HealthHealth is considered optimal functioning of the patient, the family, the healthcare provider, or the community (Dowd, 2010, p. 711).NursingNursing is the intentional assessment of comfort needs, design of comfort in-terventions to address those needs, and reassessment of comfort levels after implementation compared to baseline (Dowd, 2010, p. 711).¥ Assessment and reassessment of comfort may be achieved through subjective, intuitive, or objective methods¥ Comfort measures are planned for each area of comfort needs and for each of the context of comfort areas¥ Strategies to enhance comfort vary depending on the specific context of comfort and needs of the patient¥ Focuses on reassessment of the comfort of the patientPlanningEvaluationAssessmentImplementationFigure 2-17 The nursing process and KolcabaÕs theory of comfort.CHAPTER 2 Frameworks for Professional Nursing Practice90
depends on the individual or population. Indeed, indicators of well-being are as diverse as human perceptions of health and wellness. Examples of indicators of well-being are life satisfaction, positive self-concept, hopefulness, happiness, and having meaning in life. Well-being is viewed as a correlate and an outcome of self-transcendence (Reed, 2008, 2014).The third major concept, vulnerability, is the awareness of personal mortality and the likelihood of experiencing difficult life situations. Self-transcendence emerges naturally in health experiences when a per-son is confronted with mortality and immortality. Life events, such as illness, disability, aging, childbirth, or parentingÑall of which heighten a personÕs sense of mortality, inadequacy, or vulnerabilityÑcan trig-ger developmental progress toward a renewed sense of identity and expanded self-boundaries (Reed, 2014). According to Reed (2008), self-transcendence is evoked through life events and can enhance well-being by transforming losses and difficulties into healing experiences.Additional concepts in ReedÕs theory include moderating- mediating factors and points of intervention. Moderating-mediating factors are personal and contextual variables, such as age, gender, life experiences, and social environment, that can influence the rela-tionships between vulnerability and self-transcendence and between self-transcendence and well-being. Nursing activities that facilitate self-transcendence are referred to as points of intervention (Coward, 2010). Two points of intervention are intertwined with the process of self-transcendence: Nursing actions can focus either directly on a personÕs inner resource for self-transcendence or indirectly on the personal and contextual factors that affect the relationship between vulnerability and self-transcendence and the relationship between self-transcendence and well-being. The metaparadigm concepts of nursing as defined by Reed are summarized in Table 2-18. An overview of ReedÕs theory in the context of the nursing process is illustrated in Figure 2-18.TABLE 2-18 Metaparadigm Concepts as DeÞned in ReedÕs Self-Transcendence TheoryPersonPersons are human beings who develop over the life span through interac-tions with other persons and within an environment (Coward, 2010, p. 622).EnvironmentThe environment is composed of family, social networks, physical surroundings, and community resources (Coward, 2010, p. 622).HealthWell-being is a sense of feeling whole and healthy, according to oneÕs own criteria for wholeness and health (Reed, 2008).NursingThe role of nursing activity is to assist persons through interpersonal processes and therapeutic management of their environment to promote health and well-being (Coward, 2010, p. 622).Overview of Selected Nursing Theories91
Merle MishelÕs Uncertainty in Illness TheoryThe purpose of the uncertainty in illness theory is to Òdescribe and explain uncertainty as a basis for practice and researchÓ (Mishel, 2014, p. 54). Uncertainty, the central concept of the theory, is defined as Òthe inability to determine the meaning of illness-related events in-clusive of inability to assign definite value and/or to accurately predict outcomesÓ (p. 56). The second central concept in the theory, cognitive schema, is defined by Mishel as a ÒpersonÕs subjective interpretation of illness-related eventsÓ (p. 56).The uncertainty in illness theory is organized around three themes: antecedents of uncertainty, appraisal of uncertainty, and coping with un-certainty. Antecedents of uncertainty include the stimuli frame, cognitive capacities, and structure providers. According to the model, uncertainty is a result of these antecedents, with the major path to uncertainty being through the stimuli frame variables (Mishel, 2014). The stimuli frame encompasses the form, composition, and structure of the stimuli that the person perceives. It has three components: symptom pattern, event famil-iarity, and event congruence. The symptom pattern refers to the degree to which symptoms occur with enough consistency to be perceived as following a pattern. Event familiarity refers to the degree to which a situ-ation is repetitive or contains recognized cues. Event congruence refers to the consistency between what is expected and what is experienced (Mishel, 1988). The stimuli frame is the foundation for cognitive schema or the personÕs interpretation of the events (Bailey & Stewart, 2014). Cognitive capacities refer to the information-processing ability of the per-son, and structure providers refer to the resources, such as education, so-cial support, and credible authority, available to assist the person as he or she interprets the stimuli frame. Thus, cognitive capacities and structure providers influence the components of the stimuli frame (Mishel, 2014).¥ Nurse assesses indicators of self-transcendence, well-being, and vulnerability as well as moderating-mediating factorsAssessment andplanningEvaluationImplementation¥ Focus on either or both points of intervention that intersect with the process of self- transcedence¥ Based on effectiveness of nursing activities to facilitate self- transcendence and well- beingFigure 2-18 The nursing process and ReedÕs self-transcendence theory.CHAPTER 2 Frameworks for Professional Nursing Practice92
The second theme, appraisal of uncertainty, refers to the process of placing a value on the uncertain event or situation. Appraisal of un-certainty has two components: inference and illusion. Inference refers to the evaluation of uncertainty by using examples; it is predicated on personality disposition, experience, knowledge, and contextual cues. Illusion comprises the construction of beliefs to create a positive out-look (Mishel, 2014).The third theme, coping with uncertainty, includes the concepts of danger, opportunity, coping, and adaptation. Danger refers to the possibility of a harmful outcome, whereas opportunity is the possibil-ity of a positive outcome. Coping in the context of a danger appraisal encompasses activities directed toward reducing uncertainty and managing emotions; coping in the context of an opportunity appraisal comprises activities directed toward maintaining uncertainty (Mishel, 2014). Adaptation in the context of the uncertainty theory is defined as biopsychosocial behavior occurring within a personÕs range of usual behavior and is the outcome of coping.The reconceptualized uncertainty in illness theory presents the process of moving from uncertainty appraised as danger to uncertainty appraised as an opportunity and resource for a new view of life. The revised theory incorporates two new concepts: self-organization and probabilistic thinking. Self-organization refers to the reformulation of a new sense of order resulting from the inte-gration of continuous uncertainty into self-structure, where uncer-tainty is accepted as the natural rhythm of life. Probabilistic thinking refers to the belief in a conditional world in which the expectation of certainty is abandoned (Bailey & Stewart, 2014; Mishel, 2014).The metaparadigm concepts of nursing as defined by Mishel are summarized in Table 2-19. An overview of MishelÕs theory in the con-text of the nursing process is illustrated in Figure 2-19.TABLE 2-19 Metaparadigm Concepts as DeÞned in MishelÕs Uncertainty in Illness TheoryPersonThe concept of person is the central focus of the theory and may be an indi-vidual or the family of an ill individual (Mishel, 2014, p. 54); the individual is viewed as a biopsychosocial being who is an open system, exchanging energy with the environment.EnvironmentNot explicitly defined but is acknowledged to exchange energy with the person system.HealthDefined in terms of uncertainty in the context of the illness experience, with the concept of health or well-being congruent with the formulation of a new life view and probabilistic thinking.NursingNurses are viewed as a part of the antecedent variable of structure providers (Mishel, 2014, p. 71).Overview of Selected Nursing Theories93
Cheryl Tatano BeckÕs Postpartum Depression TheoryTwo major concepts are included in the postpartum depression theory: postpartum mood disorders and loss of control. Postpartum mood disorders include postpartum depression, maternity blues, postpartum psychosis, postpartum obsessiveÐcompulsive disorder, and postpartum-onset panic disorder (Beck, 2002). The second major concept in BeckÕs theory describes the experience of loss of control in all areas of womenÕs lives. Loss of control is a basic psychosocial problem with which women attempt to cope through a four-stage process labeled by Beck as Òteetering on the edge,Ó referring to what women describe as walking a fine line between sanity and insanity. The four stages of the coping process consist of (1) encountering ter-ror in the form of symptoms, such as anxiety attacks, fogginess, and obsessive thinking, that hit unexpectedly and suddenly; (2) dying of self, as mothers who no longer know who they have become isolate themselves and contemplate and sometimes attempt self-destruction; (3) struggling to survive, as they battle the healthcare system and seek help from support groups and prayer; and (4) regaining control of their lives during transition and guarded recovery while mourning lost time with their infant (data from Beck, 1993).Additional concepts in BeckÕs theory include predictors or risk factors for postpartum depression. These concepts include prenatal depression, childcare stress, life stress, social support, prenatal anxiety, marital satisfaction, history of depression, infant temperament, mater-nity blues, self-esteem, socioeconomic status, marital status, and un-planned or unwanted pregnancy (Beck, 2003). Concepts that are used for screening in the postpartum depression screening scale include sleeping and eating disturbances, anxiety and insecurity, emotional ¥ Collect data related to antecedents of uncertainty, appraisal of uncertainty, and coping with uncertainty to identify patients at risk for increased uncertaintyAssessment andplanningEvaluationImplementation¥ Implement strategies to impact antecedents of uncertainty, appraisal of uncertainty, and coping with uncertainty¥ Based upon the positive adaptation of the patient to the illness experienceFigure 2-19 The nursing process and MishelÕs uncertainty in illness theory.CHAPTER 2 Frameworks for Professional Nursing Practice94
lability, mental confusion, loss of self, guilt and shame, and suicidal thoughts (Beck & Gable, 2000). Modifications to the postpartum depression theory have occurred as research reveals new information. In addition to these concepts, the four metaparadigm concepts of nursing are presented in the context of BeckÕs postpartum depression theory. These concepts are summarized in Table 2-20.While BeckÕs theory does not specifically address the nursing pro-cess, concepts specific to stages of the process can be identified. An overview of the postpartum depression theory in the context of the nursing process is illustrated in Figure 2-20.TABLE 2-20 Metaparadigm Concepts as DeÞned in BeckÕs Postpartum Depression TheoryPersonDescribed in terms of wholeness with biological, sociological, and psychological aspects, with personhood understood in the context of family and community (Maeve, 2014, p. 678).EnvironmentViewed broadly in terms of individual factors and external factors (Maeve, 2014, p. 678).HealthNot defined explicitly; traditional ideas of physical and mental health are viewed as a consequence of womenÕs responses to the contexts of their lives and environments (Maeve, 2014, p. 678).NursingA caring profession with caring obligations; the nurse accomplishes the goals of health and wholeness through interpersonal interactions (Maeve, 2014, p. 678).¥ Administer postpartum depression predictors inventory (PDPI) once each trimester and periodically after delivery to identify riskAssessment andplanningEvaluationImplementation¥ Target interventions to decrease risk based upon the identification of modifiable risk factors¥ Based upon the early intervention for signs and symptoms of postpartum depression or prevention of onsetFigure 2-20 The nursing process and BeckÕs postpartum depression theory.Overview of Selected Nursing Theories95
The American Association of Critical-Care Nurses Synergy Model for Patient CareThe synergy model is a conceptual framework for designing practice competencies to care for critically ill patients with a goal of optimiz-ing outcomes for patients and families. Optimal outcomes are realized when the competencies of the nurse match the patient and family needs.The synergy model for patient care is the result of the Ameri-can Association of Critical-Care Nurses (AACN) envisioning a new paradigm for clinical practice. In 1993, the AACN Certification Cor-poration convened a think tank that included nationally recognized experts to develop a conceptual framework for certified practice. The initial work resulted in the description of 13 patient characteristics based on universal needs of patients and 9 characteristics required of nurses to meet patient needs. The patient characteristics identified were compensation, resiliency, margin of error, predictability, com-plexity, vulnerability, physiologic stability, risk of death, independence, self-determination, involvement in care decisions, engagement, and resource availability. The characteristics of nurses were engagement, skilled clinical practice, agency, caring practices, system management, teamwork, diversity responsiveness, experiential learning, and being an innovatorÐevaluator. The think tank suggested that the synergy emerging from the interaction between the patient needs and the nurse characteristics should result in optimal outcomes for the patient and that these characteristics of the nurse would determine competen-cies for certified practice (Hardin, 2005).In 1995, the AACN Certification Corporation decided to refine this model, to conduct a study of practice and job analysis of criti-cal care nurses, and to test the validity of the concepts in critical care nurses. The group refined the patient characteristics into eight concepts, merged the nurse characteristics into eight concepts, and delineated a continuum for the characteristics. The eight patient characteristics identified in the current model are resiliency, vulner-ability, stability, complexity, resource availability, participation in care, participation in decision making, and predictability. The eight nurse characteristics are clinical judgment, advocacy, caring practices, col-laboration, systems thinking, response to diversity, clinical inquiry, and facilitation of learning (Hardin, 2005, 2013). Each patient char-acteristic is placed on a scale from 1 to 5, with the level of each pa-tient characteristic being critical in terms of the competency required of the nurse (Hardin, 2005). The eight nurse characteristics can be considered essential competencies for providing care for critically ill patients. All eight competencies reflect an integration of knowledge, skills, and experience of the nurse. Each nurse characteristic can be understood on a continuum from 1 to 5 (Hardin, 2005).CHAPTER 2 Frameworks for Professional Nursing Practice96
The synergy model delineates three levels of outcomes: outcomes derived from the patient, outcomes derived from the nurse, and out-comes derived from the healthcare system. Outcomes data derived from the patient include functional changes, behavioral changes, trust, satisfaction, comfort, and quality of life. Outcomes data derived from nursing competencies include physiologic changes, the presence or absence of complications, and the extent to which treatment objec-tives are attained (Curley, 1998). Outcomes data derived from the healthcare system include readmission rates, length of stay, and cost utilization (Hardin, 2005). The metaparadigm concepts of nursing as defined in the synergy model for patient care are summarized in Table 2-21. An overview of the synergy model in the context of the nursing process is illustrated in Figure 2-21.TABLE 2-21 Metaparadigm Concepts as DeÞned in the Synergy Model for Patient CarePersonPersons are viewed in the context of patients who are biological, social, and spiritual entities who are present at a particular developmental stage.EnvironmentThe concept of environment is not explicitly defined; however, included in the assumptions is the idea that environment is created by the nurses for the care of the patient.HealthThe concept of health is not explicitly defined; an optimal level of wellness as defined by the patient is mentioned as a goal of nursing care.NursingThe purpose of nursing is to meet the needs of patients and families and to provide safe passage through the healthcare system during a time of crisis (Hardin, 2005, p. 8).¥ Assessment of eight patient characteristics including understanding of status of each on a continuum from 1Ð5¥ Match competency level of the nurse with the eight patient characteristics¥ Strategies are based on need identified related to the eight patient characteristics and may vary based on the competency of the nurse¥ Based on patient outcomes during illness¥ Incorporates matching of nurse competencies with the needs of patients and their familiesPlanningEvaluationAssessmentImplementationFigure 2-21 The nursing process and the synergy model of patient care.Overview of Selected Nursing Theories97
Overview of Selected Nonnursing TheoriesNursing as a discipline with a distinct body of theoretical knowledge has developed over time, but nonnursing theories have influenced and still do influence nursing theory, research, and practice. Brief overviews of nonnursing theories that are commonly used in nursing follow.General System TheoryVon Bertalanffy (1968) emphasized that systems are open to and interact with their environments and that they can evolve as they acquire new properties. Rather than reducing an entity to the properties of its parts or elements, system theory focuses on the ar-rangement of and relations between the parts that connect them into a whole. This particular organization defines a system. Major concepts of general system theory include a systemÐenvironment boundary, input and output processes, and the organizational state of the system. General system theory is founded on the premise that the world is composed of systems that are interconnected and influenced by one another. The two primary assumptions of the theory are that energy is needed to maintain an organizational state and that dysfunction in one system has an effect on other systems (Boulding, 1956). RoyÕs adaptation model, KingÕs interacting sys-tems framework and theory of goal attainment, and NeumanÕs sys-tem model are all nursing theories that have foundations in general system theory.Social Cognitive TheorySocial cognitive theory explains human behaviors in terms of dynamic reciprocal interactions among cognitive, behavioral, and environmen-tal influences. According to Albert Bandura (1986), human behavior is learned observationally through modeling or observing others. Once a behavior is observed, the person forms an idea of how the new behav-ior is performed; on a later occasion, this coded information serves as a guide for action. Principles derived from social cognitive theory are often used to promote behavior change.Bandura incorporated the concept of self-efficacy into social learning theory (now called social cognitive theory) in 1977. The con-cept of self-efficacy refers to a personÕs confidence in his or her ability to take action and to persist in that action to reach goals. The concept of self-efficacy can be important in influencing health behavior change (Bandura, 1997) and is frequently used by nurses engaged in health education and behavior modification. Nola Pender is a nurse theorist CHAPTER 2 Frameworks for Professional Nursing Practice98
who identifies social learning theory as central to her health promo-tion model, with the concept of self-efficacy being included as a cen-tral construct of the model (Sakraida, 2014).Stress and Coping Process TheoryRichard Lazarus suggested that stress might be an organizing concept for understanding a wide range of phenomena rather than a variable. Stress as conceptualized by Lazarus emphasizes the relationship of the person to the environment, with the judgment of whether a specific personÐenvironment relationship is stressful dependent on cognitive appraisal (Lazarus & Folkman, 1984). He identified three types of cognitive appraisal: primary, secondary, and reappraisal. Vulnerability is related to the concept of cognitive appraisal because the vulnerable individual is one whose coping resources are deficient (Lazarus & Folkman, 1984). Patricia Benner credits Lazarus with mentoring her in the area of stress and coping.General Adaptation SyndromeHans Selye introduced the notion of a general adaptation syndrome in 1950 (Selye, 1950). In 1974, Selye defined stress as the nonspecific response of the body to any demand for change. General adaptation syndrome is based on physiologic and psychobiologic responses to stress. According to Selye, a stressor results in a three-stage response that includes alarm, resistance, and exhaustion, also known as coping with stress. The goals of coping with stress are adaptation and ho-meostasis (Selye, 1950, 1974).Betty Neuman used SelyeÕs definition of stress in her systems model (Lawson, 2014). Sister Callista Roy also used concepts from Selye in the refinement of her adaptation model (Phillips & Harris, 2014).Relationship of Theory to Professional Nursing PracticeHow will theory affect your nursing practice? Using a theoretical framework to guide your nursing practice assists you as you organize patient data, understand and analyze patient data, make decisions re-lated to nursing interventions, plan patient care, predict outcomes of care, and evaluate patient outcomes (Alligood & Tomey, 2002). Why? The use of a theoretical framework provides a systematic and knowl-edgeable approach to nursing practice. The framework also becomes a tool that assists you to think critically as you plan and provide nurs-ing care.KEY OUTCOME 2-2Example of Domain 1 sub-competency for entry-level professional nursing education.1.1a Identify concepts, derived from theories of nursing and other disci-plines, which distinguish the practice of nursing (p. 26).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing .org/Portals/42/AcademicNursing/pdf /Essentials-2021.pdfRelationship of Theory to Professional Nursing Practice99
How do you begin? Now that you know why nursing theory is important to your nursing prac-tice, it is time to identify a theoretical framework that fits you and your practice. Alligood (2006) presented guidelines for selecting a framework for theory-based nursing practice. Following are the steps:1. Consider the values and beliefs in nursing that you truly hold.2. Write a philosophy of nursing that clarifies your beliefs related to person, environment, health, and nursing.3. Survey definitions of person, environment, health, and nursing in nursing models.4. Select two or three frameworks that best fit with your beliefs related to the concepts of person, environment, health, and nursing.5. Review the assumptions of the frameworks that you have selected.6. Apply those frameworks in a selected area of nursing practice.7. Compare the frameworks on client focus, nursing action, and client outcome.8. Review the nursing literature written by persons who have used the frameworks.9. Select a framework and develop its use in your nursing practice.ConclusionAs demonstrated by the descriptions of the philosophies, conceptual models, and theories presented in this chapter, there is a wide variety of perspectives and frameworks from which to practice nursing. There is no one right or wrong answer. Various nursing theories represent different realities and address different aspects of nursing (Meleis, 2007). For this reason, the multiplicity of nursing theories presented in this chapter should not be viewed as competing theories but rather as complementary theories that can provide insight into different ways to describe, explain, and predict nursing concepts and/or pre-scribe nursing care. Curley (2007) describes this understanding in an interesting way by comparing the multiplicity of nursing theories to a collection of maps of the same region. Each map might display a different characteristic of the region, such as rainfall, topography, or air currents. Although all the maps are accurate, the best map for use depends on the information needed or the question being asked. This is precisely the case with the nurseÕs choice of nursing theories for practice.Begin with whichever theoretical framework seems to Òfit,Ó and then practice using it as you provide nursing care. ÒThe full real-ization of nursing theoryÐguided practice is perhaps the greatest CRITICAL THINKING QUESTION✶Think about the definitions of the metapara-digm concepts and the assumptions or prop-ositions of each of the theories presented. Which of the theories most closely matches your beliefs?✶KEY OUTCOME 2-3Example of Domain 4 sub-competency for entry-level professional nursing education.4.1c Apply theoretical framework(s)/models in practice (p. 38).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing .org/Portals/42/AcademicNursing/pdf /Essentials-2021.pdfCHAPTER 2 Frameworks for Professional Nursing Practice100
challenge that nursing as a scholarly discipline has ever facedÓ (Cody, 2006, p. 119). Be patient; developing your nursing prac-tice guided by nursing theory takes time and practice. All nursing theories require in-depth study over time to master them fully (this chapter provides only a brief introduction), but the incorporation of theory into your practice can transform your nursing practice. The end result of this process will be seen in the excellent nursing care that you can provide to patients over the course of your profes-sional nursing career.CASE STUDY 2-1 ■ MR. M.Mr. M. is a 34-year-old White male who presents to the mental health clinic with depression and com-plaints of fatigue. An interview reveals that his wife and both of his children were killed in a traffic ac-cident 6 months ago. The nurse knows that Mr. M. is vulnerable as a result of the loss of his family but that self-transcendence is evoked through life events and that well-being can be enhanced by transforming losses and difficulties into healing experiences.Case Study Questions1. The nurse uses ReedÕs self-transcendence theory to focus nursing activity for Mr. M. on facilitating self-transcendence. Based on the assessment, what intrapersonal strategies might be appropriate?2. Which interpersonal strategies might be ap-propriate during follow-up visits to facilitate connecting to others?Classroom Activity 2-1Divide into small groups and give each group a copy of the same case study. Assign a differ-ent nursing theory to each group and ask the groups to develop a plan of care using the as-signed nursing theory as the basis for practice. Each group should share its plan of care with the class. Discuss the differences and similari-ties in the foci of care based on each of the selected theories.Classroom Activity 2-2Think about the metaparadigm concepts of nursing. Draw each of the concepts in relation to the other concepts to show your ideas of how each concept interfaces with the others. Pres-ent your Òconceptual modelÓ to the class and discuss your ideas about each of the concepts represented. This activity works best if you use colored pencils, crayons, or markers and a large piece of paper or newsprint. Actual student ex-amples are presented in Figures 2-22 and 2-23.Conclusion101
Figure 2-22 Student conceptual model.Used with permission of Heather Grush.Figure 2-23 Student conceptual model.Used with permission of Linzee McGinnis.CHAPTER 2 Frameworks for Professional Nursing Practice102
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Watson, J. (1996). WatsonÕs philosophy and theory of human caring in nursing. In J. P. Riehl-Sisca (Ed.), Conceptual models for nursing practice (pp. 219Ð235). Appleton & Lange.Watson, J. (1997). The theory of human caring: Retrospective and prospective. Nursing Science Quarterly, 10, 49Ð52.Watson, J. (2001). Jean Watson: Theory of human caring. In M. E. Parker (Ed.), Nursing theories and nursing practice (pp. 343Ð354). F. A. Davis.Watson, J. (2008). Nursing: The philosophy and science of caring (Rev. ed.). University Press of Colorado.Wojnar, D. M. (2010). Kristin M. Swanson: Theory of caring. In M. R. Alligood & A. M. Tomey (Eds.), Nursing theorists and their work (7th ed., pp. 741Ð752). Mosby.Young, A., Taylor, S. G., & McLaughlin-Renpenning, K. (2001). Connections: Nursing research, theory, and practice. Mosby.References107
What is truth? Where do our ideas about truth originate? Why does truth matter? The four principal domains of nursingÑperson, envi-ronment, health, and nursingÑare the building blocks for all philoso-phies of nursing. As you are learning about these ideas, you are also learning that many nurses develop nursing theories or models. Think about it . . . nurses creating theory! Yet who better to describe our profession than professional nurses? All right, so maybe you are not that excited about this reality. Still, you have to admit that the ability to articulate nursing values and beliefs to guide us in our understand-ing of professional nursing is impressive. More than impressive, nurs-ing theory is necessary.In this chapter, we look more closely at nursing philosophy and its significance to professional nursing. We study the difference be-tween beliefs and values and investigate the importance of values clarification. Finally, we examine guidelines for creating a personal philosophy of nursing.Key Terms and Concepts ÈIdealism ÈParadigm ÈRealism ÈValues ÈValues clariÞcationAfter completing this chapter, the student should be able to:1. Identify various philosophical views of truth.2. Differentiate between values and beliefs.3. Discuss the process of value clariÞcation.4. Explain the major components of nursing philosophy.5. Articulate the purpose for having a personal philosophy of nursing.6. Begin the development of a personal philosophy of nursing.Learning ObjectivesPhilosophy of NursingMary W. StewartCHAPTER 3© Nuu Jeed/Shutterstock109
PhilosophyAlthough no single definition of the term philosophy is uncontrover-sial, it is defined in the following ways by the American Heritage Dic-tionary of the English Language (2000):¥ Love and pursuit of wisdom by intellectual means and moral self-discipline¥ Investigation of the nature, causes, or principles of reality, knowl-edge, or values, based on logical reasoning rather than empirical methods¥ A system of thought based on or involving such inquiry (e.g., the philosophy of Hume)¥ The critical analysis of fundamental assumptions or beliefs¥ The disciplines presented in university curricula of science and the liberal arts, except medicine, law, and theology¥ The discipline composed of logic, ethics, aesthetics, metaphysics, and epistemology¥ A set of ideas or beliefs relating to a particular field or activity; an underlying theory (e.g., an original philosophy of advertising)¥ A system of values by which one lives (e.g., has an unusual phi-losophy of life)Examples of philosophies can be found in university catalogs, clinical agency manuals, and nursing school handbooksÑand they are prolific on the Internet. Needless to say, people have strong values and beliefs about many topics. A written statement of philosophy is a good way to communicate to others what you see as truth.Some people are anxious to prescribe their own system of val-ues to others by implying what Òshould be.Ó However, each person or group of persons is responsible for delineating a particular phi-losophy. At the same time, how the insiderÕs philosophy fits with the outsiderÕs view is also important, particularly in such situations as nursing. Because nursing is inextricably linked to society, those of us within the profession must consider how society defines the values and beliefs within nursing.How do we please everyone all the time? The answer is simple: We donÕt. We do, however, consider our own values and beliefs, which are interdependent of society, as we convey our professional phi-losophy of nursing. Does the philosophy ever change? Absolutely. As society and individuals change, our philosophy of nursing changes to be congruent with new and renewed understanding. How did we get started on this journey? A brief look at the beginnings of philosophy can help answer that question.CHAPTER 3 Philosophy of Nursing110
Early PhilosophyAs society and individuals change, our philosophy of nursing changes to be congruent with new and renewed understanding. In the begin-ning, the Greeks moved from seeking supernatural to natural expla-nations. One assumption by the early Greek philosophers was that ÒsomethingÓ had always existed. They did not question how some-thing could come from nothing. Rather, they wanted to know what the ÒsomethingÓ was. The pre-Socratics took the first step toward sci-ence in that they abandoned mythological thought and sought reason to answer their questions.Heraclitus, a pre-Socratic philosopher, is well known for his thesis Òeverything is in flux.Ó He moved from simply looking at ÒbeingÓ to Òbecoming.Ó A popular analogy he used was that of a river, saying, ÒYou cannot step into the same river twice, for different and again different waters flow.Ó More emphasis was placed on the senses versus reasoning.On the other hand, Parmenides, who followed Heraclitus, said these two things: (1) Nothing can change, and (2) our sensory percep-tions are unreliable. He is called the first metaphysician, a Òhard-core philosopher.Ó Metaphysics is the study of reality as a whole, including beyond the natural senses. What is the nature of reality? The uni-verse? He starts with what it means and then moves to how the world must ultimately be. He does not go with his sense or experience. Par-menides thought that everything in the world had always been and that there was no such thing as change. He did, of course, sense that things changed, but his reason told him otherwise. He believed that our senses give us incorrect information and that we can rely only on our reason for acquiring knowledge about the world. This is called rationalism.Probably a name more familiar to us is Socrates (469Ð399 b.c.), famous for philosophy that focused on man, not nature. There is no evidence that Socrates wrote down his ideas; however, his student Plato wrote about the teachings of Socrates, indicating that Socrates believed in the immortal soul and that natural phenomena are merely shadows of eternal forms or ideas. Plato himself was a rationalist, meaning that we know with our reason.Aristotle (384Ð322 b.c.) followed Socrates and Plato. His father was a physician, apparently framing AristotleÕs interest in the natural world. He is known for his contribution to logic. Aristotle believed that the highest degree of reality is what we perceive with our senses. Unlike Plato, Aristotle did not believe in forms as separate from the real objects. When an object has both form and matter, it is called a Early Philosophy111
substance. Aristotle said happiness was manÕs goal and came through balance of the following: life of pleasure and enjoyment, life as a free and responsible citizen, and life as a thinker and philosopher.During the Neoplatonism age in the third century, philosophy became known as the soulÕs vehicle to return to its intelligible roots. There was an extrarational approach to reach union with the One. Thinking was that truth, and certainty was not found in this world. This was a revival of the Òother worldlinessÓ thinking of Plato.The birth of Christianity and Western philosophy came at the death of classicism. Augustine of Hippo (a.d. 354Ð430) became a Christian and was attracted to Neoplatonism, where existence is di-vine. In that period, evil was defined as an absence or incompleteness. Saint Thomas Aquinas (a.d. 1225Ð1274) is credited with bringing theology and philosophy together.Throughout the centuries, from the Greeks to the present day, peo-ple have debated the same questions: What is man [sic]? What is God? How do God and man relate? How does man relate to man? One can become dizzy thinking about the possibilities. Humans have been ask-ing questions for a very long time, and thankfully that practice is not about to change. People have searched for truth and will continue to do so. Therefore, we should not strive to find absolute answers; rather, we should endeavor to be comfortable with the questioning. Table 3-1 provides an overview of the perspectives of truth through the ages. From the pre-Socratics to the poststructuralists and postmodern think-ers, ways of knowing and finding truth have changed.TABLE 3-1 Overview of the Perspectives of Truth through the AgesSchool of ThoughtMeaning of Truth (Philosophers)Classical philosophersTruth corresponds with reality, and reality is achieved through our per-ceptions of the world in which we live.Truth could be found in the natural worldÑthrough our sensory experi-ences. (Heraclitus, Aristotle)Truth can be found in the natural worldÑthrough our rational intellect. (Parmenides, Plato)Truth is found when one knows self. (Socrates)Truth is not of this world. (Plotinus)TheocraticsTruth comes through an understanding of God.Truth can be found through both the senses and the intellect. (St. Thomas Aquinas)EmpiricistsTruth is based on experience and relating to our experiences. (Bacon, Locke, Hume, Mill)(continues)CHAPTER 3 Philosophy of Nursing112
Now, back to the real world: What is the purpose for this dia-logue in a text on professional nursing? One of the critical theorists, Habermas, would say, ÒCommunication is the way to truth.Ó We have this discussion because it leads us to truth. In this case, the dialogue leads us to truth about nursing. What we hold as truth does not come through mere reading, studying, or debating. The truth comes through dialogue. LetÕs continue.ParadigmsHow do you see the world? Whether you know it or not, you have an established worldview or paradigm. A paradigm is the lens through which you see the world. Paradigms are also philosophical founda-tions that support our approaches to research (Weaver & Olson, 2006). The continuum of realism and idealism explains bipolar para-digms (Box 3-1). Most people today would agree that Òsomewhere in the middleÓ of these dichotomies lies truth.Our philosophies are established from a lifelong process of learn-ing and show us how we find truth. In other words, a philosophy is our method of knowing. The experiences we have with ourselves, others, and the environment provide structure to our thinking. School of ThoughtMeaning of Truth (Philosophers)RationalistsAll things are knowable by deductive reasoning. (Descartes, Spinoza)IdealistsTruth exists only in the mind. (Berkeley, Hegel, Kant)PositivistsTruth is science and the facts that science discovers. (Comte, Mill, Spencer)Early existentialistsTruth is found through faith in existence as it relates to God. (Kierkegaard)PragmatistsTruth is relative and practicalÑif it works, then it is truth. (James, Peirce, Dewey)RelativistsTruth is always dependent on the knower and the knowerÕs context. (Kuhn, Laudan)PhenomenologistsTruth is in human consciousness. (Husserl, Heidegger)ExistentialistsIf truth can be found, it can be found only through the search for self. (Sartre, Merleau-Ponty, Gadamer)Poststructuralists/PostmodernistsTruth (if there is truth) is not singular and is always historical.Truth can be found in the deconstruction of language. (Derrida)Truth is (evolves from) the outcomes of events. (Foucault)Truth is created through dialogue with a purpose of emancipatory action. (Habermas, Freire)Truth is unique to gender. (Feminists)Paradigms113
Ultimately, our philosophies are demonstrated in the outcomes of our day-to-day living. NursesÕ values and beliefs about the profession come from observation and experience (Buresh & Gordon, 2000).Your worldview of nursing began long before you enrolled in nursing school. As far as you can remember, think back on your un-derstanding of nursing. What did you think you would do as a nurse? Did you know a nurse? Did you have an experience with a nurse? What images of the nurse did you see on television or in the movies? Since that time, your worldview of nursing has changed. What experi-ences in school have changed your perspective of nursing? Undoubt-edly, how you see nursing now will differ from your worldview in a few yearsÑor even a few months.BeliefsA chief goal of this chapter is to provide a starting point for writing a personal philosophy of nursing. To do that, we must have a discussion of beliefs and values. Beliefs indicate what we value, and according to Steele (1979), beliefs have a faith component. Rokeach (1973) identi-fies three categories of beliefs: existential, evaluative, and prescriptive/proscriptive beliefs. Existential beliefs can be shown to be true or false. An example is the belief that the sun will come up each morn-ing. Evaluative beliefs describe beliefs that make a judgment about whether something is good or bad. The belief that social drinking is immoral is an evaluative belief. Prescriptive and proscriptive beliefs refer to what people should (prescriptive) or should not (proscriptive) do. An example of a prescriptive or desirable belief is that everyone should vote. An example of an undesir-able or proscriptive belief is that people should not BOX 3-1 THE CONTINUUM OF REALISM AND IDEALISMRealism¥ The world is static.¥ Seeing is believing.¥ The social world is a given.¥ Reality is physical and independent.¥ Logical thinking is superior.Idealism¥ The world is evolving.¥ There is more than meets the eye.¥ The social world is created.¥ Reality is a conception perceived in the mind.¥ Thinking is dynamic and constructive.CRITICAL THINKING QUESTION✶Where do you see yourself and your under-standing of truth on the continuum of real-ism and idealism?✶CHAPTER 3 Philosophy of Nursing114
be dishonest. Beliefs demonstrate a personal confi-dence in the validity of a person, object, or idea.Consider the second concept in nursing: envi-ronment. How do you define the internal (within the person) and external (outside the person) envi-ronments? Is it important that nurses look beyond the individual toward the surroundings and struc-tures that influence quality of human life? If yes, then how do you see the relationship between the internal and external environments? Is one dimen-sion more important than the other? How do they interact with each other? Martha Rogers, a grand theorist in nursing, described the environment as continuous with the person, no boundaries, in con-stant exchange of energy. Would you agree?Health is the third domain of nursing to ponder. Is health the same as the absence of illness? Is health perception? A person who is living and surviving may be described as Òhealthy.Ó Would you support that as a comprehensive definition of health? Doheny et al. (1997) referred to health in the following way:Health is dynamic and ever changing, not a stagnant state. Health can be measured only in relative terms. No one is absolutely healthy or ill. In addition, health applies to the total person, including progression toward the realization and fulfillment of oneÕs potential as well as maintaining physical, psychosocial health. (p. 19)Maybe that definition is sufficient, but probably not. All definitionsÑ including yoursÑhave limitations. Definitions merely give us a way to express our beliefs and may, as our beliefs do, evolve over time.Finally, consider common beliefs about nursing. Clarke (2006) posed that question in ÒSo What Exactly Is a Nurse?ÓÑan article ad-dressing the problematic nature of defining nursing. The American Nurses Association (ANA) provided a much-used definition of nurs-ing in 1980: ÒNursing is the diagnosis and treatment of human re-sponses to actual and potential health problemsÓ (p. 9). Fifteen years later, the ANA (1995) expanded its basic definition of nursing to acknowledge four fundamental aspects. According to this definition, professional nursing includes attention to the full range of human experiences and responses to health and illness without restriction to a problem-focused orientation, integration of objective data with an understanding of the subjective experience of the patient, application of scientific knowledge to the processes of diagnosis and treatment, and provision of a caring relationship that facilitates health and heal-ing. In 2003, the ANA added two essential features to this list that CRITICAL THINKING QUESTIONS✶How would you define person? Look at the following attributes given to a person: (1) the ability to think and conceptualize, (2) the capacity to interact with others, (3) the need for boundaries, and (4) the use of language (Doheny et al., 1997). Would you agree? What about MaslowÕs descrip-tion of humanness in terms of a hierarchy of needs with self-actualization at the top? Another possibility is that persons are the major focus of nursing. Do you see humans as good or evil?✶Beliefs115
reflect nursingÕs commitment to meeting the needs of society amid constant changes in the healthcare environment. These additional features are the advancement of nursing knowledge through schol-arly inquiry and the influence on social and public policy for the promotion of social justice.The definition of nursing has been only slightly modified since the 2003 revision: ÒNursing is the protection, promotion, and optimiza-tion 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 populationsÓ (ANA, 2010, p. 10), with the newest revision (2015) specifically including the concept of facilitation of healing and add-ing groups to the list of recipients of nursing care. Four essential characteristics of nursing identified from the definition are Òhuman responses or phenomena, theory application, nursing actions or inter-ventions, and outcomesÓ (ANA, 2010, p. 10).How would you define nursing? Understanding our beliefs and articulating them in definitions are beginning steps for developing a personal philosophy. Definitions tell us what things are. Our philoso-phy tells us how things are. One other piece must be addressed before we begin writing our personal philosophy: the topic of values.ValuesValues refer to what the normative standard should be, not necessar-ily to how things actually are. Values are the principles and ideals that give meaning and direction to our social, personal, and professional lives. Steele (1979) defines value as Òan affective disposition towards a person, object, or ideaÓ (p. 1). The values of nursing have been ar-ticulated by such groups as the ANA in the Code of Ethics (2001), the National League for Nursing (NLN) Education Competencies Model (2010), and the American Association of Colleges of Nursing (AACN) in The Essentials: Core Competencies for Professional Nursing Edu-cation (2021). The NLN identifies seven core values as foundational for all nursing practice that include caring, diversity, ethics, excellence, holism, integrity, and patient centeredness. The AACN essentials for baccalaureate nursing education (2008) calls for integration of profes-sional nursing values in baccalaureate education that include altruism, autonomy, human dignity, integrity, and social justice. The AACNÕs reenvisioned essential document integrates the values of diversity, eq-uity, and inclusion throughout the domains (2021, p. 5).Nursing values have been identified as the fundamentals that guide our standards, influence practice decisions, and provide the framework used for evaluation (Kenny, 2002). Nevertheless, nurs-ing has been criticized as not clearly articulating what our values CRITICAL THINKING QUESTION✶What are your beliefs about the major con-cepts in nursingÑperson, environment, health, nursing?✶KEY OUTCOME 3-1Example of Domain 9 subcompetency for entry-level professional nursing education.9.5b Demonstrate the core values of professional nursing identity (p. 55).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfCHAPTER 3 Philosophy of Nursing116
are (Kenny, 2002). If nursing is to engage in the move to Òinter-professional working,Ó which is beyond uniprofessional and mul-tiprofessional relationships, we have to define our values clearly. Interprofessional working validates what others provide in health care, and the relationships depend on mutual input and collabora-tion. Values in nursing need to be clearly articulated so that they can be discussed in the context of interprofessional partnership. We can then work together across traditional boundaries for the good of patients. Nursing offers something to health care that no other profession does, but that something must first be clear to those of us in nursing. ÒIt is not enough just to argue that caring is never value-free, and that values are a fundamental aspect of nursing. What is required is greater precision and clarity so that values can be identi-fied by those within the profession and articulated beyond itÓ (Kenny, 2002, p. 66).Statements such as those by the ANA, the NLN, and the AACN mentioned earlier are a step in the right direction. Others have identi-fied nursing values using different language. Antrobus (1997) sees nursing values as humanistic and include (1) a nurturing response to someone in need, (2) a view of the whole individual, (3) an empha-sis on the individualÕs perspective, (4) concentration on developing human potential, (5) an aim of well-being, and (6) maintenance of the nurseÐpatient relationship at the heart of the helping situation. Nursing values have also been listed as caregiving, accountability, integrity, trust, freedom, safety, and knowledge (Weis & Schank, 2000).Rokeach (1973) makes the following assertions about values:¥ Each person has a few.¥ All humans possess the same values.¥ People organize values into systems.¥ Values are developed in response to culture, society, and personality.¥ Behaviors are manifestations or consequences of values.The process of valuing involves three steps: (1) choosing values, (2) prizing values, and (3) acting on values (Chitty, 2001). To choose a value is an intellectual stage in which a person selects a value from identified alternatives. Second, prizing values involves the emotional or affective dimension of valuing. When we ÒfeelÓ a certain way about our values, it is because we have reached this second step. Finally, we have to act on our intellectual choice and emotion. This third step in-cludes behavior or action that demonstrates our value. Ideally, a genu-ine value is evidenced by consistent behavior.Steele (1979) distinguished between intrinsic and extrinsic values. An intrinsic value is required for living (e.g., food and water), whereas an extrinsic value is not required for living and is originated external Values117
to the person. According to Simon and Clark (1975), the following criteria must be met in acquiring values:¥ Must be freely chosen¥ Must be selected from a list of alternatives¥ Must have thoughtful consideration of each of the outcomes of the alternatives¥ Must be prized and cherished¥ Must involve a willingness to make values known to others¥ Must precipitate action¥ Must be integrated into lifestyleValue acquisition refers to when a new value is assumed, and value abandonment is when a value is relinquished. Value redistribution oc-curs when society changes views about a particular value. Values are more dynamic than attitudes because values include motivation as well as cognitive, affective, and behavioral components. Therefore, people have fewer values than attitudes (feelings or dispositions toward a per-son, object, or idea). In the end, values determine our choices.According to Steele (1979), values can compete with one another on our Òhierarchy of values.Ó We typically have values that we hold about education, politics, gender, society, occupations, culture, reli-gion, and so on. The values that are higher in the hierarchy receive more time, energy, resources, and attention. For change to occur, there must be conflict among the value system. For example, if a patient values both freedom from pain and long life but is diagnosed with bone cancer, a conflict in values will occur. If professional responsi-bilities and religious beliefs conflict, the solution is not as simple as Òright versus wrong.Ó Rather, it is the choice between two goods. For example, suppose you have strong religious views about abor-tion. During your rotation, you are assigned to care for someone who elects to have an abortion. As a nurse, you must balance the value of the patientÕs choice with your personal value about elective abortions. These decisions are not easy.Dowds and Marcel (1998) conducted a study involving 40 female nursing students who were taking a psychology class. The students completed the World Hypothesis Scale, which provided 12 items, each with four possible explanations of an event. Each of the four explana-tions represented a distinct way of thinking. A list of definitions and descriptions of the different ways of thinking includes the following:¥ Contextualism: Understanding is embedded in context; meaning is subjective and open to change and dependent on the moment in time and the personÕs perspective.¥ Formism: Understanding events in relationship to their similarity to an ideal or objective standard comes from categorization (e.g., the classification of plants and animals in biology).CHAPTER 3 Philosophy of Nursing118
¥ Mechanism: Understanding is in terms of cause-and-effect rela-tionships, the common approach used by modern medicine.¥ Organicism: Understanding comes from patterns and relation-ships; must understand the whole to understand the parts (e.g., cannot look at a childÕs language development without looking at his or her overall development history).The students ranked the explanations in terms of their preferences for understanding the event. Nursing students chose mechanistic think-ing significantly more than all other ways of thinking and chose contex-tualistic thinking significantly less than the other worldviews. No other comparisons were significant among or between the four worldviews. In other words, the nursing students did not choose options that allowed for more than one right answer. They resisted the options that allowed for ambiguity. What this tells us in relationship to values is that we can say that we value human response and the whole individual, but do we really? Human situations are dynamic, fluid, and open to multiple op-tions. Nursing claims to respond to these contextual needs, but do we?Values ClariÞcationClarifying our values is an eye-opening experience (Figure 3-1). The process of values clariÞcation can occur in a group or individually and KEY OUTCOME 3-2Example of Domain 9 sub-competency for entry-level professional nursing education.9.5c Demonstrate sensitiv-ity to the values of others (p. 55).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing .org/Portals/42/AcademicNursing/pdf /Essentials-2021.pdfFigure 3-1 Nursing students engaged in a classroom values clarification exercise to help discern both personal and professional values.© Iakov Filimonov/Shutterstock.Values119
helps us understand who we are and what is most important to us. The outcome of values clarification is positive because the outcome is growth. If the process occurs in a group, there must be trust within the group. No one should be embarrassed or intimidated. Everyone is respected.Values clarification exercises help people discern their individual values. A simple approach to begin the process is considering your responses to such statements as ÒPatients have a right to know every-thing that is in the medical record.Ó What is your immediate reaction? How do you feel about the options available in this situation? Have you acted on these beliefs in the past? Another statement to consider is this: ÒEveryone should have equal access to health careÑregardless of income.Ó Ask yourself the same questions. Other exercises involve real or hypothetical clinical situations. For example, a 19-year-old male with human immunodeficiency virus is totally dependent. His parents remain at his bedside but do not say a word. Another example is a single mom who has recently been diagnosed with multiple scle-rosis. What about a 70-year-old man who loses his wife of 42 years, only to remarry a woman who is soon diagnosed with dementia? Re-flect. What questions do you have? Why are these people in these situ-ations? Does that matter? What in the patientÕs life choices conflicts with your choices? Share this with your peers, your friends, and your teachers.In values clarification, one should consider the steps identified earlier as necessary for value acquisition: (1) choosing freely from among alternatives, (2) experiencing an emotional connection, and (3) demonstrating actions consistent with a stated value. We act on values as the climax of the values clarification process. We are more aware, more empathetic to others, and have greater insight into ourselves and those around us for having gone through this process. Our words and actions are not so different, and we become more content with the individuals we are (i.e., self-actualization). Values clarification also al-lows us to be more open to accepting othersÕ choice of values.We must keep in mind that values vary from person to person. Returning to the concept of health, if we asked several people ÒWhat is health?Ó we would get different responses because it means differ-ent things to different people. Most likely, we would find that others do not place health as high in their hierarchy of values as we do. This helps explain why some people go to the physician for every little ail-ment, whereas others wait until the situation is critical. Maintaining a nonjudgmental attitude about the values of others is crucial to the nurseÐpatient relationship.In health care, we need to clarify values for both the consumer and the provider in society. Referring once again to health, we rec-ognize that although the majority of our society states that health is a right, not a privilege, not everyone has health care. Is health KEY OUTCOME 3-3Example of Domain 9 subcompetency for entry-level professional nursing education.9.6b Demonstrate aware-ness of personal and professional values and conscious and unconscious biases (p. 55).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing .org/Portals/42/AcademicNursing/pdf /Essentials-2021.pdfCHAPTER 3 Philosophy of Nursing120
positioned at the top of societyÕs hierarchy of val-ues? We also have to assess the individualÕs values for congruency with the societal values. As re-search gives us new options to consider, continual reassessment of values is essential. A questioning attitude is healthy and necessary.As a profession, nursing is responsible for clar-ifying our values on a regular basis. Just as society places a value on health, society also determines the value of nursing in the provision of health. In addition, nurses need to be involved in all levels where decisions based on values are made, particularly with ethical decisions. The values that nursing sup-ports need to be communicated clearly to those making the policies that affect the health of our society.Values clarification is done for the purpose of understanding selfÑto discover what is important and meaningful (Steele, 1979). Throughout life, the process continues as it gives direction to life. As you work through the course of values clarification, keep in mind that personal and professional values are not necessarily the same.Developing a Personal Philosophy of NursingBefore we begin writing our individual nursing philosophies, consider the following comments about philosophy. According to Doheny et al. (1997), philosophy is defined as Òbeliefs of a person or group of per-sonsÓ and Òreveals underlying values and attitudes regarding an areaÓ (p. 259). In this concise definition, these authors mentioned the build-ing blocks of philosophy that we have discussed thus far: attitudes, beliefs, and values. Another definition that is not as concise reads, ÒNursing philosophy is a statement of foundational and universal as-sumptions, beliefs, and principles about the nature of knowledge and truth (epistemology) and about the nature of the entitiesÑnursing practice and human healing processesÑrepresented in the metapara-digm (ontology)Ó (Reed, 1999, p. 483). Finally, philosophy Òlooks at the nature of things and aims to provide the meaning of nursing phe-nomenaÓ (Blais et al., 2002, p. 90).In NursingÕs Agenda for the Future, the ANA (2002) identified the need for nurses to Òbelieve, articulate, and demonstrate the value of nursingÓ (p. 15). To do that, each professional nurse is responsible for clearly articulating a personal philosophy of nursing. Suggestions for developing personal professional philosophies have been presented in the literature (Brown & Gillis, 1999). The overall purpose of per-sonal philosophy is to define how one finds truth. Because there are different ways of knowing, each person has a unique way of finding KEY OUTCOME 3-4Example of Domain 1 subcompetency for entry-level professional nursing education.1.2d Examine inßuence of personal values in decision making for nursing practice (p. 27).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing .org/Portals/42/AcademicNursing/pdf /Essentials-2021.pdfCRITICAL THINKING QUESTIONS✶Do you believe there is more than one right answer to situations? How do you value the whole individual? What barriers prevent us from responding to the contextual needs of our patients?✶Developing a Personal Philosophy of Nursing121
truthÑin other words, identifying our individual philosophy. There-fore, your philosophy of nursing will be unique.How do you start writing? A suggested guide for writing your personal philosophy of nursing is in Box 3-2. When defining nursing, you may refer to definitions by professional individuals or groups. You may also choose to write an original definition, which is cer-tainly acceptable. A final challenge would be this: Once you have used words to describe your personal philosophy, try drawing it. This exercise can enlighten you to gaps in your understanding and further clarify the picture for you.Writing a philosophy does not have to be a difficult exercise. In fact, you have one alreadyÑyou just need to practice putting it on paper. Keep in mind that your philosophy will change over time. In addition, composing a nursing philosophy will help you see yourself as an active participant in the profession.Consider the scene if no one in nursing had a philosophy. What would happen? Unfortunately, we would find ourselves doing tasks without considering the rationale and performing routines in the ab-sence of purpose. Most likely, we would find ourselves devalued by our patients and fellow care providers.BOX 3-2 GUIDE FOR WRITING A PERSONAL PHILOSOPHY OF NURSING1. Introductiona. Who are you?b. Where do you practice nursing?2. Define nursing.a. What is nursing?b. Why does nursing exist?c. Why do you practice nursing?3. What are your assumptions or underlying beliefs about:a. Nurses?b. Patients?c. Other healthcare providers?d. Communities?4. Define the major domains of nursing and provide examples:a. Personb. Healthc. Environment5. Summarya. How are the domains connected?b. What is your vision of nursing for the future?c. What are the challenges that you will face as a nurse?d. What are your goals for professional development?KEY COMPETENCY 3-1Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesProfessionalism:Knowledge (K7) Under-stands ethical principles, values, concepts, and deci-sion making that apply to nursing and patient careSkills (S7c) IdentiÞes and responds to ethical con-cerns, issues, and dilem-mas that affect nursing practiceAttitudes/Behaviors (A7c) ClariÞes personal and professional values and recognizes their impact on decision making and pro-fessional behaviorAttitudes/Behaviors (A7d) Values acting with honesty and integrity in relationships with patients, families, and other team members across the con-tinuum of careMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. https://www.mass.edu/nahi /documents/nofrncompetencies_updated _march2016.pdfCHAPTER 3 Philosophy of Nursing122
Although our individual philosophies vary, there are similarities that link us in our universal philosophy as a profession. As a whole, we are kept on track by continually evaluating our at-titudes, beliefs, and values. We can evaluate our efforts by reflecting on our philosophies. In the process of personal and professional reflection, we are challenged to reach global relevancy and to begin the development of a global nursing philoso-phy (Henry, 1998).ConclusionIn this chapter, we have discussed one of the most ambiguous concepts in professional disciplinesÑnursing philosophy. The history of philosophy helps us to see that asking questions about humans, environment, health, and nursing is a continual process that leads to a better understanding of truth in our profession. Our own values and beliefs must be clarified so that we can authentically respond to the healthcare needs of our patients and to society as a whole. Along the way, our philosophies are changing. Therefore, we must constantly question the values of our profession, our society, and ourselvesÑaiming to better the health of all people worldwide.Hegel, an early philosopher, said, ÒHistory is the spirit seeking freedom.Ó On this path of searching for truth, we ask the same ques-tion but in different contexts and with distinct experiences. The an-swers for one person do not provide the same satisfaction for another person. Through our individual and collective searching, we become truth knowers. Habermas, the supporter of dialogue, would suggest that the journey does not end with communication and question-ing alone. When truth is revealed, oppressive forces are acknowl-edged, and the truth knowers are then responsible to move to action. Through that action comes a change in the social structure and the hope of rightness in the world.CRITICAL THINKING QUESTIONS✶Do I believe in health care for everyone? Does health care for everyone have value to me as a person? Does it have value to me as a nurse? What value does universal health care have to my patients?✶CRITICAL THINKING QUESTIONS✶How does my personal philosophy fit with the context of nursing? Does it fit? What ar-eas, if any, need assessing?✶KEY COMPETENCY 3-2Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesProfessionalism:Knowledge (K8a) Under-stands responsibilities inherent in being a member of the nursing professionSkills (S8a) Understands the history and philosophy of the nursing professionAttitudes/Behaviors (A8b) Values and upholds altruistic and humanistic principlesMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. https://www.mass.edu/nahi /documents/nofrncompetencies_updated _march2016.pdfClassroom Activity 3-1Take about 15 minutes after the class discus-sion related to developing a philosophy of nursing to begin answering the questions in Box 3-2. Jot down answers to the questions in Box 3-2. Ask questions as necessary while still in the classroom. This simple activity will make it easier when actually writing a per-sonal philosophy of nursing.Conclusion123
Classroom Activity 3-2After thinking about your answers to the questions in Box 3-2 related to the metapara-digm concepts (person, health, environment, and nursing), draw each of these concepts as you define them on a separate piece of paper. Save your drawings and think about them and refine them as you develop your philosophy of nursing. This activity works best if you use colored pencils, crayons, or markers. An ex-ample is presented in Figure 3-2.BodySoul(emotion, intellect, and will)Spirit(conscience,intuition,communion)Figure 3-2 Drawing of the concept of person.Reproduced from Masters, K. (2006). Drawing of concept of person. Unpublished classroom exercise, as adapted from Nee, W. (1968). The spiritual man. Christian Fellowship Publishers.CHAPTER 3 Philosophy of Nursing124
ReferencesAmerican Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. https://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08 .pdfAmerican Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Essentials-2021.pdfAmerican heritage dictionary of the English language (4th ed.). Houghton Mifflin.American Nurses Association. (1980). Nursing: A social policy statement. Author.American Nurses Association. (1995). NursingÕs social policy statement. Author.American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Author.American Nurses Association. (2002). NursingÕs agenda for the future: A call to the nation. Author.American Nurses Association. (2003). NursingÕs social policy statement: The essence of the profession. Author.American Nurses Association. (2010). NursingÕs social policy statement: The essence of the profession. Author.American Nurses Association. (2015). Nursing: Scope and standards of practice (3rd ed.). Author.Antrobus, S. (1997). An analysis of nursing in context: The effects of current health policy. Journal of Advanced Nursing, 45, 447Ð453.Blais, K. K., Hayes, J. S., Kozier, B., & Erb, G. (2002). Professional nursing practice: Concepts and perspectives (4th ed.). Prentice Hall.Brown, S. C., & Gillis, M. A. (1999). Using reflective thinking to develop personal professional philosophies. Journal of Nursing Education, 38, 171Ð176.Buresh, B., & Gordon, S. (2000). From silence to voice: What nurses know and must communicate to the public. Cornell University Press.Chitty, K. K. (2001). Philosophies of nursing. In K. K. Chitty (Ed.), Professional nursing: Concepts and challenges (pp. 199Ð217). Saunders.Clarke, L. (2006). So what exactly is a nurse? Journal of Psychiatric and Mental Health Nursing, 13, 388Ð394.Doheny, M. O., Cook, C. B., & Stopper, M. C. (1997). The discipline of nursing: An introduction (4th ed.). Appleton & Lange.Dowds, B. N., & Marcel, B. B. (1998). StudentsÕ philosophical assumptions and psychology in the classroom. Journal of Nursing Education, 37, 219Ð222.Henry, B. (1998). Globalization, nursing philosophy, and nursing science. Image: Journal of Nursing Scholarship, 30, 302.Kenny, G. (2002). The importance of nursing values in interprofessional collaboration. British Journal of Nursing, 11(1), 65Ð68.Massachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. https://www.mass.edu/nahi/documents/nofrncompetencies_updated_march2016.pdfMasters, K. (2006). Drawing of concept of person. Unpublished classroom exercise.National League for Nursing. (2010). Outcomes and competencies for graduates of practical/vocational, diploma, associate degree, baccalaureate, masterÕs, practice doctorate, and research doctorate programs in nursing. Author.Nee, W. (1968). The spiritual man. Christian Fellowship.Reed, P. G. (1999). A treatise on nursing knowledge development for the 21st century: Beyond postmodernism. In E. C. Polifroni & M. Welch (Eds.), Perspectives on philosophy of science in nursing (pp. 478Ð490). Lippincott.Rokeach, M. (1973). The nature of human values. Free Press.References125
Simon, S. B., & Clark, J. (1975). Beginning values clarification: A guidebook for the use of values clarification in the classroom. Pennant Press.Steele, S. (1979). Values clarification in nursing. Appleton-Century-Crofts.Weaver, K., & Olson, J. K. (2006). Understanding paradigms used for nursing research. Journal of Advanced Nursing, 53, 459Ð469.Weis, D., & Schank, M. J. (2000). An instrument to measure professional nursing values. Journal of Nursing Scholarship, 32, 201Ð204.CHAPTER 3 Philosophy of Nursing126
OverviewThe art and science of nursing are based on a framework of caring and respect for human dignity. A compassionate approach to pa-tient care mandates that nurses provide care in a competent manner (Massachusetts Department of Higher Education [MDHE], 2010). Competence has been defined as the ability to demonstrate an inte-gration of knowledge, attitudes, and skills necessary to function in a specific role and work setting. As applied to nursing, competence is an expected and measurable level of nursing performance that inte-grates knowledge, skills, abilities, and judgment, based on established scientific knowledge and expectations for nursing practice (American Nurses Association [ANA], 2015, p. 86).In response to calls from the Institute of Medicine (IOM) for increases in safety and quality near the turn of the century, renewed interest in competency in nursing practice emerged, with organiza-tions publishing documents delineating expectations for nursing Key Terms and Concepts ÈClinical judgment ÈClinical reasoning ÈCompetence ÈConcept mapping ÈCritical thinking ÈJournaling ÈMindfulness ÈNursing process ÈReßective thinkingAfter completing this chapter, the student should be able to:1. Describe core competencies for graduates of prelicensure nursing programs.2. Describe the relationships among critical thinking, clinical judgment, clinical reason-ing, decision making, and mindfulness.3. Explore the characteristics of critical thinking and the critical thinker.4. Explore the process involved in critical thinking.5. Explore strategies to develop critical thinking skills.6. Explore models of clinical judgment.Learning ObjectivesCompetencies for Professional Nursing PracticeKathleen Masters and Jill RushingCHAPTER 4© Nuu Jeed/Shutterstock127
education and practice. For example, the American Association of Colleges of Nursing (AACN, 2008) Essentials document outlines outcomes expected for the baccalaureate-prepared nurse, and the Technology Informatics Guiding Education Reform (TIGER), or what is known as the TIGER Initiative, has become the standard for informatics competencies for practicing nurses (TIGER, 2009).The best-known initiative that emerged during this era was the Quality and Safety Education for Nurses (QSEN) project, funded by the Robert Wood Johnson Foundation, that began in 2005. Six com-petences were identified during the QSEN project: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, informatics, and safety. In addition to the identification and definition of the competencies, sets of knowledge, skills, and atti-tudes for each competency were developed (QSEN, 2018). The sets of knowledge, skills, and attitudes for each QSEN competency provided a framework to assess or measure the attainment of each competency as relevant to nursing practice.Nursing CompetenciesNurse of the Future: Nursing Core CompetenciesThe Nurse of the Future: Nursing Core Competencies also provides a framework for the provision of competent nursing care (MDHE, 2010). What makes this model different is that it builds on many doc-uments in nursing that include the AACNÕs (2008) Essentials of Bacca-laureate Education for Professional Nursing Practice, National League for Nursing Council of Associate Degree Nursing competencies, IOM recommendations, QSEN competencies, and ANA standards as well as other professional organization standards and recommendations.The 10 essential competencies included in the Nurse of the Fu-ture: Nursing Core Competencies that are intended to guide nursing curricula and practice emanate from the central core of the model that represents nursing knowledge (MDHE, 2016). The 10 compe-tencies included in the model are patient-centered care, professional-ism, informatics and technology, evidence-based practice, leadership, systems-based practice, safety, communication, teamwork and col-laboration, and quality improvement. Essential knowledge, skills, and attitudes (KSAs) reflecting cognitive, psychomotor, and affective learn-ing domains are specified for each competency. The KSAs identified in the model reflect the expectations for initial nursing practice follow-ing the completion of a prelicensure professional nursing education program (MDHE, 2016). Nurse of the Future: Nursing Core Com-petencies are included throughout each chapter through the use of competency boxes that link examples of the KSAs appropriate to the CHAPTER 4 Competencies for Professional Nursing Practice128
chapter content to Nurse of the Future: Nursing Core Competencies required of entry-level professional nurses. The competency model in its entirety is available online at http://www.mass.edu/nahi /documents/NOFRNCompetencies_updated_March2016.pdf.The Nurse of the Future: Nursing Core Competencies graphic illustrates through the use of broken lines the reciprocal and con-tinuous relationship between each of the competencies and nursing knowledge, that the competencies can overlap and are not mutually exclusive, and that all competencies are of equal importance. In addi-tion, nursing knowledge is placed as the core in the graphic to illus-trate that nursing knowledge reflects the overarching art and science of professional nursing practice (MDHE, 2016). Figure 4-1 depicts the Nurse of the Future: Nursing Core Competencies.PRACTICE ENVIRONMENT PRACTICE ENVIRONMENT PRACTICE PRACTICE K-KnowledgeS-SkillsA-AttitudesNursingknowledgeBOARD OF HIGHER EDUCATION NURSING INITIATIVENURSING CORE COMPETENCIESThe science and practice of nursingSafetyInformaticsLeadershipPatient-centeredcareProfessionalismCommunicationSystem-basedpracticeTeamwork andcollaborationEvidence-basedpracticeQualityimprovementFigure 4-1 The Nurse of the Future: Nursing Core Competencies graphic.Massachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdfNursing Competencies129
The Nurse of the Future: Nursing Core Competencies (MDHE, 2016) document addresses the knowledge base and relationships among concepts important to the practice of nursing. In the context of nursing knowledge, the concepts of patient, environment, health, and nursing are defined in Table 4-1.The Nurse of the Future: Nursing Core Competencies for the reg-istered nurse includes the following 10 core competencies, each with a corresponding definition:¥ Patient-centered care: ÒThe Nurse of the Future will provide ho-listic care that recognizes an individualÕs preferences, values, and needs and respects the patient or designee as a full partner in pro-viding compassionate, coordinated, age and culturally appropriate, safe and effective careÓ (MDHE, 2016, p. 10).¥ Professionalism: ÒThe Nurse of the Future will demonstrate ac-countability for the delivery of standard-based nursing care that is consistent with moral, altruistic, legal, ethical, regulatory, and humanistic principlesÓ (MDHE, 2016, p. 14).¥ Leadership: ÒThe Nurse of the Future will influence the behavior of individuals or groups of individuals within their environment in a way that will facilitate the establishment and acquisition/achievement of shared goalsÓ (MDHE, 2016, p. 18).¥ Systems-based practice: ÒThe Nurse of the Future will demonstrate an awareness of and responsiveness to the larger context of the health care system and will demonstrate the ability to effectively call on work unit resources to provide care that is of optimal qual-ity and valueÓ (MDHE, 2016, p. 22).TABLE 4-1 Metaparadigm Concepts as DeÞned in the Nurse of the Future: Nursing Core CompetenciesHuman being/patientsÒThe recipient of nursing care or services . . . Patients may be individuals, families, groups, communities, or populationsÓ (AACN, 1998, p. 2, as cited in MDHE, 2016, p. 9).EnvironmentÒThe atmosphere, milieu, or conditions in which an individual lives, works or playsÓ (ANA, 2004, p. 47, as cited in MDHE, 2016, p. 9).HealthÒAn experience that is often expressed in terms of wellness and illness, and may occur in the presence or absence of disease or injuryÓ (ANA, 2004, p. 5, as cited in MDHE, 2016, p. 9).NursingÒ[T]he 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, groups, communities, and populationsÓ (ANA, 2001, p. 5, as cited in MDHE, 2016, p. 9).CHAPTER 4 Competencies for Professional Nursing Practice130
¥ Informatics and technology: ÒThe Nurse of the Future will be able to use advanced technology and to analyze as well as synthesize information and collaborate in order to make critical decisions that optimize patient outcomesÓ (National Academies of Sciences, Engineering, and Medicine, 2015, as cited in MDHE, 2016, p. 26).¥ Communication: ÒThe Nurse of the Future will interact effectively with patients, families, and colleagues, fostering mutual respect and shared decision making, to enhance patient satisfaction and health outcomesÓ (MDHE, 2016, p. 32).¥ Teamwork and collaboration: ÒThe Nurse of the Future will func-tion effectively within nursing and interdisciplinary teams, foster-ing open communication, mutual respect, shared decision making, team learning, and developmentÓ (adapted from QSEN, 2007, as cited in MDHE, 2016, p. 37).¥ Safety: ÒThe Nurse of the Future will minimize risk of harm to pa-tients and providers through both system effectiveness and individ-ual performanceÓ (QSEN, 2007, as cited in MDHE, 2016, p. 42).¥ Quality improvement: ÒThe Nurse of the Future uses data to monitor the outcomes of care processes, and uses improvement methods to design and test changes to continuously improve the quality and safety of health care systemsÓ (QSEN, 2007, as cited in MDHE, 2016, p. 45).¥ Evidence-based practice: ÒThe Nurse of the Future will identify, evaluate, and use the best current evidence coupled with clinical expertise and consideration of patientsÕ preferences, experience and values to make practice decisionsÓ (adapted from QSEN, 2007, as cited in MDHE, 2016, p. 47).The committee that designed the Nurse of the Future: Nursing Core Competencies also identified several assumptions and principles to serve as a framework. The assumptions include:1. Education and practice partnerships are key in developing an effective model.2. It is imperative that leaders in nursing education and practice de-velop collaborative curriculum models to facilitate the achievement of a minimum of a baccalaureate degree in nursing for all nurses.3. A more effective education system must be developed, one capable of incorporating shifting demographics and preparing the nursing workforce to respond to current and future healthcare needs and population health issues.4. The nurse of the future will be proficient in a core set of competencies.5. Nurse educators in education and practice settings will need to use a different set of knowledge and teaching strategies to effectively in-tegrate the Nurse of the Future core competencies into curriculum.6. The nursesÕ role is integral in recognizing the social and cultural determinants of health that are essential to disease prevention and Nursing Competencies131
health promotion efforts needed to improve health and health care and to build a culture of health across the Commonwealth and the nation.7. With societal shifts, information-related innovations and a focus on teamwork and collaboration, health professions education will be interprofessional and focused on collaborative practice.8. To create competencies for the future, there must be an ongoing process of evaluation and updating of the competencies to en-sure that they are reflective of contemporary healthcare practice. (MDHE, 2016, p. 4)Just as the Nurse of the Future: Nursing Core Competencies have changed between the first publication in 2010 and the current revi-sion (MDHE, 2010, 2016), expectations for the profession of nursing will continue to change with increases in knowledge and changes in technology that affect both nursing practice and patient outcomes. These changes promise to be constant, requiring professional nurses who are vigilant in their practice when it comes to maintaining competency through continuous, lifelong education and workplace training.The Essentials: Core Competencies for Professional Nursing EducationThe reenvisioned Essentials establishes the expected competencies of graduates from baccalaureate, masterÕs, and doctor of nursing practice (DNP) programs prepared to work in the current healthcare environment. The Essentials are built on the foundation of nursing as a discipline, the foundation of a liberal arts education, and principles of competency-based education (AACN, 2021, p.2) and introduce 10 domains of professional nursing practice with competencies and subcompetencies in each of the domains (AACN, 2021, pp. 10Ð11). The 10 domains with descriptors include:¥ Knowledge for nursing practice: ÒIntegration, translation, and application of established and evolving disciplinary nursing knowledge and ways of knowing as well as knowledge from other disciplinesÓ (AACN, 2021, p. 10).¥ Person-centered care: Ò[F]ocuses on the individual within multiple complicated contexts . . . is holistic, individualized, just, respectful, compassionate, coordinated, evidence-based, and developmentally appropriateÓ (AACN, 2021, p. 10).¥ Population health: Ò[S]pans the healthcare delivery continuum from public health prevention to disease management of popula-tions and describes collaborative activitiesÓ (AACN, 2021, p. 10).¥ Scholarship for nursing practice: ÒThe generation, synthesis, trans-lation, application, and dissemination of nursing knowledge to improve health and transform health careÓ (AACN, 2021, p. 10).CHAPTER 4 Competencies for Professional Nursing Practice132
¥ Quality and safety: ÒEmployment of established and emerging principles of safety and improvement science. Quality and safety, as core values of nursing practice, enhance quality and minimize risk of harm to patients and providers through both system effec-tiveness and individual performanceÓ (AACN, 2021, p. 10).¥ Interprofessional partnerships: ÒIntentional collaboration across professions and with care team members, patients, families, commu-nities, and other stakeholders to optimize care, enhance the health-care experience, and strengthen outcomesÓ (AACN, 2021, p. 10).¥ Systems-based practice: ÒResponding to and leading within com-plex systems of health careÓ (AACN, 2021, p. 11).¥ Information and healthcare technologies: ÒInformatics processes and technologies are used to manage and improve the delivery of safe, high quality, and efficient healthcare services in accordance with best practice and professional and regulatory standardsÓ (AACN, 2021, p. 11).¥ Professionalism: ÒFormation and cultivation of sustainable profes-sional nursing identity, accountability, perspective, collaborative disposition, and comportment that reflects nursingÕs characteristics and valuesÓ (AACN, 2021, p. 11).¥ Personal, professional, and leadership development: ÒParticipation in activities and self-reflection that foster personal health, resilience, and well-being, lifelong learning, and support the acquisition of nursing expertise and assertion of leadershipÓ (AACN, 2021, p. 11).Reproduced from American Association of Colleges of Nursing. (2021). The Essentials: Core Competencies for Professional Nursing Education. https://www .aacnnursing.org/Portals/42/AcademicNursing/pdf/Essentials-2021.pdfIn addition to the domains, competencies, and subcompeten-cies, concepts essential to nursing practice are integrated throughout the Essentials. These concepts include clinical judgment, communi-cation, compassionate care, diversity, equity and inclusion, ethics, evidence-based practice, health policy, and social determinants of health (AACN, 2021, pp. 11Ð14).It is predicted that the future of healthcare delivery will occur in four spheres of care, so it is also important that the professional nurse is competent to practice across all four spheres of care with diverse populations, across the life span, and in a variety of settings. The competencies for each domain are designed to be applicable across all four spheres of care. The four identified Òspheres of care include dis-ease prevention/promotion of health and well-being; chronic disease care; regenerative or restorative care; and hospice/palliative/ supportive careÓ (reproduced from AACN, 2021, p. 6).Examples of the AACN Essentials domains and applicable sub-competencies are integrated throughout this text as Key Outcomes. The Essentials: Core Competencies for Professional Nursing Educa-tion may be viewed in its entirety at https://www.aacnnursing .org/Portals/42/AcademicNursing/pdf/Essentials-2021.pdf.Nursing Competencies133
Critical Thinking, Clinical Judgment, and Clinical Reasoning in Nursing PracticeNursing competence plays a large role in ensuring patient safety. In addition to such initiatives as QSEN (2018) and Nurse of the Future: Nursing Core Competencies (MDHE, 2016), in 2008, the Robert Wood Johnson Foundation and the IOM launched a 2-year initiative to respond to the need to assess and transform the nursing profession. The IOM report points out that nurses are going to have a critical role in the future, especially in producing safe, high-quality care and coverage for all patients in our healthcare system (IOM, 2011). The Agency for Healthcare Research and Quality (2008), in collaboration with the Robert Wood Johnson Foundation, developed a handbook for nurses on patient safety and quality. The handbook provides a wealth of information for nursing, including background research and tools for improving the quality of care. As one can see, many initiatives in nursing during the past decade focused on patient safety.A majority of sentinel events occur in acute care settings, where new graduate nurses traditionally begin their professional nursing careers. The inability of a nurse to set priorities and to work safely, effectively, and efficiently can delay patient treatment in a critical situation and result in serious life-threatening consequences. The ability of nurses to think critically and to make sound clinical judg-ments is essential to providing safe, competent, and high-quality nursing care.New realities of health care require nurses to master complex information, to coordinate a variety of care experiences, to use ad-vanced technology for healthcare delivery and evaluation of patient outcomes, and to assist patients with managing and navigating an increasingly complex system of care. Some of the trends that have added to the complexities of the healthcare environment include increases in longevity, markedly shortened hospital stays (which are moving patients out of the hospital Òquicker and sickerÓ), scientific advances and major advances in technology, increased diversity in the U.S. population, and an increased incidence of chronic diseases and infectious diseases. Complicating things is the phenomenon known as information overload or cognitive overload, which is the inter-pretation that one makes in response to breakdowns, interruptions, or imbalances between demand and capacity. The interpretation of overload is affected by the situation, including the developmental level and expertise of the registered nurse (Sitterding, 2015), making it im-perative that nurses enter the profession with experiences that enable CHAPTER 4 Competencies for Professional Nursing Practice134
effective interpretation and clinical judgment to function efficiently in the complex healthcare system.The responsibilities of a professional registered nurse (RN) have increased significantly over the years. Nurses and nursing students must be able to function within the complicated environment of the healthcare system. The effect of advanced technology and the in-creased acuity level and complexity of patients, combined with the accountability and responsibility nurses have in the delivery of safe and effective care, make it essential, now more than ever, for nurses to possess the ability to think critically. In nursing, critical thinking is the ability to think in a systematic and logical manner, solve problems, make decisions, and establish priorities in the clinical setting. Critical thinking is the competent use of thinking skills and abilities to make sound clinical judgments and safe decisions.Critical thinking in nursing is an essential component of profes-sional accountability and high-quality nursing care. Concern for pa-tient safety has grown as high rates of error and injury continue to be reported. To improve patient safety, nurses must be able to recognize changes in patient condition, perform independent nursing interven-tions, anticipate orders, and prioritize.New nurses need to be prepared to practice safely, accurately, and compassionately, in varied settings, where knowledge and innovation increase at astonishing rates (Benner et al., 2010). Nursing students must use a complex array of nursing skills and knowledge at the same time and practice thinking in changing situations, always for the good of the patient (Benner et al., 2010).Recent studies indicate that new nursing graduates have deficien-cies in critical thinking ability, including recognition of problems, reporting of essential clinical data, initiating independent nursing interventions, anticipating relevant medical orders, providing relevant rationale to support decisions, and differentiating urgency (Fero et al., 2009). New graduate nurses practice at the novice or advanced begin-ner level (Benner, 1984). New graduate nurses are at the early stage of developing a skill set and applying critical thinking (Figure 4-2). For the novice, the beginning nursing student, the difficulty encoun-tered in setting priorities is that all tasks, requests, and concerns seem to be of equal weight or importance and must all be done (Benner et al., 2010). Determining which tasks are most important or urgent requires deliberate thought because the student has not yet learned to see the big picture or gained the skill to recognize quickly what is most urgent or most important in each clinical situation; this level of thinking is often difficult for the novice (Benner et al., 2010). For ex-ample, you are about to administer medications to a patient. What is the bigger picture? Why is the patient being given these medications? Alternatively, you have a patient who has just returned from surgery. What should be carried out in the first hours after surgery?Critical Thinking, Clinical Judgment, and Clinical Reasoning in Nursing Practice135
What Is Critical Thinking?Critical thinking is an integral part of nursing practice that promotes high-quality nursing care and positive patient outcomes. Although critical thinking is widely regarded as a component of clinical rea-soning and decision making, it is difficult to define, and there is no single, simple definition that explains critical thinking. In nursing, critical thinking for clinical decision making is the ability to think in a systematic and logical manner, with openness to question and reflect on the reasoning process used to ensure safe nursing practice and high-quality care. It is providing effective care based on sound reasoning (Scriven & Paul, 2017). Critical thinking in nursing is an essential component of professional accountability and high-quality nursing care. Critical thinkers exhibit the following habits of mind: confidence, contextual perspective, creativity, flexibility, inquisitive-ness, intellectual integrity, intuition, open-mindedness, perseverance, Figure 4-2 The nurse at the novice or new beginner stage must specifically think through questions to set priorities.© Maridav/Shutterstock.CHAPTER 4 Competencies for Professional Nursing Practice136
and reflection. In nursing, critical thinkers prac-tice the cognitive skills of analyzing, applying standards, discriminating, seeking information, reasoning logically, predicting, and transforming knowledge (Scheffer & Rubenfeld, 2000).There is a strong link between critical think-ing and clinical judgment. The following definition offers a comprehensive description of elements incorporating critical thinking from a nursing perspective. Critical thinking and clinical judg-ment in nursing (1) are purposeful, informed, outcome- focused thinking; (2) carefully identify key problems, issues, and risks; (3) are based on principles of nursing process, problem solving, and the scientific method; (4) apply logic, intuition, and creativity; (5) are driven by patient, family, and community needs; (6) call for strategies that make the most of human potential; and (7) require constant reevaluating (Alfaro-Lefevre, 2009). Thus, critical thinking, problem solving, and decision making are processes that are interrelated. Deci-sion making and critical thinking need to occur concurrently to produce reasoning, clarification, and potential solutions.Competence in critical thinking is one of the expectations of nursing education. Critical thinkers are described as well informed, inquisitive, open minded, and orderly in complex matters. Critical thinking competence is an outcome for quality nursing care and for the development of clinical judgment. The ability to think critically is also described as reducing the research practice gap and fostering evidence-based nursing (Wangensteen et al., 2010).Learning to be a nurse requires more than memorizing facts. It requires that you learn to think like a nurse, to think through and reason at a greater depth, and to draw a more sophisticated or deeper understanding of what you are doing in clinical practice so that you provide safe, good-quality patient care. Nursing is not a careless, mindless activity. All acts in nursing are deeply significant and require the nurseÕs mind to be fully engaged. The following illustration shows that nursing involves both thinking and doing: The physician has ordered an intravenous (IV) line to be placed in a patient. How do you choose between a butterfly and an IV intracath? First, you must consider why the line is being placed. You take into consideration whether it is a short-term, keep-open IV with limited medications; if so, then the butterfly IV is more comfortable and presents less of a threat of phlebitis. Doctors vary in their preferences as well, and this, CRITICAL THINKING QUESTION✶You are assigned to care for Ms. C., an 81-year-old patient who was admitted to-day with symptoms of increasing shortness of breath over the last week. She is currently receiving oxygen through a nasal cannula at 3 L/min. You go into the room to assess her. You find that she is sitting up in bed at a 60-degree angle. She is restless and her respirations appear labored and rapid. Her skin is pale with circumoral cyanosis. You ask if she feels more short of breath. Because she is unable to catch her breath enough to speak, she nods her head yes. Which action should you take first?¥ Listen to her breath sounds.¥ Ask when the shortness of breath started.¥ Increase her oxygen flow rate to 6 L/min.¥ Raise the head of the bed from 75 to 85 degrees.Based on knowledge you have learned, you realize the patientÕs symptoms indicate acute hypoxemia, so improving oxygen de-livery is the priority. The other actions also are appropriate, but they are not as critical as the initial action.✶Critical Thinking, Clinical Judgment, and Clinical Reasoning in Nursing Practice137
too, must be considered. In addition, the condi-tion of the patient and his or her veins make a great deal of difference. For example, special skill is required with older patients. The veins look as though they are going to be easy to get because they look large, but they are very fragile. If you do not use a very slight tourniquet, the vein will pop open (Benner, 1984).Characteristics of Critical ThinkingHow do you know when critical thinking is taking place? Critical thinking has some of the following characteristics (Wilkinson, 2007):¥ Critical thinking is rational and reasonable.¥ Critical thinking involves conceptualization.¥ Critical thinking requires reflection.¥ Critical thinking involves cognitive (thinking) skills and attitudes (feelings).¥ Critical thinking involves creative thinking.¥ Critical thinking requires knowledge.Critical thinking is rational and reasonable. It is based on reasons rather than on preferences, prejudice, or self-interest. It uses facts and observa-tions to draw conclusions. For example, suppose that during an election you decide to vote for the Democratic candidate because your family has al-ways voted for Democrats. This decision is based on preference, prejudice, and, possibly, self-interest. By contrast, suppose you took the time to reflect on what the candidates in the election said about the issues and based your choice on that. Even though you still might vote for the Democrat, you would be thinking rationally, using facts and observations to draw your conclusions (Wilkinson, 2007).Critical thinking involves conceptualization. Conceptual think-ing is the ability to understand a situation by identifying patterns or connections, focusing on key underlying issues, and integrating them into a conceptual framework. It involves using professional training and experience, creativity, and inductive reasoning that lead to solu-tions or alternatives that may not be easily identified. Conceptual thinking involves a willingness to explore and having an openness to a new way of seeing things or Òlooking outside the box.Ó Consider, for example, a case in which a patient with heart failure is coughing up CRITICAL THINKING QUESTION✶What do the following scenarios have in common?¥ An elderly male becomes acutely con-fused and refuses to follow directions for his safety.¥ A teen comes into an urgent care setting requesting information about sexually transmitted infections.¥ A mother visits a school nurse and re-quests information about how the school handles sex education.¥ A team leader needs to rearrange as-signments when one team member goes home sick.¥ Nursing staff in an intensive care unit need to develop an evacuation plan.Answer: They all require critical thinking skills.✶CRITICAL THINKING QUESTION✶You will be taking care of a patient in a nursing home for the first time. Your assign-ment is to care for an older man who has heart disease. In addition, he has five other medical problems and takes 20 medica-tions. While developing a plan of care for this patient, you can identify 8 to 10 nursing problems. You have no previous experience with nursing homes, and most of what you have heard and read about them is negative. Will you find yourself dreading the clinical day and expecting a negative experience be-fore you even begin?✶CHAPTER 4 Competencies for Professional Nursing Practice138
yellow sputum. If the nurse suspects that the patient is short of breath from infection, he or she will evaluate other indicators of infection. The nurse will check the patient for an elevated temperature and will assess the last white blood cell count in the patientÕs chart to see if it is elevated. The nurse will also consider factors that may place the patient at risk for infection, such as immobility, poor nutrition, or im-mune suppression (Craven & Hirnle, 2007).Critical thinking uses reflection. Reßective thinking is deliberate thinking and careful consideration. It is the process of analyzing, mak-ing judgments, and drawing conclusions. Reflective thinking involves creating an understanding through oneÕs experiences and knowledge and exploring potential alternativesÑassessing what you know, what you need to know, and how to bridge that gap. Processes of reflective thinking involve the following:¥ Determine what information is needed (what you need to know) for understanding the issue.¥ Examine what you have already experienced about an issue.¥ Gather the available information.¥ Synthesize the information and opinions.¥ Consider the synthesis from different perspectives and frames of reference.¥ Create some meaning from the relevant information and opinions.Reflective thinking is important during complex problem-solving situations because it provides an opportunity to step back and think about how to actually solve problems and how problem-solving strat-egies are used for achieving set goals. Reflection allows students to observe and reflect, pulling together what they learn in the clinical and classroom settings in taking care of patients. Students can build and in-tegrate knowledge and skills. Reflecting on a nursing experience or sit-uation can assist nurses in critically reflecting on their practice. Choose a clinical situation and ask yourself some of the following questions:¥ What was my role in this situation? Did I feel comfortable or un-comfortable? Why?¥ What actions did I take? How did others and I respond? Was it appropriate?¥ How could I have improved the situation for myself, the patient, and others involved? What can I change in the future?¥ What have I learned through this situation?¥ Did I expect anything different to happen? What and why?¥ Has this situation changed my way of thinking in any way?¥ What knowledge from theory and research can I apply in this situation?¥ What broader issues, for example, ethical, social, or political, arise from this situation?Critical Thinking, Clinical Judgment, and Clinical Reasoning in Nursing Practice139
Through reflection, students manage to be more organized and effective because they have a better understanding of who the patient is and what his or her care needs are. Reflection on practice helps the student develop a self-improving practice (Benner et al., 2010).Critical thinking involves cognitive (thinking) skills and attitudes (feelings). Critical thinking involves having thinking skills as well as the motivation to use them. It involves the willingness to use complex thought processes compared to easily understood ones. Critical think-ers do not oversimplify. Critical thinking is about being willing and able to think.Critical thinking also involves creative thinking. Creativity is part of the thinking process. When you brainstorm potential problem solutions or possible decisions, you are using creativity. Creative and critical thinkers combine ideas and information in ways that form new solutions or innovative ideas. A creative thinker is an open-minded thinker. Nurses can use creative thinking when encountering a patient situation in which traditional methods are not effective. For example, a pediatric nurse is caring for 9-year-old Pauline, who has ineffective respirations following abdominal surgery. The physician has ordered incentive spirometry breathing treatments, but Pauline is frightened by the equipment and she quickly tires during the treatments. The nurse offers Pauline a bottle of soap bubbles and a blowing wand. The nurse knows that the respiratory effort in blowing bubbles will promote alveolar expansion and suggests that Pauline blow bubbles between incentive spirometry treatments (Wilkinson, 2007).What Are the Characteristics of a Critical Thinker?Nurses are required to think critically in all settings. NursesÕ ability to think critically is one of their most important skills, and a commitment to think critically increases the nurseÕs ability to care for patients most effec-tively. A critical thinker has many characteristics, including the following:¥ Critical thinkers are flexibleÑthey can tolerate ambiguity and uncertainty.¥ Critical thinkers base judgments on facts and reasoning, not personal feelings. They identify inherent biases and assumptions. Critical thinkers separate facts from opinions.¥ Critical thinkers do not oversimplify.¥ Critical thinkers examine available evidence before drawing conclusions.¥ Critical thinkers think for themselves and do not simply go along with the crowd.¥ Critical thinkers remain open to the need for adjustment and adaptation throughout the inquiry stages.CHAPTER 4 Competencies for Professional Nursing Practice140
¥ Critical thinkers accept change.¥ Critical thinkers empathize; they appreciate and try to understand othersÕ thoughts, feelings, and behaviors.¥ Critical thinkers welcome different views and value examining issues from every angle.¥ Critical thinkers know that it is important to explore and under-stand positions with which they disagree.¥ Critical thinkers discover and apply meaning to what they see, hear, and read.Approaches to Developing Critical Thinking SkillsAs students develop in their nursing role, they learn and build critical thinking skills and apply them to real healthcare situations. Critical thinking requires conscious, deliberate effort. Critical think-ing does not just come naturally; people tend to believe what is easy to believe or what those around them believe (Wilkinson, 2007). With effort and practice, everyone can achieve some level of critical thinking to become an effective problem solver and decision maker. As the elements of critical thought develop into a habit, nurses improve their ability to assess complex situations and engage in the practice of nursing. The objectives for critical thinking in nurs-ing include the ability to ask pertinent questions, analyze multiple forms of evidence, and evaluate options before coming to a conclu-sion. Following are examples that can be used as approaches to developing critical thinking skills.The Nursing ProcessThe ANA standards have set forth the framework necessary for criti-cal thinking in the application of the nursing process. The nursing process is the tool by which all nurses can become equally profi-cient at critical thinking. The nursing process contains the following criteria: (1) assessment, (2) analysis (identifying the problem or nurs-ing diagnosis), (3) planning, (4) implementation, and (5) evaluation. Through the application of each of these components, the nurse can become proficient at critical thinking. Nurses use critical thinking in each stage of the nursing process. This approach to critical think-ing entails purposeful, informed, outcome-focused thinking, which requires identification of the nursing and healthcare needs of clients (Knapp, 2007).The nursing process is a systematic, problem-solving approach to giving nursing care that allows the nurse to be accountable by us-ing critical thinking before taking action. Nurses provide effective care based on sound reasoning, which is the reasonable reflection on nursing problems before selecting one of a variety of solutions. This is KEY COMPETENCY 4-1Examples of applicable Nurse of the Future: Nursing Core CompetenciesLeadership:Knowledge (K2) Under-stands critical thinking and problem-solving processesSkills (S2a) Uses systematic approaches in problem solvingSkills (S2b) Demonstrates purposeful, informed outcome-oriented thinkingAttitudes/Behaviors (A2) Values critical thinking pro-cesses in the management of client care situationsMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfCritical Thinking, Clinical Judgment, and Clinical Reasoning in Nursing Practice141
accomplished by regularly employing the elements of critical thought, such as defining the problem, identifying the goal, and analyzing the evidence (Caputi, 2010).Each of the following thinking skills is commonly used when a nurse gathers data (Caputi, 2010):¥ Assessing systematically and comprehensively¥ Checking accuracy and reliability¥ Clustering related information¥ Collaborating with coworkers¥ Determining the importance of information¥ Distinguishing relevant from irrelevant information¥ Gathering complete and accurate data and then acting on those data¥ Judging how much ambiguity is acceptable¥ Recognizing inconsistencies¥ Using diagnostic reasoningEach of the following thinking skills is commonly used when nurses provide care to patients (Caputi, 2010):¥ Applying the nursing process to develop a treatment plan¥ Communicating effectively¥ Predicting and managing potential complications¥ Resolving conflicts¥ Resolving ethical dilemmas¥ Setting priorities¥ Teaching othersAssessment The nursing assessment answers the questions of what is happening or what could happen (Figure 4-3). It involves systematically collecting, organizing, and analyzing information about the client patient. Once data or information have been collected and it is determined that the data are accurate and complete, the nurse performs data analysis or data interpretation. What are the clientÕs actual and/or potential problems? A problem list is then developed based on the data, and the nurse prioritizes the clientÕs problems. The nurse performs an ongoing assessment throughout the implementation of the nursing process.Analysis The nurse analyzes and derives meaning from the assessment information. Analysis results in the identification of a problem or nursing diagnosis. It is a statement that describes a specific response to an actual or potential health problem. For example, a problem statement for a selected patient might be Òdecreased cardiac output related to inability of the heart to pump effectively, and occlusion and constriction of vessels impairing blood flow.ÓKEY COMPETENCY 4-2Examples of applicable Nurse of the Future: Nursing Core CompetenciesProfessionalism:Knowledge (K1b) JustiÞes clinical decisionsSkills (S1b) Exercises critical thinking and clinical reasoning within standards of practiceAttitudes/Behaviors (A1b) Shows commitment to pro-vision of high-quality, safe, and effective patient careMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfCHAPTER 4 Competencies for Professional Nursing Practice142
Planning During planning, the nurse develops a plan to provide consistent, continuous care that meets the clientÕs unique needs. Planning includes developing expected outcomes and working with the client to identify goals and to determine appropriate nursing actions and interventions that will reduce the identified problem. The nurse uses critical thinking to develop goals and nursing interventions for problems that require an individualized approach. Nurses use judgment to determine which interventions have a probability of achieving desired outcomes. To continue with the previous example, expected outcomes might include the following:¥ Patient will be free of chest pain during my shift.¥ Patient will maintain O2 saturation of 90% during my shift.Figure 4-3 Collecting and analyzing assessment data are critical components of the nursing process that enable the nurse to prioritize problems and determine appropriate interventions.© Monkey Business Images/Shutterstock.Critical Thinking, Clinical Judgment, and Clinical Reasoning in Nursing Practice143
¥ Vital signs will remain stable: T < 99.0¡F, HR > 60 < 110 beats/min, R > 12 < 24 breaths/min, and SBP > 90 mm Hg while under my care.¥ Patient will have no further weight gain and will have a decrease in edema during my shift.Implementation Implementation involves carrying out the plan of care and depends on the first three steps of the nursing process. These steps provide the basis for nursing actions performed during the implementation phase of the nursing process (Figure 4-4). The nurse carries out nursing interventions individualized to the patient, reassesses the client, and validates that the plan of care is accurate and successful. In this stage, to each patient care situation the nurse applies knowledge and principles from nursing and from related courses. The ability to apply, not just memorize, principles is a component of critical thinking (Wilkinson, 2007). For the patient with decreased cardiac output, the nurse could implement some of the following individualized interventions:¥ Assess level of consciousnessÑconfusion, anxiety.¥ Provide reassurance to the patient.¥ Monitor vital signs every 4 hours.Figure 4-4 The nurse carries out nursing interventions individualized for the patient that are grounded in the nurseÕs clinical judgment and based on the previous steps in the nursing process.© Monkey Business Images/Shutterstock.KEY COMPETENCY 4-3Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesPatient-Centered Care:Knowledge (K1) IdentiÞes components of nursing process appropriate to individual, family, group, community, and population health care needs across the life spanSkills (S1a) Provides priority-based nursing care to individuals, families, and groups through inde-pendent and collaborative application of the nursing processSkills (S1b) Demonstrates cognitive, affective, and psychomotor nursing skills when delivering patient careAttitudes/Behaviors (A1a) Values use of scientiÞc inquiry, as demonstrated in the nursing process, as an essential tool for provision of nursing careAttitudes/Behaviors (A1b) Appreciates the difference between data collection and assessmentMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfCHAPTER 4 Competencies for Professional Nursing Practice144
¥ Assess heart rate and rhythm; monitor telemetry or electrocardiography.¥ Monitor for jugular vein distension.¥ Monitor for chest pain.¥ Monitor peripheral pulses; assess capillary refill.¥ Auscultate lung sounds; monitor respiratory rate and rhythm; monitor oxygen saturation; assess for cough and sputum.¥ Look at skin color and temperature.¥ Monitor for fatigue and activity tolerance.¥ Assess intake and output, daily weight, and edema in dependent areas.¥ Assess abdomen for distension or bloating, ascites, and bowel function.¥ Monitor lab and x-rays: complete blood count, prothrombin time/partial thromboplastin time, electrolytes, cardiac enzymes, arterial blood gases, and chest x-ray.¥ Elevate head of bed to improve gas exchange.¥ Administer oxygen as ordered to improve gas exchange.¥ Administer morphine sulfate as prescribed to relieve chest pain, provide sedation and vasodilation, and monitor for respiratory depression and hypotension after administration.¥ Administer diuretics as prescribed to reduce preload, enhance renal excretion of sodium and water, reduce circulating blood volume, and reduce pulmonary congestion; closely monitor potas-sium level, which might decrease as a result of diuretic therapy.¥ Provide teaching: Identify precipitating risk factors of heart fail-ure and prescribed medication regimen; notify physician if unable to take medications because of illness; avoid large amounts of caffeine; provide cardiac diet instruction; look for signs of exacer-bation; monitor fluids; balance periods of activity and rest; avoid isometric activities that increase pressure in the heart.Evaluation During evaluation, the nurse compares the patientÕs current status to the patientÕs goals. Were the goals achieved? The nurse analyzes outcomes to determine if the interventions worked, and if not, why? The information provided during evaluation can be used to begin another plan of care sufficient to meet the patientÕs needs. Continuing with the previous example, the evaluation might include the following:¥ Patient denies chest pain on my shift. Patient rates pain 0 on pain scale.¥ PatientÕs O2 saturation dropped to 85% when oxygen at 3 L nasal cannula was removed. With oxygen on, patientÕs O2 saturation remained at 92%.¥ Vital signs were: T 101.0¡F, HR 100Ð110 beats/min, R 32 breaths/min and labored, BP 90/50 mm Hg.¥ PatientÕs weight was 241 lbs with 2+ edema in lower extremities.Critical Thinking, Clinical Judgment, and Clinical Reasoning in Nursing Practice145
Concept MappingConcept mapping is another strategy that can be used to develop criti-cal thinking skills. A concept map is a visual representation of the relationships among concepts and ideas. The concepts are represented by boxes and linked with lines. In nursing, concept maps are used to organize and link information about a patientÕs health problems. This allows the nurse to see relationships among the patientÕs prob-lems and helps to plan interventions that can address more than one problem.To begin a concept map, start in the center of the page with the main idea or central theme and work outward in all directions, pro-ducing a growing organized structure composed of key words or pic-tures. Place words or pictures around the main idea to illustrate how they relate to one another and to the central theme. Pictures, words, or a combination of both can be used to create a map.Concept maps are useful for summarizing information, consoli-dating information from different sources, thinking through com-plex problems, and presenting information in a format that shows the overall structure of your subject. Figure 4-5 illustrates a mind mapping technique used by students with a patient case.JournalingKeeping a journal of clinical experiences that were meaningful or trou-bling to you is a recommended way to help enhance and develop rea-soning skills. Think about and record experiences that bother you and consider what you could and would do differently in the future. This is a form of reflection and allows you to view your own thinking, reasoning, and actions. It helps create and clarify meaning and new understandings of a particular experience. When you encounter a similar situation, you should be able to recall what you did or would do differently as well as the reasoning behind your actions (Raingruber & Haffer, 2001).Some suggestions you should try to address when journaling your nursing experience include the following:¥ What happened? What are the facts?¥ What was my role in the event?¥ What feelings and senses surrounded the event?¥ What did I do?¥ How and what did I feel about what I did? Why?¥ What was the setting?¥ What were the important elements of the event?¥ What preceded the event, and what followed it?¥ What should I be aware of if the event recurs?It is important that you write in your journal as soon as pos-sible after an event to capture the essence of what happened in the CHAPTER 4 Competencies for Professional Nursing Practice146
clinical experience. The following is an example of a journal excerpt that illustrates reflection on events and the feelings elicited by those events over the course of many patient care encounters during the career of a nurse:I have learned, not so easily, that my job is not just about saving a life, trying to keep people well, or helping them get well when they are ill, but importantly, it also entails providing that same dedicated care to them as they take their last breaths in life. It is my job, my duty, and, I have learned, my privilege. As I care for a dying patient, listening to the rise and fall of methodical machines imitating life, I hope I never am calloused to the point that I say, ÒI do this 1. Decreased cardiac output related to inability of the heart to pump effectively, occlusion and constriction of vesselsSacral edemaYellow secretionsHX; Smoking ⋅ 20 years Wt. 240 lbs.HR 100, BP 88/60K+ 2.9RBC 4.0H & H 11.0 & 35Glucose 210PT 31.0, PPT 80 ALB 3.0PC02 32 EKG NSR old infarct CXR − Bil. inflt, enlarged heartBR w BRPHOB 40¡1800 cal ADA, low, NAlow chol, & low fatFluid restriction 1200 ccDaily wt.VS Q4h I & O FoleyTelemetryD-sticksEgg crateTed hoseO2 3 L/NCO2 SatEKG for CP Daily lab;H & H, PT/PTTDigoxinLasixPotassiumPrinivilHumulin R & NPHHeparinAlbuterolMorphineColaceDx; Exacerbation of CHFHX; HTN, CAD, MI CABGFamily HX: CVA, MI, diabetesC/O SOB, productive/ congested cough,Swelling in legs, chest painObese pt,3+ edemaLungs w ralesO2 sat 86%JVDDX exacerbation of CHF & pneumonia HGB 11.0 Daily H & H Hx: CAD, PVD, CABG PC02 32 BC for T>101C/O SOB, productive cough, chest pain CXRÑBil. Infl & enlarged heartO2 3 L/NCObese BR w BRP O2 Sat3+ edema HOB 40¡ EKG prn CPLungs w rales Fluid rest. 1200 cc LasixO2 Sat 86% Daily Wt. HeparinJVD I & O Albuterol via HHNYellow secretions Foley MorphineHx: SmokingÑ20 yrs. TelemetryWt. 240 Ibs. Egg crateHRÑ100, RÑ34 Ted hoseExacerbation ofCHF & pneumoniaSecondary diagnosisType I diabetesHTNCADHypothyroidismPVDChief medical diagnosis:3. Altered nutrition related to inability of pancreas to secrete insulinDx; Exacerbation of CHFHx: Diabetes type I, CAD, PVD, MIFamily Hx: Diabetes, MI, CABG, CVA C/O SOB, CPObeseÑ240 Ibs.Labored resp, chest painTÑ99¡ WBC 14,000K+ 2.9H & H 11.0 & 35RBC 4.0Glucose 210ALB 2.9 Prot. 5.6BR1800 cal ADA, low, NA low chol, & low fatFR 1200 ccDaily wt.VS Q4Daily H & H BC for T > 101 I & O FoleyD-sticksEgg crateTed hoseMorphineColacePotassiumHumulin R & N Lasix2. Impaired gas exchange related to mucus buildup in alveoli impairing oxygen movement Figure 4-5 Mind mapping techniques.Critical Thinking, Clinical Judgment, and Clinical Reasoning in Nursing Practice147
every day. It is just another patient.Ó I want to appreciate that every individualÕs life has been remarkable in some wayÑwhich they are remarkable in some way. I want to make my patientÕs journey through this last chapter in their life a little easier, provide comfort, recognize their fears, hold their hand, and always realize this is not another patient but a person.Group Discussions and ReßectionAnother way to enhance critical thinking skills is by using group discussions and reflection to explore alternatives and arrive at conclusions (Figure 4-6). Group discussions among nursing students and teachers can take place in the class-room or following clinical experiences. During discussions, students are encouraged to formulate alternatives to clinical or ethical decisions. Teacher and learner group discussions over clinical and ethical scenarios should encourage questions, analysis, and reflection. Group discussions can assist nursing students in connecting clinical events or decisions with information obtained in CRITICAL THINKING QUESTIONS✶Think about a clinical experience that was troubling to you. Reflect on what bothered you about the experience. What could you have done differently? What were the rea-sons behind your actions? Try to create and clarify meaning or a new understanding of the particular situation.✶CRITICAL THINKING QUESTIONS✶Beginning nursing students often tend to fo-cus primarily on their routines, including to get their list of tasks done, including assess-ments, ordered treatments, daily care, and charting. What if an unexpected situation occurred during the day? Do you think you would be able to reason, plan, and take ap-propriate actionÑthink critically?✶Figure 4-6 Working through a case study in class is one way to enhance critical thinking skills through discussion and reflection.©Jacoblund/iStock/Getty Images Plus/Getty Images.CHAPTER 4 Competencies for Professional Nursing Practice148
the classroom. This form of cooperative learning occurs when groups work together to maximize their own and one anotherÕs learning. For example, following a clinical experience, students and teacher use re-flection and discussion on a certain clinical experience that a student encountered. Together they discuss different scenarios of ÒWhat if?Ó and ÒWhat else?Ó and ÒWhat then?Ó to encourage the formulation of alternatives or clinical decisions. Other examples of this process include the following:¥ You are going into a patientÕs roomÑwhat are you going to do? When you go in there, what are you going to do? Walk yourself through it step by step.¥ What are you going to do first? What should be done first? Which one takes importance and then where do you go from there?¥ This is the patient, and this happens. What do you do next?¥ These are your assessment findings. What else do you need to know?Engaging in individual reflection is also important to developing critical thinking skills and learning from experiences. For example, consider that you are working in an acute care clinical situation. After receiving the report, you have started your morning routines. Every-thing is going as planned, and you are about to start preparing your medications. The wife of a patient reports that the oxygen is burning his nose and wants you to get an oxygen humidifier. All of a sudden, the daughter of another patient, Mr. Peary, rushes toward you and informs you that her father is spitting up blood. He looked fine when you observed him a few minutes ago. You walk rapidly toward the patientÕs room, thinking, ÒWhat am I going to do when I get there? I have to get the oxygen humidifier for room 202. His nose was burn-ing, and his wife was waiting for me. What could be happening with Mr. Peary?ÓYou enter the room, and the first thing you think is: ÒHeÕs lying flat,Ó and you think to yourself, ÒI need to elevate his head. That is what I did on the respiratory unit where I recently worked.Ó The daughter tells you that Mr. Peary coughed up some blood in the em-esis basin. There is a small amount of bright red blood in it. You do not know what to do next. An RN stops by the room and tells you that the wife of the patient in room 202 is asking about the burning in her husbandÕs nose again. Your mind does not seem to be able to think about anything. Do you feel scattered and things seem out of control at this point? Do you feel a little overwhelmed and cannot think what to do next? The RN says she will take over with Mr. Peary while you follow up with the patient in room 202. Later, you recall the situation and cannot believe you did not think to take Mr. PearyÕs blood pressure, count respirations, ask about pain, or listen to his lungs or anything else. All you did was just raise his head. You wonder why you missed so many things.Critical Thinking, Clinical Judgment, and Clinical Reasoning in Nursing Practice149
¥ What do you think was going on in the situation that influenced what was happening and caused you to lose your ability to think and plan what to do next?¥ What would you do differently in this situation after having a chance to reflect on it? Prioritize the order in which you would have done things.¥ If this had happened to you and no one helped you through it, what would you have done to mobilize yourself to think about what to do?Thinking Like a NurseThe cognitive work of nurses is invisible but includes clinical reasoning over a specific period of time for multiple patients that is informed by both obvious and subtle changes that require knowledge and situational awareness that enable the nurse to make sound clini-cal judgments. Clinical decision making in nursing requires the use of a cognitive workload management strategy known as cognitive stack-ing in order to negotiate multiple care delivery requirements, maintain a mental list of tasks that must be accomplished, prevent error, and minimize bad outcomes despite working in a complex environment plagued by interruptions, inadequate communication, and design flaws (Sitterding & Ebright, 2015, p. 16). To prepare nursing students for the multifaceted role of professional nurse, the learning process involves components that will provide a solid foundation for develop-ing clinical judgment and clinical reasoning skills. In other words, the student must learn to think like a nurse. What does it mean to think like a nurse? How does one begin to think like a nurse?Clinical judgment is a complex observed outcome that includes critical thinking, problem solving, ethical reasoning, and decision mak-ing. Clinical judgment necessitates a Òflexible and nuanced ability to recognize salient aspects of an undefined clinical situation, interpret their meanings, and respond appropriatelyÓ (Tanner, 2006, p. 2005). According to Tanner (2006), clinical judgment is developed through reflection, thus enhancing critical thinking skills. What exactly is clini-cal judgment? According to Tanner, clinical judgment refers to Òan interpretation or conclusion about a patientÕs needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed ap-propriate by the patientÕs responseÓ (p. 204). How does that differ from clinical reasoning? Again, according to Tanner, clinical reasoning refers to Òthe processes by which nurses and other clinicians make their judgments, and includes both the deliberative process of gener-ating alternatives, weighing them against the evidence, and choosing the most appropriate, and those patterns that might be characterized KEY COMPETENCY 4-4Examples of applicable Nurse of the Future: Nursing Core CompetenciesProfessionalism:Knowledge (K4c) Under-stands the importance of reßection to advancing practice and improving outcomes of careSkills (S4b) Demonstrates ability for reßection in ac-tion, reßection for action, and reßection on actionAttitudes/Behaviors (A4c) Values and is commit-ted to being a reßective practitionerMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfKEY OUTCOME 4-1Example of Domain 1 subcompetency for entry-level professional nursing education.1.3a Demonstrate clinical reasoning (p. 27).Reproduced from American Association of Colleges of Nursing. (2021). The Essentials: Core Competencies for Professional Nursing Education. https://www .aacnnursing.org/Portals/42 /AcademicNursing/pdf/Essentials-2021.pdfCHAPTER 4 Competencies for Professional Nursing Practice150
as engaged, practical reasoning,Ó including recognition of a pattern, an intuitive clinical grasp, or a response without evident forethought (pp. 204Ð205).Clinical judgment requires knowledge. In most academic dis-ciplines, the educational system uses an expert to deliver a body of knowledge to the unpracticed novice, who will later be expected to go out and apply the knowledge and rules learned in school to various work situations. In nursing, a specific educational knowledge base is required before applying that knowledge in patient care. It is impor-tant to know that the process is being applied correctly. In essence, to become a nurse you must learn the knowledge to think like a nurse. On the flip side of this, as the level of experience of the nurse increases, so will the scientific knowledge base that the nurse applies. For exam-ple, you are caring for a patient with heart failure. After obtaining the vital signs, what heart rate would prevent you from ambulating this patient? If you did not have knowledge regarding heart failure or did not know that the normal heart rate was between 60 and 100 beats per minute, you could not make the good decision that ambulation should be postponed if the heart rate is above 100 beats per minute for this patient.TannerÕs Clinical Judgment ModelBased on a review of nearly 200 studies, Tanner (2006, p. 204) proposed the following:¥ Clinical judgments are influenced by what nurses bring to the situ-ation more than by the facts.¥ Clinical judgment depends on knowing the patientÕs pattern of re-sponses as well as knowledge of the patient concerns.¥ Clinical judgments are shaped by both the situation and the cul-ture of the patient care unit.¥ Nurses use an assortment of reasoning patterns in making clinical judgments.¥ A breakdown in clinical judgment may trigger reflection which is essential for the development of clinical reasoning skills.TannerÕs model of clinical judgment includes four areas: notic-ing, interpreting, responding, and reflecting. Noticing is a grasp of the situation and has a basis in the nursesÕ expectations of the situation, which stem from the nursesÕ knowledge of the patient and the patient patterns of responses as well as the nursesÕ clinical experience with similar patients and textbook knowledge. Inter-preting includes developing an understanding of the meaning of the data in the situation. During this process, the nurse may immedi-ately recognize a pattern, interpret, and respond or may produce KEY OUTCOME 4-2Example of Domain 1 subcompetency for entry-level professional nursing education.1.3c Integrate knowledge from nursing and other disciplines to support clinical judgment (p. 27).Reproduced from American Association of Colleges of Nursing. (2021). The Essentials: Core Competencies for Professional Nursing Education. https://www .aacnnursing.org/Portals/42 /AcademicNursing/pdf/Essentials-2021.pdfThinking Like a Nurse151
interpretive hypotheses and conduct additional assessment to rule out hypotheses until the nurse reaches an interpretation that is supported by most of the data and suggests a course of action or response. Reflecting includes reviewing the outcomes of actions, focusing on what was noticed, how was it interpreted, and the response of the nurse. Reflection may be categorized as reflection-in-action and reflection-on-action. Reflection-in-action refers to how the patient responds to the nursing interventions. Reflection-on-action facilitates the use of clinical experience to contribute to clinical knowledge development and the capacity of the nurse to make good clinical judgments in future situations (Tanner, 2006, pp. 208Ð209).Tanner (2006) concludes that thinking like a nurse is a form of engaged moral reasoning because nurses enter the care of the patient with a fundamental sense of what is good and right and a vision of what excellent care entails. Further, clinical reasoning should occur in relation to the particular patient and situation and be informed by the knowledge of the nurse and rational processes but Ònever as a detached objective exercise, with the patientÕs concerns as a sidebarÓ (p. 210).Clinical Judgment Measurement ModelThe National Council of State Boards of Nursing (NCSBN) developed a model of clinical judgement that is built on and expands the nursing process in response to the dissatisfaction of employers of new gradu-ate nurses related to their clinical decision-making abilities. The model identifies six cognitive skills that are necessary to make sound clinical judgments. These skills include recognizing cues, analyzing cues, pri-oritizing hypotheses, generating solutions, taking action, and evaluat-ing outcomes (NCSBN, 2021).In this model, recognizing cues includes identifying information from various sources (e.g., patient record, vital signs, observation) and then asking questions such as ÒWhat is most important?Ó or ÒWhat is an immediate concern?Ó Analyzing cues includes recognizing and linking cues to the patientÕs clinical presentation. The nurse will con-sider multiple possibilities. Evaluating and ranking hypotheses based on priority includes asking questions such as ÒWhat is the most likely explanation?Ó and ÒWhat possible explanation is the most serious?Ó Next, the nurse will generate solutions that include identifying in-terventions to achieve expected outcomes followed by implementing solutions to impact the highest priorities. Finally, the nurse will deter-mine if interventions were effective by comparing observed outcomes with expected outcomes. This evaluation should also include consider-ing if other interventions could have been more effective (Dickison & Lasater, 2019).KEY OUTCOME 4-3Example of Domain 1 subcompetency for entry-level professional nursing education.1.3b Integrate nursing knowledge (theories, multiple ways of knowing, evidence) and knowledge from other disciplines and inquiry to inform clinical judgment (p. 27).Reproduced from American Association of Colleges of Nursing. (2021). The Essentials: Core Competencies for Professional Nursing Education. https://www .aacnnursing.org/Portals/42 /AcademicNursing/pdf/Essentials-2021.pdfCHAPTER 4 Competencies for Professional Nursing Practice152
MindfulnessAnother concept that is important in learning to Òthink like a nurseÓ is mindfulness. Weick and Sutcliffe (2007, p. 32) define mindfulness as Òa rich awareness of discriminatory detail.Ó In other words, when people act, they are aware of context, of ways in which details differ, and of deviations from their expectations. Mindfulness is similar to situation awareness but is different in the sense that mindfulness involves Òthe combination of ongoing scrutiny of existing expectations and continuous refinement and differentiation of expectations based on newer experiencesÓ (p. 32). Mindfulness also involves a Òwillingness and capability to invent new expectations that make sense of unprecedented events, a more nuanced appreciation of context and ways to deal with it, and iden-tification of new dimensions of context that improve foresight and current functioningÓ (p. 32).Weick and Sutcliffe (2007) also note that certain conditions improve awareness. Awareness improves when attention is not dis-tracted, when attention is focused on the present situation, when one is able to keep attention on the problem of interest, and when one is wary of fixing attention on preexisting categories. This pattern of awareness and attention is known as mindfulness and is used in many industries to facilitate quality and safety. In terms of nursing practice, mindfulness implies keeping attention focused on the present, result-ing in the ability to see salient aspects of the clinical situation and to take decisive action to prevent harm.ConclusionIn nursing, critical thinking is the ability to think in a systematic and logical manner, solve problems, make decisions, and establish priori-ties in the clinical setting. Nurses need to develop critical thinking skills to make sound clinical judgments and to provide safe, compe-tent patient care. Nursing requires constant decision making. What should I do first? What is the most important thing to do at this time? Prioritizing nursing actions involves recalling important nursing in-formation as well as using complex problem-solving skills to make decisions in order to provide safe and effective patient care. Other tips for nurses at the bedside to improve safety include practicing mindfully, communicating clearly, reporting unsafe conditions and errors, responding to error justly, and recognizing personal limitations (Hershey, 2015).All of us want to believe that we will never be involved in an error that harms a patient. But as is evident, errors that result in pa-tient harm do occur. This creates what has become known as Òthe second victim,Ó a term coined by Wu (2000) to describe the pain and Conclusion153
suffering experienced after making a healthcare error. A nonjudgmen-tal, supportive, and compassionate environment is recommended with the use of such responses as ÒThis must be difficult, are you okay?Ó or ÒCan we talk about it?Ó or ÒYou are a good nurse working in a complex environmentÓ (Hershey, 2015, p. 149). Creating a defensive environment does not allow the nurse at the sharp end of care to con-tribute to the safety process and therefore does nothing to increase patient safety. Thus, Òresponding to second victims with openness and compassion is not only the right thing to do, it is also the safe thing to doÓ (Hershey, 2015, p. 149).CASE STUDY 4-1 ■ JIM FULLERJim Fuller is a 40-year-old male patient. He is currently in the recovery room following an inguinal hernia repair under general anesthesia. His vital signs are T 99.0¡F, BP 120/80 mm Hg, HR 80 beats/min, R 18 breaths/min.Case Study Questions1. Are Mr. FullerÕs vital signs within normal limits? List normal adult ranges.2. What factors might affect body temperature?3. List sites where a nurse might take a patientÕs pulse. What sites are most commonly used?4. What factors might influence respiratory rate?Two hours postoperative, Mr. Fuller begins to complain of abdominal pain. Vital signs at this time are T 99.5¡F, BP 90/60 mm Hg, HR 122 beats/min, R 24 breaths/min.5. What could Mr. FullerÕs vital signs indicate?6. What nursing interventions are indicated? What should the nurse assess in Mr. Fuller at this time?7. What clinical signs associated with an elevated temperature might the nurse assess?8. If Mr. FullerÕs fever persists and increases, what might the nurse suspect is happening, and what might be done?Classroom Activity 4-1Critical thinking gives you the power to make sense of something by deliberately choosing how to respond to events that you encounter. You take in information, examine and ask questions about it, look at new perspectives, and identify a plan. You use problem-solving and decision-making strategies.¥ Choose a decision that you need to make soon and write it down.¥ What goal or desired outcomes do you seek from this decision? Prioritize goals or desired outcomes and write them down.¥ Identify who and what will be affected by your decision and indicate how your decision will affect them.¥ Identify any available options you might have.¥ Taking into account and evaluating your information, identify a plan or decide what you are going to do.¥ After you have made your decision, evaluate the result.CHAPTER 4 Competencies for Professional Nursing Practice154
Classroom Activity 4-2You are receiving morning reports on the following patients from the night-shift nurse. After receiving the report, which patient would you choose to see first? As you make your decision, think about your thought processes and how you made your decision.a. A woman who is scheduled to have a bi-opsy on a breast lump this morning and who is scared and cryingb. An 85-year-old man who was admitted during the night because of increased confusion who remains disoriented this morningc. A woman who had lung surgery the previ-ous day and who has two chest tubes in place with minimal drainaged. A man who is scheduled to have a colon resection in 2 hours and is complaining of chillsAnswer: You should have answered the client who is scheduled for surgery and is ex-hibiting symptoms of infection. This patient needs to be assessed immediately for infection and the doctor notified. If an infection is pres-ent, the surgery needs to be postponed. The other patients are stable, and their needs do not have to be addressed immediately.ReferencesAgency for Healthcare Research and Quality. (2008). Patient safety and quality: An evidence-based handbook for nurses (Vols. 1Ð3). U.S. Department of Health and Human Services.Alfaro-Lefevre, R. (2009). Critical thinking and clinical judgment: A practical approach to outcome-focused thinking (4th ed.). Saunders Elsevier.American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Author.American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Essentials-2021.pdfAmerican Nurses Association. (2015). Nursing: Scope and standards of practice (3rd ed.). Author.Benner, P. (1984). From novice to expert. Addison-Wesley.Benner, P. E., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. Jossey-Bass.Caputi, L. (2010). Developing critical thinking in the nursing student. In L. Caputi (Ed.), Teaching nursing: The art and science (2nd ed., pp. 381Ð390). College of DuPage Press.Craven, R. F., & Hirnle, C. J. (2007). Fundamentals of nursing: Human health and function (5th ed.). Lippincott Williams & Wilkins.Dickison, P., & Lasater, K. (2019). Integrating the National Council of State Boards of Nursing clinical judgment model into nursing educational frameworks. Journal of Nursing Education, 58(2), 71Ð78.Fero, L., Witsberger, C., Wesmiller, S., Zullo, T., & Hoffman, L. (2009). Critical thinking ability of new graduate and experienced nurses. Journal of Advanced Nursing, 65(1), 139Ð148.Hershey, K. (2015). Culture of safety. Nursing Clinics of North America, 50, 139Ð152.Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. National Academies Press.Knapp, R. (2007). Nursing educationÑthe importance of critical thinking. http://www.articlecity.com /articles/education/article_1327.shtmlReferences155
Massachusetts Department of Higher Education. (2010). Nurse of the future: Nursing core competencies. http://www.mass.edu/currentinit/documents/NursingCoreCompetencies.pdfMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdfNational Council of State Boards of Nursing. (2021). NCSBN clinical judgment measurement model. https://www.ncsbn.org/14798.htmQuality and Safety Education for Nurses. (2018). Project overview. http://qsen.org/about-qsen /project-overview/Raingruber, B., & Haffer, A. (2001). Using your head to land on your feet: A beginning nurseÕs guide to critical thinking. F. A. Davis.Scheffer, B. K., & Rubenfeld, M. G. (2000). A consensus statement on critical thinking in nursing. Journal of Nursing Education, 39(8), 352Ð359.Scriven, M., & Paul, R. (2017). Defining critical thinking. http://www.criticalthinking.org/pages /defining-critical-thinking/766Sitterding, M. C. (2015). An overview of information overload. In M. C. Sitterding & M. Broome (Eds.), Information overload: Framework, tips, and tools to manage in complex healthcare environments (pp. 1Ð9). American Nurses Association.Sitterding, M. C., & Ebright, P. (2015). Information overload: A framework for explaining the issues and creating solutions. In M. C. Sitterding & M. Broome (Eds.), Information overload: Framework, tips, and tools to manage in complex healthcare environments (pp. 11Ð33). American Nurses Association.Tanner, C. A. (2006). Thinking like a nurse: A research-based mode of clinical judgment in nursing. Journal of Nursing Education, 4(6), 204Ð211.Technology Informatics Guiding Education Reform. (2009). The TIGER initiative. Collaborating to integrate evidence and informatics into nursing practice and education: An executive summary. https://tigercompetencies.pbworks.com/f/TICC_Final.pdfWangensteen, S., Johansson, I. S., Bjorkstrom, M. E., & Nordstrom, G. (2010). Critical thinking dispositions among newly graduated nurses. Journal of Advanced Nursing, 66(10), 2170Ð2181.Weick, K. E., & Sutcliffe, K. M. (2007). Managing the unexpected: Resilient performance in an age of uncertainty (2nd ed.). Jossey-Bass.Wilkinson, J. (2007). Nursing process and critical thinking (4th ed.). Pearson.Wu, A. (2000). Medical error: The second victim: The doctor who makes the mistake needs help too. British Medical Journal, 320, 726Ð727.CHAPTER 4 Competencies for Professional Nursing Practice156
Nursing continues to evolve into a profession with a distinct body of knowledge, specialized practice, and standards of practice. Accord-ing to the American Nurses Association (ANA), Ònursing is a learned profession built on a core body of knowledge that reflects its dual components of science and artÓ (2015b, p. 7), and as such it is a scien-tific discipline as well as a profession. The science of nursing, based on the nursing process, is an analytical framework for critical thinking. Nursing practice also requires knowledge of the principles of biologi-cal, physical, behavioral, and social sciences. The art of nursing is based on respect for human dignity and caring, although it is impor-tant to note that a compassionate approach to care carries a mandate to provide competent care. The professional nurse is responsible for practice that incorporates this specialized body of knowledge and standards of practice with care that demonstrates respect and caring (ANA, 2015b).What has traditionally been known as socialization to profes-sional nursing is the process of acquiring the knowledge, skills, and sense of identity that are characteristic of the profession. It is a process by which a student internalizes the attitudes, beliefs, norms, Key Terms and Concepts ÈAdvanced beginner ÈCompetent ÈEthical comportment ÈExpert ÈFormation ÈNovice ÈProfessional values ÈProÞcient ÈRole transition ÈSalience ÈSocializationAfter completing this chapter, the student should be able to:1. Discuss the essential features of nursing.2. Describe the stages of educational so-cialization or formation in professional nursing.3. Describe the process of socialization or formation in professional nursing.4. Identify factors that facilitate professional role development.Learning ObjectivesEducation and Formation in Professional NursingKathleen Masters and Melanie GilmoreCHAPTER 5© Nuu Jeed/Shutterstock157
values, and standards of the profession into his or her own behavior pattern. Professional socialization has four goals: (1) to learn the technology of the professionÑthe facts, skills, and theory; (2) to learn to internalize the professional culture; (3) to find a personally and professionally acceptable version of the role; and (4) to integrate this professional role into all the other life roles (Cohen, 1981). Benner et al. (2010) make the case for using the term formation to describe this process that occurs over time because it better denotes Òthe de-velopment of perceptual abilities, the ability to draw on knowledge and skilled know-how, and a way of being and acting in practice and in the worldÓ (p. 166). Whatever terminology is chosen, the process described in this chapter refers to the transformation of the layperson into a skilled nurse who is prepared to respond skillfully and respect-fully to persons in need of nursing care, or, as described by Benner et al. (2010), Òthe lay student moves from acting like a nurse to being a nurseÓ (p. 177). This development of professional identity occurs initially through the formal educational process and culminates in the practice setting.Professional Nursing Roles and ValuesWhat is it that professional nurses do? The scope of nursing practice describes the Òwho,Ó Òwhat,Ó where,Ó Òwhen,Ó Òwhy,Ó and ÒhowÓ of nursing practice (ANA, 2015b, p. 2). The standards of professional nursing practice are authoritative statements that describe the duties that all registered nurses are expected to competently perform. The standards of professional nursing practice are composed of standards of practice and standards of professional performance. The standards of practice describe competent nursing care as demonstrated by use of the nursing process. The standards of professional performance de-scribe a competent level of behavior in the professional nursing role (ANA, 2015b).According to the ANA (2010), there are seven essential features of nursing. These features include the provision of a caring relation-ship that facilitates health and healing, attention to the range of experiences and responses to health and illness within the physical and social environments, and integration of assessment data with knowledge gained from an appreciation of the patient or group. In addition, nursing includes the application of scientific knowledge to the processes of diagnosis and treatment through the use of judgment and critical thinking, advancement of professional nursing knowl-edge through scholarly inquiry, influence on social and public policy to promote social justice, and assurance of safe, high-quality, and evidence-based practice (ANA, 2010).CHAPTER 5 Education and Formation in Professional Nursing158
The American Association of Colleges of Nursing (AACN, 2008) lists the roles of the professional nurse as provider of care, designer/manager/coordinator of care, and member of a profession. As a provider of direct and indirect care, the nurse is a patient advocate and patient educator. The nurse provides care based on best, current evidence and from a holistic, patient-centered perspective. Profes-sional nurses are members of the healthcare team delivering care in an increasingly complex healthcare environment. Nurses function au-tonomously and interdependently within the healthcare team to pro-vide patient care and are accountable for the care provided and for the tasks delegated to others. The nurse as a professional implies the formation of a professional identity and accountability for the profes-sional image portrayed. Nursing requires a broad knowledge base for practice as well as strong communication, critical reasoning, clinical judgment, and assessment skills. In addition, professional nursing re-quires the development of an appropriate value set and ethical frame-work for practice (AACN, 2008).Professional values are considered a component of excellence, and the existence of a code is considered a hallmark of professionalism. Professional values are beliefs or ideals that guide interactions with patients, colleagues, other professionals, and the public. The develop-ment of professional values begins with professional education in nursing and continues along a continuum throughout the years of nursing practice. Professional values associated with nursing are out-lined in the ANAÕs Code of Ethics (ANA, 2001, 2015a). The values of (1) commitment to public service, (2) autonomy, (3) commitment to lifelong learning and education, and (4) a belief in the dignity and worth of each person epitomize the caring, professional nurse. Caring is a concept central to the profession of nursing and inherent in this value is a strong commitment to public service. Nursing is a help-ing profession directed toward service to the public through health promotion and disease prevention for individuals, families, and com-munities. The role of the nurse is focused on assessing and promoting the health and well-being of all humans. Registered nurses remain in nursing to promote, advocate, and protect the health and safety of pa-tients, families, and communities (ANA, 2015b).Autonomy is the right to self-determination as a professional. The role of the professional nurse is to honor and assist individuals and families to make informed decisions about health care and to provide information so that they can make informed choices. The professional nurse respects patientsÕ rights to make decisions about their health care.Commitment to lifelong learning and education is necessary in the dynamic healthcare arena that surrounds nursing practice in this century. Nurses need continuous education to maintain a safe level of practice and to expand their level of competence as professionals. With new technologies and the rapid growth of medical and nursing KEY OUTCOME 5-1Example of Domain 9 sub-competency for entry-level professional nursing education.9.5a Describe nursingÕs professional identity and contributions to the healthcare team (p. 54).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfProfessional Nursing Roles and Values159
knowledge, the nurse must actively and continuously seek to expand professional knowledge. Professional nursing involves a commitment to be resourceful, to respond to the dynamic challenges of delivering health care, to incorporate technology into their caring, and to remain visionaries as the future unfolds (ANA, 2010).Human dignity is respect for the inherent worth and uniqueness of individuals and communities and is such a deeply held value in the profession of nursing that it is the topic of Provision 1 in the Code of Ethics for Nurses (ANA, 2015a). According to the International Council of NursesÕ Code of Ethics for Nurses (2012), Òinherent in nursing is respect for human rights, including cultural rights, the right to life and choice, to dignity and to be treated with respect. Nursing care is respectful of and unrestricted by considerations of age, color, creed, culture, disability or illness, gender, sexual orientation, nation-ality, politics, race or social statusÓ (p. 1).The Formation ProcessFormation into a profession is a process of adapting to and becoming a part of the culture of the profession (Ousey, 2009). This process begins during the studentÕs formal educational program and continues after graduation and licensure in the practice setting.Formation Through EducationStudents new to the nursing profession begin to learn the role while still in the educational setting. Cohen (1981) used the theories of cognitive development to create a model of professional nursing socializa-tion or formation through education. The model describes four stages students must experience as they begin to internalize the roles of a profession. In stage 1, Unilateral Dependence, the individual places complete reliance on external controls and searches for the one right answer (Cohen, 1981). In essence, the student looks to the instructor for the right answers and is unlikely to question the authority. As the student gains foundational knowledge and skill, process of questioning the authority begins.During stage 2, Negative/Independence, the student begins to pull away from external controls and is characterized by cognitive rebel-lion. The student begins to think critically and begins to question the instructor and relies more on his or her own judgments.Stage 3, Dependence/Mutuality, marks the beginning of empathy and commitment to others (Cohen, 1981). In this stage, the student begins to apply knowledge to practice and tests information and facts. ÒStudents have a knowledge base upon which to anchor criti-cal thought and can relate new material to their previous knowledge KEY COMPETENCY 5-1Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesProfessionalism:Knowledge (K4a) Describes factors essential to the promotion of professional developmentSkills (S4a) Participates in lifelong learningAttitudes/Behaviors (A4a) Committed to lifelong learningMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdf CRITICAL THINKING QUESTIONS✶As a nursing student, do you share the values of commitment to public service, autonomy, commitment to lifelong learning and educa-tion, and the belief in the dignity and worth of each person? Do nurses with whom you have interacted demonstrate these values?✶ KEY OUTCOME 5-2Example of Domain 10 sub-competency for entry-level professional nursing education.10.2f Participate in ongoing learning activities that em-brace principles of diver-sity, equity, inclusion, and antidiscrimination (p. 57).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfCHAPTER 5 Education and Formation in Professional Nursing160
baseÓ (Cohen, 1981, p. 18). In this stage, the student is actively en-gaged in learning and thinking through problems. For this stage to emerge, the learning environment must support and value risk taking. The role of the teacher is that of coach, mentor, and senior learner. The mentor helps the student link theory to practice while in the clini-cal areas, thus helping the student to learn from experiences and to improve practices to support professional socialization.Stage 4, Interdependence, occurs when neither mutuality nor autonomy is dominant. Learning from others and gaining the ability to solve problems independently are evident. This is the stage of the professional lifelong learner who demonstrates reflection in practice and is responsible for continued learning. Professional socialization toward the stage of interdependence requires a supportive educational climate that values autonomy, independent thinking, and authenticity. Students become professionals.Professional FormationSeveral models in the literature describe professional socialization or formation. Regardless of the model embraced, formation into a pro-fessional nurse must include new competencies for the 21st century. The Institute of Medicine (IOM, 2011) reported that nurses need requisite competencies, including leadership, health policy, system improvement, research and evidence-based practice, and teamwork and collaboration, to meet the needs of the current dynamic health-care environment. Nursing educators must provide students with opportunities to develop the requisite skills that equip them for the profession as well as instill in them the desire to become lifelong learners because nurses currently need continuous education to main-tain a safe level of practice and to expand their level of competence as professionals.Benner (1984) describes the development of the professional clinical practice of nurses. BennerÕs model identifies the stages of novice, advanced beginner, competent, proficient, and expert that are based on the nurseÕs experience in practice. With an under-standing of this progression of knowledge and skills, educational programs have developed supportive curricula using a continuum of experiences to enhance skill and knowledge development. Healthcare environments have also incorporated this model to facilitate the nurseÕs professional practice by assessing the nurseÕs stage of development. This model is not limited to the student ex-perience or to that of the new graduate nurse. Experienced nurses also benefit from situations designed to move the nurse toward the stage of expert.The first stage, novice, is characterized by a lack of knowledge and experience. In this stage, the facts, rules, and guidelines for KEY COMPETENCY 5-2Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesProfessionalism:Knowledge (K4c) Under-stands the importance of reßection to advancing practice and improving outcomes of careSkills (S4b) Demonstrates ability for reßection in ac-tion, reßection for action, and reßection on actionAttitudes/Behaviors (A4c) Values and is commit-ted to being a reßective practitionerMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfThe Formation Process161
practice are the focus. Rules for practice are context-free, and the studentÕs task is to acquire the knowledge and skills. The stage of novice is not related to the age of the student but rather to the knowl-edge and skill in the area of study. For example, learning how to give injections would be presented with the procedural guidelines, and the novice would then practice the skill. At this stage, much of the studentÕs energy and attention are aimed at remembering the rules. Because the focus is on remembering rules, the studentÕs practice is inflexible, the student is unable to use discretionary judgment, and the student is dependent on and has confidence in those with greater expertise rather than having confidence in his or her own judgment (Benner, 1984; Benner et al., 2009). This stage can be compared to an experience that most nursing students can relate to: learning to drive a car. Initially, the experience is characterized by halting progress as the student driver actively tries to gauge the pressure required on the gas pedal and the brake, remember how many feet before the corner to use the turn signal, and remember how many feet to keep between cars. This analogy simplifies the stage of novice related to nurse for-mation, but most can remember the excitement and the frustrations of learning to drive a car as well as the transition when driving began to require less effort.In the next stage, advanced beginner, the nurse can formulate principles that dictate action. For example, the advanced beginner grasps the rationale behind why different medications require differ-ent injection techniques. However, advanced beginners still lack the experience to know how to prioritize in more complex situations and might feel at a loss in terms of what they can safely leave out, making the patient care situation appear as a perplexing set of problems they must figure out how to solve.The advanced beginner will still emphasize tasks that need to be accomplished, as well as rules, but does not have the experience to adjust or adapt the rules to the situation. In this stage, action and interpretation are the central focus rather than decision making. Both knowledge and experience are limited in the advanced begin-ner nurse, which means that subtle cues about a patientÕs condition may be missed (Sitterding, 2015). The nurse in the stage of advanced beginner still requires guidance (Figure 5-1). Given the complexity of nursing practice and the range of clinical experiences, new gradu-ates can be described as advanced beginners (Benner, 1984; Benner et al., 2009).BennerÕs stage 3, competent, is characterized by the ability to look at situations in terms of principles, analyze problems, and pri-oritize, and thus a nurse in this stage has the ability to plan as well as to alter plans as necessary. The nurse in this stage has improved time management and organizational skills as well as technical skills. The nurse in the competent stage will also demonstrate increased ability in CHAPTER 5 Education and Formation in Professional Nursing162
diagnostic reasoning, which means he or she is able to make a clinical case for action to other members of the healthcare team. Movement from one stage to the next does not cross distinct boundaries, but the nurse at this stage has had experience in a variety of clinical situa-tions and can draw on prior knowledge and experience; typically, the nurse will have 1 to 2 years of experience in a similar job situation. The competent stage of learning is important in the formation of the ethical comportment of the nurse. Ethical comportment refers to good conduct born out of an individualized relationship with the patient that involves engagement in a particular situation and entails a sense of membership in the relevant professional group. It is socially embed-ded, lived, and embodied in practices, ways of being, and responses to a clinical situation that promote the well-being of the patient (Day & Benner, 2002). Continued active learning and mentoring are impor-tant for movement to the proficient stage. Students who have the opportunity to have extended internships in a specialty area during their education can graduate entering this stage (Benner, 1984; Benner et al., 2009).Stage 4, proÞcient, refers to the professional nurse who can grasp the situation contextually as a whole and whose performance is guided by maxims. This nurse has a solid grasp of the norms as well as solid experiences that shed light on the variations from the norm. Based on an intuitive grasp of the situation, the nurse recognizes the most salient aspects of the situation or the most salient recurring Figure 5-1 The nurse at the advanced beginner stage still requires guidance from more experienced nurses.© Monkey Business Images/Shutterstock.The Formation Process163
meaningful components of the situation. Salience is a perceptual stance or embodied knowledge whereby aspects of a situation stand out as more or less important (Benner, 1984); therefore, the nurse at this stage knows what can wait and what cannot. The nurse has moved into a place where he or she can engage in a clinical situation and connect with the patient and family in ways that are truly benefi-cial. Incorporated into practice is the ability to test knowledge against situations that might not fit and to solve problems with alternative approaches. In this stage, the professional tests the rules and theories and looks at cases that can lead to developing alternative rules and theories. One might say that this is the stage when the professional begins to Òbreak the rulesÓ because he or she sees that the rules do not always apply. Achieving this level of proficiency in nursing typically takes 3 to 5 years of practice with similar patient populations (Benner, 1984; Benner et al., 2009).BennerÕs final stage, expert, means the nurse has moved beyond a fixed set of rules (Figure 5-2). The expert has an internalized un-derstanding grounded in a wealth of experience as well as depth of knowledge. Benner describes the expert nurse as demonstrating em-bodied intelligence. The expert nurse is able to skillfully manage mul-tiple tasks simultaneously and knows not only what to do and when to do it but also how to do what is needed. The expert nurse has a grasp of the whole with an ability to move beyond the immediate Figure 5-2 Critically ill patients require care from nurses with extensive experience.© Tyler Olson/Shutterstock.CHAPTER 5 Education and Formation in Professional Nursing164
clinical situation but to remain attuned to the clinical situation at a level that allows a Òmindful readingÓ of the patient responses even without conscious deliberation. The nurse may have difficulty explain-ing how he or she knows something because the recognition and as-sessment language are so linked with actions and outcomes that they are obvious to the expert nurse, although not obvious to others. The expert is always learning and always questioning using subjective and objective knowing. Benner (1984, 1999; Benner et al., 2009) proposes that not all nurses can obtain this stage; when it is obtained, it is only after extensive experience.The typical career in nursing is not a linear process. There is considerable variation in progression of nurses related to degree attainment and career growth. In addition, with the focus of in-creasing the percentage of nurses with baccalaureate degrees and doctoral degrees in nursing (IOM, 2011), many nurses are returning to school for additional academic degrees in order to advance their careers. This often results in a change in the nurseÕs practice role. It can be stressful to transition from a role where the nurse is an expert to a new role where the nurse will not function at the same level of expertise. For example, when the expert pediatric nurse graduates from a pediatric nurse practitioner program, passes the certification exam, and begins to function in the advanced practice role, the nurse will not be an expert pediatric nurse practitioner. With experience in the new, advanced practice role, he or she will again transition through the stages of professional development. The same type of role transition occurs when the expert clini-cian changes practice roles to become a nurse educator or nurse researcher.Facilitating the Transition to Professional PracticeProfessional formation requires that the student learn the technology of the profession, learn to internalize the professional culture, find a personally and professionally acceptable version of the role, and integrate this professional role into all of his or her other life roles (Cohen, 1981).Students are taught an ideal, theoretical, research-based prac-tice that shelters them from the realities of the world where nursing practice consists of not only theory and research but also of human emotion and response, along with the policies and procedures of the particular working environment. This concept of idealism is impor-tant to the profession because it contributes to a high standard of pro-fessional practice. The perceived disconnection between education and practice is known as role discrepancy. Therefore, when students enter KEY OUTCOME 5-3Example of Domain 10 sub-competency for entry-level professional nursing education.10.2c Commit to personal and professional growth (p. 57).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfFacilitating the Transition to Professional Practice165
the practice environment, the culture of the classroom and the culture of clinical practice can seem worlds apart. Reality shock has been the traditional phrase to describe the transition from nursing student to registered nurse (Kramer, 1974).Reality shock occurs when the perceived role (how an individual believes he or she should perform in a role) comes into conflict with the performed role (Catalano, 2009). Many new graduates experi-ence this reality shock of knowing what to do and how to do it but encountering circumstances that prevent them from performing the role in that way (Figure 5-3). Role conflict exists when a nurse cannot integrate the ideal, the perceived, and the actual performed role into one professional role.Role transition shock is the experience of moving from the known role of student to the role of practicing professional (Duch-scher, 2009). For many nursing students, role conflict occurs when they transition from the role of student to that of registered nurse (Pellico et al., 2009). The new graduate moves from a perceived role of what the professional nurse is and does to the actual performed role where his or her actions and beliefs might be challenged.Figure 5-3 Role transition shock can result in role conflict and overwhelming stress for the new graduate nurse.© Studio Light and Shade/Shutterstock.CHAPTER 5 Education and Formation in Professional Nursing166
The reality shock or role transition shock that new graduates experience can be reduced, to some extent. Many schools of nursing have implemented opportunities for externships or prolonged precep-tor clinical experiences with a professional nurse before graduation. Research (Ruth-Sahd et al., 2010) shows participation in extern programs eases the gap between education and practice. One goal of this experience is to help the student assimilate the role of the professional nurse just before gradu-ation. During this time, the student can experience a more realistic view of clinical practice in the real-world environment. As one student commented, ÒAll the lectures and assignments in nursing school cannot compare with the application of theory that this externship offeredÓ (Ruth-Sahd et al., 2010, p. 83). Externships and preceptor clinical ex-periences can help nursing students begin the transition from perceived role expectations to actual role expectations, thus easing the transition from student nurse to practicing professional.In addition to internship and externship programs before the graduation of the nurse, some hospitals are also offering nurse resi-dency programs to facilitate the socialization into the profession. Nurse residency programs go beyond the orientation focused on poli-cies and procedures that occurs to prepare the nurse to function in a particular setting. A residency program that focuses on transition into practice is formalized and focused on facilitating the transition of the newly licensed nurse from education to practice (Spector et al., 2015).Hospitals offering formalized graduate nurse residency programs provide graduates with rotations through a number of clinical ar-eas that include preceptor support. Evidence suggests that a sense of belonging contributes to professional formation or socialization (Zarshenas et al., 2014). After the completion of residency programs, new nurses report gaining a sense of belonging, thus supporting claims that these programs can lead to enhanced socialization into the clinical workplace (McKenna & Newton, 2009). In addition to formal education, preceptors can assist students to develop skills of assertion, reflection, and critical thinking that are required to provide holistic, evidence-based care (Mooney, 2007).Nurse residency programs focused on transition to practice also result in decreased stress and increased job satisfaction, with research demonstrating decreased attrition during the first year of practice for newly licensed nurses. In addition to promoting retention and assist-ing the new nurse to adjust to the practice environment, nurse resi-dency programs also affect quality and safety. Newly licensed nurses in hospitals with established transition to practice programs also dem-onstrated higher competency levels, fewer patient errors, and fewer negative safety practices (Spector et al., 2015). CRITICAL THINKING QUESTIONS✶What do you think are the barriers to the process of professional formation? Do you think different environments might foster or hinder the process of professional for-mation? Do you think that the personal characteristics of nurses might influence the process of professional formation?✶Facilitating the Transition to Professional Practice167
In response to evidence on the effect of nurse residency programs, the National Council of State Boards of Nursing (NCSBN) has devel-oped a model for transitioning new nurses into practice. The NCSBN Transition to Practice (TTP) model comprises five transition models that include patient-centered care, communication and teamwork, evidence-based practice, quality improvement, and informatics with a goal of promoting Òpublic safety by supporting newly licensed nurses during their critical entry period and progression into practiceÓ (Spector, 2013, p. 55). These modules are designed as a 6-month pro-gram and are available at a cost per module or cost per program basis. In addition, a preceptor module is available to nurse preceptors to learn about the roles and responsibilities of preceptors and effective behav-iors and strategies to foster growth in new graduates (NCSBN, 2018).ConclusionThe goal in the formation of nurses today and for the future is to achieve caring with autonomy. The challenge for the profession is cap-italizing on the strengths of everyone and finding a means of accom-modating all individuals as a way of maintaining the viability of the profession (Leduc & Kotzer, 2009). Professional formation in nurses in a profession that fully embraces caring for self and others reflects the internalization of what Roach (1991) refers to as Òthe five CÕs: compassion, competence, confidence, conscience, and commitmentÓ (p. 132), representing a framework for human response from which professional caring is expressed.Nursing education should be humanistic and caring, with caring ex-perts as role models who contribute to the formation of future genera-tions of nurses and help them become caring experts in nursing practice. Through their research, Condon and Sharts-Hopko (2010) report that reflection can be an effective means of understanding human emotion and responses. One student stated, ÒI think the most important time is after the clinical training when I go home. I think about the informa-tion I get from the patient. What does it mean? What does it mean for the patient? I should connect to itÓ (Condon & Sharts-Hopko, 2010, p. 169). Regarding role development and formation, it is important to remember that we learn what we live (Becker-Hentz, 2004).Classroom Activity 5-1Incorporate actual quotes from the nurses who were interviewed in BennerÕs book From Novice to Expert (1984) in class discussions to illustrate the differences among each of the stages: novice, advanced beginner, competent, proficient, and expert. This activity is simple but enlightening to students as they differenti-ate between the stages.CHAPTER 5 Education and Formation in Professional Nursing168
ReferencesAmerican Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Author.American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Essentials-2021.pdfAmerican Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Author.American Nurses Association. (2010). NursingÕs social policy statement: The essence of the profession. Author.American Nurses Association. (2015a). Code of ethics for nurses with interpretive statements. Author.American Nurses Association. (2015b). Nursing: Scope and standards of practice (3rd ed.). Author.Becker-Hentz, P. (2004). Understanding relationships: Learning what we live. Unpublished manuscript.Benner, P. (1984). From novice to expert. Addison-Wesley.Benner, P. (1999). From novice to expert: Excellence and power in clinical nursing practice. Addison-Wesley.Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. Jossey-Bass.Benner, P. E., Tanner, C. A., & Chelsea, C. A. (2009). Expertise in nursing practice: Caring, clinical judgment, and ethics (2nd ed.). Springer.Catalano, J. (2009). Nursing now! (5th ed.). F. A. Davis.Cohen, H. A. (1981). The nurseÕs quest for a professional identity. Addison-Wesley.Condon, E., & Sharts-Hopko, N. (2010). Socialization of Japanese nursing students. Nursing Education Perspectives, 31(3), 167Ð169.Day, L., & Benner, P. (2002). Ethics, ethical comportment, and etiquette. American Journal of Critical Care, 11(1), 76Ð79.Duchscher, J. E. B. (2009). Transition shock: The initial stage of role adaptation for newly graduated registered nurses. Journal of Advanced Nursing, 65(5), 1103Ð1113. doi:10.1111/j.1365-2648.2008.04898.xGordon, S. (2006). What do nurses really do? Topics in Advanced Practice Nursing eJournal, 6(1). http://www .medscape.com/viewarticle/520714Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. National Academies Press.International Council of Nurses. (2012). The ICN code of ethics for nurses. Author. https://www.icn.ch/sites /default/files/inline-files/2012_ICN_Codeofethicsfornurses_%20eng.pdfKramer, M. (1974). Reality shock, why nurses leave nursing. Mosby.Leduc, K., & Kotzer, M. (2009). Bridging the gap: A comparison of the professional nursing values of students, new graduates and seasoned professionals. Nursing Education Perspectives, 30(5), 279Ð284.Massachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. https://www.mass.edu/nahi/documents/nofrncompetencies_updated _march2016.pdfClassroom Activity 5-2Read excerpts from the 2006 article ÒWhat Do Nurses Really Do?Ó by Suzanne Gordon (available at www.medscape.com/viewarticle /520714) in class to stimulate discussion, and ask the following questions:¥ What do you think nurses actually do?¥ What do you think about the current im-age of nursing?¥ What do you think about the effect of the fo-cus on caring over the knowledge of nurses?References169
McKenna, L., & Newton, J. M. (2009). After the graduate year: A phenomenological exploration of how new nurses develop their knowledge and skill over the first 18 months following graduation. Contemporary Nurse: A Journal for the Australian Nursing Profession, 31(2), 153Ð162.Mooney, M. (2007). Professional socialization: The key to survival as a newly qualified nurse. International Journal of Nursing Practice, 30, 75Ð80.National Council of State Boards of Nursing. (2018). NCSBN learning extension: Transition to practice. https://ww2.learningext.com/newnurses.htmOusey, K. (2009). Socialization of student nursesÑthe role of the mentor. Learning in Health and Social Care, 8(3), 175Ð184.Pellico, L. H., Brewer, C. S., & Kovner, C. T. (2009). What newly licensed registered nurses have to say about their first experiences. Nursing Outlook, 57, 194Ð203.Roach, M. S. (1991). Creating communities of caring. In National League for Nursing (Ed.), Curriculum revolution: Community building and activism (pp. 123Ð138). National League for Nursing Press.Ruth-Sahd, L. A., Beck, J., & McCall, C. (2010). Transformative learning during a nursing externship program: The reflections of senior nursing students. Nursing Education Perspectives, 31(2), 78Ð83.Sitterding, M. C. (2015). An overview of information overload. In M. C. Sitterding & M. E. Broome (Eds.), Information overload: Framework, tips, and tools to manage in complex healthcare environments (pp. 1Ð9). American Nurses Association.Spector, N. (2013). Transition to practice: An essential element of quality and safety. In K. S. Amer (Ed.), Quality and safety for transformational nursing: Core competencies. Pearson, 2013: 48Ð60.Spector, N., Blegen, M. A., Silvestre, J., Barnsteiner, J., Lynn, M. R., Ulrich, B., . . . Alexander, M. (2015). Transition to practice in hospital settings. Journal of Nursing Regulation, 6(1), 4Ð13.Zarshenas, L., Farhondeh, S., Molazem, Z., Khayyer, M., Zare, N., & Ebadi, A. (2014). Professional socialization in nursing: A content analysis. Iranian Journal of Nursing and Midwifery Research, 14(4), 432Ð438.CHAPTER 5 Education and Formation in Professional Nursing170
Successful management of your professional nursing career does not occur by accident or default. Rather, it is a deliberate, purposeful, informed process requiring self-appraisal of your need for further professional growth and development, attentiveness to projected trends in healthcare delivery, dialogue with nurse colleagues who have demonstrated success in advancing their careers, exploration of nurs-ing education programs that will support your career advancement, consideration of how to balance work and study demands and remain healthy, and investment of self to pursue these professional nursing career options. Be reflective and proactive in seizing opportunities to shape and refine your professional nursing career.Nursing: A Job or a Career?Your initial motivators for choosing to become a professional regis-tered nurse (RN) may be far different from the reasons why you stay in professional nursing practice. Over time, nurses begin to appreci-ate that the practice of professional nursing as a career is a serious, sustained, and rewarding undertaking, dedicated to Òthe protection, Key Terms and Concepts ÈBurnout ÈCareer management ÈCompassion fatigue ÈMentoring ÈProfessional portfolio ÈResilienceAfter completing this chapter, the student should be able to:1. Discuss the difference between a job and a career.2. Articulate the importance of proactively managing his or her nursing career.3. Discuss the beneÞts of a mentoring relationship.4. Explore the effect of work-related stress.Learning ObjectivesAdvancing and Managing Your Professional Nursing CareerMary Louise Coyne and Cynthia ChathamCHAPTER 6© Nuu Jeed/Shutterstock171
promotion, and optimization of health and abilities, prevention of ill-ness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populationsÓ (American Nurses Association [ANA], 2015b, p. 1). Further, many seasoned nurses come to realize that a career in professional nursing requires academic preparation at the bachelor of science in nursing (BSN) degree level or higher, engagement in lifelong or career-long learning to expand knowledge and clinical and management compe-tencies, willingness to translate research evidence into practice on a continuous basis, and commitment to advance the health of patients and the profession of nursing. Supplemental methods for awarding credit and recognition for learning such as the use of e-portfolios, cer-tification, micro-credentials. or badges are several trends in education that support career-long learning.Professional nursing is a career to be managed and not just a job where you Òpunch in and punch out.Ó Table 6-1 compares two views of nursing as a job and as a career. In advocating for career management in nursing, Daggett (2014) notes,A degree and a nursing license might be the ticket that gets you started on the journey, but without a destination, an itinerary, and a map, you will not travel very far. Like any TABLE 6-1 Do You View Nursing as a Job or as a Professional Career?FactorView Nursing as a JobView Nursing as a CareerAcademic preparationObtains the least amount needed for nurs-ing licensureObtains a BSN and often pursues an advanced nursing degree: master of science in nursing (MSN), doctor of nursing practice (DNP), and/or doctor of philosophy (PhD)Continuing educationObtains the minimum continuing education (CE) units required for licensure and/or the jobEngages in formal and informal lifelong or career-l ong learning experiences across the nurseÕs professional career in order to:Deepen and broaden knowledge and skill competenciesImprove the delivery of safe, cost-effective, quality- based patient careImprove patient outcomesLevel of commitmentContinues with the job as long as it meets his or her personal needs; expects reasonable work for rea-sonable pay; responsibil-ity ends with shiftActively and joyfully engages in practicing the art and science of professional nursing as a member and, possibly, leader in professional nursing ini-tiatives within the nurseÕs healthcare agency and in professional nursing organizations (local, re-gional, state, national, and/or international levels)CHAPTER 6 Advancing and Managing Your Professional Nursing Career172
important journey, a career requires research and planning; otherwise, you risk missing opportunities and critical mile-stones along the way. One should always assess the current location before planning future directions. Just as you track progress with a map while on a road trip, you should have a plan for managing your career, lest you find yourself wan-dering in the wilderness without making any true progress toward your career goals. (p. 168)Purposefully manage your careerÑno one else can do this for you! Do not rely on healthcare employers to manage your career. Your best interests are yours and yours alone. Your career man-agement and your short- and long-term goals are yours. For the career-oriented nurse, goals usually include (1) pursuit of an academic program to obtain a BSN degree or graduate-level nursing education for advanced practice, admin-istration, teaching, or research within a specified time frame, and/or (2) assuming a new position within a healthcare organization that has more re-sponsibility and accountability in order to advance his or her nursing career.Direction is needed to accomplish these goals. Without such a ca-reer map, nurses may wander aimlessly. Where am I going? How am I going? Part of career management is having the map to accomplish goals. Career mapping provides nurses with a clear direction, includ-ing short-term stops to accomplish goals and a realistic time of arrival at the ultimate career destination. This may include position changes within an agency or a change in agencies. The map includes the skills obtained, the skills needed, and the resources needed to obtain skills (Hein, 2012). The pathway usually includes yearly goals as well as long-term goals. Without goals, nurses may leave the profession or risk beginning to view nursing as only a job that pays the bills.Trends That Affect Nursing Career DecisionsHealthcare agencies are constantly changing, with the goal of provid-ing care to the community while containing costs. Although there is sufficient evidence demonstrating a professional nursing shortage in many areas across the United States, healthcare agencies are con-fronted with escalating costs, stringent cost containment initiatives, streamlined reimbursement systems, and a plethora of state and fed-eral regulations that often constrain how well or poorly these agen-cies are able to deliver health care. In response to these budgetary constraints, many hospitals have responded by moving traditional inpatient care to ambulatory care in outpatient settings, hiring fewer CRITICAL THINKING QUESTIONS✶Do you view nursing as a career or as a job? What are your professional goals related to nursing?✶Trends That Affect Nursing Career Decisions173
professional nurses, training more unlicensed assistive nursing person-nel, cutting nursing salaries, hiring more RNs to part-time positions to avoid providing health and retirement benefits, and relying on fewer RNs to cover unfilled positions.As you consider how to advance your nursing career, it is critical to examine projected trends in health care, particularly as they apply to (1) where health care is delivered, (2) the type of practitioners needed, and (3) the nursing educational preparation required to provide this care. The U.S. Department of Labor, Bureau of Labor Statistics (2019) reported that 93% of RNs worked in the following areas:¥ 60% hospitals; state, local, and private¥ 18% ambulatory healthcare services¥ 7% nursing and residential care facilities¥ 5% government¥ 3% educational services; state, local, and privateIn forecasting the future needs of the U.S. healthcare delivery sys-tem, the Institute of Medicine (IOM, 2010) projects that by 2020, the profession of nursing will need to double the number of nurses with a doctorate and increase the number of nurse practitioners in hospitals, home health, hospice, and nursing homes. In addition, the American Association of Colleges of Nursing (AACN, 2015) reports that the nursing shortage may be easing in some parts of the country, but the demand for RNs prepared with baccalaureate, masterÕs, and doctoral degrees continues to increase.Investigate where the shortages are in the location where you will be practicing, what types of practitioners are needed to meet these needs, and what type of advanced nursing education is required for these positions. Remember, you are in charge of making choices that best fit your short- and long-term career goals. You are your own best advocate in planning your nursing career!Crafting the direction of your professional nursing career and executing the plan is transformational. The IOM (2011) report, The Future of Nursing: Leading Change, Advancing Health, provides a blueprint for how the entire profession must be transformed in order to advance the health of patients and simultaneously direct needed changes in the healthcare delivery system. In setting the agenda for nursingÕs future, the IOM Committee on Nursing identified four key messages and eight related recommendations that have the potential for the greatest effect and for accomplishment within the next decade. The four key messages are:¥ Nurses should practice to the full extent of their education and training.¥ Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.CHAPTER 6 Advancing and Managing Your Professional Nursing Career174
¥ Nurses should be full partners, with physicians and other health-care professionals, in redesigning health care in the United States.¥ Effective workforce planning and policy making require better data collection and an improved information infrastructure (IOM, 2011, p. 4).The eight specific recommendations include:¥ Remove scope of practice barriers¥ Expand opportunities for nurses to lead and diffuse collaborative improvement efforts¥ Implement nurse residency programs¥ Increase the proportion of nurses with a baccalaureate degree to 80% by 2020¥ Double the number of nurses with a doctorate by 2020¥ Ensure that nurses engage in lifelong learning¥ Prepare and enable nurses to lead changes to advance health¥ Build an infrastructure for the collection and analysis of interpro-fessional healthcare workforce data (IOM, 2011, pp. 9Ð14).The IOM report on the future of nursing is a great starting point for setting your professional nursing career goals and planning your career trajectory. Careful deliberation on these initiatives and recom-mendations provides insight into the questions that you might ask in setting your own professional nursing career goals. See Box 6-1 for a list of questions to ask yourself as you plan your career goals. BOX 6-1 QUESTIONS TO ASK AS YOU PLAN YOUR CAREER GOALS¥ What is the future of nursing for me?¥ Am I currently practicing to the fullest extent of my nursing edu-cation and training? (IOM, 2011, Initiative 1)¥ What changes need to occur in my current practice in order to actualize this personal vision of my career?¥ What are the projected employment trends and opportunities for nursing in my area?¥ Have I achieved the highest level of education and training (IOM, 2011, Initiative 2) to support my desired career goals?¥ What career path am I best equipped for and motivated to pursue to lead change and advance health? Should I pursue a BSN, MSN, DNP, or PhD, and if so, what specialization should I consider: a nurse practitioner, a nurse educator, a nurse anesthetist, a nurseÐmidwife, a nurse researcher, and/or a nurse executive?¥ Have I sought out and had a dialogue with seasoned colleagues who have demonstrated success in advancing their nursing careers (continues)Trends That Affect Nursing Career Decisions175
Showcasing Your Professional SelfShowcasing your nursing story is an important aspect of career man-agement and includes how you present yourself in your professional portfolio and in the interview process. A rŽsumŽ and cover letter will assist in getting an interview, but a complete professional portfolio may be what secures you the new position. A portfolio provides sev-eral advantages, including self-enlightenment, career enhancement, a record of growth and development, a record of performance over time, and a tool for planning, and it can act as a resource for others looking to create one (Masor, 2013).A professional portfolio, whether a print or electronic version, contains a cover letter; a rŽsumŽ; examples of accomplishments cited but not elaborated upon in your rŽsumŽ; selections of high-quality projects, papers, presentations, teaching tools/programs, patient or nursing care forms, policies, or procedures that you may have de-veloped or codeveloped across your career; and copies of licensure, certifications, awards, and professional organizational membership cards. In todayÕs culture, being bilingual can be a definite advantage. Each language and dialect, if appropriate, should be included in your portfolio, including competencies in reading, understanding, speaking, and writing. Awards received can be a testament to your diligence in a position and willingness to go beyond the job requirements. Being an officer in an organization shows leadership abilities (Schmidt, n.d.).The portfolio will look different depending on the position you are seeking and the competencies you wish to showcase. Examples of some differences in the portfolio based on experience and desired po-sition are as follows:¥ If you are applying for a first-time position as a new RN, the portfolio can be used to showcase your competencies, intellectual and elicited their input on trends in nursing practice and nursing education options?¥ Have I explored nursing education program options at accredited academic institutions that will support my career advancement interests?¥ Have I pursued ways to pay for advancing my nursing education through reimbursement at work, state and federal scholarships and traineeships, and/or public and private foundations?¥ How will I balance work/family/study demands and remain physically, psychologically, and financially healthy?¥ Last and perhaps most important, am I ready to take action in advancing my professional nursing career? BOX 6-1 QUESTIONS TO ASK AS YOU PLAN YOUR CAREER GOALS (continued)CHAPTER 6 Advancing and Managing Your Professional Nursing Career176
skills, and teamwork during your time as a student. New gradu-ates, in particular, have to showcase themselves to stand apart from other applicants (Health eCareers Network, 2012).¥ If you are applying for an advanced practice position, the IOM (2011) recommends that the portfolio be used as a means to docu-ment competencies and experience with patient populations.¥ If you are applying for a staff position, you may consider provid-ing a short case study describing the types of patients you have cared for and the specific skills and competencies you demon-strated in caring for this patient population.¥ If you are applying for a management position, you may consider providing examples of leadership/management situations you have been engaged in, such as decision-making situations, schedules completed, and quality improvement initiatives.Your cover letter should be directed to the human resources direc-tor, one page in length, word-processed, printed on white stock paper with black ink, and should clearly identify the correct title of the position you are seeking, the length of time you have been an RN, a request for an interview, and your contact information.Your rŽsumŽ provides a brief overview of your professional ca-reer. Most rŽsumŽs contain the following sections: identification, edu-cation, licensure and certifications, professional nursing employment history, professional committee engagement, and professional nursing organizations. Most rŽsumŽs are one page in length and order entries from most recent to distant. See Figure 6-1 for an example rŽsumŽ.First impressions made during the interview are also important. Arriving early and dressing professionally are a good beginning. Being prepared with answers for potential questions will only enhance the impression you make. Information concerning the job requirements, including duties, patient census and type, salary, and benefits, should be provided by the interviewer. Your follow-up questions assist you in understanding the expectations of the position. In ÒWhat Every Nurs-ing Student Should Know When Seeking Employment: An Interview Tip Sheet for Baccalaureate and Higher Degree Prepared Nurses,Ó the AACN (n.d.-c) discusses characteristics of the organization that the applicant should assess. These eight hallmarks or characteristics are in the following list. Prior to your interview, refer to the brochure, which is available on the AACN website, for specific questions under each of the categories. The brochure is available at http://www.aacnnursing .org/Students/Career-Resources.¥ Manifest a philosophy of clinical care emphasizing quality, safety, interdisciplinary collaboration, continuity of care, and profes-sional accountability.¥ Recognize the value of nursesÕ expertise on clinical care quality and patient outcomes.Showcasing Your Professional Self177
NAME123 Street NameCity, State, Zip Code(area code) phone numberemail addressEDUCATION2013Bachelor of Science in Nursing (BSN), College of Nursing, Name of University,City, State.LICENSURE AND CERTIFICATIONS2013Ð2015Registered Nurse. Multi-State License, Mississippi Board of Nursing.2013Ð2015 Advanced Cardiac Life Support Provider (ACLS). American Heart Association.PROFESSIONAL MEMBERSHIP2013Ð2015American Nurses Association2012Ð2015 Gamma Lambda Chapter, Sigma Theta Tau International Honor Society 2010Ð2015 Basic Life Support Provider (BLS). American Heart Association.PROFESSIONAL NURSING EMPLOYMENT HISTORY2013Ð2015Primary Care Nurse, Adult Medical Intensive Care Unit, Memorial Hospital at Gulfport, Gulfport, Mississippi. Responsible for providing comprehensive andPROFESSIONAL COMMITTEE ENGAGEMENT2014Ð2015Member. Electronic Health RecordÑNursing Implementation Committee, Memorial Hospital at Gulfport, Gulfport, Mississippi.2013Ð2015Member. Infection Control Committee, Memorial Hospital at Gulfport, Gulfport, Mississippi.rapid assessments and management of critically ill adult patients requiringintravenous and central lines, ventilator, tracheostomy and wound care;member of Rapid Response Team.of NursingFigure 6-1 Example rŽsumŽ.CHAPTER 6 Advancing and Managing Your Professional Nursing Career178
¥ Promote executive-level nursing leadership.¥ Empower nursesÕ participation in clinical decision making and or-ganization of clinical care systems.¥ Demonstrate professional development support for nurses.¥ Maintain clinical advancement programs based on education, cer-tification, and advanced preparation.¥ Create collaborative relationships among members of the health-care team.¥ Use technological advances in clinical care and information systems.It is illegal for employers to ask certain questions. Knowing those questions and, more important, knowing the questions that are al-lowed are key in preparation for the interview (Compare Business Products, 2013). Many interviewers use silence as a tool to evaluate the candidate. Use the silence to gather your thoughts and let the in-terviewer break the silence. At the conclusion of the interview, thank the interviewer for his or her time and ask about the timeline for filling the posi-tion. Send a follow-up note thanking the person for the interview and state that you are looking forward to a response.MentoringThe IOM report on The Future of Nursing (2011) recommends mentoring to assist in increasing the readiness and retention of nurses to improve patient outcomes (Figure 6-2). Mentoring is a relationship between two nurses in which the more experienced nurse provides leadership and guidance to the nurse with less experience, often re-ferred to as the ÒmenteeÓ (Minority Nurse, 2013). Preceptors and mentors play different roles. A mentor provides counsel regarding career management, and the mentoring relationship may take place in the beginning of a nursing career, when changing positions, or when a nurse is furthering his or her education. The mentorÐmentee relationship may be a long-term relationship. In contrast, a precep-tor provides direct short-term coaching to a new graduate nurse, a newly hired nurse, or a nurse who transfers to another unit and orients the nurse to roles and responsibilities on the unit and within the organization. A mentor may also serve as a preceptor; however, a preceptor is not a mentor. It is not uncommon for mentees to become mentors, guiding others in their pursuit of professional growth and development.Being a mentor takes time and requires patience. The mentor must be reasonable, competent, committed to assisting the mentee in being successful in his or her career, adept at providing feedback, CRITICAL THINKING QUESTION✶What kind of first impression do you make when searching for a new position?✶Mentoring179
and open to sharing knowledge. Professional growth should be the outcome for both mentor and mentee. It is the responsibility of the person seeking career mentorship to find a mentor. The mentor may be a nursing faculty member, an experienced nurse within a healthcare organization or nursing school, or a nurse from a professional nurs-ing organization. This relationship has benefits for both. The mentor receives confirmation from witnessing the career development and advancement of the mentee in professional nursing. The benefits of being mentored are many and include:¥ Increased self-confidence¥ Enhanced leadership skills¥ Accelerated acclimation to the culture of the unit/facility¥ Advancement opportunities¥ Enhanced communication skills¥ Reduced stress¥ Improved networking ability¥ Political savvy¥ Legal and ethical insightProblems with mentoring may occur with either person (Minority Nurse, 2015). The mentee may outgrow the mentor in knowledge and in the profession. The commitment in time and energy of the mentor may become overwhelming. The relationship may even become toxic Figure 6-2 Mentoring is a formalized relationship with a more experienced nurse providing guidance to a nurse with less experience.© Monkey Business Images/Shutterstock. KEY COMPETENCY 6-1Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesProfessionalism:Knowledge (K4b) Describes factors essential to the promotion of professional developmentSkills (S3b) Provides and receives constructive feed-back to/from peersAttitudes/Behaviors (A3b) Values collegiality, open-ness to critique, and peer reviewAttitudes/Behaviors (A4b) Values the mentoring relationship for profes-sional developmentMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfCHAPTER 6 Advancing and Managing Your Professional Nursing Career180
if the mentor becomes inaccessible or harmful to the mentee and may even block the learning and progression of the mentee. If any of these become evident in the relationship, both must communicate and dis-cuss the situation. They may agree to a separation or to repairing the relationship.Education and Lifelong or Career-Long LearningThe profession of nursing needs a more educated workforce for the sake of increasing healthcare quality and patient safety. The ANA standards of professional nursing practice, Standard 12, indicate that it is the responsibility of every nurse to seek Òknowledge and com-petence that reflects current nursing practice and promotes futuristic thinkingÓ (2015b, p. 76). The competencies associated with this stan-dard reflect commitment to lifelong learning, the maintenance of a professional portfolio, and a commitment to mentoring. Every state board of nursing should require mandatory continuing education for all practicing RNs, but not all do. The call for a more educated pro-fessional nursing workforce to lead change and advance health has been mandated in the initiatives of the IOM (2011):¥ ÒIncrease the proportion of nurses with a baccalaureate degree to 80 percent by 2020.Ó (Initiative 4)¥ ÒDouble the number of nurses with a doctorate by 2020.Ó (Initia-tive 5)¥ ÒEnsure that [all] nurses engage in lifelong learning.Ó (Initiative 6)In 2018, the U.S. Department of Health and Human Services, Health Resources and Services Administration reported the distribu-tion of RNs by initial nursing education as follows:¥ 11.4% were diploma-prepared RNs¥ 48.5% of RNs had an associate degree in nursing (ADN)¥ 39.3% had a BSN¥ 0.9% had a graduate degreeThe U.S. Department of Health and Human Services, Health Re-sources and Services Administration also reported the distribution of RNs by highest nursing or nursing-related educational preparation was as follows:¥ 6.4% were diploma-prepared RNs¥ 29.6% of RNs had an ADN¥ 44.6% had a BSN¥ 17.5% had a masterÕs degree¥ 1.9% had a doctoral degreeEducation and Lifelong or Career-Long Learning181
These numbers show significant improvement in educational prepara-tion of the nursing workforce compared to the survey conducted 10 years prior and demonstrate continued education of nurses beyond their initial education.In the 50 states and the District of Columbia:¥ 23.5% (12) had no mandatory continuing education (CE) require-ment for RN licensure¥ 76.5% (39) had a mandatory continuing education requirement ranging from 14 to 30 hours every 2 years or, in some cases, only if the RN was not engaged in practice during the previous renewal time (AAACEUs.com, 2021).The profession of nursing expects that nurses will practice the science of nursing with care. At the core of ADN and BSN academic programs are foundational science courses in biology, anatomy, physi-ology, microbiology, chemistry, pathophysiology, pharmacology, and statistics (Figure 6-3). These courses serve as the basis for translating research evidence into the science of nursing practice in such courses as adult health, pediatrics, obstetrics, psychiatric-mental health, and community health nursing. Although we readily acknowledge the es-sence of nursing as Òcaring for patients,Ó we often do not embrace that nurses are also scientists committed to practicing the science of nursing with care and compassion toward patients. Caring is not Figure 6-3 Formal academic education is required to become eligible for both nursing licensure and advanced practice certification.© Alejandrophotography/E+/Getty Images.CHAPTER 6 Advancing and Managing Your Professional Nursing Career182
enough. Science is not enough. Nursing is both an art and a science that is continuously evolving based on research findings, resulting in a deepening and broadening of the knowledge base fundamental to pro-fessional nursing practice. As nurses, we must be committed to and actively engaged in lifelong professional learning across our careers. Ongoing nursing education through CE programs, certification pro-grams, and/or formal academic programs to pursue a BSN, an MSN, a DNP, and/or a PhD must be an expectation of professional nurses if we are to keep pace with the science of nursing, have credibility as a profession, and maintain our commitment to patients. It is only in this way that the profession of nursing will actualize the IOM mandates for leading change and advancing health.Advancing your nursing career often means returning to school. In an unprecedented move advocating support for academic progres-sion in nursing, the American Association of Community Colleges, the Association of Community College Trustees, the American As-sociation of Colleges of Nursing, the National League for Nursing, and the National Organization for Associate Degree Nursing issued a powerful joint statement calling for nursing to work together in order to facilitate unity of nursing education programs and advance oppor-tunities for academic progression, which may include seamless transi-tion into associate, baccalaureate, masterÕs, and doctoral programs. Collectively, we agree that every nursing student and nurse should have access to additional nursing education, and we stand ready to work together to ensure that nurses have the support needed to take the next step in their education. (National League for Nursing, 2015, para. 3)At the core of a seamless academic progression in nursing is re-spect for the academic integrity of educational programs provided by community colleges, colleges, and universities and efforts made to enable nursing students and nurses to readily progress from ADN to RN-BSN or RN-MSN to DNP or PhD programs. The AACN (n.d.-a) website provides a user-friendly search engine called Nursing Pro-gram Search for academic programs in nursing at every level, such as RN-BSN, RN-MSN, LPN to BSN, entry-level BSN, accelerated BSN, BSN to DNP, BSN to PhD, entry-level MSN, MSN, CNL, MSN to DNP, DNP, and PhD programs.If you are contemplating or have decided to return to school to pursue a BSN or an advanced graduate degree in nursing, be sure that you consider and investigate the following:¥ Possess certainty about the specific courses that will successfully transfer and knowledge of the specific courses and their associated credit hours that need to be taken prior to admission.¥ Prepare for and take any preliminary test required, such as the Graduate Record Examination, and know the expected scores for admission.Education and Lifelong or Career-Long Learning183
¥ Adhere to the application process, including admission dates.¥ Be knowledgeable of the cost of the program in its entirety: tuition, books, and fees, such as online fees, clinical fees by course, and fees for validation credits of previously earned coursework that has been successfully completed. Some programs advertise that they give Òlife experienceÓ credits. Be sure you receive in writing what these experiences are, whether you meet the criteria or if additional courses need to be taken or papers written describing these experi-ences, how many credit hours are awarded, and what the fees are for transferring these credits into your program of study.¥ Be aware of tuition reimbursement options through work and the expected time commitment in return for tuition assistance.¥ Be cognizant of and investigate opportunities and requirements for scholarships, loans, and/or traineeship programs awarded by the state government, the federal government, private foundations, and/or professional nursing organizations.Information is power! In appraising your nursing career options, be informed about specialty areas available and of interest to you. The BSN degree is the sole academic portal of entry for graduate studies in nursing (MSN, DNP, and PhD) for such roles as nurse practitioner, nurse anesthetist, clinical nurse leader, nurse executive, nurse educator, and nurse researcher. There are several nursing career paths supported by graduate-level academic programs for you to consider:¥ An expert clinician is an advanced practice registered nurse pre-pared at the graduate level, such as an adult, family, geriatric, or psychiatric-mental health nurse practitioner, nurse anesthetist, or nurseÐmidwife, or clinical nurse specialist who provides safe, evidence-based, and cost-effective care to a specific patient popula-tion (academic level: MSN, DNP).¥ A clinical nurse leader (CNL) guides nurse colleagues and interdis-ciplinary teams in direct patient care situations to implement clini-cal practice guidelines and to enable these patient populations to achieve positive outcomes (academic level: MSN, DNP).¥ A nurse executive directs the infrastructure of the practice of nurs-ing within an organization on clinical and fiscal levels and repre-sents and advocates for nursing within the context of the business of health care (academic level: MSN, DNP, PhD).¥ A nurse educator works in academic settings, guiding students to deepen and broaden their knowledge and practice of safe, quality-based professional nursing practice (academic level: MSN, DNP, PhD).¥ A nurse researcher is dedicated to executing and translating evidence-based research into practice and expanding the body of knowledge fundamental to the art and science of nursing (aca-demic level: MSN, DNP, PhD).CHAPTER 6 Advancing and Managing Your Professional Nursing Career184
The Graduate Nursing Student Academy, established by the AACN (n.d.-b), has established a series of webinars to inform you of areas of specialization and graduate degrees that may be of interest to you as you plan your career.Professional EngagementProfessional engagement is a characteristic that discriminates between a person employed in a job and one pursuing a career. A professional nurse who is managing and advancing his or her career will actively engage in professional nursing initiatives within the nurseÕs healthcare agency and in professional nursing organizations.Engagement in Your Healthcare OrganizationAs you are planning your nursing career path, seize opportunities now to actively engage in quality improvement activities that are currently under way within your healthcare organization. Examples of qual-ity initiatives include, but are not limited to, committees within your agency that address nursing policy and procedures, quality improve-ment, core measures, clinical practice guidelines, safety, the Hospital Consumer Assessment of Healthcare Providers and Systems Hospital Survey of Customer Satisfaction, and the Medicare and Medicaid Sur-vey Process for Nursing Homes or Home Health Agencies.Engagement in programs to improve quality for patients, staff, and your organization will help you gain experience in clinical prob-lem resolution, aid you in translating clinical practice guidelines and research evidence into practice, assist you with co-contributing to the creation of a milieu of safety and quality, and connect you in a collegial manner with the quality champions in your organization. If you are not sure how to get connected with these committees, start by meeting with your nurse manager and/or chief nursing officer and ex-press your interest in serving on one or more of these committees. You will learn from your participation on these committees and you will maximize your visibility as an engaged, motivated employee.Engagement in Professional Nursing OrganizationsEngaging in professional nursing organizations connects students and RNs with membership and leadership opportunities. Some of the benefits of participating in these organizations include ongoing growth and de-velopment pertinent for your career and areas of specialization, receiving mentorship and guidance from seasoned members, obtaining reduced membership rates for students, and accessing scholarship and grant op-portunities for members to supplement tuition in academic programs. KEY COMPETENCY 6-2Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesProfessionalism:¥ Skills (S4a) Participates in lifelong learning¥ Skills (S8g) Devel-ops goals for health, self-renewal, and pro-fessional development¥ Attitudes/Behaviors (A4a) Committed to life-long learningMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfProfessional Engagement185
You may join many professional nursing organizations as a stu-dent or as an RN. These organizations include, but are not limited to, the ANA and its affiliate state nurses associations; Sigma Theta Tau International Honor Society of Nursing; American Organization of Nurse Executives; American Association of Nurse Practitioners; American Association of Nurse Anesthetists; American Association of Critical-Care Nurses; Association of WomenÕs Health, Obstetric and Neonatal Nurses; and American College of Nurse-Midwives. A more thorough list of professional nursing organizations at national, state, and international levels is provided by the ANA (n.d.).Expectations for Your PerformanceAssessment of your performance as an RN is conducted on several levels, such as self-appraisal, work performance evaluations con-ducted by nurse managers on behalf of healthcare organizations, and collegial evaluations. Many performance appraisals for nurses and nursing students have their roots in professional documents, such as Nursing: Scope and Standards of Practice (ANA, 2015b), Nurse of the Future: Nursing Core Competencies (Massachusetts Department of Higher Education, 2016), The Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 2008), and The Essentials of MasterÕs Education in Nursing (AACN, 2011) as well as criteria es-tablished by specialty-based professional nursing organizations.The core questions in most of these assessments are: ÒAm I cur-rently practicing competently?Ó and ÒAm I currently practicing to the fullest extent of my nursing education and training in my current posi-tion?Ó (IOM, 2011, Initiative 1). It is important to know proactively the expectations of professional nurse competency in your specific setting so that you can meet and exceed them and continuously use them as indi-cators for identifying your strengths and areas that need further profes-sional growth and development. Assessment of your performance as an RN is your own personal quality improvement program and is essential for professional growth and development. This should not be just an annual event but an ongoing process of improving oneÕs practice. Here are some suggestions for the evaluation of your performance as an RN:¥ Conduct your own self-appraisal first in order to have a more in-formed dialogue with your nurse manager.¥ Identify your areas of strength and areas in need of growth.¥ Pursue continuing education to both enhance your strengths and narrow your limitations.¥ Accept constructive feedback with respect, gratitude, and civility.¥ If feedback does not make sense to you, ask the person to clarify what he or she said.¥ Develop an ongoing plan of quality improvement for yourself. KEY OUTCOME 6-1Example of Domain 9 sub-competency for entry-level professional nursing education.9.3e Engage in professional activities and/or organiza-tions (p. 54).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf/Essentials -2021.pdf KEY COMPETENCY 6-3Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesProfessionalism:Knowledge (K4b) Describes the role of a professional organization in shaping the culturally congruent prac-tice of nursingSkills (S8c) Advocates for professional standards of practice using orga-nizational and political processesSkills (S8i) Assumes professional responsibil-ity through participation in professional nursing organizationsMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfCHAPTER 6 Advancing and Managing Your Professional Nursing Career186
Taking Care of SelfA nurse is a person who is present at birth, at death, and during the entire life span. A nurse makes life and death decisions. A nurse interacts with everyone in the healthcare community. A nurse interacts with people from every walk of life. A nurse must multitask during every shift. A nurse works every shift, weekends, and holidays. A nurse experiences stress unknown to most other profes-sions. To prevent overwhelming stress, a nurse must take care of him- or herself by:¥ Eating a balanced diet¥ Getting enough sleep¥ Avoiding addictive substances¥ Exercising on a regular basis¥ Paying attention to mental and spiritual health¥ Being vigilant in coping with stress triggers at work and at homeSeig (2020) notes that Òmore than 40 percent of hospital nurses today suffer from the physical, emotional, or mental exhaustion characteristic of burnout. The result of unmanaged stress, burnout ac-counts for what is often a negative perception among nurses of their work and workplacesÓ (para. 1). Managing time is essential to pre-venting burnout and compassion fatigue. Dragon (2019) presents the following 10 tips for time management. Nurses can use these tips at work and during off time.¥ Arrive early.¥ Keep notes; make lists.¥ Prioritize¥ Factor in the unexpected.¥ Be organized.¥ Be efficient and get things right.¥ Learn how to delegate.¥ Learn how to say Òno.Ó¥ Take a breath.¥ Be easy on yourself.Burnout and compassion fatigue may be the end result of stress not being managed. Burnout is progressive and involves disengage-ment and withdrawal. Compassion fatigue is acute and may present itself as overinvolvement in patient care (Lombardo & Eyre, 2011). The two concepts may occur simultaneously. In caring for patients, the nurse may be depleted physically, emotionally, and spiritually. These indicators involve compassion fatigue. Burnout causes physical symp-toms that lead to feelings of being constantly tired. Some observed CRITICAL THINKING QUESTIONS✶Do you plan to be a part of a professional organization after graduation? Why or why not? What do you anticipate will be your level of involvement?✶ CRITICAL THINKING QUESTIONS✶Do you have the courage to ask for honest feedback? Do you have the courage to give honest feedback to a friend or colleague? How do you respond to negative feedback?✶ KEY COMPETENCY 6-4Example of applicable Nurse of the Future: Nurs-ing Core CompetenciesProfessionalism:Knowledge (K8b) Rec-ognizes the relationship between personal health, self-renewal, and the abil-ity to deliver sustained quality careMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfTaking Care of Self187
signs are avoiding certain patients; not feeling compassion for your patients and their families; experiencing headaches, digestive problems, fatigue, mood swings, anxiety, and/or poor concentration; and/or feel-ing underappreciated and overworked. In response, nurses may not want to go to work and/or just go through the motions when at work.Another term related to burnout that has gained attention during the past year is the concept of resilience. Resilience refers to the Òability to survive and thrive in the face of adversityÓ (AACN, 2021, p. 68) and developing resilience can be considered a form of self-care. Resilience can reduce burnout and is something that can be developed. Some ef-fective strategies to cultivate and sustain resilience include:¥ building positive relationships,¥ maintaining a positive attitude,¥ developing emotional insight,¥ creating a work-life balance,¥ reflecting on successes and challenges.Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Essentials-2021.pdf The healthcare workplace is demanding, requiring many caregiv-ing responsibilities from various members of the interdisciplinary team that must be accomplished and communicated within an ab-breviated time. Sustained workplace stress can dramatically influence how we interact with colleagues, how professionally satisfied we are with current career choices, and employee retention rates.Stress at work can be managed in a civil environment. Civility builds community and allows for efficient functioning units. Civility is defined as respect for others (Clark, 2020). A code of conduct estab-lishes ways of behaving for interacting with people. The ANA (2015a) developed a Code of Ethics for Nurses with Interpretive Statements that requires nurses to communicate with respect when interacting with colleagues, patients, and students. Civil behavior is not always easy to accomplish; it requires courage and genuine concern for oth-ers. We have the choice to be colleagues who habitually respect and assist one another and who are instrumental in creating a milieu of civility and safety or to be colleagues who are engaged either overtly or subtly in lateral and vertical workplace violence exhibited by bul-lying, harassing, speaking ill of one another, demeaning one another, and excluding colleagues.The first step toward managing stress and creating a civil milieu is to assess your work environment. Some of the characteristics of healthy collegial relationships include being a reliable and respect-ful colleague who works his or her scheduled days, arrives on time, KEY OUTCOME 6-2Example of Domain 10 sub-competency for entry-level professional nursing education.10.1a Demonstrate healthy, self-care behaviors that promote wellness and resil-iency (p. 56).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdf KEY OUTCOME 6-3Example of Domain 5 sub-competency for entry-level professional nursing education.5.3d Recognize oneÕs role in sustaining a just culture reßecting civility and re-spect (p. 42).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdf CHAPTER 6 Advancing and Managing Your Professional Nursing Career188
shares equally in patient care and management responsibilities, pro-vides care in a timely manner, and actively volunteers to help a col-league who needs assistance.Self-care strategies that promote resilient nurses may include:¥ Saying no to additional shifts and reducing overtime in order to conserve energy¥ Taking a day off in order to renew energy¥ Changing shift or unit in order to gain a new outlook on being a nurseConsulting a social worker, a chaplain, your preceptor, and/or your mentor can provide you with resources for caring for self, man-aging burnout and compassion fatigue, and sustaining a resilient self.ConclusionYou are responsible for actively managing and advancing your nursing career across your entire life span as a professional nurse. This means that you will need to make purposeful and strategic choices about your professional practice, academic preparation, and continuing education. Mentors, preceptors, and engagement in your healthcare organization and professional nursing orga-nization serve as guides for advancing your professional path. Creating a healthy lifestyle and reducing the risk of burnout and compassion fatigue are essential for sustaining your personal and professional life. KEY COMPETENCY 6-5Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesProfessionalism:Knowledge (K8d) Con-tributes to building and fostering a nurturing and healthy work environment, promoting health safety in the workplaceAttitudes/Behaviors (A8b) Values and upholds altruistic and humanistic principlesMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfClassroom Activity 6-1Have students begin creating a career map that includes short-term and long-term goals and strategies to achieve those goals. The Nursing License Map (available at http://nursinglicensemap.com) may be useful in this activity if students want to compare educa-tional requirements and salaries as they con-sider career goals.Classroom Activity 6-2Have students begin working on a pro-fessional portfolio that contains a cover letter and rŽsumŽ, along with examples of accomplishments and selec-tions of high-quality projects, papers, and presentations.Conclusion189
ReferencesAAACEUs.com (2021). Nursing continuing education requirements by state. https://www.aaaceus.com /state_nursing_requirements.aspAmerican Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Essentials-2021.pdfAmerican Association of Colleges of Nursing. (2011, March 21). The essentials of masterÕs education in nursing. https://www.aacnnursing.org/Portals/42/Publications/MastersEssentials11.pdfAmerican Association of Colleges of Nursing. (2015). Talking points: HRSA report on nursing workforce projections through 2025. https://www.njccn.org/wp-content/uploads/2015/07/HRSA-Nursing-Workforce -Projections.pdfAmerican Association of Colleges of Nursing. (n.d.-a). Students: Member program directory. http://www .aacnnursing.org/Students/Find-a-Nursing-ProgramAmerican Association of Colleges of Nursing. (n.d.-b). GNSA webinars. http://www.aacnnursing.org/GNSA /WebinarsAmerican Association of Colleges of Nursing. (n.d.-c). What every nursing student should know when seeking employment: An interview tip sheet for baccalaureate and higher degree prepared nurses. https://www.aacnnursing.org/Portals/42/Publications/Brochures/SeekingEmployment.pdfAmerican Nurses Association. (2015a). Code of ethics for nurses with interpretive statements. Author.American Nurses Association. (2015b). Nursing: Scope and standards of practice (3rd ed.). Author.American Nurses Association. (n.d.). Nursing organizations. http://www.nurse.org/orgs.shtmlClark, C. (2020, November 16). Why civility matters. https://nursingcentered.sigmanursing.org/features /more-features/Vol36_1_why-civility-mattersCompare Business Products. (2013). 30 interview questions you canÕt ask and 30 legal alternatives. https://www.comparebusinessproducts.com/fyi/30-interview-questions-you-cant-ask-and-30-sneaky-legal-getDaggett, L. M. (2014). Career management and care of the professional self. In K. Masters (Ed.), Role development in professional nursing practice (3rd ed., pp. 167Ð193). Jones & Bartlett Learning.Dragon, N. (2019). 10 time management tips for nurses and midwives. https://anmj.org.au/10-time -management-tips/Health eCareers Network. (2012, December 11). 5 common career myths for nurses. https://www .healthecareers.com/article/career/5-common-career-myths-for-nursesHein, R. (2012, December 5). Career mapping offers a clear path for both employees and employers. https://www.cio.com/article/2448964/career-mapping-offers-a-clear-path-for-both-employees-and -employers.htmlInstitute of Medicine. (2010). Report brief: The future of nursing: Focus on education. http://www.academic progression.org/about/future-of-nursingInstitute of Medicine. (2011). The future of nursing: Leading change, advancing health. National Academies Press.Lombardo, B., & Eyre, C. (2011). Compassion fatigue: A nurseÕs primer. Online Journal of Issues in Nursing, 16. https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals /OJIN/TableofContents/Vol-16-2011/No1-Jan-2011/Compassion-Fatigue-A-Nurses-Primer.htmlMasor, M. B. (2013). Let your light shine: Portfolio principles. In J. Phillips & J. M. Brown (Eds.), Accelerate your career in nursing: A guide to professional advancement and recognition (pp. 29Ð44). Sigma Theta Tau International Honor Society of Nursing.Massachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. Retrieved from Massachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. https://www.mass.edu/nahi/documents /nofrncompetencies_updated_march2016.pdfMinority Nurse. (2013). Mentoring nurses toward success. http://minoritynurse.com/mentoring-nurses -toward-success/CHAPTER 6 Advancing and Managing Your Professional Nursing Career190
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When you hear the word nurse, what images, thoughts, perceptions, and assumptions come to mind? Ask yourself, ÒWhy did I have those perceptions and assumptions about nurses?Ó The answer to your question reveals much about the social context of nursing or how society views nurses and the nursing profession. For many, the image that first comes into view is one of a White female who is dressed in a meticulously ironed white uniform with white hose and white shoes and wearing a stiff white cap. For those of us in nursing, we recognize that this traditional American view of nursing is not a reflection of reality in the current world of professional nursing. How do we com-municate the true image of nursing in the 21st century?In this chapter, we explore the social context of professional nursing and identify major influences that affect nursing in todayÕs society. This quest for a deeper understanding of nursing challenges us to identify our individual responsibilities in educating our patients Key Terms and Concepts ÈAccess to care ÈComplementary and alternative medicine ÈConsumerism ÈCultural competence ÈDisaster preparedness ÈGlobal aging ÈIncivility ÈNursing faculty shortage ÈNursing shortage ÈStereotypes ÈViolenceAfter completing this chapter, the student should be able to:1. Describe the social context of professional nursing.2. Identify factors that inßuence the publicÕs image of professional nursing.3. Identify ways that nurses can promote an accurate image of professional nursing.4. Discuss the gender gap in nursing.5. Recognize connections between changing demographics and cultural competence.6. Evaluate current barriers to health care in our society.7. Discuss present trends in society that inßuence professional nursing.8. Identify present trends associated with the profession of nursing.Learning ObjectivesSocial Context and the Future of Professional NursingMary W. Stewart, Katherine E. Nugent, and Kathleen MastersCHAPTER 7© Nuu Jeed/Shutterstock193
and the public about professional nursing as well as meeting our professional obligations to the public. The result is not necessarily an immediate change in the picture that comes to mind when one says ÒnursingÓ; however, we might begin to see nursing and those of us committed to nursing in new, more accurate ways.NursingÕs Social Contract with SocietyA mutually beneficial relationship exists between nursing and soci-ety. The profession of nursing grew out of a need within society and continues to evolve based on the needs of society. Because nursing has a responsibility to society, the interests of the profession must be perceived as serving the interests of society. Society provides the nurs-ing profession with the authority to practice, grants the profession au-thority over functions, and grants autonomy over professional affairs. The profession is expected to regulate itself and to act responsibly. This relationship is the essence of nursingÕs social contract with soci-ety (American Nurses Association [ANA], 2010).Foundational to nursingÕs social contract with society are some basic values. In brief, these values include that humans manifest an es-sential unity of mind, body, and spirit; human experience is contextually and culturally defined; health and illness are human experiences; and the relationship between the nurse and the patient occurs within the context of the values and beliefs of the patient and the nurse. In addition, public policy and the healthcare delivery system influence the health and well-being of society and professional nursing, and individual responsibility and interprofessional involvement are essential (ANA, 2010).According to NursingÕs Social Policy Statement (ANA, 2010), nurs-ing is particularly active in relation to six key areas of health care that include the organization, delivery, and financing of high-quality health care; provision for the publicÕs health through health promotion, disease prevention, and environmental measures; and expansion of nursing and healthcare knowledge (through research and evidence in practice) and application of technology. Also included are expansion of healthcare resources and health policy to enhance the capacity for self-care; defini-tive planning for health policy and regulation; and duties under extreme conditions, which means that nurses weigh their duty to provide care with obligations to their own health during extreme emergencies.Public Image of NursingThe public values nursing. According to the 2020 Gallup poll, nurses received the top ranking for honesty and ethical standards (Saad, 2020). The honor of being the most trusted profession has been CHAPTER 7 Social Context and the Future of Professional Nursing194
bestowed on the profession of nursing every year but one since 1999, when nursing was first added to the Gallup poll. The only year when nurses did not rank number one was in 2001 when firefighters took the top spot after the September 11 terrorist attacks. When asked to defend this nationwide trust of nurses, people often respond with anecdotal stories of personal experiences with nurses. Popular stories include those of relatives or friends who are nurses and positive expe-riences with nurses in a clinical setting. The fact that nurses serve so-ciety seems to have an automatically positive effect on societyÕs value of nursing.Although the trust is evident, there remains a gap between the publicÕs perception of the nursing profession and the reality of nurs-ing. For example, the general public might think that it requires only 2 years to become a registered nurse (RN), with the ÒtrainingÓ consisting primarily of learning to administer medications, providing personal care, and sitting at the bedside. However, reality provides a stark revelation that nurses are educated at the baccalaureate, mas-terÕs degree, and doctoral levels and work in areas of education, re-search, and independent clinical practice.Nurses are aware of the gaps in societyÕs knowledge of nursing. Hence, nurses should take the lead in ensuring that the public has an accurate picture of the vast knowledge and expertise that are present in the 3 million RNs in the United States (U.S. Department of Health and Human Services [USDHHS], 2010b). Where do we start? We must first begin with the realization that not all nurses are the same. As previously stated, many well-educated persons do not understand the various educational programs available to become an RN. Like-wise, knowledge about the differences in preparation and responsibil-ity of licensed practical nurses, RNs, and advanced practice nurses is lacking.As you are preparing to be a professional nurse, ask yourself, ÒHow do I clarify and communicate the significance of professional nursing?Ó First, become familiar with the scope of practice of profes-sional nurses and understand the multifaceted roles for which you are being educated. Second, be able to identify the unique place that pro-fessional nurses have in the healthcare system. This comes by acquir-ing knowledge of the nursing profession and by being aware of the roles, responsibilities, and contributions of other healthcare profes-sionals. Most important, it is imperative that you share your story of nursing. Although the public holds nurses in high regard, they know very little about what nurses actually do (Buresh & Gordon, 2000, 2006, 2013). Without articulating more clearly and loudly on our professionÕs behalf, we might be at a loss when trying to defend our place in the current healthcare system.Suzanne Gordon, an award-winning journalist, has dedicated much of her career to telling the stories of nursing. Not a nurse herself, Public Image of Nursing195
Gordon writes to empower nurses to find their voices and to be heard. Gordon is committed to obtaining a firsthand account from nurses as they face the real challenges of being a nurse that include (1) incon-venient problems of improving patient safety (Gordon et al., 2008); (2) the challenges of standing up for themselves, their patients, and the nursing profession (Gordon, 2010); and (3) the effect of cutting health-care costs on patient care (Gordon, 2005), to name a few. If a journal-ist can commit to sharing ÒourÓ stories, that should provide a spark of motivation in us to share our experiences, triumphs, and defeats.When nurses are asked about the nurseÕs reluctance to promote nursing effectively, the responses are riddled with excuses, such as a lack of time, resources, and support from colleagues. Professional nurses work in very demanding, stressful, and taxing jobs. Frequently, we are so consumed with the responsibilities of our work that we fail to notice what we are actually accomplishing. In addition, we rarely take the time to become fully aware of and to celebrate what our nursing colleagues are doing within the profession. Profes-sional nursing organizations exist to communicate and support these achievements. However, only a small percentage of RNs are actually members of their professional nursing associations.Better insight into professional nursing must start with nurses at all levels of practice and education. Once we have obtained the neces-sary insight, we can provide a clear picture of the nursing profession to society. When these two actions are taken, the public image of nursing will be directly reflective of the reality of nursing. We want to maintain the positive impression the public now holds of nursing and to sustain the earned trust, but nursing and the public deserve a great deal more than that. All of us should be convinced of the expertise that profes-sional nursing offers: mastery of complicated technological skills; ap-preciation for the whole person; commitment to public health for all people; a keen knowledge of anatomy, physiology, pathophysiology, biochemistry, pharmacology, and other disciplines; the ability to think critically and to connect the dots in todayÕs ever-changing healthcare system; and proficiency in communication. The list continues.MediaÕs InßuenceIt is obvious that the media (television, radio, Internet) play a major role in how society views professional nursing. Historically, the nurse has been portrayed in the media in a variety of ways. First, the nurse appears as a young, seductive female whose principal qualification is the length of her slender legs and the amount of cleavage showing through her uniform. Needless to say, this nurse is usually depicted as one who is not educated and who lacks common sense and intelli-gence. Another popular view of the nurse as portrayed by the media is an unattractive, overweight, and mean female. Her intelligence is not KEY OUTCOME 7-1Example of Domain 10 sub-competency for entry-level professional nursing education.10.3h Communicates a con-sistent image of the nurse as a leader (p. 58).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdf KEY COMPETENCY 7-1Examples of applicable Nurse of the Future: Nursing Core CompetenciesProfessionalism:Skills (S5b) Promotes and maintains a positive image of nursingMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfCHAPTER 7 Social Context and the Future of Professional Nursing196
questioned, but her compassion for others is highly debatable. This nurse is shown as threatening and uncaring. Neither of these views is accurate, and probably no one would argue with this. At the same time, we continue to be perplexed when asked to define or describe the professional nurse.In their book From Silence to Voice: What Nurses Know and Must Communicate to the Public, Buresh and Gordon (2006) state that Òa professionÕs public status and credibility are enhanced by hav-ing its expertise acknowledged in the journalistic mediaÓ (p. 1). Buresh and Gordon also cite the study ÒWho Counts in News Coverage of Health Care,Ó where the data show that many professional groups had a greater voice on health issues compared to nurses. Physicians were quoted the most in media, followed by government, business, education, public relations, and so forth. This is significant and shock-ing because nurses are the largest group of healthcare professionals, yet we are the most silent group. As nurses, we have been complacent about refuting the negative stereotypes portrayed in the media. Fur-thermore, we have been lax in articulating our expertise to the media.Buresh and Gordon (2006, p. 4) describe three communication challenges faced by the nursing profession that need to be addressed:1. Not enough nurses are willing to talk about their work.2. When nurses and nursing organizations do talk about their work, too often they intentionally project an inaccurate picture of nursing by using a ÒvirtueÓ instead of a ÒknowledgeÓ script.3. When nursing groups give voice to nursing, they sometimes bypass, downplay, or even devalue the basic nursing work that occurs in direct care of the sick while elevating an image of ÒeliteÓ nurses in advanced practice, administration, and academia.Data from Buresh, B., & Gordon, S. (2006). From silence to voice: What nurses know and must communicate to the public (2nd ed.). Ithaca, NY: Cornell Univer-sity Press.Nurses should face the stereotypes present in our society and erase the lines that define us. To do this, we must first recognize our value to society and ourselves. When introducing ourselves in the professional role, we should do so with confidence and clarity. For ex-ample, we can say, ÒGood morning, Mr. Smith. IÕm Susan Jones, your registered nurse.Ó Such day-to-day engagement is important. We must tell the world what we do.In From Silence to Voice, the authors identify the following ac-tions to promote the real image of nursing:¥ Educate the public in daily life.¥ Describe the nurseÕs work.¥ Make known the agencyÑindependent thinkerÑof the RN.¥ Deal with the fear of angering the physician.Public Image of Nursing197
¥ Accept thanks from others.¥ Be ready to take advantage of openings to promote nursing.¥ Respond to queries with real-life stories from nursing.¥ Tell the details.¥ Avoid using nursing jargon.¥ Be prepared ahead of time to tell your story.¥ Do not suppress your enthusiasm.¥ Reflect the nurseÕs clinical judgment and competency.¥ Connect your work to pressing contemporary issues.¥ Respect patient confidentiality.¥ Deal with and confront the fear of failure.In an effort to address the challenges faced by nursing, Buresh and Gordon (2000, 2006, 2013) present a history and understanding of modern media and provide examples of how to interconnect with them. Knowing how news media work, how to write a letter to the editor, how to present oneself on television or radio, and how to converse with community groups are among the guidelines provided. Being proactive is essential, especially at a time when healthcare costs and cuts demand that only the fundamental players are left standing. Society needs to know that nurses are fundamental players.Sigma Theta Tau International commissioned the 1997 Woodhull Study on Nursing and the Media, which reported the lack of repre-sentation that nurses have in the media (Sigma Theta Tau Interna-tional, 1998). In approximately 20,000 articles from 16 major news publications, nurses were cited fewer than 4% of the time. Although nurses are highly relevant participants in patientsÕ stories, they were neglected in almost every case. Key recommendations from the Wood-hull Study include the following:¥ Nurses and media should be proactive in establishing ongoing dialogue.¥ If the aim is to provide comprehensive coverage of health care, the media should include information by and about nurses.¥ Training should be provided to nurses on how to speak about business, management, and policy issues.¥ Health care needs to be clearly identified as the umbrella term for specific disciplines, such as medicine and nursing.¥ Nurses with doctoral degrees should be identified correctly as doc-tors, and those with medical doctorate (MD) degrees should be identified as physicians.¥ Language needs to reflect the diverse options for health care by avoiding such phrases as ÒConsult your doctor.Ó Rather, media need to state, ÒConsult your primary healthcare provider.Ó CRITICAL THINKING QUESTION✶How can you, as a student nurse, commu-nicate to members of society what profes-sional nurses do?✶CHAPTER 7 Social Context and the Future of Professional Nursing198
In recent years, we have seen more accurate portrayals of nurses supported in the media. Instead of portraying sexual prowess or disre-spect and anger, nurses have been presented as intelligent, competent, and essential to patient care. Johnson & Johnson continues the Cam-paign for NursingÕs Future to raise public awareness of professional nursing. This positive promotion has supported student and faculty recruitment into the profession. Johnson & Johnson has taken ad-ditional steps to recognize the courageous efforts of many nurses, including those who were intensely engaged in responding during national crises, such as Hurricane Katrina. Nurses must continually evaluate the portrayal of nurses in the media. After all, if the image is inaccurate, we have a responsibility to correct it.The Gender GapWomen in NursingIn the Western culture, women have traditionally been socialized as the more passive of the gendersÑto avoid conflict and to yield to author-ity. The implications of this conventional thought are still evident in nursing practice today. Many nurses lack confidence in dealing with conflict and in communicating with those in authority. For some, it is a matter of a short supply of energy and too many other commitments. Others perceive assertiveness as clashing with peopleÕs expectations. We should ask ourselves, ÒIsnÕt the reward of knowing we do a good job enough?Ó For female nurses who assume multiple personal and professional roles, career is often not at the top of our priorities. This can be attributed to the fact that the role of women in past society was primarily geared toward family responsibility, not career. Many women who chose nursing did so without the expectation of a long-term commitment to the profession. Rather, nursing was a Ògood jobÓ when and if a woman needed to work. This centeredness on service continues in nursing today, albeit with less intensity than in the past.The womenÕs movement in the 1960s empowered intelligent career-seeking women to enter professions other than the traditional ones of teaching and nursing. After some years of competing for stu-dents, nursing saw a return of interest in the 1980s and 1990s. At this point, more women chose nursing as a career because nursing provided a natural complement to their gifts, not because it was one of only a few options available to them. As the message of varied op-portunities for women and men in nursing is shared, the social status of all nurses is elevated.Men in NursingAt the start of the new millennium, men represented approximately 5.4% of the RN population in the United States (Trossman, 2003). The Gender Gap199
In 2017, the percentage of male registered nurses was 9.1%, up from 8.0% in 2015 and 6.6% in 2013 (NCSBN, 2019). In 2018, the male registered nurse population again increased to 9.6% (USDHHS, 2019).This steady increase can be attributed to recruitment campaigns focused on attracting men into nursing. For example, the Mississippi Hospital Association published an all-male calendar with monthly features of men in nursing, ranging from men who were nursing stu-dents to practicing professionals in a variety of roles. The calendar was used as a recruiting tool to help encourage men, young and old, to consider career opportunities in nursing. These strategies help di-minish the stigma associated with men in nursing.The ANA inducted the first man into its Hall of Fame in 2004 (ANA, 2007). Dr. Luther Christman was recognized for his 65-year career and contributions to the profession, including the founding of the American Assembly for Men in Nursing. In 2007, the ANA estab-lished the Luther Christman Award to recognize the contributions of men in nursing. Current literature also helps to keep the discussion of men in nursing at the forefront. In 2006, the Men in Nursing journal was launched as the first professional journal dedicated to addressing the issues and topics facing the growing number of men who work in the nursing field.Although a seemingly recent topic, men have served in nursing roles throughout history. In the 13th century, men played a vital role in providing nursing care to vulnerable individuals. John Ciudad (1495Ð1550) opened a hospital in Grenada, Spain, so that he (along with friends) could provide care to the mentally ill, the homeless, and abandoned children (Blais et al., 2001). Saint Camillus de Lellis (1550Ð1614) was the founder of the Nursing Order of Ministers of the sick. Men in this order were charged with providing care to alco-holics and to those affected by the plague (Blais et al., 2001). In the United States, in the 1700s James Derham was an African American man who worked as a nurse in New Orleans and was subsequently able to buy his freedom and become the first Black physician in the United States.Despite her many contributions to the nursing profession, Flor-ence Nightingale did not encourage the participation of men in nurs-ing. She believed that such traits as nurturance, gentleness, empathy, and compassion were needed to provide care and that these traits existed primarily in women. Nightingale opposed men being nurses and stated that their Òhard and hornyÓ hands were not fit to Òtouch, bathe, and dress wounded limbs, however gentle their hearts may beÓ (Chung, 2000, p. 38). Thus, nursing became a predominantly female discipline in the late 1800s.Even with negative societal perceptions and stereotypes, men are now more open to pursuing nursing as a career choice CHAPTER 7 Social Context and the Future of Professional Nursing200
(Figure 7-1). In 2016, males comprised 12% of students enrolled in baccalaureate and graduate nursing programs (AACN, 2017). In 2017, the percentage of male students enrolled in baccalaureate nurs-ing programs increased to 14.3%. Male students enrolled in masterÕs degree nursing programs represented 12%. Male students represented 10.8% of the students enrolled in research-focused doctoral programs and 12.9% of students enrolled in practice-focused doctoral programs (American Association of Colleges of Nursing [AACN], 2018). These increases are largely the result of diminishing misconceptions and increased recruiting efforts. Men tend to prefer distinct practice ar-eas, including high-technology, fast-paced, and intense environments. Emergency departments, intensive care units, operating rooms, and nurse anesthesiology are examples of areas to which men are often attracted. Some speculate that men make these choices to avoid po-tential role strain if they were to choose other areas, such as obstetrics and pediatrics, and because they prefer areas that require more techni-cal expertise.There is some debate that men in nursing have an advantage over their female peers. It is not unusual for patients to assume that a male nurse is a physician or a medical student. On the other hand, men in nursing have been mistaken for orderlies. However, the percentage of men in leadership roles in nursing is much higher than the percent-age of men in nursing overall. This is partly because male nurses are more oriented and motivated to upgrade their professional status Figure 7-1 More males are choosing a career in nursing, although they do tend to prefer specific practice areas.© Monkey Business Images/iStock/Getty Images.The Gender Gap201
(American Society of Registered Nurses, 2008). As a result, women in nursing are challenged to learn how to promote themselves within the profession.What issues and challenges do men face in nursing? According to research conducted by Keogh and OÕLynn (2007), male nurses may be unfairly stereotyped. False assumptions and perceptions may deter other men from entering the profession, create gender-based barri-ers in nursing schools, and decrease retention rates of male nurses once they are licensed. Also, because most nursing faculty are female, most nursing textbooks are written by females, and most leaders in nursing are female, men might have to learn new ways of thinking and understanding to find a comfortable place of belonging in the nursing profession. For example, it is reported that a male nursing student was having difficulty answering questions on a nursing ex-amination. When the student shared a sample question with his wife (who was not a nurse), she answered the question correctly (Brady & Sherrod, 2003).As a consequence of gender bias, some patients might refuse or feel reluctant to allow men in the nursing role to care for them (American Society of Registered Nurses, 2008; Cardillo, 2001). Dur-ing labor and delivery, patients and their partners might request a female nurse to be at the bedside. Overall, the presence of a male nurse alone in the room with a patient is out of the ordinary. On the other hand, male nurses are assumed to be physically stronger and willing to do the heavier tasks of nursing care, such as lifting and moving patients (Cardillo, 2001). Still, many men and women are learning to appreciate and enjoy the emerging culture in the profes-sion (Meyers, 2003). The old biases continue to disappear as patients and providers become more educated about the need for gender diver-sity in nursing.Changing Demographics and Cultural CompetenceDespite national trends of increasing diversity, with ethnic and racial minorities reaching almost one-third of the U.S. population, minori-ties overall are underrepresented in the healthcare professions, but the trends are encouraging. The registered nurse population remains predominantly female (91%) and 73.3% White, non-Hispanic; how-ever, Hispanic nurses comprise 10.2% of the registered nurse popula-tion, 7.8% of registered nurses are Black, 5.2% are Asian American, and 1.7% of registered nurses identify as multiple races (USDHHS, 2019). Although currently most registered nurses are White women, CRITICAL THINKING QUESTIONS✶What advantages do women have in nurs-ing? What advantages do men have in the profession? What are the risks of being gen-der exclusive?✶CHAPTER 7 Social Context and the Future of Professional Nursing202
more minority students are enrolling in nursing programs now than in past decades. In 2014, 30.1% of students enrolled in baccalaureate programs were minorities, as were 31.9% of nurses enrolled in mas-terÕs programs, 28.7% of nurses enrolled in practice-focused doctoral programs, and 29.7% of nurses enrolled in research-focused doctoral programs. In 2017, 33.5% of students enrolled in baccalaureate pro-grams were minorities, as were 34% of nurses enrolled in masterÕs programs, 32.4% of nurses enrolled in practice-focused doctoral programs, and 32.5% of nurses enrolled in research-focused doc-toral programs. These numbers have increased since 2014 and have increased substantially since 2005, when only 24.1% of students en-rolled in baccalaureate programs, 22% of nurses enrolled in masterÕs programs, and 18.4% of nurses enrolled in research-focused doctoral programs were minorities. (AACN, 2015, 2018).Why is this data important? Health services research shows that minority health professionals are more likely to serve minority and medically underserved populations. In 2003, the Institute of Medicine (IOM) warned of the Òunequal treatmentÓ minorities sometimes face when encountering the healthcare system. Cultural differences, a lack of access to health care, high rates of poverty, and unemployment contribute to the substantial ethnic and racial disparities in health status and health outcomes (IOM, 2003b). Increasing the number of underrepresented minorities in the health professions as well as improving the cultural competency of providers are key strategies for reducing health inequities (Betancourt et al., 2003; IOM, 2003b).Cultural competence in multicultural societies continues as a ma-jor initiative for health care and specifically for nursing. The mass media, healthcare policymakers, the Office of Minority Health and other governmental organizations, professional organizations, the workplace, and health insurance payers are addressing the need for individuals to understand and become culturally competent as one strategy to improve quality and eliminate racial, ethnic, and gender inequities in health care (Purnell & Paulanka, 2008).Culturally competent healthcare providers increase access to and satisfaction with health care. The beginning of cultural competence is self-awareness. Culture has a powerful unconscious effect on health professionals and the care they provide. Purnell and Paulanka (2008) indicate that self-knowledge and understanding promote strong pro-fessional perceptions that free healthcare providers from prejudice and facilitate culturally competent care.Nursing has a long history of incorporating culture into nursing practice (DeSantis & Lipson, 2007). In 2008, the AACN released a publication identifying cultural competency in baccalaureate nurs-ing education (AACN, 2008). Yet some maintain that no matter how culturally competent the nurse might be, the patientÕs experience re-mains structured in the nurseÕs culture (Dean, 2005). Despite nursesÕ KEY OUTCOME 7-2Example of Domain 9 sub-competency for entry-level professional nursing education.9.3g Advocate for social justice and health equity, including addressing the health of vulnerable popu-lations (p. 54).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdf KEY COMPETENCY 7-2Examples of applicable Nurse of the Future: Nursing Core CompetenciesCommunication (Collegial Communication & Conßict Resolution):Knowledge (K6) IdentiÞes cultural variations in ap-proaches to interactions with othersSkills (S6) Applies self-reßection to better understand oneÕs own man-ner of communicating with othersAttitudes/Behaviors (A6) IdentiÞes how oneÕs own personality, preferences, and patterns of behavior impact communication with othersMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfChanging Demographics and Cultural Competence 203
best efforts to understand the culture of the patient, nurses often fail to understand that the patient might be experiencing health care for the first time not in his or her own culture but in the nurseÕs culture of healthcare delivery. The understanding of this concept associated with cultural competence increases the reality of the urgency of increasing the diversity in the nursing workforce.The Joint Commission and the National Committee for Qual-ity Assurance also identified the need for healthcare professionals to recognize and respect cultural differences, including dialects, regional differences, and slang (Levine, 2012). In an effort to respond to this national message, many hospitals and healthcare agencies have initi-ated the use of interactive patient-engagement technology as part of their education programs. These services are provided in several languages, including Russian, Spanish, and Mandarin. Nurses know that illness and associated stress, pain, and fear can hinder patientsÕ comprehension when learning about their condition and treatment plan. Language barriers compound the problem, resulting in major obstacles to learning and subsequent issues with adhering to the treat-ment plan. As nursing focuses more on cultural behaviors, norms, and practices, healthcare outcomes can move in a positive direction (Levine, 2012).As the general population of healthcare consumers becomes in-creasingly diverse, there is a greater need for culturally competent care (Jacob & Carnegie, 2002). To provide such nursing care, we must strive for a nursing population that more accurately represents the communities we serve. As the population continues to become more diverse, culturally competent care will be the basis for high-quality care, access to care, and alleviation of health disparities, thus promot-ing healthier population outcomes. Being culturally competentÑthat is, having the ability to interact appropriately with others through cul-tural understandingÑis an expectation for people entering the nurs-ing profession (Grant & Letzring, 2003), keeping in mind that there is a difference between learning of another culture and learning from another culture.Access to Health CareMany Americans have health insurance coverage and access to some of the best healthcare professionals in the nation. However, a large number of individuals experience disparities in our healthcare sys-tem. These disparities, or unfair differences in access, can result in poor quality and quantity of health care. According to the Agency for Healthcare Research and Quality (AHRQ, 2020), individuals who are at greatest risk for experiencing healthcare disparities are racial and ethnic minorities and those with a low socioeconomic status. Lack of health insurance is the most significant contributing factor KEY OUTCOME 7-3Example of Domain 3 sub-competency for entry-level professional nursing education.3.2c Use culturally and linguistically responsive communication strategies (p. 35).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfCHAPTER 7 Social Context and the Future of Professional Nursing204
to a decrease in disease prevention and thus is one of the foci of the Patient Protection and Affordable Care Act. Although lack of health insurance has a major effect on access to health care, other factors, such as continuity of care, sociocultural and economic barriers, and geographic barriers, may have a detrimental effect on the health and quality of life of individuals and are discussed in the following subsections.Continuity of CareIndividuals who have a provider or facility where they receive routine care are more likely to receive preventive health care (AHRQ, 2020). These individuals usually have better health outcomes and experience reduced disparities. In 2008, the percentage of people with a specific source of ongoing care was significantly lower for poor people than for high-income people (77.5% compared with 92.1%). The AHRQ also notes that having a routine provider of care correlates with a greater trust in the provider and an increased likelihood that the per-son coordinates care with the provider. In this regard, one role and responsibility of the nurse is to educate the community and patients on the importance of continuity of care with a routine healthcare pro-vider and/or facility.Sociocultural and Economic BarriersThe need for cultural and ethnic diversity in the nursing workforce has been discussed. Moreover, healthcare settings are challenged to provide an environment where people of various sociocul-tural backgrounds are respected. For example, having translators on-site or within easy contact is critical for ensuring safe care to non-English-speaking clients. Written materials should also be pro-vided in appropriate languages and at an appropriate reading level. It is not feasible or cost effective to provide educational materials and products to patients who will not use them because they are in a for-eign language or too advanced. Specifically, consent forms for surgery and other procedures must be available in the clientÕs language. To ignore the need for language-appropriate literature leads to patient harm as well as disrespect for the uniqueness of others.Undoubtedly, poverty poses the greatest risk to health status (Kavanagh, 2001). The United States has a long-standing reputation for providing the highest-quality health care to persons in the high-est socioeconomic strata. Likewise, the lowest-quality health care is provided to those at the other end of the socioeconomic continuum (Jacob & Carnegie, 2002). As the largest segment of the healthcare industry, RNs can have a positive effect on the change required in this established system. Recognizing the stronghold that poverty currently KEY COMPETENCY 7-3Examples of applicable Nurse of the Future: Nursing Core CompetenciesPatient-Centered Care:Knowledge (K4c) Un-derstands how human behavior is affected by socioeconomics, culture, race, spiritual beliefs, gen-der identity, sexual orien-tation, lifestyle, and ageKnowledge (K4d) Under-stands the effects of health and social policies on persons from diverse back-grounds and culturesSkills (S4b) Implements nursing care to meet ho-listic needs of patient on socioeconomic, cultural, ethnic, and spiritual values and beliefs inßuencing health care and nursing practiceAttitudes/Behaviors (A4a) Values opportunities to learn about all aspects of human diversity and the inherent worth and unique-ness of individuals and populationsAttitudes/Behaviors (A4b) Recognizes impact of per-sonal attitudes, values, and beliefs regarding delivery of care to diverse clientsMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfAccess to Health Care205
has on the health care of citizens is a beginning to the much-needed work in the fight for equality.Although stereotypes communicate to us that poverty is limited to certain groups, we understand that poverty affects people of all cultures and ethnicities. We must recognize the effect that poverty has on healthcare practices. If poverty were eradicated, there would be no homelessness, none who are uninsured, and no more choices between food and medicine. Until that time, nursing continues to face the chal-lenge of meeting the needs of all people.Geographic BarriersThose living in rural areas have unique concerns regarding access to care. As many rural hospitals close because of a lack of financing, more communities find themselves struggling to find primary care providers who will work in those areas. State and national efforts attempt to provide more service to these areas, but the demand out-weighs the supply.Urban dwellers are not immune to geographic barriers. Large cities have economically depressed sections with fewer healthcare providers than the more affluent areas. Dependency on public trans-portation is another factor to be managed. Finally, most rural and many urban communities do not support a full range of healthcare services in one location. These variables affect patientsÕ access to care and their continuation in prescribed treatment plans. It is imperative for the nurse to collaborate with other members of the healthcare team to become aware of various ser-vices available to enhance the health and quality of life of patients.Societal TrendsAt any time in history, societal trends affect the nursing profession. Major current movements include incivility, violence in the work-place, global aging, consumerism, complementary and alternative care, and disaster preparedness. Discussion of these issues allows us to see more clearly the social landscape and some of the challenges we face as a profession.IncivilityIncivility, or bullying, has been exposed in the media to a great extent in the past few years. This heightened attention is partly the result of media coverage of suicide attempts and homicides that were in-stigated by harassment at the physical, verbal, and electronic levels. KEY OUTCOME 7-4Example of Domain 3 sub-competency for entry-level professional nursing education.3.1g Participate in the implementation of socio-cultural and linguistically responsive interventions (p. 34).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdf CRITICAL THINKING QUESTIONS✶What barriers to health care do you see in your community? How are the under-privileged served in our current healthcare system?✶CHAPTER 7 Social Context and the Future of Professional Nursing206
Incivility is seen in every area of society, including high school, col-lege, and even on the job. Nursing is not immune to this behavior. Greater light has been shed on the incidence and prevalence of bully-ing in nurse-to-nurse, faculty-to-student, and even student-to-faculty interactions. Rocker (2008) reports that some of the behaviors include criticism, humiliation in front of others, undervaluing of effort, and teasing. It is also reported that bullying contributes to burnout, school dropout, isolation, and even attempted suicide. Bullying is costly to organizations because it contributes to increased leave, nurse attrition, and decreased nurse productivity, satisfaction, and morale.In light of this, it is vital that the nursing profession take an ac-tive step in preventing incivility not only in our communities but also in nursing programs and places of employment. The ANA (2012) has taken such action by developing a booklet, Bullying in the Work-place: Reversing a Culture, to help nurses recognize, understand, and deal with bullying in the work environment. The ANA supports zero-tolerance policies related to workplace bullying.In addition, in its professional performance standards, the ANA (2015) indicates that nurses are required to take a leadership role in the practice setting and within the profession. Two of the competen-cies listed that demonstrate the expected performance related to this standard include communicating in a way that manages conflict and contributing to environments that support and maintain respect, trust, and dignity.Violence in the WorkplaceThe violence in our society is evident and appears to be increasing in frequency and severity. What is more alarming is our desensitization to the constant exposure by Internet, radio, and television. As nurses, we can easily put a face on violence. We see the man in the emergency department with a gunshot wound to the chest. Only 30 minutes be-fore, he was leaving work for a weekend with his family when some-one decided that they needed his car more than this man needed his life. We see violence at the womenÕs shelter when we rotate through that clinical site in community health nursing. We also see troubled individuals who take out their frustration on children, colleagues, and supervisors by going on a shooting rampage, leaving a path of death and destruction. All of these examples affect nurses because we are caring for the ones who are injured and sometimes also providing care to the injurer. Nurses are required to know how to act and to provide competent care when violent incidents occur.Nurses must become socially aware and politically involved in preventing violence. We have to support legislation that proactively addresses violence and lobby for funding that provides nursing re-search into violence prevention and treatment. In every potential case, Societal Trends207
nurses must use keen assessment skills to identify people at risk and to promote reporting, treatment, and rehabilitation.Global AgingCurrently, 16.9% of the U.S. population is 65 years or older. It is es-timated that adults 65 years and older will comprise over 21% of the U.S. population (77 million) by 2034. It is projected that at this time, the number of older adults in the United States will outnumber the chil-dren for the first time. Further estimates predict 23.4% (94.7 million) adults over the age of 65 years by 2060 (U.S. Census Bureau, 2018).However, this is not a trend unique to the United States. The Year of the Older PersonÑthis is what the United Nations called the year 1999 to recognize and reaffirm global aging and the fact that our global population is aging at an unprecedented rate (Figure 7-2) (Kinsella & Velkoff, 2001). Not only are people in developed coun-tries living longer and healthier but also so are those in the developing world. In the 1990s, developed countries had equal numbers of young (people 15 years or younger) and old (people 55 years or older), with approximately 22% of the population in each category. On the other hand, 35% of the people in developing countries were children compared with 10% who were older. Still, absolute numbers of older persons around the world are large and growing, the trend beginning in higher-income countries, followed by middle- and lower-income countries. The World Health Organization (WHO) projects that the KEY OUTCOME 7-5Example of Domain 5 sub-competency for entry-level professional nursing education.5.3b Recognize how to prevent workplace violence and injury (p. 42).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfFigure 7-2 Nurses will care for an increasing number of older persons as this population continues to grow.© Monkey Business Images/iStock/Getty Images.CHAPTER 7 Social Context and the Future of Professional Nursing208
proportion of the worldÕs population over 60 years of age will nearly double from 12% to 22% between 2015 and 2050, with 80% of older adults living in low- to middle-income countries (WHO, 2018).In the United States, a decrease in fertility, an increase in urban-ization, better education, and improved health care all contribute to this social phenomenon. In addition, the older baby boomers who have turned 65 years of age have started to affect health care signifi-cantly, with increasing numbers receiving Medicare benefits. The ef-fect this will have on our healthcare system is daunting. According to the USDHHS (2020), more than 60% of older adults manage more than one chronic medical condition, such as diabetes, arthritis, heart failure, and dementia. Currently, 46% of critical care patients and 60% of medical-surgical patients in U.S. hospitals are older adults. These acute care patients are challenging for nurses and resource in-tensive to the healthcare system because these vulnerable patients gen-erally have multiple chronic conditions to treat simultaneously (Ellison & Farrar, 2015).There is a need for clear health policy at a national level if we are to be prepared to care for the increasing number of aging citizens. Preventive health services for older adults are delineated as provi-sions made in the Affordable Care Act of 2010. Healthy People 2020 included objectives specifically for older adults that should be used by healthcare professionals, including nurses, to promote healthy out-comes, including improved health, function, and quality of life for this population. Issues that emerge as nurses promote these outcomes may include coordination of care and helping older adults manage their own care (USDHHS, 2020).In response to the global aging phenomenon and the specialized set of skills required to care for older adults, most schools of nursing have either incorporated gerontology courses or increased the geri-atric content throughout the curriculum. Geriatric nurse practitioner programs have grown in number, and some schools offer dual-track adult/geriatric nurse practitioner and geriatric psychiatric mental health nurse practitioner programs in graduate programs. Clinical experiences in nursing programs include many experiences with older persons. Still, as a nation, we lack an organized plan to make certain that healthcare needs will be metÑnot only for the aging but also for those who come after them.ConsumerismSince the American Hospital AssociationÕs development of a PatientÕs Bill of Rights in 1973, consumers have assumed more control of their healthcare experiences; this shift is called consumerism. The 1992 ver-sion of the document was replaced by the brochure The Patient Care Partnership: Understanding Expectations, Rights, and Responsibilities Societal Trends209
(American Hospital Association, 2003). This brochure is available in several languages and can be accessed in its entirety via the American Hospital Association website at https://www.aha.org/system /files/2018-01/aha-patient-care-partnership.pdf. A summary of the original document is presented in Box 7-1. Gone are the days when patients blindly followed the instructions of their physicians. This is cause for celebration in the nursing arena because nursing has long sought to empower patients to take responsibility for their own health. Although pockets of medical paternalism may continue to exist, a shift has occurred, and consumers of health care now hold healthcare providers to a higher standard than ever before.The Picker Institute is another organization that has provided a road map to assist healthcare organizations in making rapid, dramatic advances in patient-centered care using what they call Always Events. Always Events refer to aspects of the patient or consumer experience that are so important to patients and families that healthcare provid-ers should always get them right and include improving communi-cation, providing consistent transitions, partnering effectively with patients and families, and improving patient safety. The Picker Insti-tuteÕs always events paved the way for the Institute of Healthcare Im-provement (IHI) Always Events Framework. The IHI Always Events Framework provides a strategy for providers to identify, develop, and achieve reliability in person-centered and family-centered care deliv-ery processes (2021).Information technology has given patients an enormous resource for gaining knowledge about diseases, medications, and treatment options as well as support groups and other self-help resources. In to-dayÕs environment, healthcare consumers search for answers to their BOX 7-1 THE PATIENT CARE PARTNERSHIPWhat to expect during your hospital stay:1. High-quality patient care2. A clean and safe environment3. Involvement in your carea. Discussing your medical condition and information about medically appropriate treatment choicesb. Discussing your treatment planc. Getting information from youd. Understanding your healthcare goals and valuese. Understanding who should make decisions when you cannot4. Protection of your privacy5. Preparing you and your family for when you leave the hospital6. Help with your bill and filing insurance claimsCHAPTER 7 Social Context and the Future of Professional Nursing210
healthcare questions and compare provider and healthcare system outcomes online. Based on the information available, they are able to make informed choices related to health care.Complementary and Alternative ApproachesAs the consumerÕs perspective grows in influence, and individuals take on greater responsibility in their healthcare decisions, they explore approaches to health care that can actually contrast with Western tra-ditions. Different terminology has been used synonymously to define this growing field, such as complementary care practices and alterna-tive medicine. According to the National Center for Complementary and Alternative Medicine (2018), ÒComplementary and alternative medicine is a group of diverse medical and healthcare systems, prac-tices, and products that are not presently considered to be part of conventional medicine.Ó Complementary medicine refers to an ap-proach that combines conventional medicine with less conventional options, whereas alternative medicine is an approach used instead of conventional medicine. Major types of complementary and alternative medicine include the following:¥ Alternative medical systems (built on complete systems of practice, such as homeopathic medicine or naturopathic medicine)¥ MindÐbody interventions (techniques designed to enhance the mindÕs capacity to affect bodily function, such as meditation, prayer, music, and support groups)¥ Biologically based therapies (use of substances found in nature, such as herbs, foods, and vitamins)¥ Manipulative and body-based methods (based on manipulation or movement of one or more parts of the body, such as chiropractic manipulation or massage)¥ Energy therapies (involves the use of energy fields through either biofield therapies, such as therapeutic touch, qi gong, or Reiki, or bioelectromagnetic-based therapies, such as magnetic therapy)Alternative and complementary therapies affect the selection of traditional choices for treatment and ignoring their existence is not an option. People persist in the use of alternative and complementary therapies for obvious reasons: (1) the therapies have been found valu-able, and (2) Western medicine has limited options. Many people are inclined not to divulge information about complementary therapy to their healthcare provider; however, some alternative therapies may interact with medications and may be contraindicated in certain circumstances, so it is imperative that healthcare providers seek out this information. Nurses should provide a safe, trusting atmosphere where patients feel free to discuss their healthcare routines and preferences.Societal Trends211
Disaster PreparednessPrior to the turn of this century, disaster preparedness was not a major topic of discussion in programs of nursing. The key roles that professional nurses now play in preparing and responding to disasters have been explored only in recent history. The World Trade Center attack in 2001 and the shock of Hurricane Katrina in 2005 opened the nationÕs eyes to our vulnerabilities and our strengths. As a result, disaster management has become common language in our schools, agencies, and communities.Disaster management, plans designating responses during an emer-gency, are coordinated by local, state, and federal groups. Firefighters, police officers, and healthcare professionals are part of response teams. Disaster training is also available to other volunteers. We have learned that caring for large groups affected by disaster requires an organized, thoughtful, unbiased approach. Professional nurses carry the burden of being knowledgeable about potential disasters, educating the public about the risks, and responding when persons are affected.Disaster resources are available from many organizations. The American Red Cross and the ANA make available policies, resources, and educational opportunities on disaster preparedness for nurses. In addition, the IOM (2009) provides guidance for entities establishing standards of care for disaster preparedness. The Centers for Disease Control and Prevention (CDC) Clinician Outreach and Communi-cation Activity program formed in 2011 in response to the anthrax attacks in the United States. The mission of the outreach program is to help healthcare professionals provide optimal care by facilitat-ing communication between clinicians and the CDC about emerging health threats, identifying clinical issues during emergencies to help inform outreach strategies, and disseminating evidence-based health information and public health emergency messages (CDC, 2018).Trends in NursingThe profession of nursing is currently facing some daunting chal-lenges that include a projected nursing shortage, workplace issues, the educationÐpractice gap, unclear practice roles, and changes in popula-tion demographics. Although it is true that each of these issues is not a new challenge to nursing practice, it is critical to now acknowledge the collective influence of all these together in the contemplation of future directions in professional nursing practice.Nursing is rich in history, resilient in its journey to develop as a profession and discipline and adaptive in its practice to meet the healthcare needs of the patient. Throughout the history of nursing, there are identifiable periods of time in which the practice and educa-tion of nurses responded to the evolving changes in health care and KEY OUTCOME 7-6Example of Domain 3 sub-competency for entry-level professional nursing education.3.6a Identify changes in conditions that might in-dicate a disaster or public health emergency (p. 37).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfCHAPTER 7 Social Context and the Future of Professional Nursing212
society. Today, nursing is again at the crossroads of a major transition in its education and practice. An awareness of the merging of these issues creates urgency when contemplating the role, practice, and edu-cation of nurses.Nurse ShortageThe shortage of nurses is not a new issue; the predicted nursing shortage has been prominent in the media for most of nursingÕs his-tory. Projections for the shortage are based on trends that include an increase in population, a larger proportion of elderly persons, and advances in technology and medical science. Other issues affecting the projected supply of nurses include declines in the number of nurs-ing school graduates, aging of the RN workforce, declines in relative earning, and emergence of alternative job opportunities, especially for women, who are still the prominent gender in nursing. History docu-ments a cyclic pattern of nursing shortages, making it difficult to com-prehend the seriousness of this shortage, especially viewed through the lens of history. The economic slowdown beginning in 2008 that resulted in decreased vacancies in healthcare agencies and the uncer-tainty of the consequences of healthcare reform given the Affordable Care Act (USDHHS, 2010a) further complicated predictions related to future nursing workforce needs.Beginning in 2008, employers in various parts of the United States began to report a decrease in the demand for RNs, and nurs-ing students report that it is more challenging after graduation to find employment. These findings have led many people to question whether the nursing shortage still existed. Experts claimed that the recession might have given some hospitals a temporary reprieve from chronic shortages, but it is not curing the longer-term problem and might be making it worse (OR Manager, 2009). The Tri-Council for Nursing (2010) released a joint statement cautioning stakeholders about declaring an end to the nursing shortage. The statement says, ÒThe downturn in the economy has led to an easing of the shortage in many parts of the country, a recent development most analysts believe to be temporaryÓ (p. 1). The council raised serious concerns about slowing the production of RNs given the projected demand for nurs-ing services, particularly in light of healthcare reform. It further states that diminishing the pipeline of future nurses could put the health of many Americans at risk, particularly those from rural and under-served communities, and leave our healthcare delivery system unpre-pared to meet the demand for essential nursing services.Where do we stand today? A report from the Bureau of Labor Statistics (2021) projects a 7% growth in the registered nursing work-force through 2029. Projections include the need for approximately 222,000 additional nurses by 2029. The AACN (2018) reported a Trends in Nursing213
1.5% enrollment increase in entry-level baccalaureate programs of nursing from fall 2016 compared to fall 2017, but this increase will be not sufficient to meet the projected demand for nursing services. Although nursing school enrollments and graduations are increasing, many more nurses will be needed to meet the healthcare needs of the population with the COVID-19 pandemic underscoring the nursing shortage issue in many communities.Nurse Faculty ShortageIn previous cycles of nursing shortages, the primary solution was to increase the enrollment in nursing programs. However, ample evidence supports the conclusion that a national nursing faculty shortage also exists, limiting the ability to increase student enrollment. Based on data from the 2019 AACN survey, we know that the professoriate continues to age, and an exodus from the ranks of faculty looms due to retirement (Figure 7-3). The mean age of doctoral faculty holding the rank of professor is 62.6 years, for faculty holding the rank of associate professor it is 56.9 years, and for assistant professors it is CRITICAL THINKING QUESTIONS✶As people age and experience health prob-lems, their needs are often more complex and acute, thereby demanding an even more highly skilled nursing workforce. Consider-ing the projections related to the nursing shortage, who will provide these healthcare services? Who will care for the old?✶Figure 7-3 The aging population also includes nurses and nursing faculty making solutions to the looming shortage of nurses more complicated than simply increasing enrollment in nursing programs.© Monkey Business Images/Shutterstock.CHAPTER 7 Social Context and the Future of Professional Nursing214
50.9 years. The national faculty vacancy rate is 7.2%. This short-age, as well as limits on clinical placement options, classroom space, insufficient numbers of clinical preceptors, and budget constraints, is limiting student capacity in nursing programs across the nation with a reported 80,407 qualified applicants turned away from baccalaureate and graduate programs in 2019 (AACN, 2020).Nursing Practice and Workplace EnvironmentGiven the anticipated nursing shortage and the increased demand for nurses, it is important to address the issues associated with the practice of nursing and the environment where nurses work. It is un-derstandable how the shortage of nurses affects the practicing nurse, especially in staff and patient ratios and workload and the resulting influences on nurse turnover rate. However, other issues associated with the nurse practice setting result in problematic quality outcomes, such as nurse job dissatisfaction, unsafe patient care, unhealthy work-place environment, and unclear role expectations.It is evident that health care and healthcare delivery have changed significantly in the past two decades. Most of these changes have been associated with response to the increasing cost of care, the decreasing reimbursement to healthcare providers, increased use of technology in practice, and the knowledge explosion concerning dis-ease management. A full discussion of each of these issues is beyond the scope of this chapter; however, it is important to note that most of the changes result from a focus on reducing the cost of health care. Cost containment strategies aim to determine the setting of the de-livery of care, the length of stay in the hospital, the cost reimbursed to providers of care, and the designation of the appropriate provider of care.Hospitals remain the most common employment setting for RNs in the United States, with 62.2% of employed RNs reporting hospitals as their primary place of employment (HRSA, 2010). Nurses in hos-pitals provide care for patients who are sicker, older, and have more complex physical, psychosocial, and economic needs (Brown, 2004; Clark, 2004). The combination of older patients with higher acuity, sophisticated technology, and shorter hospital stays creates a chaotic environment and demands that nurses assume greater responsibil-ity (Cram, 2011). This chaos increases not only the risk of errors in patient care but also the risk of health concerns for the nurse, such as the threat of infection, needle sticks, ever-increasing sensitivity to latex, back injuries, and stress-related health problems. In addition to these health risks, nurses are susceptible to workplace violence (e.g., physi-cal violence, horizontal violence) and sexual harassment (Longo & Sherman, 2006; Ray & Ream, 2007; Smith-Pittman & McKoy, 1999; Valente & Bullough, 2004).Trends in Nursing215
The issues associated with the hospital work environment have been shown to dominate problems and outcomes associated with nurs-ing practice. Because of this environment, the profession of nursing has been challenged to evaluate its practice and outcomes. In fact, a major-ity of nurses completing surveys stated they perceived that the unsafe working environment interfered with their ability to provide quality patient care (ANA, 2011; Pellico et al., 2009). Staff nurses strongly desire a practice setting in which they feel that they have the ability to provide high-quality patient care (Schmalenberg & Kramer, 2008) and a work environment that facilitates clinical decision making.Confounding the issues of the workplace environment are the shortage of qualified non-nurse healthcare workers, the supervision of unlicensed personnel, the appropriate delegation of care, manda-tory overtime, and staffing ratios. The debate over the use of unli-censed personnel and the use of other licensed personnel in providing patient care is well documented in the literature (ANA, 1992, 1997, 1999; Zimmerman, 2006), despite the evidence from research stud-ies that indicate that a decrease in RN staff increases patient care er-rors, infection rates, readmission, and morbidity (Aiken et al., 2002; Needleman et al., 2002; Sofer, 2005; Stanton & Rutherford, 2004).Given that research indicates that a decrease in RN staff or the use of unlicensed personnel and other licensed personnel influences patient quality outcomes, what is a rationale for this practice? One answer that is quickly provided is the increased costs of a higher RNÐpatient ratio. Nurses represent about 23% or more of the hospital workforce. The salary of a licensed RN is higher compared to other nonphysician healthcare providers. Thus, the basic assumption is that to employ more unlicensed personnel or other licensed personnel reduces the cost of care. This assumption is not necessarily true when costs other than salary, such as costs of hiring, benefits, training, staff turnover, and responsibilities that must be assumed by a licensed care provider, are considered. Aiken et al. (2002) found that nurses in hospitals with low nurseÐpatient ratios are more than twice as likely to experience job-related burnout and dissatisfaction with their jobs when compared to nurses in hospitals with the highest nurseÐpatient ratios. Cooper (2004) and Kalisch and Kyung (2011) note that lower nursing staff ratios also indicate higher costs in a plethora of areas that reflect the actual reality of nursing practice. McCue et al. (2003) found that a 1% increase in non-nurse personnel increased operating costs by 0.18% and dimin-ished profits by 0.021%. These data are significant in the overall bud-get considering the rising costs of health care and the current emphasis on the association of quality and safety indicators with reimbursement.Nurse RetentionThere is a connection among nurse satisfaction, work environment, and nurse retention. The strongest predictor of nurse job dissatisfaction CHAPTER 7 Social Context and the Future of Professional Nursing216
and intent to leave a job is personal stress related to the practice envi-ronment. The various causes of job stress include patient acuity, work schedules, poor physicianÐnurse interactions, new technology, staff shortages, unpredictable workflow or workload, and the perception that the care provided is unsafe (Groff-Paris & Terhaar, 2010). Surveys of practicing nurses document that job dissatisfaction, patient safety concerns, decreases in the quality of care, inadequate staffing, patient care delays, and mandated overtime are issues that negatively affect nursing practice (Aiken et al., 2002; Cooper, 2004; Pellico et al., 2009). Nurses have also reported concern about their own health and safety issues, with job stress the most frequent health problem reported. Concerns from nurses related to their own health and safety were in the news frequently during the early days of the COVID-19 pandemic when there were shortages of personal protective equipment (PPE). As the pandemic continued, the concerns focused more on inadequate staffing and the resultant exhaustion of nurses and other healthcare providers.The retention of competent professional nurses in jobs is a major problem of the U.S. healthcare industry, particularly in hospitals and long-term care facilities. The yearly nurse turnover rate is 19.1% on average for U.S. hospitals, with 60% of turnover occurring in the first year of employment (NSI Nursing Solutions, 2019). Kovner and col-leagues (2007) found that 13% of newly licensed RNs had changed principal jobs after 1 year, and 37% reported that they felt ready to change jobs (Huntington et al., 2012; Pellico et al., 2009). In a com-prehensive report initiated by the AHRQ (2020), the authors found that the shortage of RNs, in combination with an increased workload, poses a potential threat to the quality of care. In addition, every 1% increase in nurse turnover costs a hospital about $300,000 a year.Complexity of Nursing WorkThe healthcare workplace has changed over the past 20 years in re-sponse to economic and service pressures. However, some of these reforms have had undesirable consequences for nursesÕ work in hospitals and the use of their time and skills. As the pace and com-plexity of hospital care increase, nursing work is expanding at both ends of the complexity continuum. Nurses often undertake tasks that less-qualified staff could do, whereas at the other end of the spectrum they are unable to use their high-level skills and expertise. This ineffi-ciency in the use of nursing time can also negatively affect patient out-comes. NursesÕ work that does not directly contribute to patient care, engage higher-order cognitive skills, or provide opportunity for role expansion can decrease retention of well-qualified and highly skilled nurses in the health workforce (Duffield et al., 2008).The major barrier to making progress in patient safety and qual-ity is the failure to appreciate the complexity of the work in health Trends in Nursing217
care today. Current research focusing on work complexity and related issues enables an increased understanding of RN decision making, known as the invisible, cognitive work of nursing, in actual care situ-ations and demonstrates how both the knowledge and the compe-tencies of RNs, as well as the complex environments in which RNs provide care, contribute to patient safety, quality of care, and healthy work environments or lack thereof (Ebright, 2010, Sitterding & Ebright, 2015).Krichbaum et al. (2007) identify a nurse care-delivery experience they term Òcomplexity compressionÓ and note that this experience oc-curs when nurses are expected to assume, in a condensed time frame, additional, unplanned responsibilities while simultaneously conduct-ing their other multiple responsibilities. Nurses report that personal, environmental, practice, administrative, system, and technology fac-tors, as well as autonomy and control factors, all contribute to this experience. Associated with complexity compression is the phenom-enon of stacking. Stacking is the invisible, decision-making work of RNs about the what, how, and when of delivering nursing care to an assigned group of patients (Ebright et al., 2003). This process results in decisions about what care is needed, what care is possible, and when and how to deliver this care (Figure 7-4).A commitment to understanding and appreciating the complex-ity involved in RN work is needed to guide the more substantive and KEY OUTCOME 7-7Example of Domain 7 sub-competency for entry-level professional nursing education.7.3a Demonstrate a systematic approach for decision-making (p. 47).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfFigure 7-4 Advances in healthcare technology over the past several decades have created complex care environments; simultaneously, nursing work has become increasingly complex.© ERproductions Ltd/DigitalVision/Getty Images.CHAPTER 7 Social Context and the Future of Professional Nursing218
sustained improvements required to achieve safety and quality. At-tention to and action based on an understanding of the complexity of RN work and the value of safe, high-quality care; desired patient outcomes; and nurse recruitment and retention have the potential to achieve the goals of healthy work environments. Using complexity science to understand the work of nursing is becoming increasingly accepted as a very fitting approach to explaining healthcare organi-zational dynamics and the work of nursing (Lindberg & Lindberg, 2008).Nursing EducationThe healthcare system of the 21st century is complex, technologically rich, ethically challenging, and ever changing. The roles of all health-care providers evolve continually, and boundaries of practice shift regularly. Knowledge explodes at unprecedented rates, and although the evidence base for practice grows stronger every day, healthcare providers must repeatedly make decisions and take action in situa-tions that are characterized by ambiguity and uncertainty (Cowan & Moorhead, 2011).In 2003, the IOM issued a report titled Health Professions Education: A Bridge to Quality (IOM, 2003a). This report, which focuses on knowledge that healthcare professionals need to provide high-quality care, states that students in the health professions are not prepared to address the shifts in the countryÕs demographics nor are they educated to work in interdisciplinary teams. It further states that students were not able to access evidence for use in practice, determine the reasons for or prevent patient care errors, or access technology to acquire the latest information. Specifically, the report expresses concern with the adequacy of nursing education at all levels, yet it focuses intensely on education at the prelicensure level. The re-port identifies five core competencies that all clinicians should possess: (1) provide patient-centered care, (2) work in interdisciplinary teams, (3) use evidence-based practice, (4) apply quality improvement and identify errors and hazards in care, and (5) utilize informatics (IOM, 2003a).Two reports, Educating Nurses: A Call for Radical Transforma-tion (Benner et al., 2010) and The Future of Nursing: Leading Change, Advancing Health (IOM, 2011), explore the issue of whether nurses are entering practice equipped with the knowledge and skills needed for todayÕs practice and prepared to continue clinical learning for tomorrowÕs nursing, given the enormous changes in and complexity of current nursing practice and practice settings. In both reports the response is that nurses are not prepared for future healthcare change. Both reports challenge nursing education to make reforms in prepara-tion of new graduates in terms of establishing new competencies and KEY COMPETENCY 7-4Examples of applicable Nurse of the Future: Nursing Core CompetenciesSystems-Based Practice:Knowledge (K2a) Un-derstands the impact of healthcare system changes on planning, organizing, and delivering patient care at the work unit levelAttitudes/Behaviors (A2a) Appreciates the com-plexity of the work unit environmentAttitudes/Behaviors (A2b) Recognizes the complex-ity of individual and group practice on a work unitMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfTrends in Nursing219
outcomes for graduates, new curriculum designs, new pedagogy, better evaluation models, and new models for clinical education, such as residency programs. In addition, AACN has re-envisioned the essentials for both the entry-level and advanced-level nursing education that make expected compe-tencies explicit (AACN, 2021).Closing the Education and Practice GapThe gap between education and practice looms larger as the health-care setting continuously changes. In general, curricula in nursing programs have not evolved to keep pace with changes in the prac-tice setting; however, the current emphasis on integrating clinical simulation, dedicated education units, nurse residency programs, and competency-based education are significant steps in the right direction.Where do we go from here? The IOM (2011) report The Future of Nursing: Leading Change, Advancing Health provides us with a blueprint. The IOM and Robert Wood Johnson Foundation partnered to assess and respond to the need to transform nursing to ensure that the nursing workforce has the capacity, in terms of numbers, skills, and competence, to meet the present and future healthcare needs of the public. This transformation would enable nurses to be partners and leaders in advancing health for the future. The key messages of the study include the following: (1) nurses should practice to the full extent of their education and training; (2) nurses should achieve higher levels of education and training through an improved educa-tion system that promotes seamless academic progression; (3) nurses should be full partners, with physicians and other health profession-als, in redesigning health care in the United States; and (4) effective workforce planning and policy making require better data collec-tion and an improved information infrastructure (IOM, 2011, p. 4). Recommendations include to (1) remove scope-of-practice barriers, (2) expand opportunities for nurses to lead and diffuse collaborative improvement efforts, (3) implement nurse residency programs, (4) increase the proportion of nurses with a baccalaureate degree to 80% by 2020, (5) double the number of nurses with a doctorate by 2020, (6) ensure that nurses engage in lifelong learning, (7) prepare and enable nurses to lead change to advance health, and (8) build an in-frastructure for the collection and analysis of interprofessional health-care workforce data. It is imperative that professional nurses control their future and redefine their roles in practice; the recommendations and the strategies identified in this report provide the way.The national nurse survey in 2008 indicated that the initial educa-tional level of RNs was as follows: 20.4% were diploma, 45.4% were CRITICAL THINKING QUESTION✶How do changes in nursing education re-flect nursingÕs responsibility in the context of the social contract discussed earlier in this chapter?✶CHAPTER 7 Social Context and the Future of Professional Nursing220
associate degree, and 34.2% were baccalaureate (HRSA, 2010). Leaders in nursing education have worked since then to identify ways to move reg-istered nurses to higher levels of education more expediently. In the latest national nurse survey, RNs reported an initial educational level indicat-ing 11.4% were diploma, 48.5% were associate degree, 39.3% were baccalaureate, and 0.9% were graduate level but when we look at highest edu-cational level data, we see significant improvement with 6.4% with diploma, 29.6% with associate degree, 44.6% with baccalaureate de-gree, and 19.3% with a graduate-level degree (HRSA, 2019). Evidence supports that a better-educated nurse is needed in practice and it appears that we are finally on the right track.ConclusionNow, when you hear the word nursing, what image comes to mind? If the picture is blurry or confused by the expanding social context presented in this chapterÑgood! The cloudiness indicates that the tradition continues to be questioned. We have looked at some of the social phenomena and trends within the profession that help define nursing practice. Because those experiences change constantly, what we envision now will also be transformed. Are you ready to be a part of transforming professional nursing practice toward a future that continues to meet the needs of society? CRITICAL THINKING QUESTIONS✶Based on the trends and recommendations presented in this chapter, what do you think nursing education will look like in 2025? What do you think the profession of nurs-ing will look like in the year 2025?✶Classroom Activity 7-1Discuss what it means to be a professional nurse considering societal trends and the cur-rent trends in the healthcare environment and whether the identified trends pose barriers or opportunities for professional nursing prac-tice. This could be a class discussion, online discussion, or prompt for an essay.ReferencesAgency for Healthcare Research and Quality. (2020). 2019 national healthcare quality and disparities reports. https://www.ahrq.gov/research/findings/nhqrdr/nhqdr19/index.htmlAiken, L., Clarke, S., Sloane, D., Sochalski, J., & Silber, J. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association, 288(16), 1987Ð1993.American Association of Colleges of Nursing. (2008). Cultural competency in baccalaureate nursing education. http://www.aacnnursing.org/Portals/42/AcademicNursing/CurriculumGuidelines /Cultural-Competency-Bacc-Edu.pdf?ver=2017-05-18-143551-883References221
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© Nuu Jeed/ShutterstockProfessional Nursing Practice and the Management of Patient Careunit ii
Patient SafetyThe definition of safety provided by the Quality and Safety Education for Nurses (QSEN) (Cronenwett et al., 2007; QSEN, 2007) project refers to the minimization of risk of harm to patients and provid-ers through both system effectiveness and individual performance. The Massachusetts Department of Higher Education (2016) uses the QSEN definition in the development of its safety competencies for the Ònurse of the future.ÓIn its landmark report To Err Is Human: Building a Safer Health System, the Institute of Medicine (IOM, 2000) defined patient safety as freedom from accidental injury. In the same report, it estimated that at least 44,000 and possibly up to 98,000 people died each year as the result of preventable harm while receiving health care that was Key Terms and Concepts ÈAccountability measures ÈBenchmarking ÈCare bundle ÈComposite measures ÈContinuous quality improvement (CQI) ÈCore measures ÈCulture of safety ÈError ÈHealthcare transparency ÈJust cultureAfter completing this chapter, the student should be able to:1. Explore various deÞnitions of safety.2. Describe the system approach to patient care safety.3. Describe organizational culture in rela-tionship to patient safety.4. Describe the role of nurses in delivering safe health care.5. Explore the link between quality and safety.6. Discuss the relationship of transparency and reporting to healthcare quality.7. Describe nursing-sensitive measures.8. Discuss the need for continuous quality improvement (CQI) in the provision of pa-tient care.9. Discuss the role of the nurse in quality improvement.Learning ObjectivesSafety and Quality Improvement in Professional Nursing PracticeKathleen MastersCHAPTER 8© Nuu Jeed/Shutterstock229
supposed to help them. Subsequent to this report, the IOM produced nine more reports regarding patient quality and safety. Why? Because the original report brought attention to the problems related to pa-tient safety that permeate the healthcare system.Culture of SafetyThe IOM report (2000), although identifying alarming problems related to safety, was clear that the cause of the errors was defective system processes that either led people to make mistakes or failed to stop them from making a mistake, not the recklessness of individual providers. The report included such recommendations as the develop-ment of safer systems that would make it more difficult for humans to make mistakes.The IOM report (2000) defined error as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim with the goal of preventing, recognizing, and mitigat-ing harm. Adverse drug events and improper transfusions, surgical injuries and wrong site surgeries, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken patient identities were among the commonly occurring errors. Any aspect of required nursing care that is not provided or missed nursing care is classified as an error of omission (Kalisch, 2015) and by description is included in the IOM definition of an error.When errors occur, it is possible to analyze the event in two ways, a person approach or a system approach. Historically, in healthcare organizations, errors were viewed from the person approach to safety or finding out who is at fault. This approach results in making the person who committed the error the target of blame and creates an environment where providers fear admitting to mistakes and thus hide mistakes. This approach is counter to creating a culture of safety and transparency because it frequently results in disciplinary action. A safety culture, or culture of safety, is one that promotes trust and empowers staff to report risks, near misses, and errors (Hershey, 2015). Three key attributes in a culture of safety are trust of peers and management, reporting unsafe conditions, and improvement. Trust and reporting are increased when staff can observe improvements being made to correct unsafe conditions (Chassin & Loeb, 2013). Trust is lacking in many healthcare organizations, with many staff believing that error reporting will be held against them (Agency for Healthcare Research and Quality [AHRQ], 2014). This lack of trust leads to underreporting of errors and to the potential for more er-rors (Hershey, 2015). In a culture of safety, the focus is on what went wrong rather than on who made the error. Patient safety initiatives can succeed when embedded in an organizational culture of safety (Rovinski-Wagner & Mills, 2014).KEY OUTCOME 8-1Example of Domain 5 sub-competency for entry-level professional nursing education.5.2a Describe the factors that create a culture of safety (p. 41).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfKEY OUTCOME 8-2Example of Domain 5 sub-competency for entry-level professional nursing education.5.2d Assume account-ability for reporting unsafe conditions, near misses, and errors to reduce harm (p. 42).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdf ÈNever events ÈNursing-sensitive measures ÈPatient handoff ÈQuality ÈQuality improvement ÈSafety ÈSentinel eventsCHAPTER 8 Safety and Quality Improvement in Professional Nursing Practice230
A system approach to safety includes viewing the error in the con-text of prevention of future errors by looking at all the factors related to the incident. Nurses working in an organization with a system approach to safety are more likely to admit to errors or near misses because the identification of system issues will lead to patient safety. The system approach does not negate the accountability of the nurse for his or her actions but allows for analysis of the error in a way that explores system problems to prevent future errors (Figure 8-1). This balance between not blaming individuals for errors and not tolerating careless or egregious behaviors is known as a just culture (Mitchell, 2008).Measures of safety culture indicate that three areas of health care are in greatest need of improvement: a nonpunitive response to error, handoffs and transitions, and safe staffing (Hershey, 2015). If the healthcare system does include disciplinary action for error, then the basis of the punishment should be the type of behavior rather than the outcome of the error. The types of behavior that may result in error are human behavior, negligence, intentional rule violations, and reckless conduct. Human error does not change because of disci-plinary action. There are arguments for and against punishment for negligence. Much can be learned to create safer systems to prevent future errors that result from human error and negligence. In the case of intentional rule violations, it is important to look at the latent Figure 8-1 A person-centered or blaming approach to error will not solve system issues and may lead to employees hiding errors due to fear of reprimand.© Blaj Gabriel/Shutterstock.KEY COMPETENCY 8-1Examples of applicable Nurse of the Future: Nursing Core CompetenciesSafety:Knowledge (K4b) Describes factors that create a cul-ture of safetySkills (S4a) Participates in collecting and aggregating safety dataSkills (S4b) Uses organi-zational error reporting system for Ònear missÓ and error reportingMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfPatient Safety231
issues creating a situation in which staff are violating rules intended to promote patient safety rather than revert to discipline. However, in the case of reckless behavior, punishment is warranted (Marx, 2001).A root cause analysis is one method to review error that has already occurred, and along with actions to eliminate risks, it is re-quired by the Joint Commission for all sentinel events. A common approach to root cause analysis is a cause-and-effect diagram or fish-bone diagram. During this process, the problem is clarified by com-pleting an event flow diagram. The problem statement is the Òhead of the fish,Ó and the related processes or categories that are potential causes of the problem are clarified by completing an event flow dia-gram that consists of the main bones of the fish. Next, subcategories of causation or contributing factors are developed that create each of the smaller bones or branches of the diagram. The diagram is com-pleted as relationships among causal chains are identified and causal statements are developed.This process requires asking why the event happened in order to identify the underlying source of the error (Barnsteiner, 2012). This method considers elements of the total system rather than just the be-havior of an individual involved in an error and can be used to review data over time to identify the system variables that contributed to errors during the identified period (Rovinski-Wagner & Mills, 2014). See Figure 8-2 for a typical fishbone diagram.An example of the use of an ongoing root cause analysis to in-crease patient safety is the Taxonomy of Error, Root Cause Analysis, and Practice Responsibility (TERCAP) initiative by the National Council of State Boards of Nursing (2015). The goal of the TERCAP initiative is to develop a data set to distinguish human and system errors from negligence or misconduct while identifying the areas of KEY COMPETENCY 8-2Examples of applicable Nurse of the Future: Nursing Core CompetenciesSafety:Knowledge (K5) Describes how patients, families, in-dividual clinicians, health-care teams, and systems can contribute to promot-ing safety and reducing errorsSkills (S4f) Participates in safety surveysSkills (S5) Participates in analyzing errors and designing systems improvementsAttitudes/Behaviors (A5) Recognizes the value of analyzing systems and individual accountability when errors or near misses occurMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfProblemEquipmentProcessPeopleManagementEnvironmentMaterialsFigure 8-2 Typical fishbone diagram.CHAPTER 8 Safety and Quality Improvement in Professional Nursing Practice232
nursing practice breakdown in relation to standards of nursing prac-tice (Malloch et al., 2010). Practice breakdown categories include safe medication administration, documentation, attentiveness/surveillance, clinical reasoning, prevention, intervention, interpretation of autho-rized providersÕ orders, and professional responsibility/patient advo-cacy. System factors include communication, leadership/management, backup and support, environment, other health team members, staff-ing issues, and the healthcare team. Highlights of the 2014 TERCAP report (2015) reveal that of the errors related to practice breakdown and system factors, 56% did not cause harm but 44% did cause pa-tient harm. Using this framework, the data could be further analyzed to show that the most common practice breakdown categories and the most commonly reported system factors related to practice break-down. Twenty-six state boards of nursing participate in TERCAP.Another framework that is used to identify events or characteris-tics of a system that may allow potential errors is known as ReasonÕs Adverse Event Trajectory or the Swiss Cheese Model (Reason, 2000). This model explains how faults in different layers of the system can lead to error through triggers that can set up a sequence of events. Multiple defenses that have been set in place to prevent errors may at times line up, allowing multiple triggers to align and thus allow an er-ror to occur. The lining up of triggers has been illustrated as an arrow and the lining up of defenses the alignment of holes in Swiss cheese (thus the name Swiss Cheese Model). When the defenses line up, the arrow or trigger goes through the defenses (holes) and an error may occur. When the defenses do not line up, then the trigger (arrow) is blocked and the error is averted.ClassiÞcation of ErrorErrors may be classified by type. Types of errors include communi-cation, patient management, and clinical performance before, dur-ing, or after interventions. Improper delegation is an example of a patient management error. The potential for communication error occurs during transitions in care and handoffs. Standardization in handoff processes with face-to-face communication is key to patient safety. Standardized change of shift checklists and SBAR (situa-tion, background, assessment, recommendation) are two frequently used approaches to effective communication (Barnsteiner, 2012). A patient handoff is the transfer of responsibility for a patient from one clinician to another (Rovinski-Wagner & Mills, 2014) and pro-vides a frequent opportunity for error. Because of the vulnerability inherent in the patient handoff process, the Joint Commission has published expectations for handoffs in the National Patient Safety Goals. These expectations include an opportunity for questioning between the giver and receiver; provision of current information KEY OUTCOME 8-3Example of Domain 5 sub-competency for entry-level professional nursing education.5.2e Describe processes used in understanding causes of error (p. 42).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfKEY COMPETENCY 8-3Examples of applicable Nurse of the Future: Nursing Core CompetenciesSafety:Knowledge (K6a) Describes processes used in under-standing causes of error and in allocation of respon-sibility and accountabilitySkills (S6b) Participates within methods for evalu-ating and improving the overall reliability of a com-plex systemAttitudes/Behaviors (A6b) Values the importance for using a model for applying the principles of reliability to healthcare systems: prevent failure, identify and mitigate failure and redesign processes on identiÞed failureMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfPatient Safety233
regarding patient care, treatment, services, conditions, and any changes; verification of information in the form of repeat-back or read-back; the recipient of information having the opportunity to review patient data; and limits on interruptions during handoffs to minimize opportunities for information transfer failures (Barnsteiner, 2012).Errors may also be classified according to where the error occurs in the healthcare system. These errors include latent failure, arising from decisions affecting such things as organizational policies or al-location of resources, and active failure, referring to errors or harm at the ÒsharpÓ end or in direct contact with the patient. Organizational system failures are those errors related to management, organizational culture, and system process; technical failure refers to indirect failure of facilities or external resources. These terms also help identify the root cause of harm or error (Mitchell, 2008). An example of a poten-tial error that results from management decisions is related to staffing levels on patient care units. There is a clear and documented relation-ship among insufficient staffing, excessive workloads, staff fatigue, and adverse events in health care, with nurses working shifts longer than 12.5 hours being three times more likely to make a patient care error (Joint Commission, 2011).Errors that result from human factors can be classified as skill-based, rule-based, or knowledge-based error (Henriksen et al., 2008). Skill-based errors occur when there is a deviation in the pat-tern of a routine activity; for example, a skill-based error could result if a nurse is interrupted during medication administration. Workarounds and shortcuts by the nurse are examples of rule-based and knowledge-based errors that occur because of mistakes in con-scious thought. Workarounds occur when nurses create a quick way to solve a problem caused by some obstruction to providing care. Workarounds generally occur because nurses are busy or the pro-cess is time consuming or complicated. Workarounds may result in harm to patients when system defense mechanisms are bypassed. Strategies to eliminate workarounds include the addition of nurses in workflow planning as well as mechanisms within organiza-tions for reporting and solving workflow issues in a timely manner (Barnsteiner, 2012).Improving Patient SafetyReports prepared by the IOM propelled the quality and safety move-ment in the healthcare system during the first decade of the 21st century. The American Nurses Association (ANA) has contributed to patient safety through the development and dissemination of practice documents, such as NursingÕs Social Policy Statement (2010), Nurs-ing: Scope and Standards of Practice (2015b), and Code of Ethics KEY COMPETENCY 8-4Examples of applicable Nurse of the Future: Nursing Core CompetenciesSafety:Knowledge (K3) Discusses effective strategies to enhance memory and recall and minimize interruptionsSkills (S3) Uses appropri-ate strategies to reduce reliance on memory and interruptionsAttitudes/Behaviors (A3) Recognizes that both individuals and systems are accountable for a safe cultureMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfKEY COMPETENCY 8-5Examples of applicable Nurse of the Future: Nursing Core CompetenciesSafety:Knowledge (K4a) Delin-eates general categories of errors and hazards in careSkills (S4d) Utilizes timely data collection to facilitate effective transfer of pa-tient care responsibilities to another professional during transitions in care (ÒhandoffsÓ)Massachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfCHAPTER 8 Safety and Quality Improvement in Professional Nursing Practice234
with Interpretive Statements (2015a), as well as through credentialing and legislative efforts (Rowell, 2003). Other organizations, such as the Joint Commission and the National Quality Forum (NQF), have also contributed to the effort to improve patient safety through the dissemination and development of standards and patient safety re-sources. In addition, the Centers for Medicare and Medicaid Services have linked quality indicators that relate to patient safety, such as pressure ulcer prevalence and hospital-acquired infections, with hos-pital payment, and some states have passed error-reporting laws. All these efforts have begun to affect patient safety.To Err Is Human: Building a Safer Health SystemIn addition to drawing attention to the problem of error in the health-care system, To Err Is Human: Building a Safer Health System (IOM, 2000) also identified system approaches to the implementation of change in the recommendation section of the report. The nine recom-mendations were the development of user-centered designs, avoidance of reliance on memory, attending to work safety, avoidance of reliance on vigilance, training concepts for teams, involving patients in their care, anticipating the unexpected, designing for recovery, and improv-ing access to accurate, timely information.¥ The development of user-centered designs builds on human strengths and avoids human weaknesses. The first step is to make things visible to users so that users can determine what actions are possible during processes. A second step is to include affordances and natural mappings in relation to equipment and workspace, which includes clear communication of how the equipment is to be used, whether by design or through symbols indicating opera-tions. Finally, user-centered design also includes what are known as constraints or forcing functions. Constraints make it hard to do the wrong thing. A forcing function makes it impossible to do the wrong thing; for example, using different tubing connections for intravenous lines and enteral lines makes it impossible to inadver-tently switch the connections.¥ Standardization reduces reliance on memory and allows even those unfamiliar with a device to use it safely. When devices or medications cannot be standardized, they should be clearly dis-tinguishable. In addition, simplifying procedures minimizes the chance of error because less problem solving and fewer steps are required.¥ Work conditions, such as work hours, workloads, staffing ratios, and shift changes, that affect the circadian rhythm of the nurse af-fect both patient safety and worker safety.¥ People cannot remain vigilant for long periods, so the use of checklists and auditory and visual alarms can increase patient KEY COMPETENCY 8-6Examples of applicable Nurse of the Future: Nursing Core CompetenciesSafety:Knowledge (K1) IdentiÞes human factors and basic safety design principles that affect safetyKnowledge (K2) Describes the beneÞts and limitations of commonly used safety technologySkills (S1) Demonstrates effective use of technology and standardized practices that support safe practiceSkills (S2) Demonstrates effective use of strategies at the individual and sys-tems levels to reduce risk of harm to self and othersAttitudes/Behaviors (A1) Recognizes the cognitive and physical limitations of human performanceAttitudes/Behaviors (A2) Recognizes the tension be-tween professional auton-omy and standardizationMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfPatient Safety235
safety by avoiding reliance on vigilance. Avoiding long work shifts also helps decrease errors related to the limitations in vigilance of humans.¥ Because healthcare professionals work in teams, the establishment of training programs for interprofessional teams is recommended. As team members, professionals must trust the judgment and ex-pertise of colleagues.¥ Patients and family members should be invited to be active part-ners in the care process. The healthcare team is able to provide better care when they are able to obtain accurate information from patients, and safety improves when patients and their care-givers know about their care.¥ Whenever there are changes in an organization or technologies, healthcare professionals should anticipate the unexpected, which includes the possibility of an increase in error. Most organizations pilot new technologies prior to organization-wide implementation in order to test and modify as necessary to decrease the potential of unintended harm.¥ Another recommendation includes the assumption that errors will occur and to design and plan for recovery from errors. An example of a strategy used to anticipate and plan for recovery from error is using simulation training to rehearse procedures for responding to adverse events.¥ Finally, improving access to accurate, timely information, such as the use of decision-making tools at the point of care, will increase patient safety. Information coordinated across settings will also improve patient safety (Donaldson, 2008).Crossing the Quality Chasm: A New Health System for the 21st CenturyBuilding on the previous IOM report (2000), Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001) introduced performance expectations to create a system in which pa-tients are assured care that is safe, timely, effective, efficient, equitable, and patient centered. These expectations are known as the six aims for improving healthcare quality and are sometimes referred to in the literature as STEEEP.In addition, the report outlined 10 rules for redesign to move the healthcare system toward the identified performance expectations. Most of the rules relate primarily to quality, but one of the rules is specific to safety. Rule number six states that safety is a system prop-erty. This means that patients should be safe from harm caused by the healthcare system and that reducing risk and ensuring safety require attention to system processes.CHAPTER 8 Safety and Quality Improvement in Professional Nursing Practice236
Keeping Patients Safe: Transforming the Work Environment of NursesNurses are the healthcare professionals who spend the most time with patients and who provide the majority of direct care to patients. The IOM (2004) report Keeping Patients Safe: Transforming the Work Environment of Nurses specifically addressed the link between the work environment of nurses and patient quality and safety. The report identified six major concerns related to direct care in nursing: moni-toring patient status and surveillance, physiologic therapy, helping patients compensate for loss of function, emotional support, educa-tion for patients and families, and integration and coordination of care. Some of the key safety recommendations of this report included that the chief nursing executive should have a leadership role in the organization, the creation of satisfying work environments for nurses, evidence-based nurse staffing and scheduling to control fatigue, giving nurses a voice in patient care delivery, and designing work environ-ments and cultures that promote patient safety.Medication error is an area that affects nurses and is directly af-fected by nurses because nurses are primarily responsible for medica-tion administration in acute care settings. Medication errors make up the largest category of errors, with 3% to 4% of patients experiencing a serious error during hospitalization (IOM, 2006). Medication error accounts for over 7,000 deaths per year; on average, a patient in an inpatient setting will experience at least one medication error per day (Aspen et al., 2007). In response to these errors, the IOM (2006) made several recommendations to decrease medication error and to increase patient safety. These recommendations included a paradigm shift in the patientÐprovider relationship in which the patient takes an active role in the healthcare process and the provider does a better job of educating the patient about medications (Figure 8-3). Additional recommendations included using information technology to reduce medication errors, improving medication labeling and packaging, and policy changes to en-courage the adoption of practices that will reduce medication errors.Other Safety InitiativesThe goal of the NQF (2010) is to improve the quality of health care by setting national goals for performance improvement, endorsing national consensus standards for measuring and public reporting on performance, and promoting the attainment of national goals. The original set of the NQF-endorsed safe practices was released in 2003, and it was updated in 2006, 2009, and again in 2010 with the most current evidence. The endorsed safe practices Òwere defined to be universally applied in all clinical settings in order to reduce the risk of error and harm for patientsÓ (NQF, 2010, p. i). The NQF presents 34 Patient Safety237
practices that have been shown to decrease the occurrence of adverse health events. The practices are organized into seven categories for improving patient safety: creating and sustaining a culture of safety; informed consent, life-sustaining treatment, disclosure, and care of the caregiver; matching healthcare needs with service delivery capability; facilitating information transfer and clear communication; medication management; prevention of healthcare-associated infections; and con-dition and site-specific practices that include such topics as fall preven-tion, pressure ulcer prevention, and wrong site surgery (NQF, 2010).The NQF (2010) also endorses a list of 29 preventable, measur-able, serious adverse events for public reporting. These events are known as never events. Never events are not expected, and Medicare has eliminated reimbursement for certain never events. Example never events include patient suicide, sexual assault on a patient, abduction of a patient, patient death associated with a fall, infant discharged to the wrong person, surgery performed on the wrong body part, and patient death or disability associated with the use of restraints or bedrails (Haviley et al., 2014). These never events are organized into seven categoriesÑsix relating to provision of care (surgical or invasive procedure events, product or device events, patient protection events, care management events, environmental events, and radiologic events) and one category relating to four potential criminal events. The NQF acknowledges that a healthcare organization cannot eliminate all risk of adverse events; however, it can take measures to reduce risk.Figure 8-3 The nurse has a responsibility to educate the patient about medications.© Phakimata/iStock/Getty Images plus/Getty Images.CHAPTER 8 Safety and Quality Improvement in Professional Nursing Practice238
In 2002, the Joint Commission introduced the National Patient Safety Goals in order to promote improvements in patient safety. These goals are reviewed and updated annually and focus on sys-temwide solutions to problems identified in healthcare organizations (Barnsteiner, 2012). National Patient Safety Goals are organized by setting but are very similar across settings. The Hospital National Patient Safety Goals for 2021 include identifying patients correctly, using medications safely, improving effectiveness of caregiver com-munication, reducing patient harm associated with clinical alarms, reducing risk of healthcare-associated infection, identifying patient safety risks, and preventing mistakes in surgery (Joint Commission, 2021a).Never events are also sentinel events. A sentinel event is an unex-pected occurrence involving death or serious physical or psychologi-cal injury or the risk thereof and is termed sentinel because the event signals the need for immediate investigation and response. Organiza-tions are not required to report sentinel events to the Joint Commis-sion, but those accredited by the Joint Commission are encouraged to do so. Examples of sentinel events include wrong patient, wrong site, wrong procedure, delay in treatment, operative or postopera-tive complication, retention of foreign body, suicide, medication er-ror, perinatal death or injury, and criminal events. Between 1995 and 2017, 13,688 sentinel events were reviewed by the Joint Commission, most of which were self-reported occurrences in hospital settings (Joint Commission, 2021c). State laws generally require the reporting of sentinel events.With all these reports and initiatives related to patient safety, are we making progress? Progress toward IOM goals has been slow, but studies show that there has been some measurable progress in relation to patient safety. Healthcare organizations have responded to incen-tive programs, accreditation standards, and public opinion. Profes-sional organizations have responded with revisions to professional standards that place more emphasis on healthcare quality and patient safety. Educators have responded by revising curricula to infuse qual-ity and safety concepts into student didactic and clinical experiences guided by such projects as the QSEN initiative (QSEN, 2007) and Nurse of the Future (Massachusetts Department of Higher Education, 2016).When we talk about the reports and the data, we see the scope of the problem; however, when we see and hear patient stories, we un-derstand the effect of healthcare error on patient lives. Numerous vid-eos are available that relay the stories of patients who became victims of faulty systems and errors during their care. Some of the families of patient victims have used their devastating experience to try to im-prove the healthcare system and to prevent other patients and families from suffering.KEY OUTCOME 8-4Example of Domain 5 sub-competency for entry-level professional nursing education.5.1b Identify sources and applications of national safety and quality stan-dards to guide nursing practice (p. 41).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdf KEY COMPETENCY 8-7Examples of applicable Nurse of the Future: Nursing Core CompetenciesSafety:Knowledge (K6b) Discusses potential and actual impact of established patient safety resources, initia-tives and regulationsSkills (S6a) Uses estab-lished safety resources for professional development and to focus attention on assuring safe practicesAttitudes/Behaviors (A6a) Values the systemsÕ bench-marks that arise from es-tablished safety initiativesMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfPatient Safety239
Quality Improvement in Health CareThe overall quality of health care and patient safety is steadily im-proving, particularly for hospital care and for measures that are being publicly reported by the Centers for Medicare and Medicaid Services (CMS). According to the Agency for Healthcare Research and Qual-ity, hospital care was safer in 2013 than it was in 2010, with 17% less harm to patients and an estimated 1.3 million fewer hospital-acquired conditions and 50,000 fewer deaths (ARHQ, 2015). The most recent report from the Agency for Healthcare Research and Quality (AHRQ) indicates that 12 of the 26 patient safety measures showed overall improvement between 2016 and 2018. In addition, 40% of care co-ordination measures, which are critical for safety and quality, showed improvement (2020). So, we are making progress but still have need for improvement.Many reports, such as the one just cited, refer to quality and safety together. But what do we mean in health care when we speak about quality? According to the IOM (2001), quality is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Because professional knowledge is continu-ally increasing, quality is a moving target; because quality is a moving target, there will always be room for quality improvement.What is quality improvement? Quality improvement refers to the use of data to monitor the outcomes of care processes and uses improvement methods to design and test changes to continuously im-prove the quality and safety of healthcare systems (Cronenwett et al., 2007; Massachusetts Department of Higher Education, 2010; QSEN, 2007). Quality improvement focuses on systems, processes, satis-faction, and cost outcomes, usually within a specific organization. Quality improvement models assume that the process is continuous and that quality can always be improved, whereas quality assurance models seek to ensure that current quality exists (Owens & Koch, 2015).As mentioned previously, Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001) introduced perfor-mance expectations to create a system where patients are assured care that is safe, timely, effective, efficient, equitable, and patient centered (STEEEP). Safe care refers to avoiding harm to patients from care that is supposed to help them. Timely care includes reducing delays for those who receive care and for those who provide care. Effective care refers to the provision of services based on evidence to all who could benefit and refraining from providing services to those not likely to benefit. Efficient care refers to avoiding waste. Equitable refers to pro-viding care that does not vary in quality based on such characteristics as ethnicity, gender, socioeconomic status, or geographic location. KEY COMPETENCY 8-8Examples of applicable Nurse of the Future: Nursing Core CompetenciesSafety:Skills (S4c) Communicates observations or concerns related to hazards and errors involving patients, families, and/or healthcare teamSkills (S4e) Discusses clinical scenarios in which sensitive and skillful man-agement of corrective ac-tions to reduce emotional trauma to patients/families is employedAttitudes/Behaviors (A4a) Recognizes the importance of transparency in commu-nication with the patient, family, and health care team around safety and adverse events(A4b) Recognizes the com-plexity and sensitivity of the clinical management of medical errors and adverse eventsMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfCHAPTER 8 Safety and Quality Improvement in Professional Nursing Practice240
Patient-centered care refers to providing care that is responsive to patient preferences, needs, and values and ensuring that patient values guide clinical decisions.In addition, the report outlined principles or rules for redesign to move the healthcare system toward the identified performance expec-tations. The 10 rules for redesign follow:¥ Care is based on continuous healing relationships with patients receiving care whenever and wherever it is needed.¥ Care can be customized according to the patientÕs needs and pref-erences, even though the system is designed to meet the most com-mon types of needs.¥ The patient is the source of control and as such should be given enough information and opportunity to exercise the degree of con-trol the patient chooses regarding decisions that affect him or her.¥ Knowledge is shared and information flows freely so that patients have access to their own medical information.¥ Decision making is evidence based; that is, it is based on the best available scientific knowledge and should not vary illogically be-tween clinicians or locations.¥ Safety is a system property, and patients should be safe from harm caused by the healthcare system.¥ Transparency is necessary where systems make information avail-able to patients and families that enable them to make informed decisions when selecting a health plan, hospital, or clinic or when choosing alternative treatments.¥ Patient needs are anticipated rather than the system merely react-ing to events.¥ Resource waste and patient time is continuously decreased.¥ Cooperation among clinicians is a priority to ensure appropriate exchange of information and coordination of care (IOM, 2001).This IOM report and the quality reports that followed set the quality standard for the health-care system. Because patient safety and the qual-ity of health care cannot be separated, the report addressed both. Recommendations in this report have affected healthcare professional education, innovation in the realm of information technology for use in health care, accreditation, and regulation as well as policies to align payment for healthcare services with outcomes and purchasing of health care with outcomes.Another organization that has contributed to the quality move-ment is the Institute for Healthcare Improvement (IHI). In 2001, the IHI and the Voluntary Hospital Association collaborated to determine specifically how to achieve good outcomes with high levels of reli-ability in critical care units. The result of this collaborative initiative CRITICAL THINKING QUESTION✶How do best practices contribute to quality and safety?✶Quality Improvement in Health Care241
was the development of the concept of care bundles. A care bundle is defined by IHI as a small set of evidence-based interventions for a defined population of patients and care settings. Several bundles have been developed, but the original two bundles developed from the ini-tiative were the IHI ventilator bundle and the IHI central line bundle. The use of bundles has significantly increased quality of care and im-proved patient outcomes (Owens & Koch, 2015).One of the best-known initiatives of the IHI was the 100,000 lives campaign when hospitals were challenged to extend or save 100,000 lives from January 2005 to June 2006 by deploying rapid-response teams; delivering reliable, evidence-based care for acute myocardial infarction; preventing adverse drug events; preventing central line in-fections; preventing surgical site infections; and preventing ventilator-associated pneumonia. The goal of the next campaign was to prevent harm to 5 million lives from 2006 to 2008 by preventing pressure ul-cers; reducing methicillin-resistant Staphylococcus aureus; preventing harm from high-alert medications; reducing surgical complications; delivering reliable, evidence-based care for congestive heart failure to reduce readmission; and getting boards of directors involved by defin-ing and spreading new and leveraged processes for hospitalsÕ boards of directors so that they could become far more effective in accelerat-ing the improvement of care (Berwick, 2014).One of the most significant drivers of the quality movement in the healthcare system in the United States has been the implementa-tion of pay for performance and more recently value-based purchas-ing. In a pay-for-performance approach, there is financial benefit for healthcare providers to report measures and to give high-quality care. Value-based purchasing combines quality and payment but also in-cludes strategies to direct purchasers to high-performing institutions and health plans. Examples of these approaches include hospitals not being paid for secondary diagnoses related to preventable adverse events, such as harm from a fall, hospital-acquired infection, or wrong site surgery, and the systems that make these types of data available to consumers (Johnson, 2012).Quality Improvement Measurement and ProcessQuality improvement is data driven. One must have data to measure the effectiveness of care or the outcomes of care in order to know how good the care was that was provided to the patient. Another requirement for data to be useful is that language is consistent across institutions. For example, if one institution reports a fall only if the patient lands on the floor and another institution reports a fall based on the patient falling, even though she is caught before landing on CHAPTER 8 Safety and Quality Improvement in Professional Nursing Practice242
the floor, fall data will be measuring different phenomena in the two institutions (Johnson, 2012). For data to be meaningful, the measures must be valid. For data to be comparable across multiple institutions, the data must reflect measures of the same phenomena. Data collected can then provide information related to how much care varies among nurses, units, and organizations as well as from the standard that is based on current professional knowledge.In addition, measures of quality may vary based on various per-spectives. For example, hospital administrators may define quality in terms of patient satisfaction, physicians may define quality in terms of treatment of disease, and nurses may define quality in terms of meeting goals made with the patient (Amer, 2013). Regardless of the quality indicators chosen, measures are the most useful when they can be compared with measures that are considered the standard or best practice measures, thus allowing institutions to compare out-comes. Commonly, benchmarks are national or state averages and may include highest and lowest score by category (Johnson, 2012). Benchmarking may be defined as seeking out and implementing best practices or seeking to attain an attribute or achievement that serves as a standard for other institutions to emulate. Benchmarking may be either internal or external. Internal benchmarking may have the limitation of small numbers of units for comparison, whereas exter-nal benchmarking allows comparison with large numbers and top performers. Using benchmarking, data are compared to determine the level of performance and use a systematic method to identify a problem, select best practices, determine how best practices fit the unit or organization, initiate a change process, and evaluate outcomes (Vottero et al., 2012).Benchmarking begins with identification of the quality indica-tor that will be measured. Quality indicators are classified as struc-ture, process, or outcome indicators. Structure indicators reflect attributes of the care environment and may include elements like staffing or availability of technology. Process indicators include the evidence-based interventions or actions that help achieve outcomes. Outcome indicators include the end results of care delivery, such as hospital-acquired infection or pressure ulcer (Vottero et al., 2012).Healthcare Quality ReportingHealthcare transparency tends to improve care because the public availability of data allows patients to make informed choices about where they want to receive healthcare services. Healthcare transpar-ency, as defined by the IOM (2001), is making information on the healthcare systemÕs quality, efficiency, and consumer satisfaction with care, which includes safety data, available to the public so that patients and families can make informed decisions when choosing KEY OUTCOME 8-5Example of Domain 5 sub-competency for entry-level professional nursing education.5.1d Interpret benchmark and unit outcome data to inform individual and mi-crosystem practice (p. 41).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing .org/Portals/42/AcademicNursing/pdf /Essentials-2021.pdfKEY COMPETENCY 8-9Examples of applicable Nurse of the Future: Nursing Core CompetenciesQuality Improvement:Knowledge (K1) Describes the nursing context for improving careSkills (S1a) Actively seeks information about quality initiatives in their own care settings and organization(S1b) Actively seeks in-formation about quality improvement in the care setting from relevant in-stitutional, regulatory and local/national sourcesAttitudes/Behaviors (A1) Recognizes that quality im-provement is an essential part of nursingMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfQuality Improvement Measurement and Process243
care and to influence the behavior of providers, payers, and others to achieve better outcomes. Numerous websites are available that allow consumers to access information related to provider and healthcare system safety and quality. Some of the best-known sites include:¥ CMS: www.medicare.gov/hospitalcompare/search.html?¥ CMS Home Health Compare: www.medicare.gov/homehealthcompare/¥ The Joint Commission Quality Check: www.qualitycheck.org/con-sumer searchQCR.aspx¥ The Leapfrog Group Hospital Safety: www.hospitalsafetyscore.org¥ United Health Foundation: www.americashealthrankings.org¥ IPRO: www.ipro.org/for-consumers¥ IPRO: Why Not the Best? www.whynotthebest.org¥ The Commonwealth Fund: www.commonwealthfund.orgIn 1998, the Joint Commission launched the first national pro-gram for the measurement of hospital quality, initially requiring only the reporting of nonstandardized data on performance measures. In 2002, accredited hospitals were required to collect and report data for at least two of four core measure sets; these data were made publicly available by the Joint Commission in 2004 (Chassin et al., 2010).From this beginning, we now have a healthcare quality landscape in which the National Quality Forum has endorsed more than 600 quality measures, and the CMS has begun to financially penalize hos-pitals based on performance (Chassin et al., 2010). The Joint Com-mission has collaborated with the CMS to align common measures to provide hospitals with some relief related to numerous data col-lection requirements. The system in place allows the same data sets to be used to satisfy multiple data requirements. For example, the Joint Commission and the CMS common measures, as well as Joint CommissionÐonly measures, are used in the CMS Quality Reporting Programs, and the CMS Hospital Compare website reflects measures that the CMS and the Joint Commission have in common (Joint Com-mission, 2018).In 2002, the Joint Commission introduced the core measures program. Core measures are standardized performance indicators. Because the indicators are standardized, they allow for comparison of the measures across healthcare organizations and over time (Haviley et al., 2014).Measurement of performance indicator data reporting has been integrated into the accreditation process by the Joint Commission through what is known as the ORYX initiative. The initiative was one of the Joint CommissionÕs first steps to focus the accreditation process on an ongoing picture of performance to facilitate focus on continuous quality improvement related to patient care, treatment, CHAPTER 8 Safety and Quality Improvement in Professional Nursing Practice244
and service issues versus looking at data only once every 3 years dur-ing the accreditation visit (Joint Commission, 2017).For several years hospitals were required to report on four mandatory measure sets: acute myocardial infarction, heart failure, pneumonia, and surgical care improvement. In 2012, the Joint Com-mission also reclassified process performance measures into account-ability and nonaccountability measures. Accountability measures are evidence-based care processes closely linked to positive patient out-comes (Joint Commission, 2019). Accountability measures are qual-ity indicators that must meet four criteria and that are designed to identify measures that produce the greatest positive effect on patient outcomes when hospitals demonstrate improvement. The four criteria used to determine if an indicator is an accountability measure are as follows:1. Research: Strong scientific evidence demonstrates that performing the evidence-based care process improves health outcomes.2. Proximity: Performing the care process is closely connected to the patient outcome.3. Accuracy: The measure accurately assesses whether the care process has actually been provided.4. Adverse effects: Implementing the measure has little or no chance of inducing unintended adverse consequences (Joint Commission, 2019).Measures that meet all four criteria can be used by organizations for purposes of accountability, such as public reporting and accredi-tation. Those measures that are not designated as reportable ac-countability measures are still useful for quality improvement within individual healthcare organizations (Joint Commission, 2018).Composite measures combine the results of related measures into a single percentage rating calculated by adding up the number of times recommended evidence-based care was provided to patients and dividing this sum by the total number of opportunities to provide this care. Composite accountability measures are derived from 44 ac-countability measures within the 10 sets of measures. The current 10 sets of measures are heart attack care, heart failure care, pneumonia care, surgical care, childrenÕs asthma care, inpatient psychiatric ser-vices, venous thromboembolism care, stroke care, immunization, and perinatal care.Hospitals now have greater flexibility in meeting the performance measure requirements. Data reporting requirements are intended to support healthcare organizations in their quality improvement ef-forts and are available to the public on the Joint Commission website at www.qualitycheck.org. The public availability of performance measure data permits comparisons of hospital performance at the state and national levels by consumers (Joint Commission, 2017, 2021b).Quality Improvement Measurement and Process245
Measures of Nursing CareQuality measurement can be viewed in terms of structure, process, and outcome. Structure refers to the context of healthcare delivery and includes such things as buildings, staffing, and equipment. Process refers to the delivery of care, which includes the interactions between providers and patients. Finally, outcomes refer to the effect of health care on the health status of patients and populations. Using this framework, appropriate structure is required to support processes that will lead to desired outcomes (Donabedian, 1966). It stands to reason, then, that if the outcome measured has not achieved the desired stan-dard, some attention should be given to the structures and processes in place that affect the outcome in order to achieve the desired standard. This framework is proving successful for increasing the quality of care provided to patients. It is important to note, however, that although tremendous strides have been made, most of the measures captured in the standardized data sets described previously relate to outcomes of medical care processes rather than reflect the effect of nursing care. The following sections describe some ongoing efforts to capture data that reflect the contribution of nursing to patient outcomes.CAHPS Hospital SurveyThe Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS, pronounced ÒH-CAPSÓ) survey, also known as the CAHPS Hospital Survey, is the only national survey that includes a measure of nursing quality. The survey asks a core set of questions, with four of the questions relating specifically to nursing. The stan-dardized questions allow for comparisons of patient care experiences. For example, one question asks the patient about how often they got help as soon as they wanted after pushing the call button. The follow-ing questions also are included in the category:¥ How often did nurses communicate well with patients?¥ How often did nurses treat you with courtesy and respect?¥ How often did nurses listen carefully to you?¥ How often did nurses explain things in a way you could under-stand? (U.S. Department of Health and Human Services, 2011).These are simple questions, yet one can see that they relate to quality in terms of the timeliness of care and the provision of patient-centered care. Standardized questions allow for comparisons of patient care experiences across settings.National Voluntary Consensus Standards for Nursing-Sensitive CareAnother effort to identify nursing-sensitive indicators to measure qual-ity was born in 2003 when the Robert Wood Johnson Foundation KEY OUTCOME 8-6Example of Domain 5 sub-competency for entry-level professional nursing education.5.1c Implement standard-ized, evidence-based processes for care delivery (p. 41).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfCHAPTER 8 Safety and Quality Improvement in Professional Nursing Practice246
(RWJF) funded eight research projects to examine and evaluate exist-ing indicators of nursing performance. The projects found that data typically did not include the specific variables that quantify aspects of nursesÕ activities or contributions to quality of care. The studies also highlighted the need for Ònursing-sensitiveÓ measures. Nursing-sensitive measures were identified as patient-related processes or outcomesÑor structural variables that serve as proxies to these processes and outcomesÑthat reflect the nurse-quality relationship (RWJF, 2011).The RWJF turned to the NQF to endorse the compilation of nursing-sensitive measures through a consensus development process. In 2004, the NQF endorsed 15 voluntary consensus standards for nursing-sensitive care that could be used for performance measure-ment. These initial nursing-sensitive measures were referred to as the NQF-15 and included measures in three domains: patient-centered measures, nursing-centered measures, and system-centered measures (NQF, 2004). The original list of measures included three measures related to smoking cessation that have since been retired from the list. The current list includes 12 endorsed measures:¥ Death among surgical inpatients with treatable serious complica-tions (Òfailure to rescueÓ): The percentage of major surgical inpa-tients who experience hospital-acquired complications and die¥ Pressure ulcer prevalence: The percentage of inpatients who have a hospital-acquired pressure ulcer¥ Falls prevalence: The number of inpatient falls per inpatient day¥ Falls with injury: The number of inpatient falls with injury per inpatient day¥ Restraint prevalence: The percentage of inpatients who have a vest or limb restraint¥ Urinary catheterÐassociated urinary tract infection for intensive care unit (ICU) patients: The rate of urinary tract infections asso-ciated with use of urinary catheters for ICU patients¥ Central line catheterÐassociated bloodstream infection rate for ICU and high-risk nursery patients: The rate of bloodstream infec-tions associated with the use of central line catheters for ICU and high-risk nursery patients¥ Ventilator-associated pneumonia for ICU and high-risk nursery patients: The rate of pneumonia associated with the use of ventila-tors for ICU and high-risk nursery patients¥ Skill mix: The percentage of registered nurse, licensed vocational/practical nurse, unlicensed assistive personnel, and contracted nurse care hours to total nursing care hours¥ Nursing care hours per patient day: The number of registered nurses per patient day and the number of nursing staff hours (reg-istered nurse, licensed vocational/practical nurse, unlicensed assis-tive personnel) per patient dayQuality Improvement Measurement and Process247
¥ Practice Environment Scale of the Nursing Work Index (composite plus five subscales):¥ Nurse participation in hospital affairs¥ Nursing foundations for quality care¥ Nurse manager ability, leadership, and support of nurses¥ Staffing and resource adequacy¥ Collegiality of nurseÐphysician relations¥ Voluntary turnover of nursing staff: The number of nurses who leave their jobs of their own volition during the month, by cat-egory (NQF, 2004, p. 14; RWJF, 2011, pp. 15Ð16).The NQF report also identified a number of areas in which adequate measurements simply did not exist and called for fur-ther research about such topics as the relationship between nursing variables, including staffing (turnover, experience, etc.) and patient outcomes, the contribution of nurses to pain management, and the relationship between patient outcomes and process measures for nursing-centered interventions, including measures that describe the distinctive contributions of nurses, such as assessment, problem iden-tification, prevention, and patient education. The original work was intended to be a starting point rather than an ending point in identifi-cation of nursing-sensitive measures. The 2009 Implementation Guide for the National Quality Forum (NQF) Endorsed Nursing-Sensitive Care Performance Measures provided detailed specifications for the 12 national voluntary consensus standards for nursing-sensitive care endorsed by the NQF (Joint Commission, 2009); however, the work to identify a comprehensive set of nursing-sensitive measures is far from complete. Once rigorous studies that demonstrate reliability and validity related to a nursing-sensitive measure have been completed, they can be submitted to the NQF for possible endorsement.National Database of Nursing Quality Indicators (NDNQI)In 1997, the American Nurses Association also began identifying nursing-sensitive measures. These data are now part of a reposi-tory known as the National Database of Nursing Quality Indicators (NDNQI). Some of the measures included in the NDNQI are also NQF-approved measures, but other measures are not included in the NQF-approved measures list. The NDNQI provides reporting on structure, process, and outcome on 19 nursing-sensitive indicators at the unit level. Because the data from the NDNQI are unit-level data, they can be compared to other units in the organization or to similar units in other geographic locations. Because the data are unit based, the data have been used to demonstrate linkages between unit staff-ing levels and patient outcomes to demonstrate the contributions of nursing to quality patient care. Measures include patient falls, nursing hours per patient day, staff mix, restraints, hospital-acquired pressure CHAPTER 8 Safety and Quality Improvement in Professional Nursing Practice248
ulcers, nurse satisfaction, nurse education and certification, and pedi-atric pain assessment, among others (Montalvo, 2007). The NDNQI is currently owned and operated by Press Ganey, a healthcare im-provement organization.Quality Improvement Process and ToolsContinuous quality improvement (CQI) is defined as a structured or-ganizational process that involves personnel in planning and imple-menting the continuous flow of improvements in the provision of high-quality health care that meets or exceeds expectations. There are two typical pathways in the quality improvement process. The first process occurs as data that are regularly collected are monitored. If the data indicate that a problem exists, then an analysis is done to identify possible causes and a process is initiated to pilot a change. The second pathway involves the identification of a problem outside of the routine data monitoring system (Johnson, 2012).In addition to data, CQI generally has a common set of character-istics that include a link to key elements of the organizationÕs strategic plan, a quality council composed of the organizationÕs leadership, training programs for personnel, mechanisms for the selection of improvement opportunities, the formation of process improvement teams, staff support for process analysis and redesign, policies that motivate and support staff participation in process improvement, and the application of current and rigorous techniques of scientific method and statistical process control (Sollecito & Johnson, 2013). Collaboration and evidence-based practice are also key elements of successful quality improvement programs (Caramanica et al., 2003).There are several quality improvement tools that can assist in mon-itoring measures. Common tools include histograms, control charts, run charts, and scattergrams (Figure 8-4). These tools can assist in the identification of problems by visually showing the frequency of events and events outside of set parameters (Johnson, 2012). Once problems are identified, the root cause analysis technique can be used to system-atically identify the reason for the problem. A common approach to root cause analysis is to use a cause-and-effect diagram known as the Ishikawa or fishbone diagram, described previously in this chapter, which assists in identifying such problems as system issues with multi-ple dimensions. After all possible causes are identified, the team chooses the top two possible causes and then initiates a change process using one of several selected quality improvement methodologies.Popularized by William Edwards Deming, the Deming cycle of Plan, Do, Check, Act or, as he later modified it, the Plan, Do, Study, Act (PDSA) process is the most commonly used quality improvement methodology in health care (Figure 8-5). The basic premise of the PDSA is to encourage innovation by experimenting with a change, KEY COMPETENCY 8-10Examples of applicable Nurse of the Future: Nursing Core CompetenciesQuality Improvement:Knowledge (K4) Describes approaches for improving processes and outcomes of careSkills (S4a) Participates in the use of quality im-provement practices and implements changes in the delivery of care with consid-eration for population-based health careSkills (S4b) Implements best practices for prevent-ing harmAttitudes/Behaviors (A4) Recognizes the value of what individuals and teams can do to improve care pro-cesses and outcomes of careMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfKEY OUTCOME 8-7Example of Domain 5 sub-competency for entry-level professional nursing education.5.1e Compare quality im-provement methods in the delivery of patient care (p. 41).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfQuality Improvement Measurement and Process249
Figure 8-4 Many types of tools are available to assist providers in monitoring quality.© Mongta Studio/Shutterstock.DoStudyActPlanFigure 8-5 Plan, Do, Study, Act (PDSA) cycle.studying the results, and making refinements as necessary to achieve sustained desired outcomes (Strome, 2013). The process includes questions and activities that guide each phase. Examples include:¥ Plan: Begin with planning the changes to a process that are to be implemented and tested.¥ What is the objective?¥ What is the test of change?¥ Do: Carry out the plan and make the desired changes to the process.¥ Conduct the test.¥ Document unexpected observations and problems.CHAPTER 8 Safety and Quality Improvement in Professional Nursing Practice250
¥ Study: Review the effect and outcomes of the implemented changes.¥ Analyze the data.¥ Were the outcomes as expected?¥ What was learned from the test?¥ Act: Determine if the changes can be implemented as is or if fur-ther cycles are necessary for refinement.¥ What modifications should be made?¥ What is the next test? (Johnson, 2012, p. 126; Strome, 2013, p. 64).Six Sigma is another quality improvement methodology frequently used in health care. The goal of Six Sigma is to decrease the defects or errors from the current level within an organization. Six Sigma uses an approach that Òemphasizes the use of information and statistical analysis to rigorously and routinely measure and improve an organi-zationÕs performance, practices, and systemsÓ (Strome, 2013, p. 71). Approaches to Six Sigma vary by organization, but initiatives generally have five elements in common. The common elements include intent, strategy, methodology, tools, and measurements. Six Sigma initiatives are undertaken with the intent of achieving significant improvement in a short time and can be applied at a corporate level or aimed strategi-cally at an individual project. Several Six Sigma methodologies exist, but the most common one used in health care is what is known as DMAIC (Define, Measure, Analyze, Improve, Control). Tools involved in Six Sigma are numerous but fall into three categories: requirements gathering, statistical analysis, and experimentation. Finally, the most common measurements used in Six Sigma include defects/errors per unit, defects per million opportunities, and Sigma level (Strome, 2013).The five phases of the Six Sigma methodology using the DMAIC, discussed in the following list, must always be followed in precisely the same order, but they provide a rigorous approach that is effective in identifying opportunities for improvement (Figure 8-6).¥ Define: Clearly identify and state the problem that is the focus of the quality improvement initiative and outline the scope of the project. Determine the critical requirements and key benefits. Agree on the process to be improved and the plan to achieve the improvements.¥ Measure: Review all available data, measure the extent of the quality problem, and obtain baseline performance information.¥ Analyze: Use tools (such as a fishbone diagram) to study the root cause of the problem and to develop potential solution alternatives.¥ Improve: Develop alternative processes to help achieve the desired outcomes. Evaluate the alternatives based on each oneÕs potential Quality Improvement Measurement and Process251
effect on the outcome, using statistical analysis to determine the highest likelihood of achieving the desired performance.¥ Control: Sustain improvements through ongoing measurement and by conducting ongoing communication, reviews, and trainingData from Strome, T. L. (2013). Healthcare analytics for quality and performance improvement. Hoboken, NJ: Wiley.Another framework that is used to improve quality by identifying events or characteristics of a system that may allow potential errors to be averted is the ReasonÕs Adverse Event Trajectory or the Swiss Cheese Model, discussed previously (Reason, 2000).Regardless of the methodology chosen for a quality improvement initiative, there are some general commonalities among processes. In all successful quality improvement initiatives, the problem must be de-fined, opportunities for improvement must be identified, and improve-ment activities executed. Outcomes must be evaluated, and finally, change must be sustained (Strome, 2013).The Role of the Nurse in Quality ImprovementAs early as the 1860s, Florence Nightingale measured patient out-comes in relation to environmental conditions and proposed stan-dardization in the presentation of hospital statistics (Kovner et al., Figure 8-6 Five phases of the Six Sigma cycle.© Sorendls/iStockphoto.KEY COMPETENCY 8-11Examples of applicable Nurse of the Future: Nursing Core CompetenciesQuality Improvement:Knowledge (K3) Explains the importance of variation and measurement in pro-viding high-quality nursing care with awareness of diverse populations and/or issuesSkills (S3) Participates in the use of quality improve-ment tools to assess per-formance and identify gaps between local and best practicesAttitudes/Behaviors (A3a) Appreciates how standardization supports high-quality patient care(A3b) Recognizes how unwanted variation com-promises careMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfCHAPTER 8 Safety and Quality Improvement in Professional Nursing Practice252
2010; Owens & Koch, 2015). Today, nurses continue to have a role in quality improvement.ANA standard of professional performance number 14 states that the registered nurse contributes to high-quality nursing practice with competencies that include the nurseÕs role in various quality im-provement activities, such as collecting data to monitor quality and collaboration with the interprofessional team to implement quality improvement plans and interventions (ANA, 2015b). Knowing that the registered nurse participates in quality improvement activities, the American Association of Colleges of Nursing (AACN, 2008) includes statements in The Essentials of Baccalaureate Education for Profes-sional Nursing Practice related to the expectations of nurses graduat-ing from programs of nursing in the realm of quality improvement. According to the AACN (2008), a graduate of a baccalaureate nursing program will Òunderstand and use concepts, processes, and outcome measures . . . be able to assist or initiate basic quality and safety in-vestigations; be able to assist in the development of quality improve-ment action plans; and assist in monitoring the results of these action plansÓ (p. 13). AACN (2021) proposes that everyone in health care is responsible for quality and safety and that nurses, due to their knowl-edge and ethical code, are well-positioned to lead and co-lead teams that address improvement in quality and safety (p. 40).The role of the nurse in quality improvement builds on the ability of the nurse to collect and analyze patient data, something all nursing students learn early in their programs of study. The novice nurse and the expert nurse alike participate in quality improvement initiatives. The novice nurse will be involved in data collection and will assist with improvement interventions, whereas the expert nurse may be leading the quality improvement initiative, but all nurses should be prepared for this nursing role (Figure 8-7).The nurseÕs role in quality improvement is especially important in hospitals that promote a culture of patient safety. Registered nurses at the bedside use quality improvement techniques that were once employed only by quality assurance personnel. Nurses actively monitor outcomes of patient care processes using spreadsheets, flow diagrams, computer programs, and control charts to record and monitor data when analyzing a clinical problem or situation. Trended data collected by nurses are provided by the risk management department or performance improvement council and disseminated to the units.In addition to the processes of data monitoring, analysis, and change that occur as a part of the routine quality improvement cycle, nurses are frequently involved in the identification of a problem outside of the routine data monitoring system. Nurses may initiate CRITICAL THINKING QUESTION✶How can the commitment to quality im-provement be integrated throughout all roles and at all levels of the professional nursing practice?✶The Role of the Nurse in Quality Improvement253
the process of quality improvement based on observations of clini-cal issues in daily practice. These observations may lead to the con-duct of health record audits to compare care provided to standards or evidence-based clinical practice guidelines. The results of such a health record audit lead to the development of a quality improvement plan to align practice with current best practices. The recommenda-tions may be based on a variety of guidelines depending on the set-ting and patient population. Examples of possible guidelines for use in the audit include IHI care bundles or best practice guidelines from the Registered NursesÕ Association of Ontario. Based on the results of the health record audit, the nurse will present the data visually (as a control chart or histogram, for example) and collaborate with appro-priate stakeholders to develop the quality improvement plan. The re-sulting quality improvement implementation plan will need to include a specific plan for sustainability and evaluation to be successful. An example template for a health record audit matrix based on guideline recommendations is provided in Table 8-1. In the example template, an x indicates that the guideline recommendation was documented in the health record. A blank indicates that there was no documentation of the recommended activity. The matrix may alternatively be marked with Y and N for yes and no because just as with a cause-and-effect diagram, there is no one correct way to create this document. The Figure 8-7 The professional nurse is responsible for the use of quality improvement tools to assess performance and identify gaps between local and best practices.© Jose Luis Pelaez Inc/DigitalVision/Getty Images.KEY OUTCOME 8-8Example of Domain 5 sub-competency for entry-level professional nursing education.5.1a Recognize nursingÕs essential role in improv-ing healthcare quality and safety (p. 41).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing .org/Portals/42/AcademicNursing/pdf /Essentials-2021.pdfCHAPTER 8 Safety and Quality Improvement in Professional Nursing Practice254
quality improvement tools should be developed in the format that best fosters data collection, analysis, and planning, evaluating, and sustaining quality outcomes.Quality improvement is also tied into a nurseÕs performance evaluation. Individual nurse and team goals for quality and safety are important components of each staff memberÕs annual review. As nursing leadership and staff foster a culture of safety and quality, they emphasize reporting near misses and unintended outcomes as a means to identify and fix weak links in processes of care (Caramanica et al., 2003). But nurses have identified challenges to their role in quality improvement processes, including adequacy of resources, engaging nurses from management to the bedside in the process, the increasing number of quality improvement activities, the administrative bur-den of quality improvement initiatives, and the lack of preparation of nurses in traditional nursing education programs for their role in quality improvement (Draper et al., 2008). Thirty-nine percent of new graduates report that they are not prepared to adequately imple-ment quality improvement initiatives or to use quality improvement techniques, despite having the content in their prelicensure programs (Kovner et al., 2010).ConclusionWhy is it important for nurses to be involved in quality improvement efforts? Nurses are at what is known as the sharp end of health care, meaning that nurses have significant, direct contact with patients at the bedside. Because of this closeness to clinical activity, nurses rec-ognize the need for change, see the effects when the best care is not provided, and see the effect of changes. Thus, nurses are able to bring both clinical expertise and firsthand experience to discussions about quality improvement efforts within their organizations (Haviley et al., 2014). More than ever before, quality improvement is considered a core responsibility of the professional nurse.TABLE 8-1 Example of a Simple Audit Matrix TemplateDiagnosis (Diagnosis ßow sheet/tab)Health Record #1Health Record #2Health Record #3Health Record #4Health Record #5Recommendation 1.1xxxxRecommendation 1.2xxxxRecommendation 2.1xxxRecommendation 2.2xxxxxKEY COMPETENCY 8-12Examples of applicable Nurse of the Future: Nursing Core CompetenciesQuality Improvement:Knowledge (K2) Compre-hends that nursing con-tributes to systems of care and processes that affect outcomesSkills (S2) Participates in the use of quality improve-ment models and tools to make processes of care interdependent and explicitAttitudes/Behaviors (A2) Recognizes how team col-laboration is important to quality improvement and values the input from the interprofessional teamMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfConclusion255
Classroom Activity 8-1Provide students with a list of measures and have students search some of the websites listed under the Healthcare Transparency heading to find safety and quality information about your local hospitals. Discuss the results in the context of quality outcomes and con-sumer choice.Classroom Activity 8-2Provide students with case studies that de-scribe nursing errors, such as the historical case studies in Emrich (2010). Have students work in groups to either identify the root cause of the error using a fishbone diagram and then engage in a PDSA process to plan a small-scale quality improvement initiative or identify how to prevent the errors using the Swiss Cheese Model.Classroom Activity 8-3Provide small groups of students with chart audit results and appropriate clinical guidelines. The students should work together as a team to develop a quality improvement plan.Classroom Activity 8-4The IHI is a quality improvement organiza-tion dedicated to sharing information to im-prove healthcare safety. IHI Open School has free online courses and experiential learning opportunities available at http://www.ihi .org/education/IHIOpenSchool/Pages/default.aspx. Choose activities from the website for students to complete that meet specific course objectives.Classroom Activity 8-5Numerous classroom and clinical activities related to safety and quality improvement are available on the QSEN website at https://qsen .org. Choose activities from the website for students to complete that meet specific course objectives.CHAPTER 8 Safety and Quality Improvement in Professional Nursing Practice256
ReferencesAgency for Healthcare Research and Quality. (2014). 2013 national healthcare quality report. U.S. Department of Health and Human Services. https://nhqrnet.ahrq.gov/inhqrdr/reports/qdrAgency for Healthcare Research and Quality. (2015). 2014 national healthcare quality and disparities report (AHRQ Publication No. 15-0007). Author.Agency for Healthcare Research and Quality. (2020). 2019 national healthcare quality and disparities report. U.S. Department of Health and Human Services. https://www.ahrq.gov/research/findings /nhqrdr/nhqdr19/index.htmlAmerican Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Author.American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Essentials-2021.pdfAmerican Nurses Association. (2010). NursingÕs social policy statement: The essence of the profession. Author.American Nurses Association. (2015a). Code of ethics with interpretive statements. Author.American Nurses Association. (2015b). Nursing: Scope and standards of practice (3rd ed.). Author.Amer, K. S. (2013). Quality and safety models. In K. S. Amer (Ed.), Quality and safety for transformational nursing: Core competencies (pp. 16Ð40). Pearson.Aspen, P., Walcott, J., Bootman, L., & Cronenwett, L. (2007). Identifying and preventing medication errors. National Academies Press.Barnsteiner, J. (2012). Safety. In G. Sherwood & J. Barnsteiner (Eds.), Quality and safety in nursing: A competency approach to improving outcomes (pp. 149Ð169). Wiley.Berwick, D. M. (2014). Promising care: How we can rescue health care by improving it. Jossey-Bass.Caramanica, L., Cousino, J. A., & Petersen, S. (2003). Four elements of a successful quality program: Alignment collaboration, evidence-based practice, and excellence. Nursing Administration Quarterly, 27(4), 336Ð343.Chassin, M. R., & Loeb, J. M. (2013). High-reliability healthcare: Getting there from here. Milbank Quarterly, 91, 459Ð490.Chassin, M. R., Loeb, J. M., Schmaltz, S. P., & Wachter, R. M. (2010). Accountability measuresÑUsing measurement to promote quality improvement. New England Journal of Medicine, 363, 683Ð688. doi:10.1056/NEJMsb1002320Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., . . . Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122Ð131.Donabedian, A. (1966). Evaluating the quality of medical care. Milbank Memorial Fund Quarterly, 44(3 Suppl.), 166Ð206.Donaldson, M. S. (2008). An overview of To Err Is Human: Re-emphasizing the message of patient safety. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses (Vol. 1, pp. 37Ð45; Publication No. 08-0043). Agency for Healthcare Research and Quality.Draper, D. A., Felland, L. E., Liebhaber, A., & Melichar, L. (2008). The role of nurses in hospital quality improvement (Vol. 3). Center for Studying Healthcare System Change.Emrich, L. (2010). Practice breakdown: Medication administration. In P. E. Benner, K. Malloch, & V. Sheets (Eds.), Nursing pathways for patient safety (pp. 30Ð46). Mosby.Haviley, C., Anderson, A. K., & Currier, A. (2014). Overview of patient safety and quality of care. In P. Kelly, B. A. Vottero, & C. A. Christie-McAuliffe (Eds.), Introduction to quality and safety education for nurses (pp. 1Ð37). Springer.Henriksen, K., Dayton, E., Keyes, M. A., Carayon, P., & Hughes, R. (2008). Understanding adverse events: A human factors framework. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses (Vol. 1, pp. 67Ð85; Publication No. 08-0043). Agency for Healthcare Research and Quality.References257
Hershey, K. (2015). Culture of safety. Nursing Clinics of North America, 50, 139Ð152.Institute of Medicine. (2000). To err is human: Building a safer health system. National Academies Press.Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academies Press.Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment of nurses. National Academies Press.Institute of Medicine. (2006). Preventing medication errors: Quality chasm series. National Academies Press.Johnson, J. (2012). Quality improvement. In G. Sherwood & J. Barnsteiner (Eds.), Quality and safety in nursing: A competency approach to improving outcomes (pp. 113Ð132). Wiley.Joint Commission. (2009). Implementation guide for the NQF endorsed nursing-sensitive care measure set, 2009. https://www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc /system-folders/assetmanager/nsc-manualpdf.pdf?db=web&hash=B7C3F09508A4E5709D8A8386F28F2CDAJoint Commission. (2011). Sentinel event alert issue 48: Health care worker fatigue and patient safety. http://www.jointcommission.org/sea_issue_48/Joint Commission. (2017). Facts about ORYX¨ for hospitals (national hospital quality measures). https://www.jointcommission.org/measurement/reporting/accreditation-oryx/Joint Commission. (2018). AmericaÕs hospitals: Improving quality and safety: Annual report 2017. https://www.new-media-release.com/jointcommission/2017_annual_report/2017-annual-report.pdfJoint Commission. (2019). Accountability measures. https://www.jointcommission.org/-/media/tjc /documents/fact-sheets/accountability-measures-fact-sheet-10-31-19.pdfJoint Commission. (2021a). 2021 hospital national patient safety goals. https://www.jointcommission.org /standards/national-patient-safety-goals/hospital-national-patient-safety-goals/Joint Commission. (2021b). Quality check and quality reports. https://www.jointcommission.org/about-us /facts-about-the-joint-commission/quality-check-and-quality-reports/Joint Commission. (2021c). Summary data of sentinel events reviewed by the Joint Commission. https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/Kalisch, B. (2015). Errors of omission: How missed nursing care imperils patients. American Nurses Association.Kovner, C. T., Brewer, C. S., Yingrengreung, S., & Fairchild, S. (2010). New nursesÕ views of quality improvement education. Joint Commission Journal of Quality and Patient Safety, 36(1), 29Ð35.Malloch, K., Benner, P., Sheets, V., Kenward, K., & Farrell, M. (2010). Overview: NCSBN practice breakdown initiative. In P. E. Benner, K. Malloch, & V. Sheets (Eds.), Nursing pathways for patient safety (pp. 1Ð29). Mosby.Marx, D. (2001). Patient safety and the Òjust cultureÓ: A primer for health care executives. Medical event reporting system-transfusion medicine. Columbia University.Massachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. https://www.mass.edu/nahi/documents/nofrncompetencies_updated_march2016.pdfMitchell, P. (2008). Defining patient safety and quality care. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses (Vol. 1, pp. 1Ð6; Publication No. 08-0043). Agency for Healthcare Research and Quality.Montalvo, I. (2007). The national database of nursing quality indicators (NDNQI). Online Journal of Issues in Nursing, 12(3). doi:10.3912/OJIN.Vol12No03Man02National Council of State Boards of Nursing. (2015). TERCAP: Taxonomy of error, root cause analysis, and practice-responsibility. https://www.ncsbn.org/TERCAP_10yearsafterIOM.pdfNational Quality Forum. (2004). National voluntary consensus standards for nursing-sensitive care: An initial performance measure set. Author.National Quality Forum. (2010). Safe practices for better healthcare 2010: A consensus report. Author.CHAPTER 8 Safety and Quality Improvement in Professional Nursing Practice258
Owens, L. D., & Koch, R. W. (2015). Understanding quality patient care and the role of the practicing nurse. Nursing Clinics of North America, 50, 33Ð43.Quality and Safety Education for Nurses. (2007). QSEN competencies. http://qsen.org/competencies /pre-licensure-ksas/Reason, J. (2000). Human error: Models and management. British Medical Journal, 320, 768Ð770.Robert Wood Johnson Foundation. (2011). Measuring the contributions of nurses to high-value health care: Special report. https://www.rwjf.org/en/library/research/2011/05/measuring-the-contributions-of -nurses-to-high-value-health-care.htmlRovinski-Wagner, C., & Mills, P. D. (2014). Patient safety. In P. Kelly, B. A. Vottero, & C. A. Christie-McAuliffe (Eds.), Introduction to quality and safety education for nurses (pp. 95Ð130). Springer.Rowell, P. (2003). The professional nursing associationÕs role in patient safety. Online Journal of Issues in Nursing, 8(3). https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume82003/No3Sept2003/AssociationsRole.htmlSollecito, W. A., & Johnson, J. K. (2013). McLaughlin and KaluznyÕs continuous quality improvement in health care (4th ed.). Jones & Bartlett Learning.Strome, T. L. (2013). Healthcare analytics for quality and performance improvement. Wiley.U.S. Department of Health and Human Services. (2011). National strategy for quality improvement in health care. Author.Vottero, B. A., Block, M. E., & Bonaventura, L. (2012). Benchmarking quality performance. In P. Kelly, B. A. Vottero, & C. A. Christie-McAuliffe (Eds.), Introduction to quality and safety education for nurses (pp. 221Ð247). Springer.References259
Evidence-Based Practice: What Is It?Evidence-based practiceÑit is more than a recent buzzword in nurs-ing. Evidence-based practice is a mechanism that allows nurses to provide safe, high-quality patient care based on evidence grounded in research and professional expertise rather than on tradition, myths, hunches, advice from peers, outdated textbooks, or even what the nurse learned in school 5, 10, or 15 years ago. Advances in informa-tion technology have facilitated the dissemination of research and other types of evidence, making them widely available. Only three decades ago nurses had to hand-search indexes and hard-copy jour-nals to access research results, but nurses now have quick access to the most current evidence from professional journals and best practice guidelines available via the Internet.Evidence-based practice provides a strategy to ensure that nursing care reflects the most up-to-date knowledge available so that what we Key Terms and Concepts ÈClinical practice guidelines ÈEvidence-based practice ÈPICO(T)After completing this chapter, the student should be able to:1. Describe the importance of evidence-based nursing care.2. Identify barriers to the implementation of evidence-based nursing practice.3. Identify strategies for the implementation of evidence-based nursing practice.4. Describe how and where to search for evidence.5. Identify methods to evaluate the evidence.6. Discuss approaches to integrating evi-dence into practice.7. Identify models of evidence-based nursing practice.Learning ObjectivesEvidence-Based Professional Nursing PracticeKathleen MastersCHAPTER 9© Nuu Jeed/Shutterstock261
do in practice matches what we know. Nursing practice that is based on evidence is now the accepted standard for practice as well as one of the six core competencies for all registered nurses identified in the Quality and Safety Education for Nurses (QSEN) project (Cronenwett et al., 2007). Nurses are accountable for the interventions they provide to pa-tients. Evidence-based practice provides a systematic approach for deci-sion making and offers a framework for the nurse to use to incorporate best nursing practices into the clinical care of patients (Pugh, 2012).According to the American Association of Colleges of Nursing (AACN, 2008), professional nursing practice is grounded in the trans-lation of current evidence into practice. One of the skills expected of prelicensure graduates of nursing programs is the ability to base an individualized care plan on patient values, clinical expertise, and evidence (QSEN, 2015). In addition, Standard 13 of the standards of professional nursing practice indicates that the nurse will integrate evidence and research findings into practice (American Nurses Asso-ciation [ANA], 2015).Most nurses want to provide care for their patients based on the most current evidence, but for many nurses, trying to integrate evidence-based practice into patient care in the clinical environment raises questions. The goal of this chapter is to answer those questions. To begin with, what exactly is evidence-based practice?Evidence-based practice is a framework used by nurses and other healthcare professionals to deliver optimal health care through the integration of best current evidence, clinical expertise, and patient/family values (QSEN, 2015). Evidence-based practice is described by Melnyk et al. (2010) as a problem-solving approach that integrates best research evidence and patient data with clinician expertise and values. Houser (2008) describes this triad of evidence-based prac-tice using the illustration of a three-legged stool. Just as each leg of the stool is necessary for the function of the stool, each of the three componentsÑbest current evidence, clinical expertise, and incorpora-tion of patient/family valuesÑare all necessary for the effective use of evidence-based practice.Another question one might ask is, How is evidence-based prac-tice relevant and applicable to nursing practice? Evidence-based prac-tice is relevant to nursing practice because it does the following:¥ Helps resolve problems in the clinical setting¥ Results in effective patient care with better patient outcomes¥ Contributes to the science of nursing through the introduction of innovation to practice¥ Keeps practice current and relevant by helping nurses deliver care based on current best research¥ Decreases variations in nursing care and increases confidence in decision makingCHAPTER 9 Evidence-Based Professional Nursing Practice262
¥ Supports Joint Commission readiness because policies and proce-dures are current and include the latest research¥ Supports high-quality patient care and achievement of magnet sta-tus (Beyea & Slattery, 2006; Spector, 2007)It takes approximately 17 years for clinical research to be in-tegrated into patient care practices. Nurses and other healthcare providers can minimize the time from discovery to implementation through the process inherent in evidence-based practice that in turn will lead to improved patient outcomes. Because of the link between evidence-based practice and improved patient outcomes, the Institute of Medicine (IOM, 2008) has promoted the goal that by the year 2020, 90% of all health decisions will be based on evidence.The evidence-based practice process enhances practice by en-couraging reflection about what we know; it is applicable to virtually every area of nursing practice, including patient assessment, diagnosis of patient problems, planning, patient care interventions, and evalu-ation of patient responses. In addition, evidence can be used as the foundation for policies and procedures and as the basis for patient care management tools, such as care maps, pathways, and protocols (Houser, 2011).The seven steps involved in the evidence-based practice process address the question of how to begin.1. Cultivate a spirit of inquiry and culture of evidence-based practice among nurses and within the organization.2. Identify an issue and ask the question.3. Search for and collect the most relevant and best evidence to answer the clinical question.4. Critically appraise and synthesize the evidence.5. Integrate evidence with clinical expertise and patient preferences to make the best clinical decision.6. Evaluate the outcome of any evidence-based practice change.7. Disseminate the outcomes of the change (Melnyk & Fineout- Overholt, 2014).Barriers to Evidence-Based PracticeBecause evidence-based practice is now the standard for professional nursing practice, one would think that practice based on evidence is commonplace; however, this is not the case. Practicing nurses cite many barriers to evidence-based practice. Common barriers to imple-menting evidence-based practice include the following:¥ Lack of value for research in practice¥ Difficulty in changing practice¥ Lack of administrative supportBarriers to Evidence-Based Practice263
¥ Lack of knowledgeable mentors¥ Insufficient time¥ Lack of education about the research process¥ Lack of awareness about research or evidence-based practice¥ Research reports and articles not readily available¥ Difficulty accessing research reports and articles¥ No time on the job to read research¥ Complexity of research report¥ Lack of knowledge about evidence-based practice¥ Lack of knowledge about the critique of articles¥ Feeling overwhelmed by the process¥ Lack of sense of control over practice¥ Lack of confidence to implement change¥ Lack of leadership, motivation, vision, strategy, or direction among managers (Beyea & Slattery, 2006; Revell, 2015; Spector, 2007)Additional barriers to using evidence-based practice include the overwhelming information available in the research literature that is sometimes contradictory as well as the perception that evidence-based practice is equivalent to Òcookbook medicine.Ó In addition, there may be a perceived lack of authority for clinicians to make changes in practice or peer pressure to maintain the status quo (Houser, 2011).Promoting Evidence-Based PracticeDespite barriers, nurses are making a difference in patient outcomes through the use of evidence-based practice. Strategies that can be use-ful in the promotion of evidence in practice generally fall into two cat-egories: strategies for individual nurses and organizational strategies.Strategies for individual nurses include the following:¥ Educate yourself about evidence-based practice through such avenues as websites, original research articles, evidence reports, conferences, and participation in professional organizations that provide resources related to evidence-based practice (Revell, 2015).¥ Conduct face-to-face or online journal clubs that can be used to edu-cate yourself about the appraisal of evidence, share new research re-ports and guidelines with peers, and provide support to other nurses.¥ Share your results through posters, newsletters, unit meetings, or a published article to support a culture of evidence-based nursing practice within the organization and the profession.¥ Adopt a reflective and inquiring approach to practice by question-ing the rationale for approaches to care that do not result in desired patient outcomes and by continuously asking yourself and others within your organization such questions as ÒWhat is the evidence for this intervention?Ó or ÒHow do my patients respond to this in-tervention?Ó (Beyea & Slattery, 2006; QSEN, 2015). KEY COMPETENCY 9-1Examples of applicable Nurse of the Future: Nursing Core CompetenciesEvidence-Based Practice:Knowledge (K2) De-scribes the concept of evidence-based practice (EBP), including the com-ponents of research evi-dence, clinical expertise, and patient/family valuesSkills (S2) Bases individual-ized care on best current evidence, patient values, and clinical expertiseAttitudes/Behaviors (A2) Values the concept of EBP as integral to determining best clinical practiceMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfCHAPTER 9 Evidence-Based Professional Nursing Practice264
Strategies for overcoming barriers and increas-ing adoption of evidence-based practice within an organization include:¥ Specific identification of the facilitators and barriers to evidence-based practice. This will require administrative support by providing the time and the funds for necessary resources as well as enhancement of job descriptions to include criteria related to evidence-based practice.¥ Education and training to improve knowledge and strengthen beliefs related to the benefits of evidence-based practice. This may require offering incentives, such as a paid registration to a confer-ence for the best clinical question in a unitwide contest.¥ Creation of an environment that encourages an inquisitive approach to patient care. Achievement of this environment may require the development of a center of evidence-based practice, access to electronic resources in the workplace, providing opportunities for nurses to collaborate with nurse researchers or faculty with nursing research expertise, and providing opportunities to disseminate the results of evidence-based practice projects (Houser, 2011, p. 12).Whichever strategies are incorporated, it is important to note that multifaceted interventions are much more likely to be effective in facilitating evidence-based practice within an organization. It is also important to note that once evidence-based practice projects are com-plete, passive dissemination of results within an organization is inef-fective in changing practice.Searching for EvidenceCompetencies expected of the nurse include reading original research and evidence reports related to the practice area and the ability to lo-cate relevant evidence reports and guidelines (QSEN, 2015). In order to find the evidence, the nurse must learn to ask clinical questions and to search electronic indexes and other resources (Figure 9-1).Asking the QuestionNurses must learn to ask questions in a format that facilitates searching for evidence. Developing a question that accurately reflects the practice to be evaluated, in a format that focuses the search for evidence, is a good place to begin (Tracy & Barn-steiner, 2014). It has been suggested that all nurses should learn how to use the PICO(T) format to ask clinical questions. PICO(T) is an acronym that CRITICAL THINKING QUESTIONS✶How do I know what I know about nursing practice? Are my nursing decisions based on myths, traditions, experience, authority, trial and error, ritual, or scientific knowledge?✶ CRITICAL THINKING QUESTIONS✶How is new evidence disseminated to the bedside nurse in the organization in which you practice as a nursing student? How does the organization promote evidence-based practice? Do the nurses in the organization use current evidence in practice?✶Searching for Evidence265
assists in the formatting of clinical questions. Using this format helps the nurse to ask pertinent clinical questions, focus on asking the right questions, and choose relevant guidelines. P = Patient, Population, or Problem How would I describe a group of patients similar to mine? What group do I want information on? I = Intervention or Exposure or Topic of Interest Which main intervention am I considering? What event do I want to study the effect of? C = Comparison or Alternate Intervention (if appropriate) What is the main alternative to compare with the intervention? Compared to what? Better or worse than no intervention at all or than another intervention? O = Outcome What can I hope to accomplish, measure, improve, or affect? What is the effect of the intervention? (Levin, 2006a)Some researchers also add the element of time or time frame to the PICO question format and refer to the format as PICOT, although the time frame might not be applicable to all questions.Figure 9-1 The nurse must know both how to ask the question and how to search electronic resources for evidence.© Wavebreakmedia/Shutterstock. KEY OUTCOME 9-1Example of Domain 4 sub-competency for entry-level professional nursing education.4.2a Evaluate clinical prac-tice to generate questions to improve nursing care (p. 39).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfCHAPTER 9 Evidence-Based Professional Nursing Practice266
T = Time or Time Frame How much time is required to demonstrate an outcome? How long are participants observed?After determining the patient, intervention, comparison, and out-come of interest, the nurse then combines these four elements into a single question in combinations, such as the following examples:¥ In (patient or population), what is the effect of (intervention or ex-posure) on (outcome) compared with (comparison)? (Levin, 2006b)¥ For (patient or population), does the introduction of (interven-tion or exposure) reduce the risk of (outcome) compared with (comparison intervention)? (Levin, 2006b)Electronic ResourcesBecause the PICO(T) question may have already been asked and an-swered by other nurses, beginning the search with sites that provide systematic reviews or guidelines is helpful (Tracy & Barnsteiner, 2014). Electronic resources are available that can assist the nurse in uncover-ing the most current evidence for practice in the form of systematic re-views and guidelines. Some of the most commonly used include these:¥ National Library of Medicine: www.nlm.nih.gov¥ Cochrane Library: www.cochrane.org¥ National Guideline Clearinghouse: www.guideline.gov¥ Joanna Briggs Institute: www.joannabriggs.org¥ Agency for Healthcare Research and Quality (AHRQ): www .effective healthcare.ahrq.gov¥ Centre for Health Evidence: www.cche.net¥ Registered NursesÕ Association of Ontario: http://rnao.ca/bpg /guidelines¥ McGill UniversityÕs Ingram School of NursingÕs Clinical and Research Resources: www.mcgill.ca/nursing/outreach/today/links /clinicalThe Cochrane Library is a collection of databases that contain high-quality, independent evidence to inform healthcare decision mak-ing. Cochrane reviews represent the highest level of evidence on which to base clinical treatment decisions. In addition to the Cochrane sys-tematic reviews, the Cochrane Library also offers other sources of in-formation, including the Database of Abstracts of Reviews of Effects, Cochrane Controlled Trials Register, Cochrane Methodology Register, NHS Economic Evaluation Database, Health Technology Assessment Database, and Cochrane Database of Methodology Reviews.Another site with high-quality evidence is the National Guide-line Clearinghouse. As a part of the AHRQ, the National Guideline Clearinghouse includes structured summaries containing information KEY COMPETENCY 9-2Examples of applicable Nurse of the Future: Nursing Core CompetenciesEvidence-Based Practice:Knowledge (K1) Demon-strates knowledge of basic scientiÞc methods and processesSkills (S1a) Participates in the development of clini-cal questions for potential research (S1b) Critiques/appraises research for ap-plication to practice (S1c) Participates in data col-lection and other research activities (S1d) Follows the guidelines and require-ments pertaining to Human Subject Protection for con-ducting researchAttitudes/Behaviors (A1a) Appreciates strengths and weaknesses of scientiÞc bases for practice (A1b) Values the need for ethical conduct of practice and researchMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfSearching for Evidence267
about each guideline, including comparisons of guidelines covering similar topics that show areas of similarity and differences; full text or links to full text; ordering details for full guidelines; annotated bibli-ographies on guideline development, evaluation, implementation, and structure; weekly email updates; and guideline archives. Guidelines may be searched by topic or by organization.The Registered NursesÕ Association of Ontario provides high-quality best practice guidelines specifically focused on nursing care. Many of these guidelines are also available via the National Guideline Clearinghouse site. The guidelines are available online in full text and free of charge.Electronic IndexesReviews may also be indexed, but if no reviews or guidelines are found relevant to your PICO(T) question, then individual articles must be searched (Tracy & Barnsteiner, 2014). Electronic indexes provide options for narrowing or broadening a topic to identify relevant lit-erature. Most electronic indexes provide citation information and will indicate if the selected articles are available locally in print form or if the items are available in an electronic format. Three of the most com-mon electronic indexes used in health care are the Cumulative Index to Nursing and Allied Health Literature (CINAHL), available at www.cinahl.com; MEDLINE, available at www.nlm.nih.gov; and PubMed, a web-based format of MEDLINE available at www.pubmed.gov.Evaluating the EvidenceRegardless of the source, the nurse needs to evaluate the quality of the evidence. By evaluating the rigor of the evidence, we can have confidence that the evidence is accurate. This is important because it could contrib-ute to a decline rather than to an improvement in patient outcomes if we base changes to care on inaccurate research evidence (Sellers & McCrea, 2014). Begin by asking such questions as the following:¥ What is the source of the information?¥ When was it developed?¥ How was it developed?¥ Does it fit the current clinical environment?¥ Does it fit the current situation?Levels of EvidenceThe best evidence for practice includes empirical evidence from ran-domized controlled trials, evidence from descriptive and qualitative research, and information from case reports, scientific principles, and expert opinion. When insufficient research is available, healthcare CHAPTER 9 Evidence-Based Professional Nursing Practice268
decision making is derived principally from nonresearch evidence sources, such as expert opinion and scientific principles (Titler, 2008).Several classification systems exist to evaluate the level or strength of the evidence. The AHRQ serves as the recognized authority regard-ing the assessment of clinical research in the United States. Standard levels of evidence include the classifications listed here (Melnyk & Fineout-Overholt, 2014):1. Meta-analysis or systematic reviews of multiple well-designed con-trolled studies2. Well-designed randomized controlled trials3. Well-designed nonrandomized controlled trials (quasi-experimental)4. Observational studies with controls (retrospective, interrupted time, case-control, cohort studies with controls)5. Systematic review of descriptive and qualitative studies6. Single descriptive or qualitative study7. Opinions of authorities and/or reports of expert committeesUsing this classification system, the strongest evidence comes from the first level, representing systematic reviews that integrate findings from multiple well-designed controlled studies. The weakest evidence is represented by the seventh level and is based on expert opinion (Polit & Beck, 2017).In addition, grading the strength of a body of evidence should incorporate three domains: quality, quantity, and consistency. Quality has to do with the extent to which a study minimizes bias in the de-sign, implementation, and analysis. Quantity refers to the number of studies that have evaluated the research question as well as the sample size across the studies and the strength of the findings. The category of consistency refers to both the similarities and the differences of study designs that investigate the same research question and report similar findings (AHRQ, 2002; LoBiondo-Wood & Haber, 2014).Appraisal of ResearchPrior to applying evidence in clinical practice, there must be an appraisal process (Figure 9-2). Key issues to address in an appraisal include the credibility of the study, including the researcherÕs credentials and experi-ence; any evidence of bias due to a conflict of interest of the researcher or the journal; the statement of a blind peer review; and dates included in the journal to indicate the timeliness of publication. In addition, ap-praisals should include questions about the design of the study, sample size, sampling procedures, reliability and validity of instrumentation, and appropriate statistical analysis (DelMonte & Oman, 2011).The Critical Appraisal Skills Programme (CASP, 2020) is a re-source that provides checklists that help the user to interpret research evidence. The checklists are specific to various types of research, including randomized controlled trials, systematic reviews, cohort KEY COMPETENCY 9-3Examples of applicable Nurse of the Future: Nursing Core CompetenciesEvidence-Based Practice:Knowledge (K3) Describes reliable sources for locat-ing evidence reports and clinical practice guidelinesSkills (S3) Locates evi-dence reports related to clinical practice topics and guidelines within appropri-ate databasesAttitudes/Behaviors (A3) Appreciates the impor-tance of accessing relevant clinical evidenceMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdf KEY OUTCOME 9-2Example of Domain 4 sub-competency for entry-level professional nursing education.4.2b Evaluate appropriate-ness and strength of the evidence (p. 39).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdf Evaluating the Evidence269
studies, case-control studies, and qualitative studies. The checklists also provide frameworks to determine the strength and reliabil-ity of research reports. CASP tools are available free of charge at www.casp-uk.net (Sellers & McCrea, 2014).Appraisal of Clinical Practice GuidelinesIn addition to the appraisal of research, the nurse will need skills in the appraisal of guidelines to practice based on evidence. Clinical practice guidelines are developed to guide clinical practice and to represent an effort to put a large body of evidence into a manage-able form. Clinical practice guidelines are usually based on systematic reviews and give specific recommendations for clinicians. Guidelines usually attempt to address all the issues relevant to a clinical decision, including risks and benefits.The IOM (2011), at the request of the U.S. Congress, developed a set of eight standards for the development of rigorous and trustwor-thy clinical practice guidelines. To evaluate the effects of the standards on clinical practice guideline development and healthcare quality and outcomes, the IOM has encouraged the AHRQ to pilot-test the stan-dards and to assess their reliability and validity. The standards are:¥ Standard 1: Establishing transparency related to funding and de-velopment processes.¥ Standard 2: Management of conflict of interest.¥ Standard 3: Guideline development group composition should be multidisciplinary and balanced, including a variety of experts and patient populations.Figure 9-2 The nurse is responsible for appraising the strength and relevance of evidence when choosing practice interventions.© Goodluz/Shutterstock.CHAPTER 9 Evidence-Based Professional Nursing Practice270
¥ Standard 4: Use of systematic reviews that meet standards.¥ Standard 5: Establishing evidence foundations for and rating strength of recommendations.¥ Standard 6: Articulation of recommendations maintains a stan-dardized form.¥ Standard 7: External review by stakeholders.¥ Standard 8: Updating should occur when new evidence suggests the need for modification of clinically important recommendations.Data from Institute of Medicine. (2011). Clinical practice guidelines we can trust. National Academies Press. https://www.nap.edu/resource/13058/Clinical-Practice -Guidelines-2011-Report-Brief.pdfIn addition to the IOM standards, there is an ongoing collabo-ration that has focused on improving the quality and effectiveness of clinical practice guidelines for over a decade. The group has es-tablished a framework for determining the quality of guidelines for diagnoses, health promotion, treatments, or clinical interventions. The instrument, known as the Appraisal of Guidelines for Research and Evaluation (AGREE), can be used with new, existing, or updated guidelines. First published in 2003 by the AGREE Collaboration, the instrument was revised in 2009 and most recently updated in 2017 and is now known as AGREE II (AGREE Next Steps Consor-tium, 2017). The AGREE II replaces the original instrument and is the preferred tool. The full version of the AGREE II instrument and training materials are available online at no cost at www.agreetrust.org. The AGREE instrument is composed of six categories containing the 23 items listed here as well as 2 final items that require an overall judgment about the practice guideline:¥ Scope and purpose¥ Overall objectives of the guideline are specifically described.¥ The health questions covered by the guideline are specifically described.¥ The population (patients, public, etc.) to whom the guideline is meant to apply is specifically described.¥ Stakeholder involvement¥ The guideline development group includes individuals from all relevant professions.¥ The views and preferences of the target population (patients, public, etc.) have been sought.¥ Target users of the guideline are clearly defined.¥ Rigor of development¥ Systematic methods were used to search for evidence.¥ The criteria for selecting the evidence are clearly described.¥ The strengths and limitations of the body of evidence are clearly described.¥ The methods used for formulating the recommendations are clearly described.Evaluating the Evidence271
¥ The health benefits, side effects, and risks have been considered in formulating recommendations.¥ There is an explicit link between the recommendations and the supporting evidence.¥ The guideline has been externally reviewed by experts prior to publication.¥ A procedure for updating the guideline is provided.¥ Clarity and presentation¥ Recommendations are specific and unambiguous.¥ Different options for management of the condition or health issue are clearly presented.¥ Key recommendations are easily identifiable.¥ Application¥ The guideline describes facilitators and barriers to its application.¥ The guideline provides advice and/or tools on how the recom-mendations can be put into practice.¥ The potential resource implications of applying the recommen-dations have been considered.¥ The guideline presents monitoring and/or auditing criteria.¥ Editorial independence¥ The views of the funding body have not influenced the content of the guideline.¥ Competing interests of guideline development group members have been recorded and addressed.Brouwers, M., Kho, M. E., Browman, G. P., Cluzeau, F., Feder, G., Fervers, B., Hanna, S. & Makarski, J. on behalf of the AGREENext Steps Consortium (2010). AGREE II: Advancing guideline development, re-porting and evaluation in healthcare. Canadian Medical Association Journal, 182: E839ÐE842. doi: 10.1503/cmaj.090449The usefulness of a guideline depends on whether the actual recommendations in the guideline are meaningful and practical. Rec-ommendations should be practical in relation to implementation, be as unambiguous as possible, address the frequency of screening and follow-up, and address clinically relevant actions. Other questions that the clinician must address in relation to guidelines include such factors as the setting of care, the patient population, and the strength of the recommendations (Beyea & Slattery, 2006).Implementation Models for Evidence-Based PracticeA number of models have been developed to guide the design and implementation and to strengthen evidence-based decision making. Forty-seven prominent evidence-based practice models can be identi-fied in the literature (Stevens, 2013). KEY COMPETENCY 9-4Examples of applicable Nurse of the Future: Nursing Core CompetenciesEvidence-Based Practice:Knowledge (K4) Differenti-ates clinical opinion from research and evidence summariesSkills (S4a) Applies research and evidence reports related to area of practice(S4b) Understands the use of best practice and evidence at the patient level, clinical level, popula-tion level, and across the systemAttitudes/Behaviors (A4) Appreciates that the strength and relevance of evidence should be deter-minants when choosing clinical interventionsMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdf KEY OUTCOME 9-3Example of Domain 4 sub-competency for entry-level professional nursing education.4.2c Apply best evidence in practice (p. 39).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfCHAPTER 9 Evidence-Based Professional Nursing Practice272
Differences exist among evidence-based practice models, but most models do have common elements that include selection of a practice topic, critique and synthesis of evidence, implementation, evaluation of the effect on patient care and provider performance, and consideration of the context in which the practice is implemented (Titler, 2008). No one model of evidence-based practice is a perfect fit for every organization. Some models focus on the perspective of the individual clinician, or the researcher, whereas others focus on institu-tional efforts. Therefore, before embarking on this journey, the nurse or organization should consider several models and select or adapt one that fits the needs of the nurse or organization.ACE Star Model of Knowledge TransformationThe Center for Advancing Clinical Evidence (ACE) Star Model of Knowledge Transformation, developed by Dr. Kathleen Stevens, is avail-able at http://nursing.uthscsa.edu/onrs/starmodel/star-model.asp. The model involves five steps: knowledge discovery, evidence summary, translation into practice recommendations, integration into practice, and evaluation. Discovery refers to the original research. During the second step, the task is to synthesize all the related research into a meaningful whole. It is during this step that information is reduced to a manageable form. During the step of translation, the scientific evidence is consid-ered in the context of clinical expertise and values. This results in clini-cal practice guidelines, best practices, protocols, standards, or clinical pathways. During the stage of implementation, changes take place in practice. During evaluation, the effect of the change is measured. Such variables as specific health outcomes, length of stay, or patient satisfac-tion are examples of possible outcomes that might be examined.The Iowa Model of Evidence-Based PracticeThe Iowa Model of Evidence-Based Practice is a guide for the evidence-based practice process. This model resembles a decision- making tree that identifies either problem-focused or knowledge-focused triggers that initiate the process in the organization. Problem-focused triggers within an organization can include risk management data, process improvement data, benchmarking data, financial data, or the identification of clinical problems. Knowledge-focused triggers within an organization can include the publication of new research or literature, a change in organizational standards and guidelines, changes in philoso-phies of care within the profession or organization, or questions from an institutional standards committee. Once there is either a problem-focused or a knowledge-focused trigger within the organization, a team must identify whether the topic is a priority for the organization. If the topic is indeed a priority, evidence is examined, and the change in prac-tice can be piloted. This process is followed by monitoring and analysis KEY COMPETENCY 9-5Examples of applicable Nurse of the Future: Nursing Core CompetenciesEvidence-Based Practice:Knowledge (K5) Explains the role of evidence in determining best clinical practiceSkills (S5) Facilitates in-tegration of new evidence into standards of practice, policies, and nursing prac-tice guidelinesAttitudes/Behaviors (A5a) Questions the rationale of supporting routine ap-proaches to care processes and decisions(A5b) Values the need for continuous improvement in clinical practice based on new knowledgeMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfImplementation Models for Evidence-Based Practice273
of both the process and the outcome data and finally by dissemination of the results (Iowa Model Collaborative, 2017).Agency for Healthcare Research and Quality ModelA model for maximizing and accelerating the transfer of research results from the AHRQ patient safety research portfolio to healthcare deliv-ery includes three major stages of knowledge transfer: (1) knowledge creation and distillation, (2) diffusion and dissemination, and (3) orga-nizational adoption and implementation. More specifically, knowledge creation and distillation refer to conducting research and then packag-ing relevant research findings into usable form, such as practice recom-mendations. The diffusion and dissemination stage involves partnering with professional leaders, professional organizations, and healthcare or-ganizations to disseminate knowledge to potential users, such as nurses, physical therapists, or physicians. During the final stage of the process, the focus is on organizational adoption and implementation of evi-dence-based research findings and innovations in practice. In this model, the stages of knowledge transfer are viewed from the perspective of the researcher or the creator of new knowledge and begin with decisions about which research findings ought to be disseminated (Titler, 2008).Johns Hopkins Nursing Evidence-Based Practice ModelThe process used in the Johns Hopkins Nursing Evidence-Based Prac-tice Model is known as PET, which refers to asking a practice question, finding the evidence, and translating the evidence to practice (Dang & Dearholt, 2017). In the model, the first step is to form an interprofes-sional team, define the gap between current and desired practice, and format the PICO question. Next, the research and nonresearch evi-dence undergoes appraisal for level and quality. Nonresearch evidence includes not only expert opinion, patient experience data, and guide-lines but also evidence gathered from organizational experience, such as quality improvement reports, program evaluations, and financial data analysis. The final step of the PET process is translation, assessing the evidence-based recommendations for transferability to the practice setting. During this process, practices are implemented, evaluated, and communicated, leading to a change in nursing processes and outcomes.Diffusion of Innovation FrameworkRogersÕs Diffusion of Innovation Framework (2003) posits that if a third of any group adopts a practice change based on new evidence, then the rest of the group will follow, considering the change in KEY OUTCOME 9-4Example of Domain 4 sub-competency for entry-level professional nursing education.4.2d Participate in the im-plementation of a practice change to improve nursing care (p. 39).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdf KEY OUTCOME 9-5Example of Domain 4 sub-competency for entry-level professional nursing education.4.2e Participate in the evaluation of outcomes and their implications for practice (p. 39).Reproduced from American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfCHAPTER 9 Evidence-Based Professional Nursing Practice274
practice to be the norm. The key to using this framework to guide implementation is to work with people within the organization who are known to be innovators and early adopters of change. There are five steps included in the framework: knowledge, persuasion, deci-sion, implementation /trial, and confirmation. During the knowledge step, the innovation is described so that the decision-making unit develops an understanding of the suggested change. Next, the change agent works to develop favorable attitudes toward the innovation and subsequently a decision is made to adopt or reject the innovation. During the implementation or trial step, the innovation is in place and adjustments may occur. Finally, during the step of confirmation, the decision-making unit seeks reinforcement that the decision was correct, or they may choose to reverse the decision (Sellers & McCrea, 2014).ConclusionNumerous models are available in the literature to guide nurses in the use of evidence-based practice. The models share similarities and dif-ferences but do have a common foundation because all use a planned action approach to moving knowledge to practice. The steps taken to-gether provide a process for locating and synthesizing knowledge and for systematically using the change process for integrating and sustain-ing evidence-based changes in practice (Tracy & Barnsteiner, 2014).Currently, the greatest challenge we face in fully implementing evidence-based practice in nursing as a profession is how to get the evidence to the practicing nurse. Nurses are very busy taking care of patients. From the perspective of the individual, it can indeed be daunting, especially when many practicing nurses are not knowledge-able about evidence-based nursing practice. Nevertheless, daunting or not, the impetus for evidence-based practice will continue to grow. As healthcare costs continue to climb, consistent, data-based answers to patient care problems are an expectation.CASE STUDY 9-1 ■ MR. P.Mr. P. is a 52-year-old, married, Hispanic male who is approximately 100 pounds overweight. Mr. P. has developed hypertension and adult-onset diabetes. He is currently being followed in a clinic setting. As a nurse working in the clinic setting, you have noticed that many of the patients you see in the clinic who are demographically similar to Mr. P. experience poorer health outcomes as compared with your patients who are members of different patient populations.Case Study Questions1. What PICO(T) questions can you ask to gener-ate evidence for the patient population and pa-tient problem(s) represented in the case study?2. Based on a search of the literature, your ex-pertise, and what you know about the pref-erences of this patient population, what are some evidence-based nursing interventions that you might want to translate into clinical practice in this clinic setting?Conclusion275
Classroom Activity 9-1Have students create clinical questions in the PICO(T) format for a patient in a case study provided by the instructor or for a patient re-cently cared for in the clinical setting.Classroom Activity 9-2Have students bring laptops to class or go to the computer lab as a class and ac-cess evidence from such resources to plan evidence-based care based on the questions created in Classroom Activity 9-1. If laptops or a computer lab is not available, then adapt this activity by having either students or faculty access the sites via a computer projec-tion system in the classroom and plan care as a group based on the search results. As an alternative, the students can do this activity outside of class and share their results during the following class.Classroom Activity 9-3Provide students with a clinical guideline (choose one that has recommendations stu-dents can audit for using the patient records provided), a clinical audit tool, and example patient records. Have students perform an evidence-based clinical review (or audit) using the records provided to them. Have students summarize their findings for each recommen-dation and then suggest quality improvement actions to correct the identified problems.Classroom Activity 9-4Have students partner individually or as a group with a local clinical facility to work jointly on a project. Collaborate to identify PICO(T) questions, find evidence, and plan the process of translation of evidence into practice within the facility or on a nursing unit within the facility.Classroom Activity 9-5Numerous classroom and clinical activities re-lated to evidence-based practice are available on the QSEN website at https://qsen.org. Choose activities from the website for stu-dents to complete that meet specific course objectives.CHAPTER 9 Evidence-Based Professional Nursing Practice276
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Polit, D. F., & Beck, C. T. (2017). Nursing research: Generating and assessing evidence for nursing practice (10th ed.). Lippincott Williams & Wilkins.Pugh, L. C. (2012). Evidence-based practice: Context, concerns, and challenges. In S. L. Dearholt & D. Dang (Eds.), Johns Hopkins nursing evidence-based practice: Model and guidelines (2nd ed., pp. 5Ð23). Sigma Theta Tau International.Quality and Safety Education for Nurses. (2015). Evidence-based practice. http://qsen.org/competencies /pre-licensure-ksas/#evidence-based_practiceRevell, M. A. (2015). Role of research in best practices. Nursing Clinics of North America, 50, 19Ð32.Rogers, E. M. (2003). Diffusion of innovations (5th ed.). Free Press.Sellers, K. F., & McCrea, K. L. (2014). Evidence-based practice. In P. Kelly, B. A. Vottero, & C. A. Christie-McAuliffe (Eds.), Introduction to quality and safety education for nurses (pp. 339Ð370). Springer.Spector, N. (2007). Evidence-based health care in nursing regulation. National Council of State Boards of Nursing.Stevens, K. (2013). The impact of evidence-based practice in nursing and the next big ideas. Online Journal of Issues in Nursing, 18(2). https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace /ANAPeriodicals/OJIN/TableofContents/Vol-18-2013/No2-May-2013/Impact-of-Evidence-Based -Practice.htmlTitler, M. G. (2008). The evidence for evidence-based practice implementation. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses (pp. 1Ð49). Agency for Healthcare Research and Quality.Tracy, M. F., & Barnsteiner, J. (2014). Evidence-based practice. In G. Sherwood & J. Barnsteiner (Eds.), Quality and safety in nursing: A competency approach to improving outcomes (pp. 133Ð148). Wiley.CHAPTER 9 Evidence-Based Professional Nursing Practice278
What exactly is patient-centered care (PCC)? As one of the six dimen-sions of quality identified by the Institute of Medicine (IOM), PCC is defined as Òproviding care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisionsÓ (2001, p. 40). The Qual-ity and Safety Education for Nurses (QSEN) initiative refined this definition in the formation of the PCC competency. PCC is defined by QSEN in terms of the nurse recognizing Òthe patient or designee as the source of control and full partner in providing compassion-ate and coordinated care based on respect for the patientÕs prefer-ences, values, and needsÓ (Cronenwett et al., 2007, p. 123). Another competency-based definition for PCC is that the nurse Òwill provide holistic care that recognizes an individualÕs preferences, values, and needs and respects the patient or designee as a full partner in provid-ing compassionate, coordinated, age and culturally appropriate, safe and effective careÓ (Massachusetts Department of Higher Education, 2016, p. 10).Key Terms and Concepts ÈAge-related changes ÈAndragogy ÈFamily-centered care (FCC) ÈHealth Belief Model (HBM) ÈHealth literacy ÈLearning domains ÈPatient education ÈPatient teaching ÈPatient-centered care (PCC) ÈReadiness to learn ÈSelf-efÞcacy ÈSocial Learning TheoryAfter completing this chapter, the student should be able to:1. Describe the characteristics of patient-centered care (PCC) and family-centered care (FCC).2. Discuss the dimensions of PCC.3. Discuss communication in the context of PCC and FCC.4. Describe patient education in the context of PCC.5. Describe the evaluation of PCC.Learning ObjectivesPatient Education and Patient-Centered Care in Professional Nursing PracticeKathleen Masters279CHAPTER 10© Nuu Jeed/Shutterstock
All three definitions share a common focus. The provision of care that is appropriate for each patient is based on the patientÕs prefer-ences with the patient as a partner on the healthcare team. It is im-portant to note that PCC is not the same as patient-focused care. In the patient-focused care scheme, the healthcare provider, rather than the patient, retains decision-making control (Walton & Barnsteiner, 2012). The remainder of this chapter focuses on the components of PCC and the nurseÕs role in the maintenance of a patient-centered environment.Dimensions of Patient-Centered CareDimensions of PCC that are characteristic of a patient-centered environment include respect for patientsÕ values, preferences, and expressed needs; coordination and integration of care; information, communication, and education; physical comfort; emotional sup-port; involvement of family and friends; and transition and continuity (Gerteis et al., 1993).Nurses show respect for patients as individuals by sharing in-formation with them and by actively partnering to determine care priorities and the plan of care (Figure 10-1). In addition, tailoring the patientÕs level of involvement based on his or her preferences rather than on the nurseÕs preferences and revising the plan as the situation changes also demonstrate respect for patients (Gerteis et al., 1993). For PCC to be a reality, clinicians must relinquish the role of expert, realizing that although they are technical experts, the patient and fam-ily are the experts regarding their own life experiences.The concept of compliance must be replaced by one of engage-ment and partnership, and clinicians must believe that the best deci-sions emerge through input from all who have knowledge relevant to a particular patient situation (Disch, 2012). Coordination and inte-gration of care are evident as members of the healthcare team com-municate effectively with one another and, in turn, deliver consistent messages to the patient and as nurses create smooth transitions across episodes of care. The role of nursing in the coordination and integra-tion of care is increasingly important as care becomes more complex because of the simultaneous existence of multiple chronic conditions, increasing numbers of care providers involved in the episodes of care, numerous settings for care, and shorter episodes of care (Gerteis et al., 1993).Adapting education and communication based on the patientÕs preference is a foundation of PCC. Information on clinical sta-tus, progress, and prognosis communicated to patients needs to make sense to patients and families and be at a level that they can KEY COMPETENCY 10-1Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesPatient-Centered Care:Knowledge (K2) Under-stands that care and services are delivered in a variety of settings along a continuum of care that can be accessed at any pointSkills (S2) Assesses pa-tient values, preferences, decisional capacity, and expressed needs as part of ongoing assessment, clinical interview, imple-mentation of care plan, and evaluation of careAttitudes/Behaviors (A2a) Values and respects assess-ing the healthcare situation from the patientÕs perspec-tive and belief systemsAttitudes/Behaviors (A2b) Respects and encourages the patientÕs participation in decisions about health care and servicesMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfCHAPTER 10 Patient Education and Patient-Centered Care in Professional Nursing Practice 280
understand. Education provided to patients to facilitate self-care and health promotion must also be at a level that the patient can under-stand (Gerteis et al., 1993).Physical comfort should form the basis for the individualized plan of patient care. Ensuring that the patient will be free of pain is an ex-pectation of PCC, as are assistance with activities of daily living and a clean and private environment (Gerteis et al., 1993). Periodic assess-ments of patient comfort are essential, as are the timely administra-tion of medications and the monitoring of the effects of medications and treatments (Walton & Barnsteiner, 2012). In addition to physical discomfort, patients may experience anxiety and distress during their experience of care. Patients frequently experience anxiety over their clinical status, treatments, and prognosis as well as the effect of the ill-ness on themselves, their families, and their finances. The nurse is in a position that allows for spiritual and emotional support of the patient and family during the care experience (Gerteis et al., 1993).Patient/family-centered care or family-centered care (FCC) is an extension of PCC that Òwidens the circle of concern to include those persons who are important to the patientÕs lifeÓ (Henneman & Cardin, 2002, p. 13), although it is important to note that FCC does not negate the patientÕs right to privacy and control (Figure 10-2). FCC requires the structuring of all aspects of the process of engaging the patientÕs family and friends around meeting the patientÕs needs rather than around the convenience of the organization. This includes accommodating family Figure 10-1 It is the responsibility of the nurse to create a patient-centered care environment.© Monkeybusinessimages/iStock/Getty Images Plus/Getty Images.KEY OUTCOME 10-1Example of Domain 2 sub-competency for entry-level professional nursing education.2.1c Establish mutual re-spect with the individual and family (p. 28).Reproduced from American Association of Colleges of Nursing. (2021). The Essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfDimensions of Patient-Centered Care 281
and friends, including family in decision making (based on patient pref-erence), recognizing the needs of the family, and providing support for the family in their caregiving role (Gerteis et al., 1993). It is important to view this aspect of PCC within the total context of the patientÕs care rather than based on a few policies because FCC is a philosophy that considers the patient in the context of his or her family (Walton & Barnsteiner, 2012); however, policies that promote the inclusion of the family may reflect the family-centered care philosophy of an organiza-tion. It is also important to note that in the context of PCC, family re-fers to those persons whom the patient decides to call family rather than those defined by the provider (Walton & Barnsteiner, 2012).Lastly, patients express anxiety about their ability to care for themselves once discharged from the healthcare setting. PCC includes support for patients as they transition to home, including information related to medications, diet, and symptoms to report, provided in a manner that patients understand. PCC also provides for continuity of care and assures that patients understand the plan, how to obtain support services, and whom to call for help once they are discharged from the acute care facility (Gerteis et al., 1993).An eighth dimension, access to care, was added when these prin-ciples became known as the Picker Principles of Patient-Centered Care (Picker Institute, n.d.). This principle simply states that patients need to know that they can access care when it is needed and also deals with waits for admission and allocation of hospital beds.Figure 10-2 The nurse, viewing the patient in the context of family, will encourage a family-centered care environment.© Creatas Images/Creatas/Getty Images Plus/Getty Images.KEY COMPETENCY 10-2Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesPatient-Centered Care:Knowledge (K3) Under-stands multiple dimensions of patient-centered care including (a) Patient/family/community preferences, values (b) Coordination and integration of care (c) Infor-mation, communication and education (d) Physical com-fort and emotional support (e) Involvement of family and signiÞcant other (f) Care transition and continuitySkills (S3a) Communicates patient values, prefer-ences, and expressed needs to other members of the health care teamSkills (S3b) Seeks infor-mation from appropriate sources on behalf of the patientAttitudes/Behaviors (A3a) Respects the patientÕs perspective regarding own health and concernsMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfCHAPTER 10 Patient Education and Patient-Centered Care in Professional Nursing Practice 282
In January 2010, the Joint Commission re-leased a set of standards for patient-centered com-munication to advance effective communication, cultural competence, and PCC. One of the new requirements specifically states that a family mem-ber, friend, or other individual will be allowed to be present with the patient to provide emotional support and comfort and to alleviate fear during the course of the hospital stay (2010). This require-ment is not meant to mandate visiting hours or other hospital policies; it is, however, intended to encourage patient-centered and FCC environments where policies allow for inclusion of those persons important to the patient.Commonly cited components of PCC and FCC delivery models include many of the same types of strategies. Some of these compo-nents are as follows:¥ Coordination of care conference that includes the patient and/or family, along with the interdisciplinary team, to discuss goals of treatment and to initiate discharge planning¥ Hourly rounding by the nurse to complete treatments that also in-cludes assessment of pain, elimination, and positioning as well as other concerns of the patient and/or family members¥ Bedside report with the patient at the center of the discussion, with family and friends present at the discretion of the patient or patient advocate¥ Use of a patient care partner (may be a family member, friend, or volunteer) selected by the patient to participate at various times in educational, psychological, physical, and spiritual support¥ Individualized care that is established on admission to include the patientÕs preferred name, the patientÕs priorities for care, the patientÕs learning style preference, and the patientÕs care partner selection¥ Open medical record policy that allows patients to view their medical record and document their perspective if they choose¥ Eliminating visiting restrictions in relation to family members be-cause, in the context of FCC, family members are members of the healthcare team rather than visitors¥ Allowing family presence with a chaperone during resuscitation and other invasive procedures, thus never separating them from the patient unless the patient requests it¥ Silence and a healing environment where the patient is invited to report any discomfort with the noise level in their environment to the nurse, who will then intervene to decrease the noise level as much as is possible (Flagg, 2015; Hunter & Carlson, 2014).CRITICAL THINKING QUESTION✶One recent change on some nursing units has been the establishment of walking rounds to patient rooms during a change of shift report. Using this model, the nurses, patient, and family members (if the patient wishes) are all involved in the exchange of information during the transition of care to the nurse coming on shift. Can you think of any other changes that you have observed in the healthcare setting that help to facili-tate a PCC environment?✶KEY COMPETENCY 10-3Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesPatient-Centered Care:Knowledge (K4b) Describes how cultural diversity, ethnic, spiritual and so-cioeconomic backgrounds function as sources of patient, family, and com-munity valuesSkills (S4a) Provides patient-centered care with sensitivity and respect for the diversity of human experienceAttitudes/Behaviors (A4b) Implements nursing care to meet the holistic needs of patient on socioeco-nomic, cultural, ethnic, and spiritual values and beliefs inßuencing health care and nursing practiceMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfDimensions of Patient-Centered Care 283
Communication as a Strategy to Support Patient-Centered CareEffective communication between healthcare providers and the pa-tient is an essential component of PCC (IOM, 2001). Communicating effectively in all areas of practice and with all members of the health-care team, including the patient and the patientÕs support network, is a central component in all areas of nursing practice and is an expecta-tion of all registered nurses, including entry-level nurses, since effec-tive communication is essential for the delivery of quality nursing care (American Nurses Association [ANA], 2015; American Association of Colleges of Nursing [AACN], 2008; QSEN, 2012; AACN, 2021, p. 12). The nurse is responsible for assessment of his or her own com-munication skills, continuous improvement of communication skills, assessment of communication ability and preferences of patients, and communication of accurate information in a manner that demon-strates respect (ANA, 2015).Examples of specific questions, known as KleinmanÕs questions, that can help clinicians relate to a patient on his or her level to pro-vide PCC are included here. The questions are designed to elicit the patientÕs perception of his or her illness. The wording of the questions can be revised based on the setting, illness, and characteristics of the patient.¥ What do you think has caused your problem?¥ Why do you think it started when it did?¥ What do you think your problem does inside your body?¥ How severe is your problem? Will it have a short or long course?¥ What kind of treatment do you think you should receive?¥ What are the most important results you hope to receive from this treatment?¥ What are the chief problems your illness has caused you?¥ What do you fear most about your illness/treatment? (Kleinman, 1980)In terms of a competency, communication is defined as the nurse interacting Òeffectively with patients, families, and colleagues, foster-ing mutual respect and shared decision making, to enhance patient satisfaction and health outcomesÓ (Massachusetts Department of Higher Education, 2016, p. 32). This definition includes not only the standards for communication and PCC but also the desired outcomes of PCC.The standards published by the Joint Commission (2010) re-lated to patient-centered communication were designed to improve the safety and quality of care for all patients and to promote bet-ter communication and patient engagement. The standards include KEY COMPETENCY 10-4Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesCommunication (Therapeu-tic Communication):Knowledge (K1a) Under-stands the principles of effective communication through various meansSkills (S1a) Uses clear, concise, and effective writ-ten, electronic, and verbal communicationsAttitudes/Behaviors (A1a) Accepts responsibility for communicating effectivelyAttitudes/Behaviors (A1b) Recognizes oneÕs individual responsibility to communi-cate effectively utilizing a collegial tone and voiceMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfCHAPTER 10 Patient Education and Patient-Centered Care in Professional Nursing Practice 284
requirements that the hospital identifies the patientÕs oral and written communication needs, including the patientÕs preferred language, and that the hospital communicates in a manner that meets the patientÕs needs.Communication may be viewed from different vantage points and may be manifested in a variety of formats and styles. For example, communication may be oral or written, empathetic or nonempathetic, and verbal or nonverbal (Bankert et al., 2014). Communication also includes intentionality, mutuality, partnership, trust, and presence (AACN, 2021, p. 12).Empathetic communication refers to communication with some-one from the vantage point of the other personÕs feelings, values, and perspective (Figure 10-3). The nurseÐpatient relationship based on empathetic communication is characterized by a genuine respect for the patientÕs opinions and decisions. Empathetic communication is the foundation for establishing relationships that are consistent with PCC (Bankert et al., 2014).Behaviors that facilitate empathetic communication include:¥ Listening carefully to the patient¥ Reflecting summary of what the patient has expressed¥ Using terminology the patient can understand¥ Calling the patient by preferred name¥ Speaking to the patient respectfullyKEY OUTCOME 10-2Example of Domain 2 sub-competency for entry-level professional nursing education.2.2b Consider individual beliefs, values, and person-alized information in com-munications (p. 29).Reproduced from American Association of Colleges of Nursing. (2021). The Essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfKEY COMPETENCY 10-5Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesCommunication (Therapeu-tic Communication):Knowledge (K2c) Describes the impact of oneÕs own communication style on othersSkills (S2e) Assesses barriers to effective communicationSkills (S2g) Assesses the impact of use of self in ef-fective communicationAttitudes/Behaviors (A2b) Values mutually respectful communicationMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfFigure 10-3 Engaging in empathetic communication is essential in creating a patient-centered care environment.© Monkey Business Images/Shutterstock.Communication as a Strategy to Support Patient-Centered Care285
¥ Asking the patient what is needed and responding to identified needs¥ Providing useful and accurate information¥ Asking the patient for feedback¥ Using self-disclosure in a professional and appropriate manner¥ Employing humor when appropriate¥ Providing words of comfort as appropriate (Bankert et al., 2014, p. 165)Behaviors can also hinder empathetic communication. Some of these behaviors may include:¥ Interrupting the patient with information that is not relevant¥ Using vocabulary that is either too simple or too complex for the patient¥ Using condescending language¥ Using language that is not considered professional¥ Reprimanding the patient¥ Lecturing the patient¥ Providing the patient with irrelevant or incorrect information¥ Asking untimely questions¥ Providing improper advice to the patient¥ Using self-disclosure in an inappropriate or unprofessional manner (Bankert et al., 2014, p. 165)Other elements to consider are verbal communication and nonverbal behaviors that, although discussed separately, take place simultaneously. The empathetic communicator will be attentive to conflicting messages related to verbal and nonverbal communica-tion, paying particular attention to nonverbal messages because these provide the nurse with insight into the patientÕs inner feelings. Nonverbal behaviors that the nurse will want to observe include eye movement, body position and movement, facial expression, and tone of voice. To communicate effectively, the nurse must learn to attend to all of these elements of the communication process (Bankert et al., 2014).Nurses often encounter patients and families during times of heightened stress. Differing expectations for outcomes of care, misun-derstandings, disagreements, and impaired trust coupled with anxiety can all lead to conflict between family members and or members of the healthcare team. Effective communication and constructive in-teractions with patients and their families can be challenging when there is conflict; so, how does the nurse provide patient-centered or family-centered care when there is conflict?Five strategies for nurses to use to partner with families during stressful circumstances are suggested by Zaider and colleagues (2016). These strategies are congruent with principles of patient-centered care KEY OUTCOME 10-3Example of Domain 2 sub-competency for entry-level professional nursing education.2.1a Demonstrate qualities of empathy (p. 28).Reproduced from American Association of Colleges of Nursing. (2021). The Essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfCHAPTER 10 Patient Education and Patient-Centered Care in Professional Nursing Practice 286
and include: (1) checking your emotional posture, (2) becoming an ally to the family, (3) framing choices, (4) responding empathetically, and (5) blocking escalation.Checking your emotional posture allows the nurse time to be mindful of their level of stress so they can respond skillfully in the stressful situation rather than reacting. During this time the nurse should pause and disengage from the anxiety in order to view the situation objectively (Zaider et al., 2016).Becoming an ally to the family focuses on acknowledging the various perspectives of family members. To accomplish this, the nurse will want to elicit family membersÕ concerns, identify overlap among their concerns, highlight positive and common intentions of fam-ily members, and identify aspects of the problem that the nurse, the patient, and the family can unite around. This can be accomplished by using strategies such as asking open questions, clarifying meaning, restating and summarizing differences (Zaider et al., 2016).When the nurse addresses differing perspectives between the patient or family and the nurse, the nurse is facilitating the framing of choices. During this process, the nurses should ask the patient and family about their wishes, acknowledge any incompatible be-liefs of the patient and the healthcare team, and underscore the caring intentions of the healthcare team. This assists the nurse to continue to support and collaborate with the patient and fam-ily. During this process the nurse should be transparent with the patient and family about the choices that are actually available (Zaider et al., 2016).Responding empathetically involves the nurse acknowledging sources of distress and expressing that concerns of the patient and family are being taken seriously. While responding empathetically, the nurse can encourage the patient and family to express their feelings, validate while assisting to reframe anger as a dimension of worry and grief, and praise the familiesÕ efforts (Zaider et al., 2016).Occasionally, patient or family distress becomes too great to maintain productive dialogue. In such cases, an effective strategy may be to block escalation by facilitating transition to a time-out. It is important that the time-out includes a clear plan to return to engage-ment with a goal of reaching a resolution. This time-out allows for space to redirect distressed family members and time to plan for next steps (Zaider et al., 2016).Conflict is a part of life but becomes concerning if it persists or interferes with patient care. It is in the best interest of everyone involved in the patientÕs care if resolution of conflict occurs and the nurse, equipped with the strategies described, is in a good position to facilitate the process. Failure to resolve conflict interferes with the therapeutic relationship and becomes a barrier to providing patient-centered and family-centered care.KEY COMPETENCY 10-6Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesCommunication (Therapeu-tic Communication):Knowledge (K3a) Under-stands the nursesÕ role and responsibility in applying the principles of verbal and nonverbal communicationKnowledge (K3b) Under-stands the nurseÕs role and responsibility in ap-plying principles of active listeningSkills (S3b) Actively listens to comments, concerns, and questionsSkills (S3c) Demonstrates effective interviewing techniquesSkills (S3d) Provides op-portunity to ask and re-spond to questionsSkills (S3e) Assesses verbal and non-verbal responsesAttitudes/Behaviors (A3a) Values the therapeutic use of self in patient careAttitudes/Behaviors (A3b) Appreciates the dynamics of physical and emotional presence on communicationMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfCommunication as a Strategy to Support Patient-Centered Care287
Patient Education as a Strategy to Support Patient-Centered CarePatient education has formally been a part of nursing care since the time of Florence Nightingale (1860/1969). During the 1900s, patient education increasingly became identified as a role of the profes-sional nurse; however, it was not until 1973 that the ANA defined patient education as a component of the practice of the registered nurse. Beginning in 1976, the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission, 1995) included pa-tient and family education as a function critical to patient care. The AACN (1998, 2008) also recognized that the implementation of the professional nursing role requires that nurses are prepared to teach patients effectively. Standard 5 of the standards of professional nurs-ing practice states that the nurse is responsible for implementation of an identified plan (ANA, 2015). A subcategory of this standard, titled Health Teaching and Health Promotion, indicates that the nurse em-ploys strategies to promote health and a safe environment. Competen-cies under this standard include those related to the nurse providing health promotion education and health teaching (ANA, 2015). Thus, in contemporary nursing practice, patient education is both a profes-sional expectation and a legal obligation of the nurse (Figure 10-4).Figure 10-4 The nurse must possess the skills to effectively communicate with patients.© SDI Productions/E+/Getty Images.CHAPTER 10 Patient Education and Patient-Centered Care in Professional Nursing Practice 288
ÒPatient education is any set of planned, educational activities designed to improve patientsÕ health behaviors, health status, or bothÓ (Lorig, 2001, p. xiii). There is nothing in this definition about improv-ing knowledge, although a change in knowledge might be necessary to reach the goal of changing the health status or health behaviors. In contrast, activities aimed at improving knowledge are known as patient teaching (Lorig, 2001). The point is that the purposes of pa-tient education are more than a change in knowledge. The purposes of patient education are to maintain health, to improve health, or to slow deterioration of health. These purposes are met through changes in health-related behaviors and attitudes (Lorig, 2001), and these changes are not easily achieved. Effective patient education requires the nurse to have the ability to communicate effectively with patients to assess the individual needs, attitudes, and preferences of the patient that can affect health behaviors before any changes can be expected (Falvo, 2004, 2011).Principles and Theories Related to Patient EducationIn addition to communication and assessment skills, if the nurse is to be effective as a patient educator, then he or she must also have suf-ficient knowledge of the information that needs to be taught. If the knowledge base of the nurse is insufficient, the nurse risks providing inadequate or inaccurate information to the patient (Falvo, 2004, 2011). Finally, to be an effective patient educator, it is important that the nurse have an understanding of how to conduct patient education. Many educational theories and principles can be used to guide the patient education process. Some that are most commonly used in the healthcare setting are presented here.Domains of LearningFirst, we should examine the nature of learning in relationship to learning domains. Identification of the learning domain reflects the type of learning desired as a result of the patient education process. Learning occurs in three domains: the cognitive, the psychomotor, and the affective (Bloom, 1956). The framework includes categories or levels of learning that comprise knowledge, comprehension, applica-tion, analysis, synthesis, and evaluation. Each level builds on the pre-vious one in a hierarchical fashion. In the cognitive and psychomotor domains, levels are arranged in order of increasing complexity. In the affective domain, levels are organized according to the degree of inter-nalization of a value or attitude.In the revised taxonomy (Anderson & Krathwohl, 2001), cogni-tive learning encompasses the intellectual skills of remembering, un-derstanding, applying, analyzing, evaluating, and creating. The use of Patient Education as a Strategy to Support Patient-Centered Care289
verbs rather than nouns to name the categories in the revised taxon-omy underscores the dynamic nature of learning. Psychomotor learn-ing refers to learning of motor skills and performance of behaviors or skills that require coordination. Affective learning requires a change in feelings, attitudes, or beliefs.Understanding which domain is the target of learning helps guide the planning, implementation, and evaluation of learning. For exam-ple, if based on assessment you know that a patient is knowledgeable about insulin administration and is committed to administering the injection but has not yet been able to manipulate the syringe correctly to administer the injection, you know that your target domain for learning is the psychomotor domain. Thus, the focus of your objec-tives, planning, learning activities, and evaluation will be on the per-formance of the identified behaviors.AndragogyAndragogy, initially defined as Òthe art and science of helping adults learnÓ (Knowles, 1970), has taken on a broader meaning over the past 40 years and is currently used to refer to learner-focused education for people of all ages (Conner, 2006). The andragogic model asserts that the following four issues be considered and addressed in learning (Knowles et al., 1998, 2011):¥ Letting learners know why something is important to learn¥ Showing learners how to direct themselves through information¥ Relating the topic to the learnersÕ experiences¥ Realizing that people will not learn until they are ready and motivatedAdults learn best when there is immediate opportunity for ap-plication. Adults in particular are motivated to learn when they rec-ognize a gap between what they know and what they want to know or what they need to know (Knowles, 1970). Therefore, adult learners are rarely interested in learning detailed anatomy and physiology re-lated to their chronic disease, but they are motivated to learn how to care for themselves after discharge from the hospital. Effective patient education will be based on principles that capitalize on these charac-teristics of the adult learner.Health Belief ModelThe Health Belief Model (HBM) is one of the most widely used frame-works in research and programs related to health promotion and patient education. This model was originally developed to predict the likelihood of a person following a recommended action and to under-stand the personÕs motivation and decision making regarding seeking health services (Hochbaum, 1958).KEY COMPETENCY 10-7Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesCommunication (Teaching/Learning):Knowledge (K8d) Is aware of the three domains of learning: cognitive, affec-tive, and psychomotorAttitudes/Behaviors (A8d) Values the need for teach-ing in all three domains of learningMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfCHAPTER 10 Patient Education and Patient-Centered Care in Professional Nursing Practice 290
According to the HBM, the likelihood of a person acting in re-sponse to a health threat depends on six factors:¥ The personÕs perception of the severity of the illness¥ The personÕs perception of susceptibility to illness and its consequences¥ The value of the treatment benefits (i.e., do the cost and side ef-fects of treatment outweigh the consequences of the disease?)¥ Barriers to treatment (i.e., expense, complexity of treatment)¥ Costs of treatment in physical and emotional terms¥ Cues that stimulate taking action toward treatment of illness (i.e., mass media campaigns, pamphlets, advice from family or friends, and postcard reminders from healthcare providers)The HBM can provide a framework for assessing areas where patients have gaps in knowledge, such as severity of illness or suscep-tibility to illness, and then addressing those areas to increase the po-tential for compliance with the treatment regimen. Through use of the HBM, you can easily categorize and cover the essential components of your educational message, thus providing the patient with a basic understanding of the severity of the illness, the risk and consequences of the illness, the value of treatment, the barriers to treatment, and the costs of treatment.Social Learning TheoryAccording to BanduraÕs Social Learning Theory, if a person believes that he or she is capable of performing a behavior (self-efÞcacy) and also believes that the behavior will lead to a desirable outcome, the person will be more likely to perform the behavior (Bandura, 1997). In contrast, if a person does not believe that he or she is capable of performing a behavior, he or she will have no incentive to do so, even if the person is actually capable. Perceptions of self-efficacy are particularly important in relation to a patientÕs learning complex activities or long-term changes in behavior (Prohaska & Lorig, 2001).There are four methods for developing or enhancing efficacy ex-pectations if assessment reveals a need for such enhancement:¥ Performance accomplishments¥ Vicarious experience or modeling¥ Verbal persuasion¥ Interpretation of physiologic statePerformance accomplishment is the most direct and influential way to enhance self-efficacy. In this method, the patient first per-forms tasks that he or she can easily handle. By succeeding with these first tasks, the patient develops a sense of competence and enhance-ment of self-efficacy before proceeding to more difficult tasks. Along Patient Education as a Strategy to Support Patient-Centered Care291
these same lines, it is also important to set short-term goals that are measurable so that patients can see their success and the effect of the change in their behavior. A patient who can see the benefits of a behavior change within a reasonable time is more likely to continue practicing the behavior.The second method for enhancing self-efficacy is through model-ing, where the patient observes others who appear to be similar and who are successfully performing behaviors. Modeling can also be achieved through the use of illustrations in pamphlets or in program-ming materials by using illustrations and models that are of various cultures, body shapes, and ages (Prohaska & Lorig, 2001).Verbal persuasion can also be an effective method of enhancing self-efficacy expectations. The content of the message needs to include basic factual information that emphasizes the importance of perform-ing the behavior. It is usually better to ask for incremental changes or to ask the patient to do just slightly more than he or she is currently doing (Prohaska & Lorig, 2001). Encouragement and support not only from the nurse but also from family and friends help the patient to be successful.Most illnesses present with symptoms, and most new behaviors cause some physiologic changes. Addressing the meaning of symptoms and physiologic states can influence self-efficacy. For example, a patient who is trying to quit smoking can expect withdrawal symptoms. If the patient understands the reasons for the symptoms and the limitation in the duration of the symptoms, the patient might decide that he or she has the ability to make the change. Without that knowledge, the patient might give up because he or she experiences physiologic changes that are not understood.The Patient Education Process: AssessmentAccording to Redman (2001, 2006), the process of patient educa-tion can be viewed as parallel to the nursing process. Each of these processes begins with assessment, negotiation of goals and objec-tives, planning, intervention, and finally evaluation (Rankin, 2005; Rankin & Stallings, 2001; Rankin et al., 2005).The goal of the nurse in the process of patient education is to assist the patient in obtaining the knowledge, skills, or attitude that will help the patient develop behaviors to meet needs and to maxi-mize the potential for positive health outcomes (Falvo, 2004, 2011). Because no patient or situation is exactly the same, an assessment is required.Many available guides are helpful in assessing the learning needs of patients (Redman, 2003). Some nurses construct their own KEY OUTCOME 10-4Example of Domain 2 sub-competency for entry-level professional nursing education.2.8b Employ individualized educational strategies based on learning theories, methodologies, and health literacy (p. 32).Reproduced from American Association of Colleges of Nursing. (2021). The Essentials: Core competencies for professional nursing education. https://www.aacnnursing .org/Portals/42/AcademicNursing/pdf /Essentials-2021.pdfCRITICAL THINKING QUESTION✶Think about your own life. Do you act to prevent a disease or accident when you per-ceive that you are not susceptible to the dis-ease or at risk for the accident?✶CHAPTER 10 Patient Education and Patient-Centered Care in Professional Nursing Practice 292
assessment tools to meet specific needs. Observation, interviews, open-ended questions, focus groups, and the patientÕs medical re-cord are additional ways to gather information for the assessment of learning needs. Rankin and Stallings (2001, p. 200) suggest some specific questions that must be addressed in the assessment of learn-ing needs:¥ What information does the patient need?¥ What attitudes should be explored?¥ What skill does the patient need to be able to perform healthcare behaviors?¥ What factors in the patientÕs environment may be barriers to the performance of desired behaviors?¥ Is the patient likely to return home?¥ Can the family or caregiver handle the care that will be required?¥ Is the home situation adequate or appropriate for the type of care required?¥ What kinds of assistance will be required?Learning StylesTo provide the most effective patient teaching, the nurse must also assess patient learning style. Although most people learn best when multiple techniques are used in patient teaching, assessment of the patientÕs learning style is a fundamental step before beginning any learning activity. Learning styles are methods of interacting with, tak-ing in, and processing information that allow individuals to learn. Learning styles are generally categorized as visual, auditory, or tactile/kinesthetic.The patient who is a visual learner prefers written instructions rather than oral instructions but prefers photographs and illustrations to written instructions. The nurse teaching the patient who is a visual learner should use a variety of interesting visual learning materials, in-cluding organized visual presentations, photographs, or computerized materials (Russell, 2006).The patient who is an auditory learner remembers oral instruc-tions well and learns through discussion. The nurse teaching a patient who is an auditory learner will want to be sure that the patient is po-sitioned to be able to hear and will want to rephrase what is said sev-eral different ways to be sure the intended message is communicated. The nurse might also want to use multimedia that incorporates sound in patient teaching (Russell, 2006).The patient who learns best through getting physically involved is the tactile or kinesthetic learner. The kinesthetic learner learns through doing or experiencing physically. The kinesthetic learner has difficulty staying in one place for very long and enjoys hands-on activities. The nurse teaching the kinesthetic learner should provide KEY COMPETENCY 10-8Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesCommunication (Teaching/Learning):Knowledge (K8c) Under-stands the principles of teaching and learningSkills (S8c) Assists patients and families in accessing and interpreting health information and identifying healthy lifestyle behaviorsAttitudes/Behaviors (A8g) Accepts the role and responsibility for provid-ing health education to patients and familiesMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfPatient Education as a Strategy to Support Patient-Centered Care293
activities during the session and should provide samples or supplies for practicing or demonstrating skills (Russell, 2006).Readiness to LearnAn important variable in the patient education process is readiness to learn. After a need to learn has been identified, a patientÕs readiness or evidence of motivation to receive information at that particular time must also be assessed (Falvo, 2004, 2011; Joint Commission, 2003; Redman, 2001). A variety of factors, such as pain, anxiety, and emo-tional reactions, can affect a patientÕs readiness to learn. Moderate to severe anxiety has been shown to interfere with a patientÕs ability to concentrate and understand new information (Stephenson, 2007). If a patient is distracted by physical or emotional pain, attempts at patient teaching will not be successful. The better choice is to wait until the pain has subsided or to address the anxiety that the patient is experi-encing, and then when the patient is ready, proceed with patient edu-cation activities (Redman, 2001, 2006; Stephenson, 2007).Health LiteracyConsidering a patientÕs health literacy is an important component in PCC. Health literacy is generally defined as the ability to read, un-derstand, and act on health information. The IOM (2004) consensus report on health literacy defined the concept as Òthe degree to which individuals have the capacity to obtain, process, and understand basic health information and services they need to make appropriate health decisionsÓ (p. 31).Today there is more access to healthcare information than at any time in history. The low health literacy problem for most is not an issue of access to information but rather is a crisis of not understand-ing medical information (Doak & Doak, 2002). Research studies have demonstrated that patients with low health literacy skills make more errors with their medications and treatments (Baker et al., 1996; Williams et al., 1998) and are also at risk for experiencing preventable adverse events (Bartlett et al., 2008). They often fail to seek preventive care and are also at higher risk for hospitalization, which results in higher annual healthcare costs (Agency for Healthcare Research and Quality [AHRQ], 2011; Baker et al., 1998; U.S. Department of Health and Human Services [USDHHS], 2018; Weiss, 1999).In the United States, one in five adults and nearly two in five older adults and minorities read at the fifth-grade level or below. Only 12% of U.S. adults are considered to have proficient health literacy. The number of adults with only basic health literacy skills or below basic-level health literacy skills has reached 77 million. One-third of the U.S. adult population has difficulty with common health tasks, such as following instructions on a medication label (USDHHS, 2018). This is significant because persons with only basic health KEY COMPETENCY 10-9Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesCommunication (Teaching/Learning):Knowledge (K8a) Under-stands the inßuences of different learning styles on the education of patients and familiesKnowledge (K8b) IdentiÞes differences in auditory, visual, and tactile learning stylesSkills (A8b) Recognizes learning styles vary by individualAttitudes/Behaviors (S8a) Assesses factors that inßuence the patientÕs and familyÕs ability to learn, in-cluding readiness to learn, preferences for learning style, and levels of health literacyMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfCHAPTER 10 Patient Education and Patient-Centered Care in Professional Nursing Practice 294
literacy skills or below basic-level health literacy skills have difficulty processing and understanding information and services and thus have difficulty making healthcare-related decisions (Miller & Stoeckel, 2017). Although health literacy is partially dependent on the patientÕs skill set, it is also dependent on the complexity of the information as well as how information is communicated (USDHHS, 2018).The Institute for Healthcare Improvement (2021) has developed a program called Ask Me 3. According to the institute, this program promotes improved health outcomes by encouraging patients to become active members of their healthcare team through improved communication between patients and their healthcare providers. The following are the three questions the program encourages patients to ask their healthcare provider:¥ What is my main problem?¥ What do I need to do?¥ Why is it important for me to do this?Another program that is used by nurses to become more effec-tive patient educators is ACTS, an acronym for assess; compare; teach three, teach back; and survey. The best education strategies begin by asking the patient to identify his or her main concern. This simple question will shift the focus of the interaction from the nurse to a patient-centered encounter. Next, the nurse must discover the needs and preferences of the patient as well as how the patient prefers to learn in order to individualize the teaching plan. Asking the patient or caregiver what they already know acknowledges his or her cur-rent level of expertise and supports the concepts of patient control and shared decision making. Finally, the nurse assesses patient core values and cultural, social, language, and physical influences. Dur-ing the compare phase, the nurse compares the available resources to the needs and preferences of the patient to match relevant content to identified knowledge gaps. Teach three, teach back refers to the process in which patients are taught three or fewer key concepts or care skills in short segments and then the patient restates the concept in his or her own words or demonstrates the skill. If the patient has difficulty with restating or with skill demonstration, teaching should be repeated. Nurses should then close the loop by asking in an open-ended manner if there are additional questions or learning needs (French, 2015).When information is complex or time is limited, nurses fre-quently provide printed materials for patients to read or review at home. These materials are helpful when they provide patients who have adequate reading skills with a resource to remind them of the instructions given by the nurse, but for those patients with low health literacy skills, the printed materials might be of no use. The average American reads at the eighth- to ninth-grade level. Most materials Patient Education as a Strategy to Support Patient-Centered Care295
used for patient education are written above the 10th-grade reading level (Doak & Doak, 2002; Doak et al., 1996). We know that when the reading level of printed materials is beyond the skill of the learner, comprehension is decreased, recall is sketchy and inaccurate, and mo-tivation to learn is decreased (Redman, 2001, 2006).Patients with low health literacy skills are generally too embar-rassed to reveal to the nurse that they cannot read or cannot read well enough to understand the written instructions. It is therefore impor-tant that the nurse take the initiative in assessing the literacy skills of patients before using written materials in the patient education process and to provide educational materials in various formats when possible.Direct questioning of patients about reading ability is usually not effective. How can you determine the reading ability of the patient? One option is to use one of several instruments that have been devel-oped to assess patient literacy quickly. Some of the literacy assessment instruments most commonly used in healthcare settings include the Rapid Estimate of Adult Literacy in Medicine (Davis et al., 1993) and the Wide Range Achievement Test (Jastak & Wilkinson, 1993).One of the best ways to assess literacy is simply through care-ful observation of your patient. Clues that might be observed in a patient with low health literacy skills include forms that are filled out incompletely or incorrectly, written materials that are handed to a person accompanying the patient, and aloofness or withdrawal during provider explanations. Additional clues might include surveillance of the behavior of others in the same situation to copy their actions or a request for help from staff or other patients. Verbal responses like ÒI will read this at homeÓ or ÒI canÕt read this now because I forgot my glassesÓ are also common (Bastable, 2016; Doak & Doak, 2002).Health literacy tools continue to focus primar-ily on reading ability, despite the IOMÕs recom-mendation that the focus change to skills-based health literacy tools that use a combination of skills that patients can use to manage health, such as verbal, computer, or other skills (AHRQ, 2011). Because reading ability continues to be the preva-lent focus, we consider assessment of readability of materials next.Assessing the Readability of Patient Education MaterialsMany health-related teaching materials are written on a level that is above the average patientÕs literacy level and contain too much medical jargon. Written materials can still be useful supplements for patients with low health literacy skills if the written materials selected are appropriate to the reading level of the patient. Print materials for most patient populations should be written between the seventh- and CRITICAL THINKING QUESTIONS✶Have you ever been assigned to read a book that had so many big words in it that you had to keep the dictionary by your side? If it was assigned for school, you probably strug-gled through it for the sake of not failing the test, but what about if you were not being graded? Would you bother to read it? If you did read it because you knew it would help you, would you have enough understanding to actually apply the information?✶CHAPTER 10 Patient Education and Patient-Centered Care in Professional Nursing Practice 296
eighth-grade reading levels. Print materials for patients with low health literacy skills should be written at or below the fifth-grade reading level (Doak & Doak, 2002).Several readability formulas are available to determine the grade level of materials (Flesch, 1948; Fry, 1968; McLaughlin, 1969). One of the easiest formulas to use is the SMOG formula, which predicts the reading grade level of materials within 1.5 grades 68% of the time (McLaughlin, 1969). Readability of materials available in an elec-tronic format can be assessed using formulas embedded in word pro-cessing programs and also for free via several readability calculation websites on the Internet.Low health literacy can be a barrier to effective patient education, but the patient with low health literacy skills is capable of learning if the nurse is willing to invest the extra time that is required. It is impor-tant for the nurse to take extra care to present information in terms that the patient is familiar with rather than using medical jargon; to use alternate formats, such as pictographs, when possible; to restate in-formation using simple words; and to verify the patientÕs understand-ing by having him or her convey the information in his or her own words. The dividends for the extra effort include the patient who is able to manage his or her own illness, make informed health decisions, and make health-related behavior changes as a result of a patient edu-cation process that has accommodated for his or her weaknesses.The Patient Education Process: PlanningThe patient and the nurse share the planning process for patient edu-cation, but it is the responsibility of the nurse to guide the process us-ing goals and objectives. Learning goals are derived from the learning assessment, and nursing diagnoses and objectives are developed based on goals in collaboration with the patient. The use of goals and objec-tives helps the nurse to focus on what is important for the patient to learn and to keep patient education centered on outcomes (Rankin & Stallings, 2001; Rankin et al., 2005).Patient education is directed toward behavioral change; therefore, the objectives for patient education are stated as behavioral objec-tives. There are three components of behavioral objectives: perfor-mance, conditions, and criteria (Mager, 1997). Performance refers to the activity that the patient will engage in and answers this question: What can the learner do? The condition refers to special circum-stances of the patientÕs performance and answers this question: Under what conditions will the learner perform the behavior? The criteria or evaluation component refers to how long or how well the behavior must be performed to be acceptable and answers this question: What is the performance standard? (Rankin & Stallings, 2001; Rankin et al., 2005).KEY COMPETENCY 10-10Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesCommunication (Teaching/Learning):Knowledge (K8e) Under-stands the concept of health literacySkills (S8a) Assesses fac-tors that inßuence the pa-tientÕs and familyÕs ability to learn, including readi-ness to learn, preferences for learning style, and lev-els of health literacyAttitudes/Behaviors (A8e) Accepts responsibility to ensure the patient receives health information that is understandableMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfPatient Education as a Strategy to Support Patient-Centered Care297
The learning objectives should be specific, measurable, and attain-able (Rankin, 2005; Rankin & Stallings, 2001; Rankin et al., 2005). Learning objectives are also written in a manner that is learning-domain specific. Recognizing the targeted domain of learning as cognitive, psy-chomotor, or affective helps guide the process of writing behavioral learning objectives and thus guides the selection of learning activities.The Patient Education Process: ImplementationThe next stage of the process involves the actual intervention. Whether the teaching will occur in a group or with an individual pa-tient, learning activities need to be consistent with learning objectives.Using various learning activities can make learning more fun and more effective. Some common learning activities include lectures, demonstrations, practice, games, simulations, role-playing, discus-sions, and self-directed learning through computer-assisted instruction or self-directed workbooks.Patient education materials are frequently used in the implemen-tation stage of the patient education process. Patient education mate-rials can be designed to be used alone or to supplement other types of patient education activities but should be previewed before use and used only if consistent with learning objectives. There are many types of patient education materials currently on the market, or you might opt to produce your own materials.Patient education materials generally include audiovisual materi-als, computer programs, Internet resources, posters, flip charts, charts, graphs, cartoons, slides, overhead transparencies, photographs, draw-ings, patient education newsletters, or written patient materials, such as handouts, brochures, or pamphlets. These materials, even if de-signed to be used alone, should not be used without some explanation as to why the patient is being instructed to view the video or read the brochure (Falvo, 2004, 2011). In addition, the nurse should keep the door of communication open by inviting questions that the patient might have as a result of exposure to the teaching materials.You must evaluate a variety of factors as you look at the appro-priateness of patient education materials. Three important criteria for judging patient education materials are the following (Doak et al., 2001, p. 184):¥ The material contains the information the patient wants.¥ The material contains the information the patient needs.¥ The patient understands and uses the material as presented.It is an expectation of the Joint Commission that the right educa-tional materials are used in patient and family education and that the materials are accurate, age specific, easily accessible, and appropriate to patient needs (Joint Commission, 2003). To address all of these CHAPTER 10 Patient Education and Patient-Centered Care in Professional Nursing Practice 298
criteria, the nurse must conduct a needs assessment before preparing or choosing patient education materials.Considerations: Patient Education with Older AdultsWhen caring for older adults, one of the primary considerations related to the patient education process is accommodation for age-related barriers to learning (Figure 10-5). The age-related barri-ers particularly important in the patient education process include age-related changes in cognition, vision, and hearing. Research has demonstrated that teaching is not as effective if it does not accom-modate age-related cognitive and sensory changes (Donlon, 1993; Masters, 2001; Weinrich et al., 1994). Gerogogy in patient education has been defined as the transferring of essential information that has been designed, modified, and adapted to accommodate for the physi-ologic and psychologic changes in elderly persons by taking into account the personÕs disease process, age-related changes, educational level, and motivation (Pearson, 2012).Age-related changes in cognitive function occur slowly and are thought to begin at approximately 60 years of age in healthy adults (Miller, 2004). Age-related visual changes are the most prevalent physical impairments affecting older adults. Hearing impairment ranks as one of the four most prevalent chronic condi-tions affecting the older population, occurring in one-third of the Figure 10-5 The nurse must accommodate for age-related cognitive and sensory changes in older adults for teaching to be effective.© Monkey Business Images/Getty Images Plus/Getty Images.Patient Education as a Strategy to Support Patient-Centered Care299
U.S. population between the ages of 65 and 74 years and in 47% of the population 75 years of age or older (National Institutes of Health, n.d.).Each of these age-related changes can have a profound effect on the teaching and learning process. Specific age-related changes in cog-nition, vision, and hearing are listed in Box 10-1.Specific strategies can be used during the patient education pro-cess to help overcome the age-related learning barriers in cognition, vision, and hearing. Some of these strategies are included in Box 10-2.Cultural Considerations in Patient EducationDeveloping an educational program that is culturally appropriate is not much different from creating any other patient education pro-gram. You begin with a needs assessment; then you write objectives and design the program. The difference is that you must be culturally sensitive and incorporate cultural information that you have learned about the target group into the patient education process (Bastable, 2016; Gonzalez & Lorig, 2001; Lengetti et al., 2007).BOX 10-1 AGE-RELATED BARRIERS TO LEARNING: COGNITIVE AND SENSORY CHANGESCognitiveChanges in encoding and storage of informationChanges in the retrieval of informationDecreases in the speed of processing informationVisualSmaller amount of light reaches the retinaReduced ability to focus on close objectsScattering of light resulting in glareChanges in color perception resulting in difficulty distinguishing colors, such as dark green, blue, and violetDecrease in depth perception and peripheral visionHearingReduced ability to hear sounds as loudlyDecrease in hearing acuityDecrease in the ability to hear high-pitched soundsDecrease in the ability to filter background noiseData from Merriam, S. B., & Caffarella, R. S. (1999). Learning in adulthood: A comprehensive guide (2nd ed.). Jossey-Bass; Merriam, S. B., Caffarella, R. S., & Baumgartner, L. M. (2007). Learning in adulthood: A comprehensive guide (3rd ed.). Jossey-Bass; Miller, C. A. (2004). Nursing for wellness in older adults: Theory and practice (4th ed.). Lippincott.KEY OUTCOME 10-5Example of Domain 2 sub-competency for entry-level professional nursing education.2.2e Use evidence-based patient teaching materials, considering health literacy, vision, hearing, and cul-tural sensitivity (p. 29).Reproduced from American Association of Colleges of Nursing. (2021). The Essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfCHAPTER 10 Patient Education and Patient-Centered Care in Professional Nursing Practice 300
BOX 10-2 STRATEGIES TO ACCOMMODATE AGE-RELATED BARRIERS TO LEARNING: COGNITIVE AND SENSORY CHANGESCognitiveSlow the pace of the presentation.Give smaller amounts of information at a time.Repeat information frequently.Reinforce verbal teaching with audiovisuals, written materials, and practice.Reduce distractions.Allow more time for self-expression of the learner.Use analogies and examples from everyday experience to illus-trate abstract information.Increase the meaningfulness of content to the learner.Teach mnemonic devices and imaging techniques.Use printed materials and visual aids that are age specificVisualMake sure patientÕs glasses are clean and in place.Use printed materials with 14- to 16-point font and serif letters.Use bold type on printed materials, and do not mix fonts.Avoid the use of dark colors with dark backgrounds for teach-ing materials; instead, use large, distinct configurations with high contrast to help with discrimination.Avoid using blue, green, and violet to differentiate type, illustra-tions, or graphics.Use line drawings with high contrast.Use soft white light to decrease glare.Light should shine from behind the learner.Use color and touch to help differentiate depth.Position materials directly in front of the learner.HearingSpeak distinctly.Do not shout.Speak in a normal voice or speak in a lower pitch.Decrease extraneous noise.Face the person directly while speaking at a distance of 3 to 6 feet.Reinforce verbal teaching with visual aids or easy-to-read materials.Data from Weinrich, S. P., Boyd, M., & Nussbaum, J. (1989). Continuing education: Adapting strategies to teach the elderly. Journal of Gerontological Nursing, 15(11), 17Ð21; Oldaker, S. M. (1992). Live and learn: Patient education for the elderly ortho-paedic client. Orthopaedic Nursing, 11(3), 51Ð56.Patient Education as a Strategy to Support Patient-Centered Care301
How important is it that you incorporate cultural information into the patient education process? Cultural awareness and sensitivity of nurses can influence the ability of patients to receive and apply in-formation regarding their health care (Campinha-Bacote et al., 1996). The way that information is communicated can influence a patientÕs perception of the healthcare system and affect adherence to prescribed treatments. In a study, patients who received care from nurses with cultural sensitivity training showed improvement not only in use of social resources but also in overall functional capacity (Majumdar et al., 2004).In addition to the difference that it can make in relationship to patient outcomes, the standards of practice are clear that the nurse is responsible for using Òhealth promotion and teaching methods in collaboration with the healthcare consumerÕs values, beliefs, health practices, developmental level, learning needs, readiness and ability to learn, language preference, spirituality, culture, and socioeconomic statusÓ (ANA, 2015, p. 65). The Joint Commission standards also require not only that the patientÕs learning needs, abilities, and readi-ness to learn are assessed but also that the patientÕs preferences are assessed. This assessment must consider cultural and religious prac-tices as well as emotional and language barriers (Joint Commission, 2003).How do you incorporate cultural information into the patient edu-cation process? Gonzalez and Lorig (2001, p. 172) suggest the following:¥ Change the information into more specific or more relevant terminology.¥ Create descriptions or explanations that fit with different peopleÕs understanding of key concepts.¥ Incorporate a groupÕs cultural beliefs and practices into the pro-gram content and process.In addition, any visual aids that are used should reflect the tar-get group or population. The use of culturally relevant analogies can also help people to understand complex, abstract, or foreign concepts (Gonzalez & Lorig, 2001).The Patient Education Process: EvaluationEvaluation determines worth by judging something against a stan-dard. The standard used in the patient education process is the learning objective. Thus, the term evaluation as used here implies measuring the outcomes resulting from systematically planned ac-tivities implemented as a part of a patient education program or pa-tient education process against the learning objectives to determine whether learning occurred.CHAPTER 10 Patient Education and Patient-Centered Care in Professional Nursing Practice 302
Initiation of the patient education evaluation process is the re-sponsibility of the nurse, and according to Rankin and Stallings (2001, p. 326), the evaluation process should include the following:¥ Measuring the extent to which the patient has met the learning objectives¥ Identifying when there is a need to clarify, correct, or review information¥ Noting learning objectives that are unclear¥ Pointing out shortcomings in patient teaching interventions¥ Identifying barriers that prevented learningNurses commonly use several methods to evaluate patient learning. These methods include direct observation, the teach-back method or asking patients to explain something in their own words, situational feedback to determine if the patient selects the appropri-ate behavior, records of health-related behaviors that patients report, patient interviews and questionnaires, and critical incidents, such as readmission, emergency department visits, and mortality (McNeill, 2012).Evaluation of Patient-Centered CareThe National Strategy for Quality Improvement in Health Care was established by the secretary of the USDHHS to set priorities to guide the nation to increase access to high-quality health care. One of the priorities identified was the delivery of PCC and FCC (USDHHS, 2011). We know that there is a link between PCC and high-quality health care but identifying specific measures of PCC is challenging.The HCAHPS (pronounced H-CAPS) survey, also known as the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospital Survey, was the first national, standardized, publicly reported survey of patientsÕ perspectives of hospital care. The intent of the survey is to provide a standard instrument to measure patient satisfac-tion with the hospital experience. The survey asks a core set of ques-tions to assess patient satisfaction with the care provided by nurses, physicians, and other members of the healthcare team; the responsive-ness of the hospital staff; pain management; communication about medications; and the cleanliness and quietness of the environment. The standardized questions allow for comparisons of patient care experiences.A more recent addition to the CAHPS survey is the integration of a supplemental item set related to health literacy. The primary goal of the survey is to measure, from the patientÕs perspective, how well health-related information was communicated to them by health KEY COMPETENCY 10-11Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesCommunication (Teaching/Learning):Knowledge (K8g) Under-stands the purpose of health educationSkills (S8g) Evaluates pa-tient and family learningMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfEvaluation of Patient-Centered Care303
professionals during their care. This survey is available in English and Spanish. CAHPS supplemental item sets are also now available to assess cultural competence, to assess technology use, and for the patient-centered medical home (USDHHS, 2018).Patient satisfaction with the care provided is recognized as a valid quality indicator (Bankert et al., 2014). As consumers, patients provide their perspectives on the quality of care, delivery of care, outcomes of care, and the extent to which they were included as an active participant. PCC requires that evaluation of the care experience include the perspective of the patient (Walton & Barnsteiner, 2012).ConclusionThe patient relationship with healthcare professionals has changed dramatically during the past few decades and continues to evolve. In just one generation, we have moved from a healthcare system in which the provider made all the decisions for the passive patient to a system where our goal is full partnership with the patient. This shift requires nurses to actively engage patients in all dimensions of their care while communicating in a manner that conveys empathy and re-spect for patient preferences.CASE STUDY 10-1 ■ MR. MARTINMr. Martin, an 82-year-old African American pa-tient, is ready for discharge from the medical unit after a 3-day hospitalization resulting from exacer-bation of heart failure. Before discharge from the hospital, the student nurse reviews the medication orders and provides Mr. Martin with standard patient education materials related to control of heart failure symptoms.Case Study Questions1. What else could the student nurse in the case study do to enhance the effectiveness of the patient education process for Mr. Martin?2. Do you have any suggestions for the student nurse related to accommodating age-related changes of this patient?3. Do you have any suggestions for the student nurse related to cultural considerations as she educates this patient?Classroom Activity 10-1Provide students with a copy of printed pa-tient education materials. These can be ob-tained from a local healthcare organization or from online sources, such as the American Heart Association. Ask students to evaluate the materials for readability using the SMOG formula. Next, ask students to evaluate the materials for use with older adults using the information presented in Box 10-1 and Box 10-2. Finally, have students evaluate the ma-terials for use with a population of a different culture. Ask students to share their findings during informal presentations to classmates.CHAPTER 10 Patient Education and Patient-Centered Care in Professional Nursing Practice 304
ReferencesAgency for Healthcare Research and Quality. (2011). Health literacy interventions and outcomes: An updated systematic review (Publication No. 11E-006). U.S. Department of Health and Human Services.American Association of Colleges of Nursing. (1998). The essentials of baccalaureate education for professional nursing practice. Author.American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Author.American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Essentials-2021.pdfAmerican Nurses Association. (1973). Standards of nursing practice. Author.American Nurses Association. (2015). Nursing: Scope and standards of practice (3rd ed.). Author.Anderson, L. W., & Krathwohl, D. R. (Eds.). (2001). A taxonomy for learning, teaching and assessing: A revision of BloomÕs taxonomy of educational objectives. Addison-Wesley.Baker, D. W., Parker, R. M., Williams, M. V., & Clark, W. S. (1998). Health literacy and the risk of hospital admission. Journal of General Internal Medicine, 13, 791Ð798.Classroom Activity 10-2Divide the class into small groups and ask stu-dents to create a patient education brochure that conforms to recommended reading levels, considers age-related learning barriers, and accommodates cultural differences. The group may choose a fictitious case scenario or an ac-tual scenario from a recent clinical experience. For this activity, several students will need to bring laptops to class or the class will need to have access to a computer lab. Alternately, this activity could be assigned to students to complete outside of class to be shared with the class or submitted for a grade.Classroom Activity 10-3Share highlights of the story of Lia Lee from Anne FadimanÕs book, When the Spirit Catches You and You Fall Down. Next, share the responses of LiaÕs mother to Dr. Arthur KleinmanÕs questions, available at https://thehealthcareblog.com/blog/2013/06/11 /the-patient-explanatory-model/. Discuss the differing perspective of the issues once some-one asks the patient and/or family what they think.Classroom Activity 10-4Numerous classroom and clinical activities related to PCC are available on the QSEN website at https://qsen.org. Choose activities from the website for students to complete that meet objectives specific to your course.References305
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Rankin, S. H., & Stallings, K. D. (2001). Patient education: Principles and practice (4th ed.). Lippincott.Rankin, S. H., Stallings, K. D., & London, F. (2005). Patient education in health and illness (5th ed.). Lippincott.Redman, B. K. (2001). The practice of patient education (9th ed.). Mosby.Redman, B. K. (2003). Measurement tools in patient education (2nd ed.). Springer.Redman, B. K. (2006). The practice of patient education: A case study approach (10th ed.). Mosby.Russell, S. S. (2006). An overview of adult-learning processes. Urologic Nursing, 26(5), 349Ð352, 370.Stephenson, P. L. (2007). Before teaching begins: Managing patient anxiety prior to providing education. Clinical Journal of Oncology Nursing, 10(2), 241Ð246.U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute. (2004). Making health communication programs work: A plannerÕs guide. https://www.cancer.gov /publications/health-communication/pink-book.pdfU.S. Department of Health and Human Services. (2011). National strategy for quality improvement in health care. Author.U.S. Department of Health and Human Services. (2018). CAHPS health literacy item sets. https://www .ahrq.gov/cahps/surveys-guidance/item-sets/literacy/index.htmlWalton, M. K., & Barnsteiner, J. (2012). Patient-centered care. In G. Sherwood & J. Barnsteiner (Eds.), Quality and safety in nursing: A competency approach to improving outcomes (pp. 67Ð89). Wiley.Weinrich, S. P., Boyd, M., & Nussbaum, J. (1989). Continuing education: Adapting strategies to teach the elderly. Journal of Gerontological Nursing, 15(11), 17Ð21.Weinrich, S. P., Weinrich, M. C., Boyd, M. D., Atwood, J., & Cervenka, B. (1994). Teaching older adults by adapting for aging changes. Cancer Nursing, 17(6), 494Ð500.Weiss, B. D. (1999). Twenty common problems in primary care. McGraw-Hill.Williams, M. V., Baker, D. W., Honig, E. G., Lee, T. M., & Nowlan, A. (1998). Inadequate literacy is a barrier to asthma knowledge and self-care. Chest, 114, 1008Ð1015.Zaider, T. I., Banerjee, S. C., Manna, R., Coyle, N., Pehrson, C., Hammonds, S., Krueger, C. A., & Bylund, C. L. (2016). Responding to challenging interactions with families: A training module for inpatient oncology nurses. Families, Systems, and Health, 34(3), 204Ð212.CHAPTER 10 Patient Education and Patient-Centered Care in Professional Nursing Practice 308
Healthcare delivery depends on information for effective decision making. Having entered the era of electronic health records (EHRs) and telecommunication systems, informatics has become an indispens-able element in the practice of nursing. All professional nurses now use informatics skills in their practice.Informatics: What Is It?Nursing informatics (NI) is both a field of study and an area of special-ization. In the mid-1900s, NI was first identified as the use of infor-mation technology in nursing practice (Hannah, 1985). In 1992, the American Nurses Association (ANA) first recognized NI as a nursing specialty. The original ANA Scope and Standards of Nursing Infor-matics Practice was published in 2001 and then revised in 2008 and 2014. A key component of the definition is that nursing informatics Key Terms and Concepts ÈCochrane Library ÈCumulative Index to Nursing and Allied Health Literature (CINAHL) ÈDatabase ÈEBSCO Publishing ÈEducational Re-source Information Center (ERIC) ÈElectronic health record (EHR) ÈEmail ÈHealth Source ÈListservsAfter completing this chapter, the student should be able to:1. Consider the role of informatics in nursing practice.2. Discuss various informatics competencies for professional nursing practice.3. Consider security and privacy issues re-lated to electronic health records (EHRs).4. Discuss basic computer competencies re-quired for nursing practice.5. Discuss the information literacy skills needed to practice nursing.6. Examine the role of information manage-ment in nursing practice.7. Envision the future of healthcare informa-tion systems based on current inßuences.Learning ObjectivesInformatics in Professional Nursing PracticeKathleen Masters and Cathy K. Hughes309CHAPTER 11© Nuu Jeed/Shutterstock
is a specialty within the profession of nursing that Òintegrates nursing science, computer science, and information scienceÓ for the purpose of managing and communicating data, information, and knowledge (ANA, 2008, p. 92). Nursing informatics is useful in supporting deci-sion making through Òinformation structures, information processes, and information technologyÓ (ANA, 2008, p. 92). Thus, the specialty of NI focuses on developing and implementing solutions for the man-agement and communication of health information pertinent to pro-viding better quality patient care (Zykowski, 2003).Clinical informatics is a broader term that includes nursing as well as other medical and health specialties and addresses the use of infor-mation systems in patient care. The domains of clinical informatics include the three areas of health systems, clinical care, and informa-tion and communication technologies and may include issues ranging from decision support to EHR documentation to electronic order entry (Alexander, 2015b). Health informatics is an even broader term that encompasses the Òthe integration of health-care sciences, computer sci-ence, information science, and cognitive science to assist in the manage-ment of healthcare informationÓ (Saba & McCormick, 2015, p. 232).Informatics, the broadest of the terms, is the science of collecting, managing, and retrieving information. The informatics discipline be-gan decades ago, but an Institute of Medicine (IOM) report published in 1991 brought national attention to the lack of use of information technology in the healthcare industry as compared to other indus-tries (IOM, 1997). That report, along with subsequent IOM reports, became the impetus for the transition to information systems to sup-port the provision of health care (Silsbee & Reed, 2014). In todayÕs healthcare systems, information and computer technologies are major infrastructure components of patient safety and integral tools used by healthcare providers (Walton, 2012).The Effect of Legislation on Health InformaticsSeveral IOM (1997, 1999, 2001) reports informed Congress about legislation needed to bring about change in health care related to infor-matics that resulted in the passage of several laws that have expedited the health informatics agenda. Three primary laws have affected health information management. The Health Insurance Portability and Ac-countability Act (HIPAA) of 1996 contains provisions for privacy and security of health information. The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 provided federal money in the form of grants to advance the use of health information technology (HIT). The Patient Protection and Affordable Care Act of 2010 also provides for funding of HIT (Silsbee & Reed, 2014).KEY COMPETENCY 11-1Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesInformatics and Technology:Knowledge (K2c) Describes the foundation of Nursing Informatics: distinguishes between healthcare and nursing informatics and describes Informatics Knowledge and its rela-tionship to Regulations, Human Factors, and Change ManagementSkills (S2c) Uses informat-ics, and knowledge of larger healthcare delivery system, to support and enhance patient careMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdf ÈMEDLINE ÈNursing informatics (NI) ÈPersonal health record ÈPsycINFO ÈSearch engines ÈSocial media ÈTelehealthCHAPTER 11 Informatics in Professional Nursing Practice310
HIPAA and Health Information PrivacyMovement toward electronic information management in health care was slow, in part because of concern over the lack of privacy of patient health records in an electronic system. In 1996, Congress passed HIPAA to improve the efficiency and effectiveness of the healthcare system by encouraging the development of a health infor-mation system. Some areas addressed by the act include simplifying healthcare claims, developing standards for data transmission, and implementing privacy regulations. The privacy regulations protect clients by limiting the ways that health plans, pharmacies, hospitals, and other entities can use clientsÕ personal medical information. The regulations protect medical records and other individually identifi-able health information, whether communicated orally, on paper, or electronically. Accompanying the privacy regulations are specific se-curity rules that protect health information in electronic form. To be in compliance, agencies must ensure the confidentiality and integrity of all electronic health information that is created, received, trans-mitted, or stored; protect against threats to security; protect against disclosures of information; and ensure compliance of their employees (Garner, 2003).Protecting an individualÕs personal and private information has historically been a significant issue for nursing. Healthcare informa-tion is a collection of data relating to personal aspects of an indi-vidualÕs life. Improper disclosure can cause devastating consequences. Patients assume that information provided to a healthcare provider will not be disclosed. It is not only possible but also probable that patients will not disclose certain types of information essential to their care if they believe the information is not confidential. The introduc-tion of electronic documentation and communication has increased the difficulty of maintaining privacy. Improved access to healthcare information can and does increase efficiency and improve patient care, but accompanying the benefits are greater difficulties in maintain-ing privacy and confidentiality. Preserving the security of the health information system is critical because unauthorized access to the computerized health information system compromises the privacy and confidentiality of patient health records. Protection against unauthor-ized access can be achieved by implementing a login process that veri-fies that the user has permission to access the system. The majority of systems rely on a user ID and password for verification. Passwords must be changed frequently to protect against breach of security. Users should never divulge or share passwords. Healthcare agencies have writ-ten policies regarding the penalties of misuse of the system. Consequences are usually severe, with many including termination of employment.KEY COMPETENCY 11-2Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesInformatics and Technology:Knowledge (K6a) Describes patient access, rights and engagement as pertains to EHRsKnowledge (K6b) Under-stands the principles of data integrity, professional ethics and legal rights of patientsSkills (S6a) Utilizes strate-gies to protect data and maintains data integritySkills (S6b) Upholds ethical standards related to data security, regulatory re-quirements, conÞdentiality, and clientsÕ right to privacyAttitudes/Behaviors (A6) Recognizes that greater patient engagement con-tributes to better health outcomesMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfCRITICAL THINKING QUESTION✶What is your role as a nurse in protecting patient healthcare information?✶The Effect of Legislation on Health Informatics 311
HITECHThe HITECH Act provided money to providers and organizations to encourage use of the electronic health record (EHR). Under the HITECH Act there are two sets of standards to help providers meet meaningful use criteria of EHRs and to ensure that EHRs meet per-formance standards. The first standard outlined metrics that providers and facilities had to achieve in order to meet meaningful use criteria and merit the incentives available through the Centers for Medicare and Medicaid Services (CMS) Incentive Program. Under this program, healthcare providers and organizations could receive financial incen-tives for meaningful use of certified EHRs through 2016. However, by 2015 a provider that had not shown meaningful use of a certified EHR received less reimbursement. A certified EHR is one that meets the requirements of interoperability and formatting standards. The second set of standards in the HITECH Act specify the standards that the technology vendors must meet to certify their products as mean-ingful useÐcertified (TIGER Initiative Foundation, 2014).The HITECH Act outlined three phases of meaningful use, with each stage within the phase building on the previous so that criteria and objectives evolved each year, moving the healthcare industry with each stage. Phase one involved data capture and sharing, such as us-ing information captured in a standardized format to track clinical conditions or coordinate care. Phase two involved advanced clinical processes, such as electronic transmission of patient care summaries across multiple settings. Phase three involved improved outcomes, such as improving quality, safety, and efficiency, leading to improved health outcomes and population health (Alexander, 2015a; Silsbee & Reed, 2014; TIGER Initiative Foundation, 2014).Nursing Informatics CompetenciesThe current expectation is that all nurses demonstrate proficiency in the use of information and patient care technology; therefore, many of the national nursing organizations have promulgated lists of expecta-tions for either nursing students or nurses related to informatics skills. Defined levels of informatics competencies vary depending on the experience and specialty of the nurse. For example, differing levels of expertise in informatics are expected from the beginning nurse, experi-enced nurse, informatics specialist, and informatics innovator (Hebda & Czar, 2009; McGonigle & Mastrian, 2009; Staggers et al., 2001).The entry-level professional nurse is expected to have computer literacy and basic information management skills. Important tech-nology skills of the entry-level nurse include knowing how to use nursing-specific software, such as computerized documentation; use of patient care technologies, such as monitors, pumps, and medication CHAPTER 11 Informatics in Professional Nursing Practice312
dispensing; and information management for patient safety (American Association of Colleges of Nursing [AACN], 2008). In our world of electronic communication and data management, maintaining privacy, security, and confidentiality of patient information as mandated by HIPAA is an expectation of all nurses, including nursing students.Experienced nurses should be skilled in information management and computer technology to sustain their specific area of practice. These skills include making judgments based on trends of data in ad-dition to collaboration with informatics nurses in the development of nursing systems. An informatics nurse specialist has graduate-level in-formatics preparation and is prepared to assist the practicing nurse in meeting his or her needs for information (ANA, 2008). The informat-ics innovator also has graduate-level informatics preparation and pos-sesses skills for developing theory and conducting informatics research (Thede, 2003). The focus of this chapter is on the generalist nurse rather than on the informatics specialist or informatics innovator.AACN Information Management and Application of Patient Care TechnologyThe AACN (2008) includes information management and applica-tion of patient care technology as an essential component of a bac-calaureate education in nursing in order to prepare the graduate to deliver safe and effective care. The AACN names informatics and technology-related outcomes for baccalaureate nursing graduates, including that the nurse will demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice; use telecommunication technologies to assist in effective communication in a variety of healthcare set-tings; apply safeguards and decision-making support tools embedded in patient care technologies and information systems to support a safe practice environment for both patients and healthcare workers; understand the issues of clinical information systems to document interventions related to achieving nurse-sensitive outcomes; use stan-dardized terminology in a care environment that reflects nursingÕs unique contribution to patient outcomes; uphold ethical standards related to data security, regulatory requirements, confidentiality, and clientsÕ right to privacy; and recognize that redesign of workflow and care processes should precede implementation of care technology to facilitate nursing practice (AACN, 2008, pp. 18Ð19).Quality and Safety Education for Nurses: Informatics CompetenciesSponsored by the Robert Wood Johnson Foundation, Quality and Safety Education for Nurses (QSEN) has the overall goal of preparing Nursing Informatics Competencies313
future nurses who will have the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work (QSEN, n.d.). The purpose of this initiative is to develop competencies of future nursing graduates in six key areas: patient-centered care, evidence-based prac-tice, quality improvement, teamwork and collaboration, safety, and informatics. The application of informatics in nursing practice is also a vital component in the mastery of the other defined KSAs.Informatics is defined in the QSEN (n.d.) initiative as the use of information and technology to communicate, manage knowl-edge, mitigate error, and support decision making (Figure 11-1). The entry-level informatics skill domain competencies identified by QSEN include the following:¥ Seek information about how information is managed in care set-tings before providing care.¥ Apply technology and information management tools to support safe processes of care.¥ Navigate the EHR.¥ Document and plan patient care in an EHR.¥ Employ communication technologies to coordinate care for patients.¥ Respond appropriately to clinical decision-making supports and alerts.Figure 11-1 The use of advanced technology enables communication and supports collaboration in decision making to mitigate error and optimize patient outcomes.© Carlos Amarillo/Shutterstock.CHAPTER 11 Informatics in Professional Nursing Practice314
¥ Use information management tools to monitor outcomes of care processes.¥ Use high-quality electronic sources of healthcare information.Nurse of the Future Core Competencies: Informatics and TechnologyThe Nurse of the Future Core Competencies for informatics uses the 2015 definition from the National Academies of Sciences, Engineer-ing, and Medicine, stating that Òthe Nurse of the Future will be able to use advanced technology and to analyze as well as synthesize information and collaborate in order to make critical decisions that optimize patient outcomesÓ (Massachusetts Department of Higher Education, 2016, p. 26).Technology Informatics Guiding Education Reform InitiativeIn 2004, the Technology Informatics Guiding Education Reform (TIGER) initiative was formed to bring together various nursing stakeholders in order to develop a shared vision, strategies, and specific actions for improving nursing practice, education, and patient care delivery through the use of information technology (Technology Informatics Guiding Education Reform, 2009). The TIGER Informatics Competencies Collaborative (TICC) developed informat-ics recommendations, and in 2011 the group published a landmark report titled Informatics Competencies for Every Practicing Nurse: Recommendations from the TIGER Collaborative (Transforming Health Through Information Technology, 2017).The TIGER Informatics competencies for all practicing nurses and graduating nursing students resulted in the TIGER Informatics Competency Model, which has three components: basic computer competencies, information literacy, and information management (TIGER, 2009).The organization of the remainder of this chapter reflects the three components of the TIGER Competency Model as well as recom-mendations in the TIGER Initiative Foundation (2014) publication The Leadership Imperative: TIGERÕs Recommendations for Integrat-ing Technology to Transform Practice and Education, that provides guidance for incorporating technology into transformational practice changes to enhance patient, family, and economic outcomes.Basic Computer CompetenciesBasic computer competencies include understanding the concepts of information and communication technology, possessing skill in the KEY COMPETENCY 11-3Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesInformatics and Technology:Knowledge (K1a) Under-stands basic computer sci-ence conceptsKnowledge (K1b) IdentiÞes the basic components of the computer systemsSkills (S1a) Demonstrates proÞciency in concepts of information and communi-cation technology; founda-tions of basic computer systems (i.e., software, operating systems, hard-ware, networks, peripheral devices, computer systems, Internet and web-based application, wireless technology)Skills (S1b) Demonstrates proÞciency in basic com-puter skills related to per-sonnel management (i.e., admin), education, and desktop softwareAttitudes/Behaviors (A1) Recognizes the importance of basic computer compe-tence to evolving nursing scienceMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfBasic Computer Competencies315
use of a computer, and managing files, word processing, spreadsheets, using databases, presentations, web browsing, and communication (TIGER, 2009). An overview of some of these skills is presented in the following sections of the chapter.Web BrowsingNot since the invention of the printing press has the speed with which new information can be accessed changed so much as with the devel-opment of the Internet. Search tools and search engines assist users in finding specific topics on the web by compiling a database of Internet sites. In addition to search engines, there are metasearch engines. A metasearch engine conducts a search of a variety of search engines. Metacrawler (www.metacrawler.com), Google (www.google.com), and Dogpile (www.dogpile.com) are examples of metasearch engines. Each search engine queries different databases using different search techniques (Bliss & DeYoung, 2002) and uses a range of engines for retrieval of information.Communication: EmailEmail (electronic mail) can be sent to anyone in the world who has an email address. In moments, messages can be sent across time zones, al-lowing instant communication. For several reasons, attention must be paid to the content of messages sent by email. Someone other than the intended recipient can access a message while it is transmitted over the Internet. In addition, messages containing sensitive information can accidentally or purposefully be forwarded. Although email can be a way of facilitating direct communication between consumers of health care and healthcare providers, precautions must be taken to ensure that only the intended recipient receives health-related email messages.To send and receive email, a person must have an individual ad-dress that consists of two main parts separated by an @ sign. The first part is called a login name or a user ID. The part after the @ is the name of the network or service provider used to access the Inter-net. The characters after the last dot in an email address indicate the domain or main subdivision of the Internet to which the computer belongs. Addresses must be accurate for the intended recipient to re-ceive the message. Appropriateness must be considered when selecting your login name. Professionals should not use suggestive or insensitive wording for their login names.Email is a special form of communication and carries its own form of etiquette. Pagana (2007) suggests that nurses follow these guidelines when sending a business or professional message:¥ Do not use all uppercase letters. Typing in all caps is deemed shouting.CHAPTER 11 Informatics in Professional Nursing Practice316
¥ Include a specific subject line.¥ Sign your messages with text that includes your email address and contact information.¥ Use the Òreply to allÓ function appropriately. Not everyone is in-terested in receiving your comments.¥ Avoid forwarding chain letters, and delete all unnecessary infor-mation from forwarded messages.¥ Do not send confidential information, and check for correct recipi-ents before sending.¥ Use the spell-check and grammar functions.¥ Do not use email for thank-you correspondence.Data from Pagana, K. D. (2007). E-mail etiquette. American Nurse Today, 2(7), 45.Communication: Listserv Groups and Mailing ListsMailing lists and listservs are forms of group email that provide an opportunity for people with similar interests to share information. Subscribing to a list is usually free. Once subscribed, you can send and receive messages to and from the list. The communication is asyn-chronous, meaning it does not occur in real time. Someone posts a question or comment to the list, and other members reply in time. List groups are usually either layperson oriented or professional oriented. There are numerous groups devoted to the topic of nursing. To find a list, ask friends and colleagues or visit CataList, an official catalog of listservs that includes a searchable database. You can access CataList at www.lsoft.com/catalist.html.Most listservs provide specific instructions on subscribing. Every listserv has two addresses. One address is used to join, and the sec-ond is used to send messages that can be read by the group. Listserv groups can be open to anyone, or you might need permission to join. It is important to remember that messages sent to the listserv are read by everyone subscribed to the listserv. Posting a personal message to an individual on a listserv is considered inappropriate. Do not send attachments to the list. The list might have hundreds of members, and some will not have computers that support sophisti-cated graphics or large files. In addition, viruses can be transmitted in attachments.Communication: Social MediaSocial media are Internet-based applications that enable communica-tion and sharing of resources and information (Lindsay, 2011). Exam-ples of social media are YouTube, Facebook, LinkedIn, and Twitter as well as blogs, wikis, and chat rooms. The many choices of how users can share information on nursing-related resources can be found on the ANA website (www.nursingworld.org).KEY OUTCOME 11-1Example of Domain 8 sub-competency for entry-level professional nursing education.8.1c Effectively use elec-tronic communication tools (p. 48).Reproduced from American Association of Colleges of Nursing. (2021). The Essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfKEY OUTCOME 11-2Example of Domain 8 sub-competency for entry-level professional nursing education.8.3a Demonstrate appro-priate use of information and communication tech-nologies (p. 49).Reproduced from American Association of Colleges of Nursing. (2021). The Essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfBasic Computer Competencies317
Growing participation in social networking sites poses challenges for nursing. Although social networking aids with personal and pro-fessional knowledge exchange and prompts interaction with others, it comes with risks. Personal and patient privacy issues can be raised, and some networking discussions might be viewed as ÒfactÓ and not validated. The ANA has adopted the Principles for Social Networking, which include the following:¥ Nurses must not transmit or place online individually identifiable patient information.¥ Nurses must observe ethically prescribed professional patientÐnurse boundaries.¥ Nurses should understand that patients, colleagues, institutions, and employers might view postings.¥ Nurses should take advantage of privacy settings and seek to sepa-rate personal and professional information online.¥ Nurses should bring content that could harm a patientÕs privacy, rights, or welfare to the attention of appropriate authorities.¥ Nurses should participate in developing institutional policies gov-erning online contact (ANA, 2011a, 2011b).The National Council of State Boards of Nursing (NCSBN) has also adopted guidelines related to the responsible use of social media and has endorsed the principles adopted by the ANA. The NCSBN (2011) guidelines, available at www.ncsbn.org/Social_Media.pdf, ad-dress issues of confidentiality and privacy; common myths and misun-derstandings related to social media; possible consequences in the use of social media, including consequences with board of nursing impli-cations; and how to avoid problems. The guidelines also include seven scenarios related to social media use by nurses with board of nursing implications.According to the NCSBN (2011) white paper, depending on the jurisdiction, the board of nursing might investigate reports of inap-propriate disclosures related to the use of social media on the grounds of the following: unprofessional conduct, unethical conduct, moral turpitude, mismanagement of patient records, revealing a privileged communication, and breach of confidentiality. If allegations are found to be true, the nurse could face disciplinary action by the board of nursing that can include a reprimand, a sanction, an assessment of a fine, or the temporary or permanent loss of licensure. In addition, im-proper use of social media might violate state and federal laws, result-ing in civil or criminal penalties that carry with them fines or jail time.Social networking can have both positive and negative conse-quences. Negative consequences can affect not only nursesÕ personal reputations but also their professional standing. Nurses should con-sider that current or future employers might view their personal social media pages.KEY OUTCOME 11-3Example of Domain 8 sub-competency for entry-level professional nursing education.8.1e Demonstrate best practice use of social networking applications (p. 49).Reproduced from American Association of Colleges of Nursing. (2021). The Essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfCHAPTER 11 Informatics in Professional Nursing Practice318
On the other hand, social media can be used in disasters as a means of disseminating information and as an emergency manage-ment tool. Social media can be a source of information in a crisis as well as part of a plan to mobilize responders. In disaster preparation, social media sites can be used to publicize training events and dates (Lindsay, 2011).Future challenges of social media include the use of the technol-ogy for the delivery of accurate and pertinent information by experts and healthcare providers and by peers and the lay public. Healthcare providersÕ uses of social media technology may include public educa-tion related to sources of information and monitoring the effect of social media on health outcomes.Communication: TelehealthTelehealth is the use of electronic information and telecommunica-tions technologies to support long-distance clinical health care, patient and professional health-related education, public health, and health administration (U.S. Department of Health and Human Services [USDHHS], n.d.-b). The use of this technology has many im-plications in the provision of health care in the context of both access and quality. For example, healthcare providers can monitor patients in their homes for changes in health status. Images and other data can be transmitted for consultation with other healthcare providers. Prac-titioners in geographically remote areas or in a prison setting can con-nect to a large hospital for consultations and second opinions without transporting the patient to that site. From a motor vehicle crash site, the emergency medical system response field team can transmit infor-mation and documentation to the emergency department for direction on care of the patient.Traditionally, policies and regulations have limited the expansion of telehealth. Many of these regulations that posed barriers to the use of telehealth were waived during the COVID-19 pandemic so that health-care providers could safely continue to care for patients. This resulted in an explosion in the use of telehealth technology. It remains to be seen if these policy waivers will remain in place after resolution of the crisis, but regulations are currently being studied to determine what policies should be maintained or revised and the outcome of these studies will certainly impact the growth of telehealth technology over the next decade.Information LiteracyInformation literacy skills are prerequisites for the practice of evidence-based nursing (TIGER, 2009). Information literacy builds on basic computer competencies and includes such skills as being able to identify information needed for specific purposes, locating pertinent KEY COMPETENCY 11-4Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesInformatics and Technology:Knowledge (K2d) Describes an understanding of electronic communica-tion strategies among healthcare providers in the healthcare systemSkills (S2d) Utilizes elec-tronic communication strategies (EHR, mHealth, personal health records)Attitudes/Behaviors (A2b) Appreciates the use of electronic communications strategies in the delivery of patient careMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfKEY OUTCOME 11-4Example of Domain 8 sub-competency for entry-level professional nursing education.8.4c Identify the basic con-cepts of electronic health, mobile health, and tele-health systems in enabling patient care (p. 50).Reproduced from American Association of Colleges of Nursing. (2021). The Essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfInformation Literacy319
information, evaluating the information, and cor-rectly applying the information. The following sec-tion discusses information location and evaluation specific to nursing and health care.Electronic DatabasesAn increasing number of databases are available on the Internet and can be accessed through local libraries or by subscription from a vendor, such as EBSCO Publishing, which provides access to online databases and e-journals. Most of the databases allow keyword searches and are capable of advanced searching. Many full-text resources are available via databases, mak-ing information available very quickly. Some of the most beneficial databases to nursing include the following:¥ The Cumulative Index to Nursing and Allied Health Literature (CINAHL) is a resource for nursing and allied health professionals, students, educators, and researchers. This database provides index-ing and abstracting for more than 1,700 current nursing and allied health journals and publications dating back to 1982, totaling more than 880,000 records.¥ The Cochrane Library is an online collection of six databases with Òindependent high-quality evidence for healthcare decision mak-ingÓ (Cochrane Collaboration, n.d.). It is available at academic institutions and is funded for free access in many countries and regions of the world.¥ The Educational Resource Information Center (ERIC) is a national in-formation system supported by the U.S. Department of Education, the National Library of Education, and the Office of Educational Research and Improvement. It provides access to information from journals included in the Current Index of Journals in Educa-tion and Resources in Education Index. ERIC provides full text of more than 2,200 digests, along with references for additional information, citations, and abstracts from more than 1,000 educa-tional and education-related journals.¥ Google Scholar (googlescholar.com), launched in 2004, contains some full-text peer-reviewed journals, abstracts, links to subscrip-tion journals, and articles for purchase as well as technical reports, theses, and books.¥ Health Source, the Nursing Academic Edition, provides more than 550 scholarly full-text journals, including more than 450 peer-reviewed journals focusing on many medical disciplines, including nursing and allied health.¥ MEDLINE, created by the National Library of Medicine, is the largest biomedical literature database and provides authoritative medical information on medicine, nursing, dentistry, veterinary CRITICAL THINKING QUESTIONS✶What needs of populations in your region or state could be addressed with the use of telehealth? What ideas can you envision to assist in the access to and delivery of health-care services where you live or work?✶KEY COMPETENCY 11-5Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesInformatics and Technology:Knowledge (K8) Describes the integration of research and evidence-based prac-tice into the EHR.Skills (S8a) Conducts on-line literature searchesSkills (S8b) Provides for ef-Þcient data collectionSkills (S8c) Uses applica-tions to manage aggre-gated dataSkills (S8d) Integrates evidence-based standards to support clinical practiceAttitudes/Behaviors (A8) Values technology as a tool for generating knowl-edge and guiding clinical practiceMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfCHAPTER 11 Informatics in Professional Nursing Practice320
medicine, the healthcare system, and preclinical sciences. In MEDLINE, users can search ab-stracts from more than 4,600 current biomedi-cal journals. Included are citations from Index Medicus, International Nursing Index, Index to Dental Literature, PREMEDLINE, AIDSLINE, BIOETHICSLINE, and HealthSTAR.¥ PsycINFO contains nearly two million citations and summaries of journal articles, book chapters, books, disserta-tions, and technical reports, all in the field of psychology. It also includes information about the psychological aspects of related disciplines, such as medicine, psychiatry, nursing, sociology, educa-tion, pharmacology, physiology, linguistics, anthropology, business, and law.Internet access to government organizations and nonprofit or-ganizations is also available. The U.S. National Library of Medicine (www.nlm.nih.gov/hinfo.html) offers access to a myriad of health information websites. PubMed and MedlinePlus permit searches of multiple retrieval systems and provide excellent information. The evaluation guidelines discussed in the following section should be ap-plied to all Internet sites before using the information in patient teach-ing (Thede & Sewell, 2010).Website EvaluationThe Internet has grown rapidly since its beginning, and information can be published easily and inexpensively. An Internet website can be created by anyone with the ability to create a webpage, and many webpage templates are available for little or no cost, making this very easy. Many sites are for commercial purposes; others simply publish the opinions of the website owner. Websites are under no guidelines or standards. In addition, no official organization is responsible for site evaluation. As a result, a vast amount of information is available on the Internet, but not all information is reliable. Applying the follow-ing guidelines can assist you in evaluating resources on the Internet so that the information you obtain is reliable:¥ Accuracy: Is the information accurate, reliable, and free from error? Spelling and punctuation errors can indicate an untrust-worthy site.¥ Authority or source: Look for the credentials of the author or the reputation of the hosting organization. A good indication of au-thority is peer review.¥ Objectivity: What are the goals and objectives of the site? What biases are present? Is the site trying to present a specific or neutral point of view?CRITICAL THINKING QUESTION✶How can you locate online sources for more information on a new treatment or medica-tions for a health condition you discussed in a nursing class or clinical this week?✶Information Literacy321
¥ Currency or timeliness: Look for publication and updated dates to determine if the information is current. Dead links can indicate old information.¥ Coverage or quality: Is the subject matter presented on the site of appropriate quality for the intended audience?¥ Intended purpose: Does the site have choices for such users as the public, healthcare providers, students, or educators?¥ Usability: Is the site designed for easy navigation? Are there ex-cessive graphics that require long download times? Are all links current, and do they load easily? (Hebda & Czar, 2009; Thede & Sewell, 2010)Health Information OnlineThe number of people accessing health informa-tion online continues to grow. This increase in numbers demonstrates how critically important it is that healthcare websites provide reliable and credible information. Nurses are responsible for assisting the public in evaluating health information available on the Internet.Whether nurses are developing online materials or using exist-ing online information, it is important for them to understand what makes the information accessible to all people and to be able to make informed recommendations about websites to individuals with dis-abilities (Carmona, 2012; Smeltzer et al., 2003). Some websites that feature webinars and online programs have closed captioning and copies of the scripts available on demand for these programs. Lan-guage options are available on some websites for print and audible programs (Thede & Sewell, 2010). Contents of sites should be pre-sented in a way that people with disabilities and with low-end tech-nology are able to navigate and use.Vulnerable populations and underserved populations, which in-clude persons with lower socioeconomic status, with lower reading levels, in rural areas, or with disabilities, have issues with access to care and access to information about health care. For persons in these populations, the term digital divide has typically been used to describe decreased access to information technologies, particularly via the In-ternet (Chang et al., 2004).More people are using the Internet for finding health informa-tion. Knowledgeable nurses need to assist patients and their families in evaluating the quality of Internet resources. The Health on the Net Foundation (HON), founded in 1995, is a nonprofit organization dedicated to assisting people in obtaining reliable health information on the Internet (HON, n.d.). To obtain certification, a website ap-plies for registration. The site is evaluated and, if approved, is quali-fied to display the HONcode seal. The site is randomly checked for CRITICAL THINKING QUESTION✶What is your role as a nurse in the evalua-tion of information on the Internet?✶CHAPTER 11 Informatics in Professional Nursing Practice322
compliance. From the HON website, Internet users can download the HON toolbar, which will be added to their web browser. When a cer-tified site is accessed, the seal will be illuminated on the userÕs toolbar. The HONcode criteria in brief include:¥ Authoritative: Indicate the qualifications of the authors.¥ Complementarity: Information should support, not replace, the doctorÐpatient relationship.¥ Privacy: Respect the privacy and confidentiality of personal data submitted to the site by the visitor.¥ Attribution: Cite the source(s) of published information; date medical and health pages.¥ Justifiability: Back up claims relating to benefits and performance.¥ Transparency: Accessible presentation, accurate email contact.¥ Financial disclosure: Identify funding sources.¥ Advertising policy: Clearly distinguish advertising from editorial content.Several sites from the Office of the National Coordinator (ONC) for Health Information Technology (ONC HIT, n.d.), such as HealthIT.gov, have information on e-health tools for the public to review and use that focus on health and wellness. Such sites as Health 2.0 Developer Challenge (n.d.) hold innovation competitions and community action programs to address solutions for key challenges in HIT.Information ManagementInformation management consists of collecting data, processing the data, and presenting and communicating the processed data as information or knowledge. A foundational concept in information management is what is known as the dataÐinformationÐknowledge continuum. Data are symbols, such as a numeric value of 1.5. Infor-mation is data that are organized or processed in a way that gives them meaning, such as 1.5 ng/ml. Knowledge is information that is transformed or combined in a way that is useful in making judgments and decisions. An example of knowledge is a combination of informa-tion, such as that a digoxin level of 1.5 ng/ml is a therapeutic level for an adult patient (TIGER, 2009).Data sets that are very large and can be analyzed to reveal pat-terns, trends, and associations are known in informatics as Òbig data.Ó Examples of healthcare databases with big data are those run by the CMS and the National Institutes of Health (NIH) Library of Medi-cine. Health Service Research Information Central is the arm of the NIH Library of Medicine that serves as the data repository.One of the current issues in nursing that prevents use of data sets to their full potential is a lack of standardized nomenclature. A lack of standardization inhibits the exchange of information, quality KEY COMPETENCY 11-6Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesInformatics and Technology:Knowledge (K2a) Describes Information Management concepts (i.e., communica-tion theories)Knowledge (K2b) Describes standardized terminology in a care environment that reßects nursingÕs unique contribution to patient outcomesSkills (S2a) Uses data, as presented through the EHR, to inform clinical decision and deliver safe, quality health careSkills (S2b) Uses data from nursing and all relevant sources, including technol-ogy, to inform the delivery of careAttitudes/Behaviors (A2a) Values the importance of nursing data to improve nursing practiceMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfInformation Management323
measurement, and analysis of data to identify patterns and associa-tions related to nursing interventions on performance measures, such as clinical outcomes. Even within one organization using similar no-menclature, after years of using the EHR, nurses still have difficulty using collected data to report on safety and quality issues. Nurses are, however, becoming increasingly skillful in the use of the EHR for tasks related to documentation and tasks associated with the routine care of patients, such as medication administration. The primary information management system used by nurses is the EHR, so this section begins with an overview of information management and then specifically addresses the EHR in more detail.Because of concern over patient privacy and lack of funding for information systems, the process of implementing health records was slow after the 1991 IOM report (IOM, 1997). In 1997, a revised report was published, again calling for progress in the use of infor-mation systems in health care. Subsequently the IOM published two landmark reports (1999, 2001) that called attention to human error in health care, called for system solutions to make it more difficult to make human errors, and recommended the use of computer systems as tools to assist with order entry, including links with clinical prac-tice guidelines, clinical decision support systems, and patient manage-ment systems.Electronic Health RecordsAs part of the National Health Information Infrastructure, President George W. Bush established a technology agenda authorizing the development of an EHR for all Americans by 2014 (Healthcare IT, 2004). Information on this agenda is available via the USDHHS web-site (White House Archives, 2004).The EHR as envisioned is to be a longitudinal record of the patientÕs healthcare record across the life span and to include input from different healthcare facilities and practitioners (Figure 11-2). Although the record is actually located in various locations and on various computers, the record appears as one record to the EHR user, as data are imported from multiple computer systems as needed. This is in contrast to the electronic medical record, which allows informa-tion to be created, gathered, managed, and consulted but can be used within only one healthcare organization. For access across institutions to occur, there must be agreed-upon standards of operability between hardware and software companies that allow for the exchange of information across health information systems. Many standards do exist, and more continue to be developed. The process of develop-ing standards for health information systems is coordinated by the Healthcare Information Technology Standards Panel of the American National Standards Institute (Silsbee & Reed, 2014).KEY OUTCOME 11-5Example of Domain 8 sub-competency for entry-level professional nursing education.8.1a Identify the variety of information and communi-cation technologies used in care settings (p. 48).Reproduced from American Association of Colleges of Nursing. (2021). The Essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfKEY OUTCOME 11-6Example of Domain 8 sub-competency for entry-level professional nursing education.8.2e Describe the impor-tance of standardized nursing data to reßect the unique contribution of nursing practice (p. 49).Reproduced from American Association of Colleges of Nursing. (2021). The Essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfKEY COMPETENCY 11-7Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesInformatics and Technology:Knowledge (K3) Explains why information and tech-nology skills are essential for the professional nurseSkills (S3a) Uses infor-mation and its sources CHAPTER 11 Informatics in Professional Nursing Practice324
Another IOM report (2011) identified characteristics for software designers to consider in the creation of electronic information systems for use by health professionals. These characteristics included that data should be accurate, timely, reliable, and entered directly into the system; easy to navigate; simple to use; and intuitive to the user, with evidence available at point of care to aid in decision making. The characteristics should also enhance and streamline workflow and au-tomate mundane tasks, have minimal time required for upgrades, and allow data to be easily imported and exchanged between systems.EHRs also include an integrated database of clinical informa-tion known as a clinical decision support system. The purpose of the clinical decision support system is to aid the nurse or other provider by leading the user through a decision-making process based on a set of data in the system. The clinical decision support system uses a decision tree model, so during this process, the EHR user is guided through a series of questions to narrow down the options for a cor-rect diagnosis or most effective treatment plan (Silsbee & Reed, 2014). In addition, EHRs include pharmacologic and lab value da-tabases and clinical guidelines, resources that are all available to the nurse at the patientÕs bedside. The EHR clinical decision support sys-tem can also provide clinical alerts and reminders, identify abnormal parameters of laboratory and assessment data, and prompt clinicians on important tasks and protocols (Hebda & Czar, 2009). The elec-tronic information system can maximize the time nurses spend with critically and incorporates selected information into his or her own professional knowledge databaseSkills (S3b) Seeks educa-tion about how information is managed in the care settingSkills (S3c) Performs basic troubleshooting when us-ing applicationsAttitudes/Behaviors (A3) Appreciates the necessity for all health professionals to seek lifelong, continu-ous learning of information managementMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfFigure 11-2 The nurse is responsible for demonstrating skill in the use of the electronic health record to facilitate safe nursing practice.© Pandpstock001/iStockphoto/Getty Images Plus/Getty Images.KEY OUTCOME 11-7Example of Domain 8 sub-competency for entry-level professional nursing education.8.4d Explain the impact of health information ex-change, interoperability, and integration on health care (p. 51).Reproduced from American Association of Colleges of Nursing. (2021). The Essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfInformation Management325
the patient at the bedside, improve the accuracy of documentation, and decrease medication errors, thus supporting patient quality and safety initiatives.Many other information systems can be imported into the EHR. Two of the most common are the computerized provider or-der entry (CPOE) and bar code medication administration (BCMA) (Figure 11-3). The CPOE feature of the EHR allows the provider to enter patient care orders directly into a computer system. The orders can be entered from any location, which not only eliminates the issue of order legibility but also eliminates the need for verbal or telephone orders. CPOE also decreases delays in care; for example, with use of the CPOE, orders for lab tests are transmitted to the lab and medica-tion orders are transmitted to the pharmacy. The BCMA is a system that receives orders from the CPOE system and prints bar-coded labels that contain a patient-specific identification number. The bar-coded label is attached to the medication sent from the pharmacy, and before the nurse administers the medication, both the bar code on the patientÕs bracelet and the bar code on the medication are scanned. This feature of the EHR checks for the right medication and the right patient as well as the right time and frequency, right dose, and right route for the medication (McGonigle & Mastrian, 2012), thus reduc-ing the potential for medication error.In the healthcare setting today, information systems are interwo-ven into almost every process. Admission/discharge/transfer systems KEY COMPETENCY 11-8Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesInformatics and Technology:Knowledge (K4) Under-stands Core Components of the EHR.Skills (S4a) Demonstrates skills in using patient care technologies, information systems, and communica-tion devices that support safe nursing practiceSkills (S4b) Demonstrates proÞciency in basic com-puter skills related to com-munication and data accessSkills (S4c) Utilizes tele-communication technolo-gies to assist in effective communication in a variety of healthcare settingsMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfFigure 11-3 The bar-coded patient identification bracelet is an essential feature of BCMA.© Monkey Business Images/Shutterstock.KEY COMPETENCY 11-9Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesInformatics and Technology:Skills (S4d) Applies safe-guards and decision-making support tools embedded in patient care technologies and information systems to CHAPTER 11 Informatics in Professional Nursing Practice326
interact with outpatient registration systems to collect and track pa-tient information, such as demographics, hospital number, relatives, and primary physician. All patient encounters are connected to these interacting systems. Information systems within healthcare organiza-tions organize data and track fiscal operations of an organization, including reporting, scheduling, payroll, and billing. Ancillary applica-tions permit sharing of information among multiple systems and spe-cialty areas, such as those of radiology, laboratory, physical therapy, and pharmacy. Acuity applications attempt to predict the resources necessary for patient care and are integrated with other systems, such as staffing, to create adequate patient unit staffing. Systems are found in specialized units within the healthcare setting that include monitor-ing equipment in intensive care units that automatically measure and record physiologic data, generate trends, sound alarms for abnormali-ties, and interact with other information systems within the patient environment, including physician notification of abnormal patient data and trends. Critical pathways, generated by information systems, identify specific patient outcomes and make integrated documentation by different disciplines possible that in turn promotes cost-effective care through effective communication. Table 11-1 shows expected EHR roles in relation to key tasks.Sensmeier (2009) offers ways to improve nursing practice with technology, including seeking nursing input related to workflow, in-vesting in informatics training, promoting informatics excellence, and working for a staged approach to adopting a paperless EHR. Thede (2008) suggests that nursing professionals must engage in discus-sion to decide how data will be used, consider which data are to be included in the EHR, and determine the acceptable terminology to be used when recording the data. Work must be done to refine and implement standardized nursing terminologies that better express nursing care. As standardized nursing terminologies become unique to nursing, some benefits will include better communication, improved patient care, and a uniform style for nursing data collection that will aid in evaluation of nursing care outcomes (Thede & Schwiran, 2011). A Òcardinal rule in informatics is one entry of a piece of data, many usesÓ (Thede, 2012, p. 2). The same data can be used in a va-riety of reports, leading to decreased redundancy of charting, and clinical documentation systems have the advantage of easily collecting data for use in planning and evaluation, particularly if the data are in a standardized format and use standardized terminology.Mobile DevicesA wide variety of mobile devices are available that may include smart-phones or personal digital assistants (PDAs), among others. Mobile devices have wireless connectivity and can synchronize data. Use of support a safe practice en-vironment for both patients and healthcare workersSkills (S4e) Utilizes EHR systems to document interventions related to achieving nurse sensitive outcomesSkills (S4f) Applies patient care technologies as ap-propriate to address the needs of a diverse patient populationAttitudes/Behaviors (A4) Values the importance of the technology on patient care and quality and safety outcomesMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfKEY OUTCOME 11-8Example of Domain 8 sub-competency for entry-level professional nursing education.8.3d Examine how emerg-ing technologies inßuence healthcare delivery and clinical decision making (p. 50).Reproduced from American Association of Colleges of Nursing. (2021). The Essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfInformation Management327
the smartphone and PDA has become popular in health care. The de-vices can be used as a digital reference for obtaining drug information, dosage calculations, and diagnostic test results as well as decision pro-tocols for administration. They are useful tools for data collection and management of patient outcomes. Some PDAs can be interfaced with the EHR to obtain and update vital patient information. Immediate access to the Internet allows the healthcare provider to obtain valu-able information through national and international resources.TABLE 11-1 Expected Electronic Health Record TasksElectronic Health Record RoleKey TasksMemoryComputationDecision SupportCollaborationReview patient historyDisplay avail-able history and demographicsProvide con-textual view of overall patient healthRecommend care based on patient characteristicsIncorporate in-formation from outside sourcesConduct patient assessmentPrompt for required informationCompute statis-tics (body mass index, etc.)Provide action-oriented clinical remindersCoordinate across multiple providersDetermine clinical decisionRelate assess-ment to patient historyDisplay trends, reference rangesSupport based on outside research/recommendationsStaff views/instructionsDevelop treatment planStandards of care, care plans, evidence-based guidelinesApply stan-dards of care based on patient characteristicsEvidence-based care adjusted by patient characteristicsPatient summary, educational toolsOrder ad-ditional servicesReview previous services/resultsDetermine appropriate provider/locationAlignment with insurance requirementsCreate referrals, facilitate provider communicationPrescribe medicationsMedication his-tory, allergies, formularyDose calculationInteractions, con-traindications, effectivenessPatient instruc-tions, side effects, and warningsDocument visitDiagnosis and treatment codesPrompts/ automatic populationInsurance guidelinesPatient education, coordination with multiple providersArmijo, D., McDonnell, C., & Werner, K. (2009). Electronic health record usability: Evaluation and use case frame-work (Publication No. 09(10)-0091-1-EF). U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality. https://healthit.ahrq.gov/sites/default/files/docs/citation /09-10-0091-1-EF.pdfKEY COMPETENCY 11-9Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesInformatics and Technology:Knowledge (K5a) Describes the EHR implementation processCHAPTER 11 Informatics in Professional Nursing Practice328
Available options for mobile devices can vary with different ser-vice plans, coverage areas, and memory size. Upon employment and when there are any policy changes, nurses must review the healthcare facility policies on the use of mobile devices while at work.HIPAA regulations must be strictly followed when using smart-phones, PDAs, and other wireless technology. The use of cell phones and PDAs in the clinical setting must be compliant with HIPAA rules and regulations; smartphones and PDAs are not allowed by many facilities because of concerns about patient privacy (Mastrian et al., 2011), although security applications are available that allow the use of mobile devices to be used while remaining compliant with HIPAA regulations.Personal Health RecordIn addition to electronic health information for professional use, patients also have access to an electronic record of health-related information through what is known as a personal health record. The personal health record conforms to interoperability standards and is available via a patient portal. The patient manages, shares, and controls the information in the personal health record. The patient portal can also be used to provide discharge or medication teaching, health promotion, and prevention education and to engage the patient as a partner in care through use of software programs and patient pathways.In addition, patients have access to a myriad of health-related technology in the form of wellness applications (apps), personal wellness devices, and wellness tracking sites. From coordination of chronic disease using implantable devices for glucose monitoring to wearable activity monitors, calorie monitors, and sleep monitors to enhance wellness, the future of both caring for the sick and personal wellness are increasingly joined to the use of technology.Current and Future TrendsThe innovative nurse leader both now and in the future will provide guidance for incorporating technology to produce changes in prac-tice that enhance patient, family, and economic outcomes through improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health care (TIGER Initiative Foundation, 2014). Clearly, technology is intertwined with most processes in health care and thus does affect health care for in-dividuals, populations, and organizations. Recognizing this fact, the Healthy People 2010 objectives (USDHHS, 2000) called for increas-ing the number of households with access to the Internet. Health communication and HIT are also objectives of Healthy People 2020, Knowledge (K5b) IdentiÞes the different roles involved in system design, analysis and management, including core nursing responsibili-ties associated with an EHR implementationKnowledge (K5c) DeÞnes informatics skills required in system developmentSkills (S5a) Participates in EHR System ImplementationSkills (S5b) Works with inter-disciplinary teams to make decisions regarding the application of technologies and the acquisition of dataSkills (S5c) Recognizes that redesign of workßow and care processes should precede implementation of care technology to facili-tate nursing practiceSkills (S5d) Participates in evaluation of information systems in practice set-tings through policy and procedure developmentAttitudes/Behaviors (A5) Values nursesÕ involvement in design, selection, imple-mentation and evaluation of information technologies to support patient careMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfCurrent and Future Trends329
KEY OUTCOME 11-9Example of Domain 8 sub-competency for entry-level professional nursing education.8.3e Identify impact of in-formation and communica-tion technology on quality and safety of care (p. 50).Reproduced from American Association of Colleges of Nursing. (2021). The Essentials: Core competencies for professional nursing education. https://www.aacnnursing.org /Portals/42/AcademicNursing/pdf /Essentials-2021.pdfwith the goal to improve healthcare quality and safety (USDHHS, n.d.-a).Because health information systems have the capacity to share information across organizations, nurse leaders are able to use data to generate knowledge related to population health and how to plan for the care needs of the future. The dashboards in these informa-tion systems allow the nurse to view performance metrics related to employee, patient satisfaction, finance, market share, and clini-cal quality and safety. Most healthcare organizations and public service agencies use the information systems as the main avenue for information delivery and communication. The development and implementation of health informatics communication platforms of-fer a way to enhance information exchange between providers and patients. In addition, information technology can reduce costs by streamlining workflow and improving efficiency (TIGER Initiative Foundation, 2014).For example, beginning in 2012, an initiative of the CMS, the Hospital Value-Based Purchasing (VBP) Program, was introduced to gather data related to performance and quality of care and uses the data to determine how much the hospital is paid for services. Measures of mortality and complications, healthcare-associated infections, patient safety, patient experience, efficiency and cost reduction, and processes are used to rank hospitals. Several specific patient care measures related to nursing are reported. Some process measures include discharge instructions, serum glucose levels for postoperative cardiac patients, and several other specific measures for the patient undergoing surgery. Measures of patient experiences include communication with nurses, communication about medi-cines, responsiveness of hospital staff, and discharge information (CMS, n.d.). Education, surveillance, reporting, and communication of VBP measures for the nursing and hospital staff will continue to be a priority for healthcare organizations because the effect is fiscal.Just as the VBP program has a fiscal influence, so do the Medi-care and Medicaid EHR Incentive Programs have the focus of the Òmeaningful useÓ of certified EHR information systems that were discussed earlier in this chapter. Financial incentives are attached to the health-related goals (Centers for Disease Control and Prevention, 2020); thus, nurses will play an essential role in aiding organizations to meet meaningful use criteria of EHR systems (Alexander, 2015a). The use of health information systems is currently vital and will con-tinue to be so in healthcare programs and delivery systems. It will be imperative to the financial viability of healthcare organizations to have a qualified workforce with the competencies to function in this increasingly complex environment. Nursing has positioned itself well to meet this challenge.KEY COMPETENCY 11-10Examples of applicable Nurse of the Future: Nurs-ing Core CompetenciesInformatics and Technology:Knowledge (K9) Describes emerging areas of infor-matics that will inßuence the development of the EHR, patient care and pro-fessional practiceSkills (S9) Discusses the value of emerging trends and how they will inßuence healthcare reformSkills (S6c) Teaches pa-tients about healthcare technologiesSkills (S6d) Adapts the use of technologies to meet patient needsAttitudes/Behaviors (A9) Values informatics as an evolving disciplineMassachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. http://www.mass.edu/nahi /documents/NOFRNCompetencies _updated_March2016.pdfCHAPTER 11 Informatics in Professional Nursing Practice330
ConclusionInformatics provides the solution to many of the challenges that health care is facingÑfrom easing the strain of the nursing shortage to improving pa-tient safety. Nurses must embrace technology and integrate it into their nursing practice. Technology will not go away. It will continue to transform healthcare delivery systems. Because of technology, individuals and groups communicate in new ways, the methods with which we teach and learn have changed, and the way health care is delivered has changed. Nursing must continue to take a leadership role in the incorporation of technology into health care, and each pro-fessional nurse should strive to fully incorporate informatics compe-tencies into his or her own practice to improve healthcare quality and patient safety.CRITICAL THINKING QUESTION✶Discuss issues of the digital divide. Explore resources in your city and county for the general public to have free Internet access and assistance. What other technologic resources are available for underserved populations?✶ReferencesAlexander, S. (2015a). The electronic health record. In S. Alexander, K. H. Frith, & H. Joy (Eds.), Applied clinical informatics for nurses (pp. 200Ð221). Jones & Bartlett Learning.Alexander, S. (2015b). Overview of informatics in health care. In S. Alexander, K. H. Frith, & H. Joy (Eds.), Applied clinical informatics for nurses (pp. 3Ð15). Jones & Bartlett Learning.Classroom Activity 11-1Explore possible online sources to locate sup-port groups available for individuals needing services in your area, county or parish, region, and state.Classroom Activity 11-2View the NCSBN Social Media Guidelines video during class and then allow discus-sion related to the guidelines, behaviors, and consequences of behaviors related to the in-appropriate use of social media. The video is available at https://www.ncsbn.org/347.htm.Classroom Activity 11-3Numerous classroom and clinical activities related to informatics are available on the QSEN website at https://qsen.org. Choose activities from the website for students to complete that meet specific course objectives.References331
American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/Portals/42/AcademicNursing/pdf/Essentials-2021.pdfAmerican Nurses Association. (2001). Scope and standards of nursing informatics practice. Author.American Nurses Association. (2008). Scope and standards of nursing informatics practice. Author.American Nurses Association. (2011a). Fact sheet. Navigating the world of social media. Author.American Nurses Association. (2011b). 6 tips for nurses using social media. Author.American Nurses Association. (2014). Nursing informatics: Scope and standards of practice (2nd ed.). Author.Armijo, D., McDonnell, C., & Werner, K. (2009). Electronic health record usability: Evaluation and use case framework (Publication No. 09(10)-0091-1-EF). U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality.Bliss, J. B., & DeYoung, S. (2002). Working the Web: A guide for nurses. Prentice Hall.Carmona, R. H. (2012). The Surgeon GeneralÕs Call to Action to Improve the Health and Wellness of Persons with Disabilities. CreateSpace Independent Publishing Platform.Centers for Disease Control and Prevention. (2020). Public health and promoting interoperability programs. https://www.cdc.gov/ehrmeaningfuluse/introduction.htmlCenters for Medicare and Medicaid Services. (n.d.). Hospital value-based purchasing. https://www.cms .gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HVBP /Hospital-Value-Based-PurchasingChang, B. L., Bakken, S., Brown, S. S., Houston, T. K., Kreps, G. L., Kukafka, R., . . . Stavri, P. Z. (2004). Bridging the digital divide: Reaching vulnerable populations. Journal of the American Medical Informatics Association, 11(6), 448Ð457.Cochrane Collaboration. (n.d.). About the Cochrane Library. http://www.cochranelibrary.com/about /about-the-cochrane-library.htmlGarner, J. C. (2003). Final HIPAA security regulations: A review. Managed Care Quarterly, 3(11), 15Ð27.Hannah, K. (1985). Current trends in nursing informatics: Implications for curriculum planning. In K. Hannah, E. J. Builenmin, & D. N. Corkin (Eds.), Nursing uses of computer and information science (pp. 181Ð187). North-Holland.Healthcare IT. (2004). President Bush continues EHR push, sets national goals. https://www.healthcareitnews .com/news/president-bush-continues-ehr-push-sets-national-goalsHealth on the Net Foundation. (n.d.). HON code of conduct. https://www.hon.ch/HONcode/Patients /Visitor/visitor.htmlHealth 2.0 Developer Challenge. (n.d.). Home. http://legacy.health2con.com/devchallenge/about/Hebda, T., & Czar, P. (2009). Handbook of informatics for nurses and healthcare professionals (4th ed.). Pearson Prentice Hall.Institute of Medicine. (1997). The computer-based patient record: An essential technology for health care. National Academies Press.Institute of Medicine. (1999). To err is human: Building a safer health care system. National Academies Press.Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academies Press.Institute of Medicine. (2011). Health IT and patient safety: Building safer systems for better care. https://pubmed.ncbi.nlm.nih.gov/24600741/Lindsay, R. (2011). Social media and disasters: Current uses, future options, and policy considerations (CRS Report R41987). Congressional Research Service.Massachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. https://www.mass.edu/nahi/documents/nofrncompetencies_updated_march2016.pdfMastrian, K. G., McGonigle, D., Mahan, W. L., & Bixler, B. (2011). Integrating technology in nursing education. Tools for the knowledge era. Jones & Bartlett Learning.CHAPTER 11 Informatics in Professional Nursing Practice332
McGonigle, D., & Mastrian, K. (2009). Nursing informatics and the foundation of knowledge. Jones & Bartlett Learning.McGonigle, D., & Mastrian, K. (2012). Introduction to cognitive science and cognitive informatics. In D. McGonigle & K. G. Mastrian (Eds.), Nursing informatics and the foundation of knowledge (2nd ed., pp. 121Ð145). Jones & Bartlett Learning.National Council of State Boards of Nursing. (2011). White paper: A nurseÕs guide to the use of social media. https://www.ncsbn.org/Social_Media.pdfOffice of the National Coordinator for Health Information Technology. (n.d.). Health IT. http://www .healthit.govPagana, K. D. (2007). E-mail etiquette. American Nurse Today, 2(7), 45.Quality and Safety Education for Nurses. (n.d.). About QSEN. http://qsen.org/about-qsen/Saba, V. K., & McCormick, K. A. (2015). Essentials of nursing informatics (6th ed.). McGraw Hill.Sensmeier, J. (2009). Deep impact: Informatics and nursing practice. Nursing Management, 2, 4, 6. https://journals.lww.com/nursing/fulltext/2009/05001/Deep_impact__Informatics_and_nursing_practice.3.aspxSilsbee, D., & Reed, F. I. (2014). Informatics. In P. Kelly, B. A. Vottero, & C. A. Christie-McAuliffe (Eds.), Introduction to quality and safety education for nurses (pp. 270Ð308). Springer.Smeltzer, S., Zimmerman, V., Frain, M., DeSilets, L., & Duffin, J. (2003). Accessible online health promotion information for persons with disabilities. Online Journal of Issues in Nursing. https://ojin .nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents /Volume92004/No1Jan04/ArticlePreviousTopic/AccessibleInformation.htmlStaggers, N., Gassert, C. A., & Curran, C. (2001). Informatics competencies for nurses at four levels of practice. Journal of Nursing Education, 40(7), 303Ð316.Technology Informatics Guiding Education Reform. (2009). The TIGER initiative. Collaborating to integrate evidence and informatics into nursing practice and education: An executive summary. http://s3.amazonaws.com/rdcms-himss/files/production/public/FileDownloads/tiger-report-executive -summary.pdfThede, L. Q. (2003). Informatics and nursing: Opportunities and challenges (2nd ed.). Lippincott Williams & Wilkins.Thede, L. (2008). The electronic health record: Will nursing be on board when the ship leaves? Online Journal of Issues in Nursing, 13(3). doi:10.3912/OJIN .Vol13No03InfoCol01Thede, L. (2012). Informatics: Where is it? Online Journal of Issues in Nursing, 17(1). doi:10.3612/OJIN .Vol17No1InfoCol01Thede, L., & Schwiran, P. (2011). Informatics: The standardized nursing terminologies: A national survey of nursesÕ experiences and attitudesÑsurvey I. Online Journal of Issues in Nursing, 16(2). doi:10.3912 /OJIN.Vol16No02InfoCol01Thede, L. Q., & Sewell, J. P. (2010). Informatics and nursing competencies and applications. Wolters Kluwer/Lippincott Williams & Wilkins.TIGER Initiative Foundation. (2014). The leadership imperative: TIGERÕs recommendations for integrating technology to transform practice and education. http://s3.amazonaws.com/rdcms-himss /files/production/public/FileDownloads/the-leadership-imperative.pdfTransforming Health Through Information Technology. (2017). The evolution of TIGER competencies and informatics resources. https://www.himss.org/sites/hde/files/media/file/2020/03/10/the-evolution-of -tiger-competencies-and-informatics-resources-final-10.2017.pdfU.S. Department of Health and Human Services. (2000). Healthy People 2010: Understanding and improving health and objectives for improving health (2nd ed.). U.S. Government Printing Office.U.S. Department of Health and Human Services. (n.d.-a). Health communication and health information technology. https://www.healthypeople.gov/2020/topics-objectives/topic/health-communication -and-health-information-technologyReferences333
U.S. Department of Health and Human Services. (n.d.-b). Telehealth programs. https://www.hrsa.gov /rural-health/telehealth/Walton, J. J. (2012). Informatics. In G. Sherwood & J. Barnsteiner (Eds.), Quality and safety in nursing: A competency approach to improving outcomes (pp. 171Ð187). Wiley.White House Archives. (2004). Fact sheet: Transforming health care for all Americans. https://georgewbush-whitehouse.archives.gov/news/releases/2004/05/20040527-2.htmlZykowski, M. E. (2003). Nursing informatics: The key to unlocking contemporary nursing practice. AACN Clinical Issues, 14(3), 271Ð281.CHAPTER 11 Informatics in Professional Nursing Practice334
Perhaps you wonder why hospitals are called healthcare delivery systems and not just hospitals or why nurses are referred to as pro-fessional nurses and not just nurses. This chapter explores what the healthcare delivery system means to us and some of the roles nurses play that define what it means to be a professional nurse. In addi-tion, various models of nursing care delivery are discussed so that the graduate nurse possesses a greater understanding of the healthcare delivery environment.Registered nurses (RNs) manage the care of specific groups of patients, perform care, direct others to provide care, and collaborate with other healthcare providers. Nurses must know how to delegate, supervise, evaluate, motivate, and communicate with other disciplines, nurses, and unlicensed personnel. The professional nurse assesses patients and evaluates the expertise of nursing staff when making as-signments. The nurseÕs role encompasses both interprofessional and intraprofessional collaboration in the continuity of care, from admis-sion to discharge and through rehabilitation. Nurses direct nursing Key Terms and Concepts ÈCase management ÈCollaborative critical pathway ÈComplex adaptive system ÈLeadership competencies ÈLeadership styles ÈLeadership theory ÈMacrosystem ÈMesosystem ÈMicrosystem ÈModels of patient care delivery ÈOrganizational theory ÈTeam nursing ÈTotal patient careAfter completing this chapter, the student should be able to:1. Describe organizational and leadership theories commonly observed in the health-care system.2. Describe complex adaptive systems in the context of the healthcare system.3. Discuss the competencies and evolving roles of nurse leaders in complex health-care systems.4. Describe nursing care delivery models and the roles of the professional nurse in the healthcare system.Learning ObjectivesLeadership and Systems-Based Professional Nursing PracticeKathleen Masters and Sharon Vincent335CHAPTER 12© Nuu Jeed/Shutterstock
care within a delivery setting to protect patients, patientsÕ significant others, and healthcare personnel. Nurses also lead teams, units, and divisions within healthcare settings. As one can see, nurses at all levels in the healthcare system need strong leadership skills to contribute to patient safety and quality care (Institute of Medicine [IOM], 2011, p. 223).Healthcare Delivery SystemThe healthcare delivery system has changed profoundly over the past several decades for many reasons. Population shifts (demographic changes), cultural diversity, the patterns of diseases, advances in technology, and economic changes have all affected the practice of nursing. Population changes affect the delivery of health care. Health care is needed now more than in the past because of changes in the population. The population is growing, the composition of the population is changing, birth rates are decreasing, and the life span is lengthening. People older than 85 years of age, who often require health care for chronic conditions, make up one of the fastest-growing segments of the population. A population with larger numbers of senior citizens, many of whom are women, obviously impacts the healthcare delivery system because of the healthcare resources consumed.A significant portion of the population also now resides in urban areas, with a steady influx of ethnic minorities. The number of home-less persons, including homeless families, are on the rise. Cultural di-versity increases as people from different nationalities enter the United States. The professional nurse working in the current healthcare sys-tem must know how to provide for the diverse needs of people from varied cultural backgrounds.In the last 50 years, evolving patterns of disease have brought sig-nificant changes to the healthcare delivery system. Infectious diseases that were once isolated are spread across the globe quickly in our in-creasingly mobile society. Because of the widespread inappropriate use of antibiotics, an increasing number of infectious agents are becoming resistant to antibiotic therapy. Obesity is now a major health chal-lenge as are its comorbidities: hypertension, coronary heart disease, diabetes mellitus, and cancer.In addition, the improvement in techniques for trauma and acute care means that more people are surviving catastrophic events and living decades longer with disability and chronic conditions. Technol-ogy has boosted surgical and diagnostic service areas so that patients can receive sophisticated treatment on an outpatient basis. Commu-nication techniques provide a means to train providers and deliver health care to remote countries or islands by satellite. For example, the Veterans Administration has a program of posttraumatic stress CHAPTER 12 Leadership and Systems-Based Professional Nursing Practice336
disorder and telemental health for veterans in tribal reservations and on remote islands.In the past, the healthcare delivery system was focused on acute care, and most care occurred in the hospital setting, including test-ing and long recuperation periods after procedures. Currently, many patients stay in the hospital for a very short time and healthcare de-livery routinely includes testing and precertification, telecommunica-tions, home health, mobile vans, and outpatient clinics. Obviously, the old system was very expensive. In 1983 when it was recognized that healthcare costs had become alarmingly high, cost containment man-dated by Congress resulted in the initiation of diagnosis-related groups (DRGs) intended to cut costs related to Medicare reimbursement. Over time, integrated healthcare systems emerged that required coordination across settings. These healthcare systems reorganized services to move care from expensive inpatient facilities to primary care and community settings and to do so as quickly as possible (AACN, 2021, p. 7).As treatment became focused on cost and profit, nurses perceived that the quality of nursing care declined, leaving many nurses stressed and disillusioned as hospitals operated with fewer resources. Nurses continue to be challenged to provide high-quality care with fewer re-sources available to them within their organizations, and thus in this healthcare environment it is imperative that nurses, particularly nurse leaders, understand the structures, systems, politics, regulations, and economics of the healthcare system in order to provide patient care that is both high quality and efficient.Organizational TheoryTo understand how healthcare organizations and systems function, it is important to understand some basic concepts related to orga-nizational theory. An organization is a collection of people working within a defined structure to achieve specific outcomes. The most popular schools of organizational theory include classical theory, systems theory, contingency theory, chaos theory, and complexity theory.The classical theory approach to organization focuses on the structure of the organization and is built around four elements: divi-sion and specialization of labor, organizational structure, chain of command, and span of control. Typically, workers are grouped by interrelated functions into departments with the division and special-ization of labor increasing both efficiency and proficiency. The chain of command refers to the hierarchy of authority and responsibility in an organization. Line authority is a type of authority in traditional healthcare delivery systems in which the supervisor directs the activi-ties of the employees he or she supervises. A chain of command al-lows employees to understand their tasks and to manage supervisory KEY OUTCOME 12-1Example of Domain 7 sub-competency for entry-level professional nursing education.7.1c Differentiate between various healthcare delivery environments across the continuum of care (p. 46).Reproduced from American Association of Colleges of Nursing. (2021). The Essentials: Core competencies for professional nursing education. https://www.aacnnursing .org/Portals/42/AcademicNursing/pdf /Essentials-2021.pdf Organizational Theory337
relationships within the organization. This structure provides an avenue for reporting issues that need managementÕs attention. Orga-nizational charts showing the chain of command illustrate the flow of responsibility from staff nurse to nurse managers and up to the chief nursing officer. This model is reflective of the traditional centralized/decentralized approach commonly observed in a hospital setting (Sullivan, 2013, p. 12).Systems theory as viewed in health care is based on the assump-tion that the organization is a complex open system with a recurrent cycle of input, throughput, and output. The process begins with the input of resources such as employees, equipment, and revenue im-ported from the environment. Energy and resources within the organi-zation are used and transformed by a process of work or throughput to produce a product or output. The output returns to the environ-ment. Throughput in health care is commonly associated with moving patients into and out of the system. Even Joint Commission accredita-tion standards require data to demonstrate systems throughput statis-tics (Sullivan, 2017).Contingency theory is based on an assumption that performance is enhanced when organizational structure matches its environment and that leadership style should vary based on the situation and the task. The environment of a healthcare organization is comprised of forces outside of the organization that include patients and potential patients, third-party payers, regulators, and competitors, as well as suppliers of the healthcare workforce and equipment. Based on the variety of external environments experienced by healthcare organiza-tions in different locations with potential employeesÕ differing skill sets and with different target patient populations, the best structure for a healthcare organization based on this theory may not be the same as an organization in another city, region, or state but, rather, will be contingent on the circumstances of that specific organization (Sullivan, 2017).Chaos theory challenges traditional thinking regarding organiza-tional design and submits that the drive to have a permanent organi-zational structure is destined to fail since organizations are complex self-organizing and self-adaptive systems. It is important to note that chaos theory reflects a different concept than the common meaning for the word chaos. In a system that conforms to chaos theory, things may appear random when analyzed using a linear method; however, the system does exhibit patterned variation when analyzed using a nonlinear approach. Thus, chaos theory is, in reality, a patterned complexity (Engebretson & Hickey, 2018). Chaos theory posits that organizations must allow flexibility and adaptability and that the role of the leader is to build resilience in the changing organization as well as maintain a balance between tension and order in order to prevent instability (Sullivan, 2017).CHAPTER 12 Leadership and Systems-Based Professional Nursing Practice338
Complexity theory specifically addresses the phenomenon of ÒcomplexityÓ and explains the behavior of complex systems in the context of the whole system rather than its constituent parts. Com-plex systems are networks of people exchanging information. Con-stant interaction, such as the communication required to maintain patient care, leads to greater system complexity. Complex systems or-ganize from within and respond collectively to stimuli external to the system boundary. This collective response may take the form of ad-aptation. The term complex adaptive system is often used to describe organizations in the context of complexity theory (Chandler, et al., 2016). Healthcare organizations are examples of complex systems that typically contain systems embedded within systems and, as such, can be considered complex adaptive systems.A complex adaptive system is highly adaptive and is character-ized by self-organization, emergence of new patterns or behaviors, and distributed rather than centralized control. Application of complex adaptive system concepts to the organizational structure of healthcare organizations can be used to describe a zone of com-plexity in which complex adaptive systems have the ability to adapt to different conditions (Engebretson & Hickey, 2018). One unit or agent can change the order of behavior; however, this change does not necessarily follow a linear pattern as far as organizational structure.Healthcare Organizations and SystemsSo, what do we mean by systems-based practice in the context of health care and healthcare organizations? Competency in systems-based practice requires the healthcare provider to be aware of and responsive to the larger context of the healthcare system and to demonstrate the ability to effectively call on resources to provide optimal care (Massachusetts Department of Higher Education, 2016, p. 22). This obviously requires teamwork between nurses and other members of the healthcare team, but at the heart of systems-based practice is a focus on the broader context of health care.The healthcare system is a heavily regulated Òkaleidoscope of fi-nancing, insurance, delivery, and payment mechanismsÓ (Shi & Singh, 2019, p. 4) that are both public and private and only loosely coor-dinated. It is important for nurse leaders to understand the position of their organization within the healthcare system to assess how the changes in financing, insurance, delivery, and payment might affect their own organization since healthcare microsystems mesosystems are directly impacted by the trends of the healthcare macrosystem. In response to changes, for example, the nurse manager at the unit level Healthcare Organizations and Systems339
may have to make decisions regarding the elimination or modification of services due to changes in funding or the realignment of resources in the unit to meet new standards (Shi & Singh, 2019, p. 20).Each member of the healthcare team will view health care and the healthcare system from a different lens or perspective depending on their discipline and upon their role within the system. For example, a nurse working within a specific hospital unit or clinic will experience the healthcare system on a daily basis at the microsystem level. The nursing leader who is responsible for nursing service provision across units in an organization will experience the healthcare system at the small macrosystem level. The nurse who is involved in healthcare policy at the national level will be involved in the healthcare system at the macro level; however, regardless of the role within the system, all nurses need to be aware of the impact that the larger system forces on their daily practice.New models of healthcare delivery have emerged as organizations have faced increasing unpredictability and change. To counteract the increasing prevalence and size of managed care organizations, pro-viders began to consolidate practices and large, integrated healthcare organizations were formed. This has resulted in many large hospitals and group practices becoming part of larger health systems and has created a system dominated by healthcare corporations (Shi & Singh, 2019, p. 122).In addition to local consolidation, the health-care system has experienced organizational integra-tion that reaches beyond local boundaries. Three of the most popular integration strategies include outright ownership through merger or acquisition, joining with an-other organization in common ownership such as a joint venture, and gaining a stake in