Role Development in Professional Nursing Practice [3 ed.] 9781449691509, 9781449681982, 2012031815

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role development in Professional Nursing Practice

The Pedagogy Rote D e v e lo p m e n t in P ro fe s s io n a l N u rs in g P ra c tic e , T h ird E d itio n drives com p rehension th ro u g h variou s s tra te g ie s th a t m e e t th e learning needs of stu d en ts, w hile also g e n e ra tin g enthusiasm ab o u t th e to p ic. This in te ra c tiv e approach addresses d iffe re n t learning styles, m aking this th e ideal te x t to ensure m a s te ry of key concep ts. The pedagogical aids th a t a p p e a r in m ost c h ap ters include th e follow ing:

Key Terms and Concepts Scientific and technological advances, economic realities, pluralistic worldviews, and global communication make it impossible for nurses to ignore important ethical issues in the world community, their individual lives, and their work. As controversial and sensitive ethical issues continue to challenge nurses and other healthcare professionals, many professionals have begun to develop an appreciation for personal philosophies of ethics and the diverse viewpoints of others. Often ethical directives are not clearly evident, which leads some people to argue that ethics can be based merely on personal opinions. However, if nurses are to enter into the global dialogue about ethics, they must do more than practice ethics based simply on their personal opinions, their intuition, or the unexamined beliefs that are proposed by other people. It is important for nurses to have a basic understanding of the various concepts, theories, approaches, and principles used in ethics throughout history and to identify and analyze ethical issues and dilemmas that are relevant to nurses in this cen­ tury. Mature ethical sensitivities are critical to professional nursing practice.

Ethics Bioethics Nursing ethics Wholeness of character Integrity Basic dignity Personal dignity

K e y Term s and C o n c e p ts Found in a list a t th e beginning of each chapter, th e s e te rm s will c re a te an expanded v o ca b u lary. Use th e access code a t th e fro n t of y o u r book to access a d d itio n a l resources online.

Deontology Utilitarianism Ethic of care Ethical principlism Autonomy

Moral suffering

After completing this chapter, the student should be 1. Discuss the meaning of key terms associated with ethical nursing practice. 2. Compare and contrast ethical theories and approaches th at m ight be used in nursing practice. 3. Discuss each of the popular bioethical principles as they relate to nursing practice: autonomy, beneficence, nonmaleficence, and justice.

L e a rn in g O b je c tiv e s These o b je c tiv e s provide in s tru c to rs and s tu d e n ts w ith a s n ap s h o t of th e key in fo rm a tio n th e y will e n c o u n te r in each chapter. T h e y s e rv e as a ch ec klist to help guide and focus study. O b je ctive s can also be found w ith in th e te x t's online resources.

C as e S tu d ie s Case studies encou rage a c tiv e learning and p ro m o te critical th in k in g skills in learn ers. S tu d en ts can read a bout re a l-life scenarios, and th en a n a ly ze th e situ atio n th e y are presented w ith . C o m p lete questions online using th e access code in th e fro n t of yo u r book. CaseStudyQuestions consultedabout Ms. Cranford's case. Answer thefol­ • to regulat^her lowingquesoons: he procedure 1. Whatarethe cental ethical issues andquesoons for a longwhile before discussingit withher sonand by "best interest" insufficiency. 'Shefeels veryored She decides that she does not want a pacemaker. Once Ms. Cranfordteds with the physicianto . 1 ^ He options. The physi­ cian andMs. Cranford's sonrevisitedthis issue with her inanattempt to persuade her to changeher mind,

C r itic a l Th in k in g Q u e s tio n s R eview key concepts w ith th e s e questions in each c hapter. R eview th e s e qu estio n s online and su b m it y o u r answ ers d ire c tly to yo u r professor.

4. Use the Four Topics Method to discuss issues, to identify additional information that might be needed, andto analyze this case. What are 5. What is the role of the nurses eating for

Nursing Practice

theseapproachestoreservea conflict?Which of impersonal universal rules and principles- In resolving approachor approacheshaveyouused? * moral conflicts and understanding a complex situation, a person must use critical thinkingto inquire about relation­ ships, circumstances, andthe problem at hand. The situ­ ation must be brought to lig' ' "“can ' ' ' light with g;enIe:ny,= patth; 8 h r n•ss,anda"

■ Ethical Principlism

self-care or is detrimental. Divide students into ■from the very begnnmg of small groups to playthe Nursng School Survival l career. Game. Students roll the dice to determine how Spaces onthe bo many spaces to move. As they move aroundthe categories if verbal questions will be at board, theywill progress fromnursingschool ad­ during the game. If this approach is used, the " mission to second semester, thud semester, fourth semester, andthengraduaoon. egories to progress aroundthe board. Another approach to this game that is fun is to have different colored pieces of paper labeled as categories of self-eare questions on the floor, creating agameboardeffect andletong the stu­ dents (either alone or in groups) move around the “game board” as they answer questions relatedto self-care.

Covey, S. R. (1989). The 7 hab

highlyeffectivepeople. NewYork, NY: Simon&

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nent. In L. A. Joel (Ed), Kellys dimensions of

Miller, T. W. (2003). W. a care.er n nmmg. fr OxfordUniversityIfress. Riley,J. B. (2004). Feedback. InJ. B. Riley(Ed), Co St. Louis, MO: Mosby.

1)

Ethical principlism, apopular app a set of ethical principles that is drawn fromthe c cencepuen of morality. The four principles that are n bioethics are a and]usoce. In 1979, andJames Childresspublishedthe first edition of Principles of Biomedical Ethics, which featured these four principles- Currently, the book is in its sixth edition, andthe four principles have become an essential foundaoon for analyzing andresolving bioethical problems. These principles, which are closely associated with rule-based ethics, provide a framework to support moral behavior anddecisionmaking- How­ ever, theprinciplesneither formatheory nor provide awell-defineddecisionThe framework of principHsmprovides a prrna facie model- As aprima facie model, principles are The four principles that are appliedbased onrules andjustificationsfor moral behavior. most commonly used in bio­ Often, more than one principle is relevant in ethical ethics are autonomy, benefi­ cence, nonmaleficence, and ciples conflict m any situation, judgment must be used m weighingwhichprinciple shouldtake precedence rnguiding actions.

C la s s ro o m A c t i v i t i e s Each c h a p te r includes classroom a c tiv itie s th a t focus on how th e in fo rm a tio n in th e te x t applies to e v e ry d a y p ra ctice . S tu d en ts can a n sw er questions in a group o r as individuals. A c tiv itie s can also be found w ith in th e te x t's online resources.

T h e In t e g r a t e d T e a c h in g a n d L e a r n in g P a c k a g e W elcom e to R o le D e v e lo p m e n t in P ro fe s s io n a l N u rs in g P ra c tic e , T h ird E d itio n . To help m e e t th e changing needs of to day's fa c u lty and s tu d e n ts, this te x t has been fu lly in te g ra te d w ith a s u ite of in s tru c to r and s tu d e n t a n cillaries, helping in stru cto rs te ac h m ore e ffic ie n tly and s tu d en ts learn m ore e ffe c tiv e ly .

STUDENT RESOURCES

INSTRUCTOR RESOURCES

The access code a t th e fro n t of yo u r book, s p ec ifica lly designed to accom pan y R o le D e v e lo p m e n t in P ro fe s s io n a l N u rs in g P ra c tic e , T h ird E d itio n , o ffers s tu d en ts a valu ab le in te g ra tio n of th e te x t and online s tu d y tools, including:

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Test Bank -C u s to m iz e q u iz z e s and te s ts th a t can be prin ted or a d m in is ­ te re d online.

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PowerPoint Presentations - M o d if y p re -m a d e c la s s ro o m p re s e n ta tio n s and use th e m in yo u r course.

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Sample Syllabus -S a v e tim e p re p a r­

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In te ra c tiv e G lossary

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Flashcards

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Crossword

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Learning O bjectives

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C ritica l Thinking Q uestions

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Case Studies

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Classroom A c tiv itie s Web Links

Learn More About Student Resources Online:

http://www.jblearning.com

ing c o u rs e p lan s w ith th is h e lp fu l guide. •

Sample Professional Development A s s ig n m e n t s - I m p l e m e n t th e s e assignm ents in your course to develop c ritic a l thin king skills in s tu d e n ts.

T h ird E d itio n

role development in Professional Nursing Practice

Edited by

Kathleen masters, dns , rn Associate Professor University of Southern Mississippi College of Nursing Hattiesburg, Mississippi

JO N E S & BARTLETT

LEARNING

W orld H ea d qu arters 5 Wall Street Burlington, M A 0 1 8 0 3 9 7 8 -4 4 3 -5 0 0 0 [email protected] www.jblearning.com Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com. Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to [email protected]. Copyright © 2014 by Jones & Bartlett Learning, LLC, an Ascend Learning Company All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner. R ole D evelopm ent in P rofessional Nursing Practice, Third Edition is an independent publication and has not been authorized, sponsored, or otherwise approved by the owners of the trademarks or service marks referenced in this product. Some images in this book feature models. These models do not necessarily endorse, represent, or participate in the activities represented in the images. The authors, editor, and publisher have made every effort to provide accurate information. However, they are not responsible for errors, omissions, or for any outcomes related to the use of the contents of this book and take no responsibility for the use of the products and procedures described. Treatments and side effects described in this book may not be applicable to all people; likewise, some people may require a dose or experience a side effect that is not described herein. Drugs and medical devices are discussed that may have limited availability controlled by the Food and Drug Administration (FDA) for use only in a research study or clinical trial. Research, clinical practice, and government regulations often change the accepted standard in this field. When consideration is being given to use of any drug in the clinical setting, the health care provider or reader is responsible for determining FDA status of the drug, reading the package insert, and reviewing prescribing information for the most up-to-date recommendations on dose, precautions, and contraindications, and determining the appropriate usage for the product. This is especially important in the case of drugs that are new or seldom used. Production Credits Executive Publisher: Kevin Sullivan Acquisitions Editor: Amanda Harvey Editorial Assistant: Sara Bempkins Associate Production Editor: Sara Fowles Marketing Communications Manager: Katie Hennessy V.P., Manufacturing and Inventory Control: Therese Connell

Composition: diacriTech Cover Design: Kristin E. Parker Cover Image: © Anton Petrus/ShutterStock; Inc. Printing and Binding: Courier Companies Cover Printing: Courier Companies

To order this product, use ISBN: 978-1-4496-9150-9 Library of Congress Cataloging-in-Publication Data Role development in professional nursing practice / [edited by] Kathleen Masters. — 3rd ed. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4496-8198-2 (pbk.) I. Masters, Kathleen. [DNLM: 1. Nursing— standards. 2. Nursing—trends. 3. Nurse’s Role. 4. Philosophy, Nursing. 5. Professional Practice. W Y 16] 610.73— dc23 2012031815 7149 Printed in the United States of America 17 16 15 14 13

10 9 8 7 6 5 4 3 2 1

Dedication This book is dedicated to my Heavenly Father and to my loving family: my husband, Eddie, and my two daughters, Rebecca and Rachel. Words cannot express my appreciation for their ongoing encouragement and support throughout my career.

Contents v_________________________________________ J Preface Contributors

XV XVII

UNIT I: FOUNDATIONS OF PROFESSIONAL NURSING PRACTICE

1

1

3

2

A H is to ry of H e a lth C a re and N u rs in g Karen Saucier Lundy Classical Era Middle Ages The Renaissance The Advancement of Science and Health of the Public The Emergence of Home Visiting The Reformation The Dark Period of Nursing Early Organized Health Care in the Americas: A Brave New World The Chadwick Report and the Shattuck Report The Industrial Revolution John Snow and the Science of Epidemiology And Then There Was Nightingale... Early Nursing Education and Organization in the United States The Evolution of Nursing in the United States: The First Century of Professional Nursing The New Century: An Era of Managed Care and Healthcare Reform The Nurse of the Future Conclusion References

3 8 9 10 11 11 12 13 13 14 16 16 27 28 40 41 42 43

F ram e w o rk fo r P ro fes sio n a l N u rs in g P ra c tic e Kathleen Masters

47

Overview of Selected Nursing Theories Relationship of Theory to Professional Nursing Practice Conclusion References

49 79 80 83

3

4

5

6

P h ilo so p h y of N u rs in g Mary W. Stewart

89

Philosophy Early Philosophy Paradigms Beliefs Values Developing a Personal Philosophy of Nursing Conclusion References

90 91 93 94 96 100 102 103

F o u n d atio n s of E th ic a l N u rs in g P ra c tic e Karen Rich and Janie B. Butts

105

Ethics in Everyday Life Bioethics Nursing Ethics Moral Reasoning Values in Nursing Ethical Theories and Approaches Professional Ethics and Codes Ethical Analysis and Decision Making in Nursing Conclusion References

106 106 107 107 108 109 114 117 122 122

S ocial C o n te x t of P ro fes sio n a l N u rs in g Rowena W. Elliott and Mary W. Stewart

125

Public Image of Nursing Media’s Influence The Gender Gap Cultural and Ethnic Diversity Access to Health Care Trends Conclusion Web Resources References

126 128 130 133 136 140 152 152 152

E d u c a tio n and S o c ia liz a tio n to th e P ro fes sio n a l N u rs in g Role Melanie Gilmore

157

Professional Nursing Values Socialization Process Reality Shock

158 159 162

7

Facilitating the Transition to Professional Practice Conclusions: Reflective Professional Practice References

163 164 164

C a re e r M a n a g e m e n t and C a re of th e P ro fes sio n a l S e lf LuannM. Daggett

167

Occupation vs. Career Common Myths and Misconceptions Setting Personal Goals Career Management Strategies Maximizing Your Visibility Networking Mentoring Evaluating Your Performance Coping with Adversity Commitment to the Profession Commitment to Ourselves Conclusion References

168 169 170 173 177 179 180 181 184 185 187 191 192

UNIT II: PROFESSIONAL NURSING PRACTICE AND THE MANAGEMENT OF PATIENT CARE 8

9

194

T h e H e a lth c a re D e liv e ry S y s te m and th e Role of th e P ro fes sio n a l N u rs e Sharon Vincent

195

Healthcare Delivery System Nursing Models of Patient Care Role of the Professional Nurse Continuous Quality Improvement Conclusion References

196 199 203 210 214 214

C ritic a l T h in k in g and C lin ica l J u d g m e n t in P ro fes sio n a l N u rs in g J ill Rushing

217

What Is Critical Thinking? Characteristics of Critical Thinking What Are the Characteristics of a Critical Thinker? Approaches to Developing Critical Thinking Skills Why Is Critical Thinking Important in Nursing Practice? Conclusion References

218 220 222 223 230 232 234

1 0

Evidence-Based Professional Nursing Practice

235

Kathleen Masters Evidence-Based Practice: What Is It? Barriers to Evidence-Based Practice Strategies to Promote Evidence-Based Practice Searching for Evidence Evaluating the Evidence Using the Evidence Models of Evidence-Based Nursing Practice Conclusion References

11

Ethical Issues in Professional Nursing Practice

235 237 237 238 240 242 243 246 247

249

Karen Rich and Janie B. Butts Relationships in Professional Practice Moral Rights and Autonomy Social Justice Death and End-of-Life Care Conclusion References

249 255 257 261 270 271

1 2 Law and the Professional Nurse Evadna Lyons and Kathleen Driscoll

275

The Sources of Law Classification and Enforcement of the Law Malpractice and Negligence Nursing Licensure Professional Accountability: Informed Consent, Privacy and Confidentiality, and Delegation Healthcare Reform Ethical, Legal, and Moral Courage to Confront Bullying in the Workplace Preventing Legal Problems Conclusion References

1 3

The Role of the Professional Nurse in Patient Education

276 278 281 287 292 300 300 301 302 303

305

Kathleen Masters Patient Education: What Is It? Theories and Principles of Learning The Patient Education Process Considerations: Patient Education with Older Adults Cultural Considerations Evaluation

306 306 309 316 319 319

Documentation of Patient Education Conclusion References

320 320 322

1 4 Informatics and Technology in Professional Nursing Practice Cathy K. Hughes

325

Nursing Informatics Defined Nursing Informatics: Direction for the Future Informatics Competencies Internet Resources Website Evaluation Electronic Databases Health Information Online Confidentiality, Security, and Privacy of Healthcare Information Electronic Health Records Communication Online Telehealth Handheld Devices Present and Future Trends Conclusion References

325 326 329 330 330 331 332 334 335 337 340 341 342 343 345

1 5 Future Directions in ProfessionalNursing Practice Katherine Elizabeth Nugent Nurse Shortage Nurse Faculty Shortage Nursing Practice and Workplace Environment Retention Workplace Environment Role Clarity Changing Demographics Nursing Education Conclusion References Appendix A Appendix B Glossary Index

American Nurses AssociationStandards o f Nursing Practice American Nurses AssociationCode o f Ethics

349 351 353 353 356 357 358 358 360 363 365 371 373 375 397

Although the process of professional development is a lifelong journey, it is a journey that begins in earnest during the time of academic preparation. The goal of this book is to provide nursing students with a road map to help guide them along their journey as a professional nurse. 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 issues related to professional nursing practice and the management of patient care. The chapters included in Unit I provide the student nurse with a basic foundation in areas such as nursing history, theory, philosophy, ethics, socialization into the nursing role, and the social context of nursing. Also included in Unit I is content related to the care of the professional self and career development in nursing. The chapters in Unit II are more directly related to patient care issues. Included are topics such as patient education, ethical issues in nursing practice, the law as it relates to patient care and nursing, clinical judgment, informatics and technology, and evidence-based nursing practice. Unit II concludes with a chapter addressing future directions in professional nursing practice. New to the third edition is the incorporation of the N urse o f the Future: N u rsin g C o r e C o m p e te n c ie s throughout each chapter. The N u rse o f th e Future: N ursing C ore C om peten cies “emanate from the foundation of nursing knowledge” (Massachusetts Department of Higher Education, 2010, p. 4) and are based on the American Association of Colleges of Nursing E ssentials o f B accalau reate E du cation fo r P rofession al Nursing Practice, National League for Nursing Council of Associate Degree Nursing competencies, Institute of Medicine recommendations, Q uality and Safety Education for Nursing competencies, and American Nurses A ssociation standards, as well as other professional organization standards and recommendations. The 10 competencies included in the model include patient-centered care, professionalism, informatics and technology, evidence-based practice, leadership, systems-based practice, safety, com m unication, team w ork and collab oration , and quality improvement. Essential knowledge, skills, and attitudes (KSA), reflecting cognitive, affective, and psychomotor learning domains, are specified for each competency. The KSA identified in the model reflect the expectations for initial nursing practice following the com pletion of a prelicensure professional nursing education program (Massachusetts Department of Higher Education, 2010, p. 4).

The N u rse o f th e Future: N ursing C ore C om p eten cies graphic illustrates through the use of broken lines the reciprocal and continuous 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 addition, nursing knowledge is placed as the core in the graphic to illustrate that nursing knowledge reflects the overarching art and science of professional nursing practice (Massachusetts Department of Higher Education, 201 0 , p. 4). This new edition has competency boxes throughout the chapters that link examples of the knowledge, skills, and attitudes (KSA) appropriate to the chapter content to N urse o f the Future: N ursing C ore C om petencies required of entrylevel professional nurses. The competency model in its entirety is available online at www.mass.edu/currentinit/documents/NursingCoreCompetencies.pdf. This new edition also contains more case studies with questions, which is congruent with Benner, Sutphen, Leonard, and Day’s (2010) Carnegie Report recommendations that nursing educators teach for “situated cognition” using narrative strategies to lead to “situated action ,” thus increasing the clinical connection in our teaching or that we teach for “clinical salience.” 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 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. K athleen M asters

References Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass. Massachusetts Department of Higher Education. (2010). Nurse o f the future: Nursing core com petencies. Retrieved from http://www.mass.edu/currentinit/documents/ NursingCoreCompetencies.pdf

Janie B. Butts, DSN, RN University of Southern Mississippi College of Nursing Hattiesburg, Mississippi Luann M . Daggett, DSN, RN Brentwood, Tennessee Kathleen Driscoll, JD , M S, RN University of Cincinnati College of Nursing Cincinnati, Ohio Rowena W. Elliott, PhD, RN , FAAN University of Southern Mississippi College of Nursing Hattiesburg, Mississippi Melanie Gilmore, PhD, RN University of Southern Mississippi College of Nursing Meridian, Mississippi Cathy K. Hughes, DNP, RN University of Southern Mississippi College of Nursing Hattiesburg, Mississippi Karen Saucier Lundy, PhD, RN , FAAN Professor Emeritus University of Southern Mississippi College of Nursing Hattiesburg, Mississippi Evadna Lyons, PhD, RN East Central Community College School of Nursing Decatur, Mississippi

Katherine Elizabeth Nugent, PhD, RN Dean, College of Nursing University of Southern Mississippi Hattiesburg, Mississippi Karen Rich, PhD, RN University of Southern Mississippi College of Nursing Long Beach, Mississippi Jill Rushing, M SN, RN University of Southern Mississippi College of Nursing Hattiesburg, Mississippi Mary W. Stewart, PhD, RN Director of PhD Program University of Mississippi Medical Center School of Nursing Jackson, Mississippi Sharon Vincent, DNP, RN , CNOR University of Southern Mississippi College of Nursing Hattiesburg, Mississippi

u n it i

Foundations of Professional Nursing Practice

A History of Health Care and Nursing Karen Saucier Lundy

v_____________________ Although no specialized nurse role per se developed in early civilizations, 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 him or her, 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 caregiver. 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 compassion, health promotion, and kindness (Bullough & Bullough, 1978).

Learning Objectives A f t e r c o m p le tin g th is c h a p te r, th e s tu d e n t should be a b le to : 1. Id e n tify s o c ia l, p o litic a l, and e c o n o m ic in flu ­ e n c e s on th e d e v e lo p m e n t o f p ro fe s s io n a l nursing p ra c tic e .

2 . Id e n tify im p o rta n t leaders and eve n ts th a t have s ig n ific a n tly a ffe c te d th e d e v e lo p m e n t o f p ro ­ fessio n al nursing p ra c tic e .

C la s s ic a l Era

Key Terms and Concepts

More than 4,0 0 0 years ago, Egyptian physicians and nurses used an abundant pharmacological repertoire to cure the ill and injured. The Ebers Papyrus lists more than 700 remedies for ailments ranging from snakebites to puerperal fever. The Kahun Papyrus (circa 1850 b . c . ) identified suppositories (e.g., crocodile feces) that could be used for contraception (Kalisch & Kalisch, 1986). Healing appeared in the Egyptian culture as the successful result of

» » » » » » »

G re e k era Roman era Deaconesses Florence Nightingale Black Death Edward Jenner Louis Pasteur

Note: This chapter is adapted from Lundy, K. S., & Bender, K. W . (2009). History of com­ munity health and public health nursing. In K. S. Lundy & S. Janes (Eds.), C om m u n ity health nursing: C aring f o r the p u b lic ’s health (2nd ed.). Sudbury, M A: Jones and Bartlett.

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Key Terms and Concepts » » » » » » » » » » » » » » » » » » » » » » » » » » » » » » » » »

Joseph Lister Robert Koch Edwin Klebs Saint Vincent de Paul Reformation Chadwick Report Shattuck Report John Snow Mary Grant Seacole William Rathbone Goldmark Report Brown Report Isabel Hampton Robb American Nurses Association (ANA) Lavinia Lloyd Dock American Journal of Nursing (AJN) Margaret Sanger Lillian Wald Jane A. Delano Annie Goodrich Mary Brewster Henry Street Settlement Elizabeth Tyler Jessie Sleet Scales Dorothea Linde Dix Clara Barton Frontier Nursing Service Mary Breckenridge Mary D. Osborne Cadet Nurse Corps Frances Payne Bolton Nursing's Agenda for Health Care Reform Managed care

a contest between invisible beings of good and evil (Shryock, 1959). The physician was not a shaman; instead there was specialization and separation of function, with physicians, priests, and sorcerers all practicing separately and independently. Some clients would consult the physician, some the sha­ man, and others sought healing from magical formulas. Many tried all three approaches. The Egyptians, quite notably, did not accept illness and death as inevitable but believed that life could be prolonged indefinitely. Because Egyptians blended medicine and magic, the concoctions believed to be the most effective were often bizarre and repulsive by today’s standards. For example, lizard’s blood, swine’s ears and teeth, putrid meat and fat, tortoise brains, the milk of a lactating woman, the urine of a chaste woman, and excreta of donkeys and lions were frequently used ingredients. At least some explanation for these odd ingredients can be found in the following: “These pharmacological mixtures were intended to sicken and drive out the intruding demon which was thought to cause the disease. Drugs containing fecal matter were in fact used until the end of the 1700s in Europe as common practice” (Kalisch & Kalisch, 1986). As early as 3000 to 1400 b . c . , the Minoans created ways to flush water and construct drainage systems. 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. Hebrews, although few in number, exercised great influence in the development of religious and health doctrine. According to Bullough and Bullough (1978), most of their genius was religious, giving birth to both Christianity and Islam. The Jewish contribution to public 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, Moses and the Hebrews were the first to codify them and link them with spiritual godliness. Their notion of disease was rooted in the “disease as God’s punishment for sin” idea. The civilization that grew up between the Tigris and Euphrates Rivers is known geographically as Mesopotamia (modern Iraq) and includes the Sumerians. Disease and disability in the Mesopotamian area, at least in the earlier period, were considered a great curse, a divine punishment for grievous acts against the gods. Having such a curse of illness resulting from sin did not exactly put the sick person in a valued status in the society. Experiencing ill­ ness as punishment for a sin linked the sick person to anything even remotely deviant; such acts as murder, perjury, adultery, and drunkenness could be the identified sins. Not only was the person suffering from the illness, but he or she also was branded by all of society as having deserved it. The illness made

Classical Era

the sin apparent to all; the sick person was isolated and disgraced. Those who obeyed God’s law lived in health and happiness. Those who transgressed the law were punished, with illness and suffering thought to be consequences. The sick person then had to make atonement for the sins, enlist a priest or other spiritual healer to lift the spell or curse, or live with the illness to its ultimate outcome. In simple terms, the person had to get right with the gods or live with the consequences (Bullough & Bullough, 1978). Nursing care by a family member or relative would be needed in any case, 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 “get sick and some don’t ” for many centuries and still persists to some degree in most cultures today.

■ The Greeks and Health In Greek mythology, the god of medicine, Asclepias, cured disease. One of his daughters, Hygeia, from whom we derive the word hygiene, was the goddess of preventive health and protected humans from disease. Panacea, Asclepias’ other daughter, was known as the all-healing “universal remedy,” and today her name is used to describe any ultimate cure-all in medicine. She was known as the “light” of the day, and her name was invoked and shrines built to her during times of epidemics (Brooke, 1997). During the G ree k e ra , Hippocrates of Cos emphasized the rational treat­ ment of sickness as a natural rather than god-inflicted phenomenon. Hip­ pocrates (4 6 0 -3 7 0 b . c . ) is considered the father of medicine because of his arrangements of the oral and written remedies and diseases, which had long been secrets held by priests and religious healers, into a textbook of medi­ cine that was used for centuries (Bullough & Bullough, 1978). Hippocrates’ contribution to the science of public health was his recognition that making accurate observations of and drawing general conclusions from actual phenomena formed the basis of sound medical reasoning (Shryock, 1959). In Greek society, health was considered to result from a balance between mind and body. Hippocrates wrote a most important book, Air, W ater an d 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 rela­ tionship between humans and their environment did not reoccur 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 Empedodes

5

of Acragas (4 9 3 -4 3 3 b . c . ). Empedodes was a philosopher and a physician, and as a result, he synthesized his cosmological ideas with his medical theory. He believed that the same four elements (or “roots of things” ) that made up the universe were found in humans and in all animate beings (Bullough & Bullough, 1978). Empedodes believed that man was a microcosm, a small world within the macrocosm, or external environment. The four humors 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 manip­ ulating the two sets of opposite qualities— hot and cold, wet and dry— balance 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 example, if a person had a fever, cold compresses would be prescribed for a chill and 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 T he R epu blic, details the importance of recreation, a balanced mind and body, nutrition, and exercise. A distinction was made among sex, 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 T h e Ilia d , a poem about the attempts to capture Troy and rescue Helen from her lover Paris, 140 different wounds are described. The mortality rate averaged 7 7 .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, 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 techniques 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. For example, the cause of the plague was unknown, so the question became how and why affected soldiers had angered the gods. According to T he Ilia d , the true healer of the plague was the prophet who prayed for Apollo to stop shooting the “plague arrows.” The Greeks applied rational causes and cures to external injuries, while internal ailments con­ tinued to be linked to spiritual maladies (Bullough & Bullough, 1978).

■ Roman Era During the rise and the fall of the R o m a n e ra (31 b . c . - a . d . 4 7 6 ), Greek culture continued to be a strong influence. The Romans easily adopted Greek

Classical Era

culture and expanded the Greeks’ accomplishments, especially in the fields of engineering, law, and government. The development of policy, law, and protection of the public’s health was an important precursor to our modern public health systems. For Romans, the government had an obligation to protect its citizens, not only from outside aggression such as warring neighbors, but from inside the civilization, in the form of health laws. According to Bullough and Bullough (1978), Rome was essentially a “Greek cultural colony” (p. 20). During the third century b . c . , Rome began to dominate the Mediterranean, Egypt, the Tigris-Euphrates Valley, the Hebrews, and the Greeks (Boorstin, 1 9 8 5 ) . Greek science and Roman engineering then spread throughout the ancient world, providing a synthesized Greco-Roman foundation for eventual public health policies (Bullough & Bullough, 1978). Galen of Pergamum (a . d . 1 2 9 -1 9 9 ), often known as the greatest Greek physician after Hippocrates, left for Rome after studying medicine in Greece and Egypt and gained great fame as a medical practitioner, lecturer, and experimenter. In his lifetime, medicine evolved into a science; he submitted traditional healing practices to experimentation 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 contributions to medicine, but the Romans surpassed the Greeks in promoting 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 portable 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 “rest cure” (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 primitive 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 strengthened its position in medical care and emerged during the Roman era as a separate and distinct specialty. The Romans developed massive aqueducts, bathhouses, and sewer systems during this era. At the height of the Rom an Empire, Rome provided 4 0 gallons of water per person per day to its 1 million inhabitants, which is com­ parable to our rates of consumption today (Rosen, 1958). Even though these engineering feats were remarkable at the

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CHAPTER 1 A History of Health Care and Nursing

time, poorer and less fortunate residents often did not benefit from the same level of public health amenities, such as sewer systems and latrines (Bullough & Bullough, 1978). However, the Romans did provide many of their citizens with what we would consider public health services.

M iddle A g es Many of the advancements of the Greco-Rom an era were reversed during the Middle Ages (a . d . 4 7 6 -1 4 5 3 ) 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 life— Greco-Roman, Germanic, and Christian— into one (Donahue, 1985). Nursing was most influenced by Christianity with the beginning of d e a c o n e s s e s , or female servants, doing the work of God by ministering to the needs of others. Deacons in the early Christian churches were apparently available only to care for men, while 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 F lo re n c e N ig h tin g a le . During this era, Roman military hospitals were replaced by civilian ones. In early Christianity, the D ia k o n ia , 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 isola­ tion 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 Hotel-Dieu in Lyons, France, founded about 542 by Childebert I, king of France. The Hotel-Dieu in Paris was founded around 652 by Saint Landry, bishop of Paris. During the Middle Ages, chari­ table institutions, hospitals, and medical schools increased in number, with the religious leaders as caregivers. The word hospital, which is derived from the Latin word hospitalis, meaning service of guests, was most likely more of a shelter for travelers and other pilgrims as well as the occasional person who needed extra care (Kalisch & Kalisch, 1986). Early European hospitals were more like hospices or homes for the aged, sick pilgrims, or orphans. Nurses in these early hospitals were religious deaconesses who chose to care for others in a life of servitude and spiritual sacrifice.

The Renaissance

■ Black Death During the Middle Ages, a series of horrible epidemics, including the B la ck D e a th or bubonic plague, ravaged the civilized world (Diamond, 1997). In the 1300s, Europe, Asia, and Africa saw nearly half their populations lost to the bubonic plague. According to Bullough and Bullough (1978), an interesting account of the arrival of the bubonic plague in 1347 claims that the disease started in the Genoese colony of Kaffa in the Crimea. The story passed down through the ages is that the city was besieged by a Mongol khan. When the disease broke out among the khan’s men, he catapulted the bodies of its vic­ tims into Kaffa to infect and weaken his enemies. The soldiers and colonists of Kaffa carried the disease back to Genoa. Worldwide, more than 60 million deaths were eventually 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 children, 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 hemorrhages gave the skin a darkened appearance. There was also acute inflammation 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). Bubonic plague is caused by the bacillus Y ersinia p estis (formerly Pasteurella pestis), which is usually transmitted by the bite of a flea carried by an animal vector, typically a rat. After the initial flea bite, the infection spreads through the lymph nodes and the nodes swell to enormous size; the inflamed nodes are called bubos, from which the bubonic plague derives its name. Medieval people knew that this disease was in some way communi­ cable, but they were unsure of the mode of transmission (Diamond, 1997); hence the avoidance of victims and a reliance on isolation techniques. The practice of quarantine in city ports was developed as a preventive measure and is still used today (Bullough & Bullough, 1978; Kalisch & Kalisch, 1986).

T h e R e n a is s a n c e During the rebirth of Europe, great political, social, and economic advances occurred along with a tremendous revival of learning. Donahue (1985) contends that the Renaissance has been “viewed as both a blessing and a curse” (p. 188). There was a renewed interest in the arts and sciences, which helped advance medical science (Boorstin, 1985; Bullough & Bullough, 1978). Columbus and

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other explorers discovered new worlds, and belief in a sun-centered rather than earth-centered universe was promoted by Copernicus (147 3 -1 5 4 3 ). Sir Isaac Newton’s (1 6 4 2 -1 7 2 7 ) theory of gravity changed the world forever. Gunpowder 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 knowledge about the human anatomy. Many artists of this time left an indelible mark and con­ tinue to exert influence today, including Michelangelo, Raphael, and Titian (Donahue, 1985).

T h e A d v a n c e m e n t of S c ie n c e and H e a lth of th e P ub lic

r K.

It took the first 50 years of the 1700s for the new knowl­ edge from the Enlightenment to be organized and digested, according to Donahue (1985). In Britain, E d w ard J e n n e r discovered an effective method of vaccination against the dreaded smallpox virus in 1798. Psychiatry developed as a separate branch of medicine, and instruments that measured and allowed for assessment of the body such as the pulse watch and the stethoscope were invented. One of the greatest scientists of this period was Louis P a s te u r (1822­ 1895). A French chemist, Pasteur first became interested in pathogenic organ­ isms through his studies of the diseases of wine. He discovered that if wine was heated to a temperature of 55°C to 60°C, the process killed the microorganisms that spoiled wine. This discovery of pasteurization was critical to the wine industry’s success in France. Pasteur investigated many fields and saved many lives from the consequences of contaminated milk and food. J o s e p h L is te r (1 8 2 7 -1 9 1 2 ) was a physician who set out to decrease the mortality resulting from infection after surgery. He used Pasteur’s research to eventually arrive at a chemical antiseptic solution of carbolic acid for use in surgery. Widely regarded as the father of modern surgery, he practiced his anti­ septic surgery with great results, and the Listerian principles of asepsis changed the way physicians and nurses practice to this day (Dietz & Lehozky, 1963). R o b e rt K och (1 8 4 3 -1 9 1 0 ), a physician known for his research on anthrax, is regarded as the father of microbiology. After identifying the organism that caused cholera, V ibrio ch olerae, he also demonstrated its transmission by water, food, and clothing. Edw in K lebs (1 8 3 4 -1 9 1 3 ) proved the germ theory, that is, that germs are the causes of infectious diseases. This discovery of the bacterial origin of diseases can be considered the greatest achievement of

It took the first 5 0 years of the 1700s for the new knowledge from the Enlightenment to be organized and digested.

A

J

The Reformation

the 1800s. Although the microscope had been around for two centuries, it remained for Lister, Pasteur, and Koch— and ultimately Klebs— to provide the missing link (Dietz & Lehozky, 1963; Rosen, 1958).

T h e E m e rg e n c e of H o m e V is itin g In 1633, S a in t V in c e n t de P au l founded the Sisters of Charity in France, an order of nuns who traveled from home to home visiting the sick. As the ser­ vices of the sisters grew, de Paul appointed Mademoiselle Le Gras as supervi­ sor of these visitors. These nurses functioned as the first organized visiting nurse service, making home visits and caring for the sick in their homes. De Paul believed that for family members to go to the hospital was disruptive to family life and that taking nursing services to the home enabled health to be restored more effectively and more efficiently.

T h e R e fo rm a tio n Religious 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 M artin Luther (1483— 1546) in Germany and John Calvin (1 5 0 9 -1 5 6 4 ) in France and Geneva. Although the various sects were numerous in the Protestant movement, the agreement among the leaders was almost 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, including nurses, were dissolved. Even in countries where Catholicism flourished, royal leaders seized monasteries frequently. Religious leaders, such as M artin Luther, who led the R e fo rm a tio n 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 “community chest” to raise funds for hospitals and nurse visitors for the poor (Dietz & Lehozky, 1963). For example, in England, where there had been at least 4 50 charitable foundations before the Reformation, only a few survived the reign of Henry VIII, who closed most of the monastic hospitals (Donahue, 1985). Eventually, Henry V III’s son Edward VI, who reigned from 1547 to 1553, was convinced and did endow some hospitals, namely, St. Bartholomew’s Hospital and St. Thomas’ Hospital, which would eventually house the Nightingale School of Nursing later in the 1800s (Bullough & Bullough, 1978).

11

T h e D a rk P eriod of N u rsin g The last half of the period between 1500 and 1860 is widely regarded as the “dark period of nursing” because nursing conditions were at their worst (Donahue, 1985). Education for girls, which had been 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 nursing 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, prostitute, or thief, she might become a nurse. Eventually, women serving jail sentences for crimes such as prostitution and stealing were ordered to care for the sick in the hospitals instead of serving their sentences 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 assigned clients. Nursing had, during this era, virtually no social standing or organiza­ tion. Even Catholic sisters of the religious orders throughout Europe “came to a complete standstill” professionally because of the intolerance of society (Donahue, 1985, p. 231). Charles Dickens, in M artin Chuzzlewit (1844), cre­ ated 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 friend’s home. Sairey Gamp was hired to care for sick family members but was instead 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): She was a fat old woman, this Mrs. Gamp, with a husky voice and a moist eye, which she had a remarkable power of turning up and showing the white of it. Having very little neck, it cost her some trouble to look over herself, if one may say so, to those to whom she talked. She wore a very rusty black gown, rather the worse for snuff, and a shawl and bonnet to correspond.... The face of Mrs. Gamp— the nose in particular— was somewhat red and swollen, and it was difficult to enjoy her society without becoming conscious of the smell of spirits. Like most persons who have attained to great eminence in their profession, she took to hers very kindly; insomuch, that setting aside her natural predilections as a woman, she went to a lying-in [birth] or a laying-out [death] with equal zest and relish. — Charles Dickens, 1844

The Chadwick Report and the Shattuck Report

E a rly O rg a n ize d H e a lth C a re in th e A m e ric a s : A B ra v e N ew W orld In the New W orld, the first hospital in the Americas, the Hospital de la Purisima Concepcion, was founded some time before 1524 by Hernando Cortez, the conqueror of M exico. The first hospital in the continental United States was erected in M anhattan 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 hospital’s founding (Bullough & Bullough, 1978). During the 1600s and 1700s, colonial hospitals with little resemblance to modern hospitals were often used to house the poor and downtrodden. Hospitals called “pesthouses” 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. Contagious 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. 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 today’s standards, hospitals in the 1800s were disgraceful, dirty, unventilated, and contaminated by infections; to be a client in a hospital actually increased one’s risk of dying. As in England, nursing was consid­ ered an inferior occupation. After the sweeping changes of the Reformation, educated religious health workers were replaced with lay people who were “down and outers,” in prison, or had no option left but to work with the sick (Kalisch & Kalisch, 1986).

T h e C h a d w ic k R e p o rt and th e S h a ttu c k R e p o rt Edwin 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 unsani­ tary conditions that shortened the life span of the laboring class and threat­ ened the wealth of Britain. Although the first sanitation legislation, which established a National Vaccination Board, was passed in 1837, Chadwick found in his classic study, R ep o rt on an Inquiry into the Sanitary Conditions o f th e L a b o rin g P opu lation o f G reat Britain, that death rates were high in

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CHAPTER 1 A History of Health Care and Nursing

large industrial cities such as Liverpool. A more startling finding, from what is often referred to simply as the C h a d w ic k R e p o rt , was that more than half the children of labor-class workers died by age 5, indicating poor living condi­ tions 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). M ore legislation followed that initiated social reform in the areas of child welfare, elder care, the sick, the mentally ill, factory health, and education. Soon sewers and fire plugs, based on an available water supply, appeared as indicators that the public health linkages from the Chadwick Report had an impact. In the United States during the 1800s, waves of epidemics of yellow 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 Chadwick’s classic study in England, Lemuel Shattuck, a Boston bookseller and publisher who had an interest in public health, organized the American Statistical Society in 1839 and issued a census of Boston in 1845. Shattuck’s census revealed high infant mortality rates and high overall population mortality rates. In 1850, in his R ep ort o f the M assachusetts Sanitary C om m ission, Shattuck not only outlined his findings on the unsanitary conditions but made recommendations for public health reform that included the bookkeeping of population statistics and develop­ ment 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 children’s health, immunizations, mental health, health education for all, and health planning. The S h a ttu c k R e p o rt was revolutionary in its scope and vision for public health, but it was virtually ignored during Shattuck’s lifetime. Nineteen years later, in 1869, the first state board of health was formed (Kalisch & Kalisch, 1986).

T h e In d u s tria l R e v o lu tio n During the mid-1700s in England, capitalism emerged as an economic system based on profit. This emerging system resulted in mass production, 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 dur­ ing this era and ultimately standardized quality; individual craftsmen were forced to give up their crafts and lands and become factory laborers for

The Industrial Revolution

the capitalist owners. All types of industries were affected; this new-found 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 the work in the cities. Urban areas grew, tenement housing projects emerged, and overcrowding in cities seriously threatened individuals’ well-being (Donahue, 1985). Workers were forced to go to the machines, rather than the other way around. Such relocations meant giving up not only farming, but a way of life that had existed for centuries. The emphasis on profit over people led to child labor, frequent layoffs, and long work days 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 industrialization 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 reformers such as John Stuart Mill (1 8 0 6 -1 8 7 3 ) 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 tolera­ tion. 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 community 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 second 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 nonexis­ tent, 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 m id-1700s typhus and typhoid fever claimed twice as many lives each year as did the Battle of Waterloo (Hanlon & Pickett, 1984). Through

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foreign trade and immigration, infectious diseases were spread to all of Europe and eventually to the growing United States.

J o h n S now and th e S cien ce of E p id em io lo g y J o h n S n o w , a prominent physician, is credited with being the first epidemiolo­

gist. In 1854, Snow demonstrated that cholera rates were linked with water pump use in London (Cartwright, 1972). Snow investigated the area around Golden Square in London and arrived at the conclusion that cholera was not carried by bad air or necessarily by direct contact. He formed the opinion that diarrhea, unwashed hands, and shared food somehow played a large part in spreading the disease. People around Golden Square in London were not supplied with water by pipes but drew their water from surface wells by means of hand-operated pumps. A severe outbreak of cholera occurred at the end of August 1853, resulting in at least 500 deaths in just 10 days in Golden Square. By mapping rates of cholera, Snow for the first time linked the sources of the drinking water at the Broad Street pump to the outbreaks of cholera. This proved that cholera was a waterborne disease. Dr. Snow’s epidemiological investigation started a train of events that eventually would end the great epidemics of cholera, dysentery, and typhoid. When Snow attended the now-famous community meeting of Golden Square and gave his evidence, government officials asked him what measures were necessary. His reply was, “Take the handle off the Broad Street pump.” The handle was removed the next day, and no more cholera cases occurred (Snow, 1855). Although he did not discover the true cause of the cholera— the identification of the organism— he came very close to the truth (Rosen, 1958).

A nd T h en T h e re W as N ig h tin g a le ... Florence Nightingale was named one of the 100 most influential persons of the last millennium by L ife magazine (The 100 people who made the mil­ lennium, 1997). She was one of only eight women identified as such. O f those eight women, including Joan of Arc, Helen Keller, and Elizabeth I, Nightingale was identified as a true “angel of mercy,” having reformed military health care in the Crimean W ar 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). F loren ce N ightingale has become synonymous with modern nursing.

Florence Nightingale was the second child born on May 12, 1820, to the wealthy English family of W illiam and F lo re n c e N ig h tin g a le has Frances Nightingale in her namesake city, Florence, Italy. become synonymous with As a young child, Florence displayed incredible curiosity modern nursing. 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 family’s dismay, she believed that God had called her to be a nurse. Nightingale was keenly aware of the suffering that industrialization created; she became obsessed with the plight of the miserable and suffering people: Conditions o f general starvation accom panied the Industrial Revolution, prisons and workhouses overflowed, and persons in all sections of British life were displaced. She wrote in the spring of 1842, “My 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 disease” (Woodham-Smith, 1951, p. 31). For Nightingale, her entire life would be haunted by this conflict between the opulent life of gaiety that she enjoyed and the plight and misery of the world, which she was unable to alleviate. She was, in essence, an “alien spirit in the rich and aristocratic social sphere of Victorian England” (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, “I crave for some regular occupation, for something worth doing instead of frittering my time away on useless trifles” (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 “calling” as it fit into the divine plan (Calabria, 1996; Dossey, 1999). The next spring, Nightingale traveled unaccompanied to the Kaiserwerth 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 Kaiserwerth and study nursing. According to Dietz and Lehozky (1963, p. 42), her mother had “hysterics” and scene followed scene. Her father “retreated into the shadows,” and her sister, Parthe, expressed that the family name was forever disgraced (Cook, 1913).

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In 1851, at the age of 31, Nightingale was finally permitted to go to Kaiserwerth, 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 Kaiserwerth. While there, Nightingale learned about the care of the sick and the importance of discipline and commitment of oneself to God (Donahue, 1985). She returned to England and cared for her then ailing father, from whom she finally gained some sup­ port for her intent to become a nurse— her lifelong dream. In 1852, Nightingale wrote the essay “Cassandra,” which stands today as a classic feminist treatise against the idleness of Victorian women. Through her voluminous journal writings, Nightingale reveals 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; throughout her writings, she poured out her detestation of the life of an idle woman (Nightingale, 1979, p. 5). In “Cassandra,” Nightingale put her thoughts to paper, and many scholars believe that her eventual intent was to extend the essay to a novel. She wrote in “Cassandra,” “Why have women passion, intellect, moral activity— these three— in a place in society where no one of the three can be exercised?” (Nightingale, 1979, p. 37). Although uncertain about the meaning of the name Cassandra, 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 generous 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 Crim ean Experience: "I Can Stand Out the W ar with Any M an” Nightingale’s opportunity for greatness came when she was offered the po­ sition of 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 L o n d o n Tim es. Pressure increased on Sir Herbert to react. He knew of one woman who was capable of bringing order out of the chaos and wrote the following now-famous letter to Nightingale on October 15, 1854, as a plea for her service: There is but one person in England that I know of who would be capable of organising and superintending such a scheme.... The difficulty of finding women equal to a task after all, full of horrors,

and requiring besides knowledge and good will, great energy and great courage, will be great. Your own personal qualities, your knowledge and your power of administration and among greater things your rank and position in Society give you advantages in such a work which no other person possesses. (Woodham-Smith, 1951, pp. 8 7 -8 9 ) Nightingale took the challenge from Sir Herbert and set sail with 38 selfproclaimed nurses with varied training and experiences, of whom 24 were Catholic and Anglican nuns. Their journey to the Crimea took a month, and on November 4, 1854, the brave nurses arrived at Istanbul and were taken to Scutari the same day. Faced with 3,0 0 0 to 4 ,0 0 0 wounded men in a hos­ pital designed to accommodate 1,700, the nurses went to work (Kalisch & Kalisch, 1986). The nurses were faced with 4 miles of beds 18 inches apart. M ost 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 hospital was literally floating on an open sewage lagoon filled with rats and other vermin (Donahue, 1985). The barrack “hospital” was more of a death trap than a place for healing before Nightingale’s arrival. In a letter to Sir Herbert, Nightingale, demon­ strating her sense of humor, wrote, with tongue in cheek, that “the vermin might, if they had but unity of purpose, carry off the four miles of beds on their backs and march them into the W ar Office” (Stanmore, 1906, pp. 3 9 3 -3 9 4 ). 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 to essentially overhaul the administrative structure of the military health services (Williams, 1961). Nightingale and her nurses were faced with overwhelming odds and deplorable conditions. No accommodations had been made for their quarters, so they ended up in one of the hospital towers, 39 women crowded into six small rooms. In addition to having no furniture, one of the rooms even had a long-neglected, forgotten corpse swarming with vermin! Ever the disciplinarian, Nightingale insisted on strict adherence to a standard nurse uniform: gray tweed dresses, gray worsted jackets, plain white caps, short woolen cloaks, and brown scarves embroidered in red with the words “Scutari Hospital” (Bullough & Bullough, 1978).

■ Florence Nightingale and Sanitation Although 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 elaborate plans, and evaluating implemented changes. She seldom believed in the “hopeless” soldier, only one who needed extra atten­ tion. Nightingale was convinced that most of the maladies that the soldiers suffered and died from were preventable (Williams, 1961). M any soldiers wrote about their experiences of the Angel of M ercy, Florence Nightingale. One soldier wrote perhaps one of the most revealing tributes to this “Lady with the Lamp”: W hat a comfort it was to see her pass even. She would speak to one and nod and smile to as many more, but she could not do it all, you know. We lay there by hundreds, but we could kiss her shadow as it fell, and lay our heads on the pillow again content. (Tyrell, 1856, p. 310) Before Nightingale’s arrival and her radical and well-documented inter­ ventions based on sound public health principles, the mortality rate from the Crimean W ar was estimated to be from 4 2 % 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 epidemiological research (Dietz & Lehozky, 1963). Upon arriving at Scutari, Nightingale’s first act was to order 200 scrub­ bing brushes. The death rate fell dramatically once Nightingale discovered that the hospital was built literally over an open, sewage lagoon. A dead horse was even retrieved from the sewer system under Scutari (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 “cox combs” 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 believed 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 admin­ istrator and organizer of a mammoth humanitarian effort. From her Crimean experience on, Nightingale involved herself primarily in organizational activi­ ties and health planning administration. Palmer contends that Nightingale “perceived the Crimean venture, which was set up as an experiment, as a golden opportunity to demonstrate the efficacy of female nursing” (Palmer, 1982, p. 4). Although Nightingale faced initial resistance from the uncon­ vinced and oppositional medical officers and surgeons, she boldly defied con­ vention and remained steadfastly focused on her mission to create a sanitary

and highly structured environment for her “children”— the British soldiers who dedicated their lives to the defense of Great Britain. Through her resil­ ience and insistence on absolute authority regarding nursing and the hospital environment, Nightingale was known to send nurses home to England from the Crimea for suspicious alcohol use and character weakness. It was through this success at Scutari that she began a long career of influence on the public’s health through social activism and reform, health policy, and the reformation of career nursing. Using her well-publicized suc­ cessful “experiment” 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 people in uniform to the present (D’Antonio, 2002). Nightingale’s ideas about proper hospital architecture and administra­ tion influenced a generation of medical doctors and the entire world, in both military and civilian service. Her work in N otes on H ospitals, published in 1860, provided the template for the organization of military health care in the Union Army when the U.S. Civil W ar erupted in 1861. Her vision for health care of soldiers and the responsibility of the governments that send them to war continues today; her influence can be seen throughout the previous cen­ tury and into this century as health care for the women and men who serve their country is a vital part of the well-being of not only the soldiers but for society in general (D’Antonio, 2002). M a ry G ra n t S e a c o le , an African nurse from Jam aica, offered her services to Nightingale after hearing of the need in Scutari. Although Nightingale was unwilling to hire Seacole as part of the nursing staff, Seacole volunteered her services without pay. Seacole was so committed to providing care to the British military that she set up an inn with her own money that provided food and lodging for soldiers and their families near Scutari (Hine, 1989). Although Seacole is less well known than Nightingale, her contributions to nursing in wartime were significant in the history of minority nursing. The School of Nursing in Kingston, Jamaica, is today named in her honor. Scores have been written about Nightingale— an almost mythic figure in history. She truly was a beloved legend throughout Great Britain by the time she left the Crimea in July 1856, 4 months after the war. Longfellow immortalized this “Lady with the Lam p” in his poem “Santa Filom ena” (Longfellow, 1857).

■ Returning Home a Heroine: The Political R eform er When Nightingale returned to London, she found that her efforts to pro­ vide 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 portrayed as a drunken

oaf with little ambition or honor, 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, nevermore the downtrodden and disrespected. After her return from the Crimea, Florence 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, “the sink it was” 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 char­ acter, she insisted that nursing 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 nursing— caregiver and political reformer— has shaped the profession as we know it today. LeVasseur (1998) contends that Nightingale’s insistence on nursing’s involvement in a larger political ideal is the historical foundation of the field and distinguishes us from other scientific disciplines, such as medicine. How did Nightingale accomplish this? You will learn throughout this text how nurses effect change through others. Florence Nightingale is the standard by which we measure our effectiveness. 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 amazing capacity for work. She used people. Her brotherin-law, Sir Harry Verney, was a member of Parliament and often delivered her “messages” in the form of legislation. When she wanted the public incited, she turned to the press, writing letters to the L o n d o n Tim es and having others of influence write articles. She was not above threats to “go public” by certain dates if an elected official refused to establish a commission or appoint a com­ mittee. And when those commissions were formed, Nightingale was ready with her list of selected people for appointment (Palmer, 1982).

■ N ightingale and M ilitary Reform s The first real test of Nightingale’s 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 recom­ mendations back to the United States based on her experiences and analy­ sis in the Crimea, and her advisement and influence gained wide publicity. Following her recommendations, the Union set up a sanitary commission and provided for regular inspection of camps. She expressed a desire to help with the Confederate military also but, unfortunately, had no channel of communication with them (Bullough & Bullough, 1978).

■ The Nightingale School of Nursing at St. Thomas: The Birth of Professional Nursing The British public honored Nightingale by endowing 5 0 ,0 0 0 pounds ster­ ling in her name upon her return to England from the 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 profes­ sional nursing (Donahue, 1985). Nightingale, at the age of 40, decided that St. Thom as’ Hospital was the place for her training school for nurses. While the negotiations for the school went forward, she spent her time writing N otes on N ursing: W hat It Is an d W hat It Is N ot (Nightingale, 1860). The small book of 77 pages, written for the British mother, was an instant success. An expanded 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 royalties 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 “Nightingale nurse,” 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 char­ acter weaknesses, and discipline was severe and swift for violators. Accounts from Nightingale’s journals and notes reveal instant dismissal of nursing stu­ dents for such behaviors as “flirtation, using the eyes unpleasantly, and being in the company of unsavory persons.” Nightingale contended that “the future of nursing depends on how these young women behave themselves” (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 evaluate their character and work habits. Every nursing student admitted to St. Thomas had to submit an acceptable “letter of good character” 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 medical staff in selecting, retaining, and disciplining students and nurses (Bullough & Bullough, 1978).

Nightingale was opposed to the use of a standardized government exami­ nation and the movement for licensure of trained nurses. She believed that schools of nursing would lose control of educational standards with the advent of national licensure, most notably those related to moral character. Nightingale led a staunch opposition to the movement by the British Nurses Association (BN A ) for licensure of trained nurses, one the BNA believed critical to protecting the public’s 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. She believed nursing involved “divergen­ cies too great for a single standard to be applied” (Nutting & Dock, 1907; Woodham-Smith, 1951).

■ Taking H ealth Care to the Com m unity: N ightingale and Wellness Early efforts to distinguish hospital from community health nursing are evi­ dence of Nightingale’s views on “health nursing,” which she distinguished from “sick nursing.” She wrote two influential papers, one in 1893, “SickNursing and Health-Nursing” (Nightingale, 1893), which was read in the United States at the Chicago Exposition, and the second, “Health Teaching in Towns and Villages” in 1894 (Monteiro, 1985). Both papers praised the success of prevention-based nursing practice. Winslow (1946) acknowledged Nightingale’s 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 one’s health. She wrote in 1891 that “There are more people to pick us up and help us stand on our own two feet” (Attewell, 1996). 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 society. She saw a logical extension of nursing in acute hospital settings to the broadest sense of community used in nursing today. Clearly, through her N otes on Nursing, she visualized the nurse as “the nation’s first bulwark in health maintenance, the promotion of wellness, and the prevention of disease” (Palmer, 1982, p. 6). W illia m R a th b o n e , 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 “district nursing service” 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 com­ munity into 16 districts; each was assigned a nurse and a social worker who 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 assistance. 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 Rathbone’s proposal, and district nursing soon spread throughout England as successful “health nursing” in the community for the sick poor through voluntary agen­ cies (Rosen, 1958). Ever the visionary, Nightingale contended that “Hospitals are but an intermediate stage of civilization. The ultimate aim is to nurse the sick poor in their own homes (1 8 9 3 )” (Attewell, 1996). She also wrote in regard to visiting families at home: “We must not talk to them or at them but with them (1 8 9 4 )” (Attewell, 1996). A similar service, health visiting, began in Manchester, England, 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 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 antici­ pated should be preventive in nature and would more than likely take place in the home and community. Her accomplishments in the field of “sanitary nursing” extended beyond the walls of the hospital to include workhouse reform and community 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 British 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 being paid a salary (Seymer, 1954).

■ The Legacy of Nightingale When Nightingale returned to London after the Crimean War, she remained haunted by her experiences related to the soldiers dying of preventable dis­ eases. She was troubled by nightmares and had difficulty sleeping in the years that followed. She wrote in her journal: “Oh my poor men; I am a bad mother to come home and leave you in your Crimean graves.... I can never forget.... I stand at the altar of the murdered men and while I live, I fight their cause” (Woodham-Smith, 1983, pp. 178, 193). Nightingale became a prolific writer and a staunch defender of the causes of the British soldier, sanitation in England and India, and trained nursing.

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CHAPTER 1 A History of Health Care and 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 post-traumatic stress disorder (PTSD) from her experiences in the 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 “cleanse” spread from the military to the British Empire; her fight for improved sanitation both at home and in India consumed her energies for the remainder of her life (Vicinus & Nergaard, 1990). A ccording to M onteiro (1 9 8 5 ), two recurrent themes are found throughout Nightingale’s writings about disease prevention and wellness outside the hospital. The most persistent theme is that nurses must be trained differently and instructed specifically in district and instructive nursing. She consistently wrote that the “health nurse” must be trained in the nature of poverty and its influence on health, something she referred to as the “pau­ perization” 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, “good intended women” could not substitute for nursing care in the home. Nightingale pushed for an extensive orientation and additional training, including prior hospital experience, before one was hired as a district nurse. She outlined the qualifi­ cations in her paper “On Trained Nursing for the Sick Poor,” in which she called for a month’s “trial” in district nursing, a year’s training in hospital nursing, and 3 to 6 months training in district nursing (Monteiro, 1985). She said, “There is no such thing as amateur nursing.” The second theme that emerged from her writings was the focus 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). Nightin­ gale believed that such activities did little to teach the poor to care for themselves and further “pauperized” them— dependent and vulnerable— keeping them unhealthy, prone to disease, and reliant 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. She stated, “Never think that you have done anything effectual in nursing in London, till you nurse, not only the sick poor in workhouses, but those at home.” By 1901, Nightingale lived in a world without sight or sound, leaving her unable to write. Over the next 5 years,

Early Nursing Education and Organization in the United States

Nightingale lost her ability to communicate and most days existed in a state of unconsciousness. In November of 1907, Nightingale was honored with the Order of Merit by King Edward VII, the first time 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 a thousand 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 family’s home at Embley, her coffin carried by six ser­ geants of the British Army. Only a small cross marks her grave at her request: “FN. Born 1820. Died 1 9 1 0 .” (Brown, 1988). The family refused a national funeral and burial at Westminster Abbey out of respect for Nightingale’s last wishes. She had lived for 90 years and 3 months.

27

w w wj CRITICAL THINKING QU ESTIO N S*

Some nurses believe that Florence Nightingale holds nursing back and represents the nega­ tive and backward elements of nursing. This view cites as evidence that Nightingale sup­ ported the subordination of nurses to physi­ cians, opposed registration of nurses, and did not see mental health nurses as part of the profession. Wheeler has gone so far as to say, “The nursing profession needs to exorcise the myth of Nightingale, not necessarily because she was a bad person, but because the impact of her legacy has held the profession back too long.” After reading this chapter, what do you think? Is Nightingale relevant in the 21st century to the nursing profession? Why or why not?V

E a rly N u rsin g E d u c a tio n and O rg a n iz a tio n in th e U n ite d S ta te s In the United States, the first training schools for nursing were modeled after the Nightingale School of Nursing at St. Thomas in London. The earliest programs for trained nurses in the United States were the Bellevue Training School for Nurses in New York City; 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 sensitive, possess high morals, and be caregivers, early nursing training required that applicants be female. Sensitivity, high moral character, purity of character, subservience, and “ladylike” behavior became the associated traits of a “good nurse,” thus setting the “feminization of nursing” 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. A significant report, known simply as the G o ld m a rk R e p o rt , Nursing an d N ursing E du cation in the U nited States, was released in 1922 and advocated 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

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CHAPTER 1 A History of Health Care and Nursing

500-page document. Josephine Goldmark, social worker and author of the pioneering research 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, 1 9 2 3 ,p . 35) The first university school of nursing was developed at the University 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. N ursing fo r the Future, or the B row n R e p o rt , authored 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 accredi­ tation through the National League for Nursing (Brown, 1936, 1948). As a result of the post-W orld 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 (RNs) (Montag, 1959). In 1950, nursing became 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 (State board test pool examination, 1952).

T h e E v o lu tio n of N u rs in g in th e U n ite d S ta te s : T h e F irs t C e n tu ry of P ro fe s s io n a l N u rsin g ■ The Profession of Nursing Is Born in the United S tates Early nurse leaders of the 20th century included Isa b e l H a m p to n R obb , who in 1896 founded the Nurses’ Associated Alumnae, which in 1911 officially became known as the A m e ric a n N u rs e s A s s o c ia tio n (A N A ) ; and L a vin ia Lloyd D o ck , who became a militant suffragist linking women’s roles as nurses to the emerging women’s movement in the United States. Mary Adelaide Nutting, Lavinia L. Dock, Sophia Palmer, and Mary E. Davis were instrumental in developing the first nursing journal, the A m e ric a n J o u r n a l o f N u r s in g ( A J N ) in October 1900. Through the ANA and the A JN , nurses then had a professional organization and a national journal with which to communicate with each other (Kalisch & Kalisch, 1986).

State licensure of trained nurses began in 1903 with the enactment of North Carolina’s 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 recogni­ tion of practice and educational standards as state after state passed similar legislation. M a rg a re t S a n g e r 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 conception, 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 pro­ pelled 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 nursing care in wartime. Mary Adelaide Nut­ ting, now Professor of Nursing 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 W ar 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 nations’ resources for military purposes (Kalisch & Kalisch, 1986). Along with Lillian W ald and J a n e A . D e la n o , Director of Nursing in the American Red Cross, Nutting initiated a national publicity campaign to recruit young women to enter nurses’ training. The Army School of Nursing, headed by A n n ie G oodrich as dean, and the Vassar 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 the most about 2 0 0 ,0 0 0 active “nurses” 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 education about hygiene and disease prevention. The successful campaign 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 2 5 % . In 1920, Congress passed a bill that provided nurses with military rank (Dock & Stewart, 1931). Following close behind, the passage of the Nineteenth Amendment to the U.S. Constitution granted women the right to vote. According to Stewart:

KEY COMPETENCY 1-1 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Professionalism: Knowledge (K 8a) Under­ stands the responsibilities inherent in being a member of the nursing profession Attitudes/Behaviors (A 8a) Recognizes the need for personal and professional behaviors that promote the profession of nursing Skills (S 8a) Understands the history and philosophy of the nursing profession Source: Massachusetts Department of Higher Education (2010, p. 15).

Probably the greatest contribution of the war experience to nurs­ ing lies in the fact that the whole system of nursing education was shaken for a little while out of its well-worn ruts and brought out of its comparative seclusion into the light of public discussion and criticism. When so many lives hung on the supply of nurses, people were aroused to a new sense of their dependence on the products of nursing schools, and many of them learned for the first time of the hopelessly limited resources which nursing educators have had to work with in the training of these indispensable public servants. Whatever the future may bring, it is unlikely that nursing schools will willingly sink back again into their old isolation or that they will accept unquestionably the financial status which the older system imposed on them. (Stewart, 1921, p. 6)

■ The Em ergence of C om m unity and Public H ealth Nursing The 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 Nightingale model. Visiting nurses were first sent to philanthropic organizations 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 work­ ers 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, Public H ealth Nursing, and C om m unity Activism Lillian Wald, a wealthy young woman with a great social conscience, gradu­ ated from the New York Hospital School of Nursing in 1891 and is credited with creating the title “public health nurse.” After a year working in a mental institution, Wald entered medical school at Women’s Medical College in New York. While in medical school, she was asked to visit immigrant mothers on New Y ork’s 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).

The Evolution of Nursing in the United States

31

BOX 1-1 LiLLiAN WALD TAKES A WALK

From the schoolroom where I had been giving a lesson in bed-making, a little girl led me one drizzling M arch morning. She had told me of her sick mother, and gathering from her incoherent account 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 assailed me from every side. Through Hester and Division Streets we went to the end of Ludlow; past odorous fish-stands, for the streets were a market-place, unregulated, unsupervised, unclean; past evil-smelling, uncovered garbage c a n s .. All the maladjustments of our social and economic relations seemed epitomized in this brief jour­ ney 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 boarders— who were literally boarders, since a piece of timber was placed over the floor for them to sleep on— and 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 condition, and when, at the end of my ministrations, they kissed my hands (those who have undergone similar experiences will, I am sure, understand), 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 miserable 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 morning’s experience was a baptism of fire. Deserted were the laboratory and the academic work of the college. I never returned to them. On my way from the sick-room to my comfortable stu­ dent 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 challenge to know and to tell. When early morning found me still awake, my naive conviction remained that, if people knew things— and “things” meant everything implied in the condition of this family— such 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 relationship to the neighborhood in which this awakening had come. S ou rce: W ald, L. D. (1915). T h e h o u se o n H en ry Street. New Y ork, N Y : Henry Holt.

What Wald found changed her life forever and secured a place for her in American nursing history. Wald (1915) said, “All the maladjustments of our social and economic relations seemed epitomized in this brief journey” (p. 6). Wald was profoundly affected by her observations; she and her col­ league, M a ry B re w s te r , quickly established the H e n ry S tr e e t S e ttle m e n t in this same neighborhood in 1893. She quit medical school and devoted the

remainder of her life to “visions of a better world” for the public’s health. According to Wald, “Nursing is love in action, and there is no finer manifesta­ tion of it than the care of the poor and disabled in their own homes” (Wald, 1915, p. 14). The Henry Street Settlement was an independent nursing service 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 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 disadvantaged 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 $ 6 0 0 ,0 0 0 a year, all from private donations. Wald hired African American nurse E liz a b e th T y le r in 1906 as evidence of her commitment to cultural diversity. Although unable to visit white clients, Tyler made her own way by “finding” African American families who needed her service. In 3 months, Tyler had so many African American families within her caseload that Wald hired a second African American 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 commit­ ment to racial and cultural diversity by employing 25 African American 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 African American nurses were often denied admission to white schools of nursing and membership in professional organizations and were denied opportuni­ ties for employment in most settings. Because hospitals of this era often set quotas for African American clients, those nurses who managed to graduate from nursing schools found themselves with few clients who needed or could afford their services. African American nurses struggled for the right to take the registration examination available for white nurses. Wald submitted a proposal to the city of New York after learning of a child’s dismissal from a New York City school for a skin condition. 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 con­ vincing 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 pro­ posed a program to the Metropolitan Life Insurance Company to provide nursing visits to their industrial policyholders. Statistics kept by the company documented the lowered mortality rates of policyholders attributed to the nurses’ public health practice and clinical expertise. The program demon­ strated savings for the company and was so successful that it lasted until 1953 (Hamilton, 1988). Wald’s other significant accomplishments include the establishment of the Children’s Bureau, set up in 1912 as part of the U.S. Department of Labor. She also was an enthusiastic supporter of and participant in women’s suffrage, lobbied for inspections of the workplace, 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 Women’s Trade Union League to protect women from sweatshop conditions. Wald first coined the phrase “public health nursing” and transformed the field of community health nursing from the narrow role of home visiting to the population focus of today’s community 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 public’s health to governmental responsibility, not private funding. As state departments of health 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 concentrated on preventive measures (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 community, they were independent, and they enjoyed recognition as specialists 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 exploitation of women and children. These nurses also played a part in prison reform and care of the mentally ill (Heinrich, 1983). Considered the first African American public health nurse, J e s s ie S le e t S cales was hired in 1902 by the Charity Organization Society, a philanthropic organization, to visit African American families infected by TB. Scales pro­ vided district nursing care to New York City’s African American families and is credited with paving the way for African American nurses in the practice of community health (Mosley, 1996).

■ Dorothea Linde Dix D o ro th e a Linde D ix , a Boston schoolteacher, became aware of the horrendous conditions in prisons and mental institutions when asked to do a Sunday school class in the House of Correction at Cambridge, Massachusetts. She was appalled at what she saw and went about studying whether the condi­ tions were isolated or widespread; she took 2 years off to visit every jail and almshouse from Cape Cod to Berkshire (Tiffany, 1890, p. 76). Her report was devastating. Boston was scandalized by the reality that the most progres­ sive 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 D ix 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 “spirit of a crusader.” For her contributions, Dix is recog­ nized 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. Officials had consulted with Night­ ingale 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 authority 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 W alt Whitman and the author Louisa May Alcott (Donahue, 1985).

■ Clara Barton The 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. C la ra B a rto n , through her work in the Civil War, had come to believe that such an orga­ nization 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 becoming the founder of the American Red Cross (Kalisch & Kalisch, 1986). Barton also played a leadership role in the Spanish-American W ar 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 presi­ dent 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 officials to allow Barton’s 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 Barton’s 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, tenaciousness, and for organizing services for the military and civilians torn apart by war. On August 13, 1898, the Spanish-American W ar 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 Barton’s Red Cross staff applauded the work of these nurses and recommended that the U.S. 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 the driving force behind the creation of the Army Nurse Corps (Frantz, 1998).

■ Birth of the M idwife in the United S tates Women have always assisted other women in the birth of babies. These “lay midwives” were considered by communities to possess special skills and some­ what of a “calling.” W ith the advent of professional nursing in England, registered nurses became associated with safer and more predictable child­ birth 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 phy­ sicians. U.S. physicians saw midwives as a threat and intrusion into medical practice. Such resistance indirectly led to the proliferation of “granny wives” 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 F ro n tie r N u rs in g S e rv ic e founded in 1925 by M a ry B re c k e n rid g e . Breckenridge gradu­ ated from the St. Luke’s 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 Appa­ lachia, 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 “cut” the pain. The people of Appala­ chia were isolated because of the terrain of the hollows and mountains, and roads were limited to most families. They had one of the highest birth rates in the United States. Breckenridge believed that if a midwifery service could work under these conditions, it could work anywhere (Donahue, 1985). Breckenridge had to use English midwives for many years and only began training her own midwives in 1939 when she started the Frontier Graduate School of Nurse Midwifery in Hyden, Kentucky, with the advent of World W ar 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. The nurse midwives under the direction of Breckenridge were suc­ cessful 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 “flapper era”— shrinking dress hemlines, short­ ened 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 procedures 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. M a ry D . O s b o rn e , who functioned as supervisor of public health nursing for the state of Mississippi from 1921 to 1946, had a vision for a collabora­ tion with community nurses and granny midwives, who delivered 80% of the African American babies in Mississippi. The infant and maternal mortality rates were both exceptionally high among African American families, and these granny midwives, who were also African American, were untrained and had little education. Osborne took a creative approach to improving maternal and infant health among African American women. She developed a collaborative network of public health nurses and granny midwives in which the nurses implemented training programs for the midwives, and the midwives in turn assisted the nurses in providing a higher standard of safe maternal and infant health care. The public health nurses used O sborne’s book, M anual fo r M idw ives, which contained guidelines for care and was used in the state until the 1970s. They taught good hygiene, infection prevention, and compliance with state regulations. Osborne’s 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 W ar II With the stock market crash of 1929 came the Great Depression, resulting in widespread unemployment of private-duty nurses and the closing of nursing schools with a simultaneous increase in 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 were a critical presence at the invasion of Normandy in 1938, as well as in North Africa, Italy, France, and the Philippines, while Navy nurses provided care aboard hospital ships. 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 on the home front resulted in the development of the C a d e t N u rs e C o rp s . F ra n c e s P a y n e B o lto n , 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 nursing students had been trained through this act, while advanced practice graduate nurses in psychiatry and public health nursing had received graduate education to increase the numbers of nurse educators (Donahue, 1985; Kalisch & Kalisch, 1986). Ernie Pyle, a famous war correspondent in World W ar II, offered Ameri­ cans a “front-seat view” through his detailed journalistic accounts of daily life on the war front. Pyle was the first journalist to put his own life in danger by reporting from the battlefront; he spent a great deal of time with soldiers during active combat and was killed during a sniper attack in Ie Shima, Japan. Chaplin Nathan Baxter Saucier was assigned to retrieve his body, conduct his service, and assist the soldiers with building his coffin. The funeral service lasted only about 10 minutes. Pyle was buried with his helmet on, at Chaplin Saucier’s request. The Navy, Marine Corps, and Army were all represented at the service. Pyle, who died during the Battle of Okinawa in 1945, was a highly regarded and humanistic voice for those serving America during World W ar II. Here is an example of Pyle’s accounts of life for nurses in a field hospital in Europe: The officers and nurses live two in a tent on two sides of a company street— nurses on one side, officers on the other.... The nurses wear khaki overalls because of the mud and dust. Pink female panties fly from a line among the brown warlike tents. On the flagpole is a Red Cross flag made from a bed sheet and a French soldier’s red sash. The American nurses— and there were lots of them turned out just as you would expect: wonderfully. Army doctors and

patients too were unanimous in their praise of them. Doctors told me that in the first rush of casualties they were calmer than the men. For the first ten days they had to live like animals, even using open ditches for toilets but they never complained. One nurse was always on duty in each tentful of 20 men. She had medical orderlies to help her. The touch of femininity, the knowledge that a woman was around, gave the wounded man courage and confidence and a feeling of security. (Pyle, 1944) Amid the Depression, many nurses found the expansion and advances in aviation as a new field for nurses. In efforts to increase the public’s confidence in the safety of transcontinental air travel, nurses were hired in the promising new role of “nurse-stewardess” (Kalisch & Kalisch, 1986). Congress created an additional relief program, the Civil Works Administration, in 1933 that provided jobs to the unemployed, including placing nurses in schools, public hospitals and clinics, public health departments, and public health education community surveys and campaigns. The Social Security Act of 1935 was passed by Congress to provide old-age benefits, rehabilitation services, unem­ ployment compensation administration, aid to dependent 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 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 profession were released during this decade. W ar N urse (1930), N ight N urse (1931), O nce to Every W om an (1934), T he W hite P arade (1934 Academy Award nominee for Best Picture), Four Girls in W hite (1939), T he W hite Angel (1936), and D octor an d N urse (1937) all used nurses as major characters. During the bleak years of the eco­ nomic depression, young women found these nurse heroines who promoted idealism, self-sacrifice, and the profession of nursing over personal desires particularly appealing. No longer were nurses depicted as subservient hand­ maidens who worked as nurses only as a temporary pastime before marriage (Kalisch & Kalisch, 1986).

■ Science and H ealth Care, 1 9 4 5 -1 9 6 0 : Decades of Change Dram atic technological and scientific changes characterized the decades following World W ar 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 expan­ sion of private health insurance coverage and the dramatic increase in the birth rate, called the “baby boom” generation. Clinical research, both in medicine and in nursing, became an expectation of health providers, and more nurses sought advanced degrees. The Jou rn al o f Nursing R esearch was first published, heralding the arrival of nursing scholarship in the United States. As a result of increased numbers of hospital beds, additional financial resources for health care, and the post-W orld W ar II economic resurgence, nursing faced an acute shortage and nurses confronted increasingly stressful working conditions. Nurses began showing signs of the strain through debates about strikes and collective bargaining demands. The American Nurses Association (ANA) accepted African American nurses for membership, consequently ending racial discrimination in the domi­ nant nursing organizations. The National Association of Colored Graduate Nurses was disbanded in 1951. M ales 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 discouraged 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 Hospitalers, 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 Kaiserwerth in Germany; Ben Franklin; and W alt Whitman during the Civil W ar all either served as nurses or were strong advocates for male nurses (Kalisch & Kalisch, 1986).

■ Years of Revolution, P rotest, and the New O rder, 1 9 6 1 -2 0 0 0 During the social upheaval of the 1960s, nursing was influenced by many changes in society, such as the wom en’s movement, the organized pro­ test against the Vietnam conflict, civil rights movement, President Lyndon Johnson’s “Great Society” social reforms, and increased consumer involve­ ment in health care. Specialization in nursing, such as cardiac ICU, nurse anesthetist training, and the clinical specialist role for nursing became trends that affected both education and practice in the healthcare system. Medicare and M edicaid, enacted in 1965 under Title X V III of the Social Security Act, provided access to health care for older adults, poor persons, and people with disabilities. The American Nurses Association took a coura­ geous and controversial stand in that same year (1965) by approving its first

40

CHAPTER 1 A History of Health Care and Nursing

position paper on nursing education, advocating for all nursing education for professional practice to take place in colleges and universities (American Nurses Association, 1965). Nurses returning from Vietnam faced emotional challenges in the form of post-traumatic stress disorder (PTSD) that affected their postwar lives. With increased specialization in medicine, the demand for primary care healthcare providers exceeded the supply (Christman, 1971). As a response to this need for general practitioners, Dr. Henry Silver, M D , and Dr. Loretta Ford, RN, collaborated to develop the first nurse practitioner (NP) program in the United States at the University of Colorado (Ford & Silver, 1967). Nurse practitioners (NPs) were initially prepared in pediatrics with advanced role preparation in common childhood illness management and well-child care. 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 programs for nurse practitioners. 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 new century, nurse practitioner programs were offered at the M SN level in family nursing; gerontology; adult, neonatal, mental health, and maternal-child areas and have expanded to include the acute care practitioner as well (Huch, 2001). Certification of nurse practitioners now occurs at the national level through the American Nurses Association and by many 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 profession heralded healthcare reform with an unprecedented collaboration of more than 75 nursing asso­ ciations, led by the American Nurses Association and the National League for Nursing, in the publication of N u rs in g 's A g e n d a fo r H e a lt h C a re R e f o r m . In this document, the challenge of m an aged c a re was addressed in the con­ text of cost containment and quality assurance of healthcare service for the nursing profession (American Nurses Association, 1991). Managed care is a market approach based on managed competition as a major strategy to contain healthcare costs, which is still the dominant approach used today (Lundy, Janes, & Hartman, 2001).

T h e N ew C e n tu ry : A n E ra of M an aged C a re and H e a lth c a re R e fo rm U.S. healthcare system reform continues to be the topic of political de­ bate with the primary focus on federal coverage, access, and healthcare

The Nurse of the Future

41

cost control. H ealthcare organizations in a managed care environment, such as preferred provider organizations and health maintenance organi­ zations, now see the economic and quality outcome benefits of caring for patients and managing their care over a continuum of settings and needs. Patients are followed more closely within the system, both during illness and wellness. Hospital stays are shorter, and more and more healthcare services are provided in outpatient facilities and through community-based settings, such as home health, occupational health, and school health (Lundy, Janes, & Hartman, 2 0 0 9 ). And more of these healthcare services are provided by nurses.

T h e N u rs e of th e F u tu re With the roles of nurses in the healthcare system expected to expand in the future, focus is placed on raising educational levels and competencies of nurses and fostering interdisciplinary collaboration to increase access, safety, and quality of patient care. For example, the latest Institute of Medicine (IOM , 2 0 1 1 ) report, titled T h e Future o f N ursing: L ea d in g C hange, A dvancing H ealth , specifically calls for interdisciplinary education, decreasing barri­ ers to nursing scope of practice, and increasing educational levels of nurses. The Robert W ood Johnson Foundation sponsored the Quality and Safety Education for Nurses (QSEN) initiative with the overall goal of “prepar­ ing 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, 2007). QSEN is directed to develop competencies of future nursing graduates in six key areas, including patientcentered care, evidence-based practice, quality improvement, teamwork and collaboration, safety, and informatics. In 20 0 6 , the Massachusetts Department of Higher Education (MDHE) and Massachusetts Organization of Nurse Executives convened a working session of stakeholders titled Creativity and Connections: Building the Framework for the Future of Nursing Education and Practice. From this beginning, the N urse o f th e Future: N ursing C ore C om peten cies (MDHE, 2 0 1 0 , p. 2) was developed in response to the goals of cre­ www 1 CRITICAL THINKING QUESTION* ating a seamless progression through all levels of nursing education and development of consensus on competen­ What do you think would be the response of cies. This movement to facilitate creation of a core set of historical nursing leaders such as Florence Nightingale, Lillian Wald, and Mary entry-level nursing competencies and seamless transition Breckenridge if they could see what the pro­ in nursing education is not singular and reflects the cur­ fession of nursing looks like today?V rent focus in the profession to increase access, safety, and quality of health care.

42

CHAPTER 1 A History of Health Care and Nursing

C o nclu sio n Consensus regarding basic education and the entry level of registered nurses has not occurred. Changes in the advanced practice role challenge the nurse education and healthcare systems as the primary healthcare needs of the U.S. population compete with acute care for scarce resources. A global community 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 and an unknown future. By considering the lessons of our past, the nursing profession is well prepared to provide a full range of quality, cost-effective services in the promotion of health throughout this century.

Classroom A ctivity 1 he r e are m a n y t h e o r i e s a b o u t N ightingale’s chronic illness, which caused her to be an invalid 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. Rumors have abounded among nursing students that she suffered from tertiary syphilis. 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 de­ veloped spondylitis, or inflam m ation of the spine. For the next 34 years, she managed

T

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 peri­ ods of depression alternating with remarkable bursts of productivity. Read about the various theories of her chronic disabling condition and reflect on your own conclusions about her mys­ terious illness. With supporting evidence, what are your conclusions about Nightingale’s health condition? 1^3^ S ou rces: Dossey, B. (2000). F loren ce N ightin gale: M ystic, v ision ary , h ea ler. Philadelphia, PA: Lippincott W illiam s & W ilkins; Nightingale suffered bipolar disorder. (2004). A ustralian N ursing Jo u rn a l, 12, 2.

Classroom A ctivity 2 'hat would Florence N ightingale’s resume or curriculum vitae look like? Check out Nightingale’s curriculum

vitae at www.countryjoe.com/nightingale/ cv.htm. m

R e fe re n c e s Abel, E. K. (1997). Take the cure to the poor: Patients’ responses to New York City’s tuberculosis program, 1894-1918. American Journal o f Public Health, 87, 11. American Nurses Association. (1965). Educational preparation for nurse practitioners and assistants to nurses: A position paper. New York, NY: Author. American Nurses Association. (1991). Nursing’s agenda for health care reform: Executive summary. Washington, DC: Author. Andrews, G. (2003). Nightingale’s geography. Nursing Inquiry, 10(4), 270-274. Attewell, A. (1996). Florence Nightingale’s health-at-home visitors. Health Visitor, 6.9(10), 406. Barker, E. R. (1989). Care givers as casualties. Western Journal o f Nursing Research, 11(5), 628-631. Boorstin, D. J. (1985). The discoverers: A history o f man’s search to know his world and himself. New York, NY: Vintage. Brainard, A. M. (1922). The evolution o f public health nursing. Philadelphia, PA: Saunders. Brockett, L. P., & Vaughan, M. C. (1867). Women’s work in the Civil War: A record o f heroism: Patriotism and patience. Philadelphia, PA: Seigler McCurdy. Brooke, E. (1997). Medicine women: A pictorial history o f women healers. Wheaton, IL: Quest Books. Brown, E. L. (1936). Nursing as a profession. New York, NY: Russell Sage Foundation. Brown, E. L. (1948). Nursing for the future. New York, NY: Russell Sage Foundation. Brown, P. (1988). Florence Nightingale. Hats, UK: Exley Publications. Buhler-Wilkerson, K. (1985). Public health nursing: In sickness or in health? American Journal o f Public Health, 75, 1155-1156. Bullough, V. L., & Bullough, B. (1978). The care o f the sick: The emergence o f modern nursing. New York, NY: Prodist. Calabria, M. D. (1996). Florence Nightingale in Egypt and Greece: Her diary and visions. Albany, NY: State University of New York Press. Carnegie, M. E. (1991). The path we tread: Blades in nursing 1854-1990 (2nd ed.). New York, NY: National League for Nursing Press. Cartwright, F. F. (1972). Disease and history. New York, NY: Dorset Press. Christman, L. (1971). The nurse specialist as a professional activist. Nursing Clinics o f North America, 6(2), 231-235. Christy, T. E. (1975). The fateful decade: 1890-1900. American Journal o f Nursing, 75(7), 1163-1165. Cohen, M. N. (1989). Health and the rise o f civilization. New Haven, CT: Yale University Press. Cook, E. (1913). The life o f Florence Nightingale (Vols. 1 and 2). London, England: Macmillan. D’Antonio, P. (2002). Nurses in war. Lancet, 360(9350), 7-12. Diamond, J. (1997). Guns, germs, and steel: The fates o f human societies. New York, NY: W. W. Norton. Dickens, C. (1844). Martin Chuzzlewit. New York, NY: Macmillan. Dietz, D. D., & Lehozky, A. R. (1963). History and modern nursing. Philadelphia, PA: F. A. Davis.

Dock, L., & Stewart, I. (1931). A short history o f nursing from the earliest times to the present day (3rd ed.). New York, NY: G. P. Putman’s Sons. Donahue, M. P. (1985). Nursing: The finest art. St. Louis, MO: Mosby. Dossey, B. M. (2000). Florence Nightingale: Mystic, visionary, healer. Springhouse, PA: Springhouse. Ford, L. C. (1979). A nurse for all seasons: The nurse practitioner. Nursing Outlook, 27(8), 516-521. Ford, L. C., & Silver, H. K. (1967). The expanded role of the nurse in child care. Nursing Outlook, 15(8), 43-45. Frantz, A. K. (1998). Nursing pride: Clara Barton in the Spanish American War. American Journal o f Nursing, 98(10), 39-41. Goldmark, J. C. (1923). Nursing and nursing education in the United States. New York, NY: Macmillan. Hamilton, D. (1988). Clinical excellence, but too high a cost: The Metropolitan Life Insurance Company Visiting Nurse Service (1909-1953). Public Health Nursing, 5, 235-240. Hanlon, J. J., & Pickett, G. E. (1984). Public health administration and practice (8th ed.). St. Louis, MO: Mosby. Heinrich, J. (1983). Historical perspectives on public health nursing. Nursing Outlook, 32(6), 317-320. Hine, D. C. (1989). Black women in white: Racial conflict and cooperation in the nursing profession 1889-1950. Bloomington, IN: Indiana University Press. Howell, J. (1996). Technology in the hospital. Baltimore, MD: Johns Hopkins University Press. Huch, M. (2001). Advanced practice nursing in the community. In K. S. Lundy & S. Janes (Eds.), Community health nursing: Caring for the public’s health (pp. 968-980). Sudbury, MA: Jones and Bartlett. Institute of Medicine. (2011). The future o f nursing: Leading change, advancing health. Washington, DC: National Academy Press. Kalisch, P. A., & Kalisch, B. J. (1986). The advance o f American nursing (2nd ed.). Boston, MA: Little, Brown. LeVasseur, J. (1998). Plato: Nightingale and contemporary nursing. Image: Journal o f Nursing Scholarship, 30(3), 281-285. Longfellow, H. W. (1857). Santa Filomena. Atlantic Monthly, 1, 22-23. Lundy, K. S., Janes, S., & Hartman, S. (2001). Opening the door to health care in the community. In K. S. Lundy & S. Janes (Eds.), Community health nursing: Caring for the public’s health (pp. 5-29). Sudbury, MA: Jones and Bartlett. Lundy, K. S., Janes, S., & Hartman, S. (2009). Opening the door to health care in the community. In K. S. Lundy & S. Janes (Eds.), Community health nursing: Caring for the public’s health (pp. 4-29). Sudbury, MA: Jones and Bartlett. MacEachern, M. T. (1932). Which shall we choose: Graduate or student service? Modern Hospital, 38, 97-98, 102-104. Massachusetts Department of Higher Education. (2010). Nurse o f the future: Nursing core competencies. Retrieved from http://www.mass.edu/currentinit/documents/ NursingCoreCompetencies.pdf Montag, M. L. (1959). Community college education for nursing: An experiment in technical education for nursing. New York, NY: McGraw-Hill.

Monteiro, L. A. (1985). Florence Nightingale on public health nursing. American Journal o f Public Health, 75(2), 181-185. Mosley, M. O. P. (1996). Satisfied to carry the bag: Three black community health nurses’ contribution to health care reform, 1900-1937. Nursing History Review, 4, 65-82. Nightingale, F. (1860). Notes on nursing: What it is and what it is not. London, England: Harrison. Nightingale, F. (1893). Sick-nursing and health-nursing. In B. Burdett-Coutts (Ed.), Women’s mission (pp. 184-205). London, England: Sampson, Law, Marston and Co. Nightingale, F. (1894). Health teaching in towns and villages. London, England: Spottiswoode & Co. Nightingale, F. (1979). Cassandra. In M. Stark (Ed.), Florence Nightingale’s Cassandra. Old Westbury, NY: Feminist Press. Nutting, M. A., & Dock, L. L. (1907). A history o f nursing: The evolution o f nursing systems from the earliest times to the foundation o f the first English and American training schools for nurses. New York, NY: G. P. Putnam’s Sons. The 100 people who made the millennium. (1997). Life Magazine, 20(10a). Palmer, I. S. (1977). Florence Nightingale: Reformer, reactionary, researcher. Nursing Research, 26(2), 13-18. Palmer, I. S. (1982). Through a glass darkly: From Nightingale to now. Washington, DC: American Association of Colleges of Nursing. Pyle, E. (1944). Here is your war: The story o f G.I. J o e . Cleveland, OH: World Publishing. Quality and Safety Education for Nurses. (2007). Quality and safety competencies. Retrieved from http://www.qsen.org/competencies.php Rathbone, W. (1890). A history o f nursing in the homes o f the poor. Introduction by Florence Nightingale. London, England: Macmillan. Richardson, B. I. W. (1887). The health o f nations: A review o f the works o f Edwin Chadwick (Vol. 2). London, England: Longmans, Green. Roberts, M. (1954). American nursing: History and interpretation. New York, NY: Macmillan. Robinson, V. (1946). White caps: The story o f nursing. Philadelphia, PA: Lippincott. Rosen, G. (1958). A history o f public health. New York, NY: M.D. Publications. Sabin, L. (1998). Struggles and triumphs: The story o f Mississippi nurses 1800-1950. Jackson, MS: Mississippi Hospital Association Health, Research and Educational Foundation. Sanger, M. (1928). M otherhood in bondage. New York, NY: Brentano’s. Seymer, L. (1954). Selected writings o f Florence Nightingale. New York, NY: Macmillan. Shryock, R. H. (1959). The history o f nursing: An interpretation o f the social and medical factors involved. Philadelphia, PA: Saunders. Smith, E. (1934). Mississippi special public health nursing project made possible by federal funds. Paper presented at the 1934 annual Mississippi Nurses Association meeting, Jackson, MS. Snow, J. (1855). On the m ode o f communication o f cholera (2nd ed.). London, England: Churchill.

Stanmore, A. H. G. (1906). Sidney Herbert o f Lea: A memoir. New York, NY: E. P. Dutton. State board test pool examination. (1952). American Journal o f Nursing, 52, 613. Stewart, I. M. (1921). Developments in nursing education since 1918. U.S. Bureau o f Education Bulletin, 20(6), 3-8. Taylor, H. O. (1922). Greek biology and medicine. Boston, MA: Marshall Jones. Tiffany, R. (1890). The life o f Dorothea Linda Dix. Boston, MA: Houghton Mifflin. Tooley, S. A. (1910). The life o f Florence Nightingale. London, England: Cassell and Co. Tyrell, H. (1856). Pictorial history o f the war with Russia 1854-1856. London, England: W. and R. Chambers. Vicinus, M., & Nergaard, B. (1990). Ever yours: Florence Nightingale: Selected letters. Cambridge, MA: Harvard University Press. Wald, L. D. (1915). The house on Henry Street. New York, NY: Holt. Wertz, R. W., & Wertz, D. C. (1977). Lying-in: A history o f childbirth in America. New Haven, CT: Yale University Press. Wheeler, W. (1999). Is Florence Nightingale holding us back? Nursing 99, 29(10), 22-23. Williams, C. B. (1961). Stories from Scutari. American Journal o f Nursing, 61, 88. Winslow, C.-E. A. (1946). Florence Nightingale and public health nursing. Public Health Nursing, 38, 330-332. Woodham-Smith, C. (1951). Florence Nightingale. New York, NY: McGraw-Hill. Woodham-Smith, C. (1983). Florence Nightingale. New York, NY: Athenaeum. Young, D. A. (1995). Florence Nightingale’s fever. British Medical Journal, 311, 1697-1700.

Framework for Professional Nursing Practice Kathleen Masters

v_____________________ Although the beginning of nursing theory development can be traced to Florence Nightingale, it was not until the second half of the 1900s that nurs­ ing 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, atten­ tion turned from the development 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 orga­ nized to be meaningful for practice, research, and further knowledge devel­ opment. The goal of this chapter is to present an organized and practical overview of the major concepts, models, philosophies, and theories that are essential in professional nursing practice. It can be helpful to define some terms that might be unfamiliar. A c o n ce p t is a term or label that describes a phenomenon (Meleis, 2004). The phenom­ enon described by a concept can be either empirical or abstract. An empirical concept is one that can be either observed or experienced through the senses. An abstract concept is one that is not observable, such as hope or caring (Hickman, 2002).

Key Terms and Concepts » » » » » » » » » » »

C o n ce p t Conceptual model Propositions Assumptions Theory Metaparadigm Person Environment Health Nursing Philosophies

Learning Objectives A f t e r c o m p le tin g th is c h a p te r, th e s tu d e n t should be a b le to : 1. Id e n tify th e fo u r m e ta p a ra d ig m c o n c e p ts of nursing. 2 . Id e n tify and describe s ev era l th e o re tic a l w orks in nursing.

3 . B eg in th e p ro ce ss o f id e n tify in g th e o re tic a l fra m e w o rk s o f nursing th a t a re co n sis te n t w ith a perso nal b e lie f s y s te m .

47

A c o n c e p tu a l m odel is defined as a set of concepts and statements that integrate the concepts into a meaningful configuration (Lippitt, 1973; as cited in Fawcett, 1994). P ro p o s itio n s are statements that describe relationships among events, situations, or actions (Meleis, 2004). A s s u m p tio n s also describe concepts or connect two concepts and represent values, beliefs, or goals. When assumptions are challenged, 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 discipline and guides the members as they propose questions and make observations relevant to the discipline (Fawcett, 1994). A th e o ry “is an organized, coherent, and systematic articulation of a set of statements related to significant questions in a discipline that are com­ municated in a meaningful whole,” according to 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 m e ta p a ra d ig m is the most global perspective of a discipline and “acts as an encapsulating unit, or framework, within which the more restricted ... structures develop” (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 metaparadigm of the discipline (Fawcett, 1994). The conceptual models and theories of nursing represent various para­ digms derived from the metaparadigm of the discipline of nursing. Therefore, although each of the conceptual models might link and define the four metaparadigm concepts differently, the four metaparadigm concepts are present in each of the models. The central concepts of the discipline of nursing are p e rs o n , e n v iro n m e n t , h e a lth , and n u rs in g . These four con­ cepts of the metaparadigm of nursing are more specifically “The person receiving the nursing, the environment within which the person exits, the health-illness continuum within which the person falls at the time of the interaction with the nurse, and, finally, nursing actions themselves” (Flaskerud & Holloran, 1980, cited in Fawcett, 1994, p. 5). Because concepts are so abstract at the metaparadigm level, many concep­ tual models have developed from the metaparadigm of nursing. Subsequently, multiple theories have been derived from each conceptual model in an effort to describe, explain, and predict the phenomena within the model.

Overview of Selected Nursing Theories

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O v e rv ie w of S e le c te d N u rsin g T h e o rie s To 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 provides an introductory overview of selected theoretical works to give you a launching point for further reflection and study as CRiTICAL THiNKiNG QUESTION V you begin your journey into professional nursing practice. Theoretical works in nursing are generally categorized What are the specific competencies for nurses either as philosophies, conceptual models, theories, or in relation to theoretical knowledge? V middle-range theories depending on the level of abstrac­ tion. We begin with the most abstract of these theoretical works, the philosophies of nursing.

■ Selected Philosophies of Nursing P h ilo so p h ies set forth the general meaning of nursing and nursing phenom­ ena through reasoning and the logical presentation of ideas. Philosophies are broad and address general ideas about nursing. Because of their breadth, nurs­ ing philosophies contribute to the discipline by providing direction, clarifying values, and forming a foundation for theory development (Alligood, 2006).

Nightingale's Environm ental Theory Nightingale’s 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 Nightingale’s philosophy are centered on her 13 canons, which follow (Nightingale, 1860/1969): • Ventilation and warming: The interventions subsumed in this canon include keeping the patient and the patient’s room warm and keeping the patient’s

TA B LE 2-1

M etaparadigm Concepts as Defined in Nightingale's Model

Person Recipient of nursing care Environment External (temperature, bedding, ventilation) and internal (food, water, and medi­ cations) Health Health is “not only to be well, but to be able to use well every power we have to use” (Nightingale, 1969, p. 24)

Nursing Alter or manage the environment to implement the natural laws of health

• • • • • • • • • • • •

room well ventilated and free of odors. Specific instructions included “keep the air within as pure as the air without” (Nightingale, 1860/1969, p. 10). 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 patient’s 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 patient’s room. Cleanliness of rooms and walls: This canon focuses on keeping the envi­ ronment clean. Personal cleanliness: This canon includes measures such as keeping the patient clean and dry. Chattering hopes and advices: Instructions in this canon include the avoid­ ance 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 Nightingale’s 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). Although Nightingale’s theory was developed long ago in response to a need for environmental reform, the nursing principles are still relevant today. Even as some of Nightingale’s rationales have been modified or disproved by advances in medicine and science, many of the concepts in her theory have not only endured, but have been used to provide general guidelines for nurses for more than 150 years (Pfettscher, 2006).

Virginia Henderson: Definition of Nursing and 14 Com ponents of Basic Nursing Care Henderson made such significant contributions to the discipline of nursing dur­ ing her more-than-60-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, The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge and to do this in such a way as to help him gain independence as rapidly as possible. (Henderson, 1966, p. 15) In her work Henderson emphasized the art of nursing as well as empathetic understanding, stating that the nurse must “get inside the skin of each of her patients in order to know what he needs” (Henderson, 1964, p. 63). She believed that “the beauty of medicine and nursing is the combination of your heart, your head and your hands and where you separate them, you diminish them . . . ” (McBride, 1997, as cited by Gordon, 2001). Henderson identified 14 basic needs on which nursing care is based. 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 one’s faith. W ork 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 (Furukawa & Howe, 2002) (Table 2-2).

Jean Watson: Philosophy and Science of Caring According to W atson’s theory (1996), the goal of nursing is to help persons attain a higher level of harmony within the mind-body-spirit. 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 caristas processes.

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TA B LE 2 - 2

CHAPTER 2 Framework for Professional Nursing Practice

M etaparadigm Concepts as Defined in Henderson's Philosophy and A rt of Nursing

Person Recipient of nursing care who is com­ posed of biological, psychological, sociological, and spiritual components Environment External environment (tempera­ ture, dangers in environment); some discussion of impact of community on the individual and family

TA B LE 2 -3

Health Based upon the patient’s ability to func­ tion independently (as outlined in 14 compo­ nents of basic nursing care) Nursing Assist the person, sick or well, in perfor­ mance of activities (14 components of basic nurs­ ing care) and help the person gain independence as rapidly as possible (Henderson, 1966, p. 15)

M etaparadigm Concepts as Defined in W atson's Philosophy and Science of Caring

Person (human) A “unity of mind-body-spirit/ nature” (Watson, 1996, p. 147); embodied spirit (Watson, 1989) Healing space and environment A nonphysical energetic environment; a vibrational field integral with the person where the nurse is not only in the environment but “the nurse IS the environment” (Watson, 2008, p. 26)

Health (healing) Harmony, wholeness, and comfort Nursing Reciprocal transpersonal relationship in caring moments guided by carative factors and caritas processes

W atson’s theory for nursing practice is based on 10 carative factors (Watson, 1979). As W atson’s work evolved, she renamed these carative fac­ tors into what she termed clinical caritas processes (Fawcett, 2005). Caritas means to cherish, to appreciate, and to give 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 one’s own spiritual practices; going beyond the ego self; deep­ ening of self-awareness • D eveloping and sustaining a h elp in g -tru stin g , au thentic caring relationship

•

• •

•

•

•

Being present to, and supportive of, the expression of positive and nega­ tive 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 caring process and engagement in artistry of caring-healing practices Engaging in a genuine teaching-learning experience within the context of a caring relationship, while attending to the whole person and subjective meaning; attempting to stay within the other’s 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 m ind-body-spirit, 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 existential dimensions of life, death, suffering; “allowing for a miracle” (Watson, 2008)

W atson (2001) refers to the clinical caritas processes as the “core” of nursing, which is grounded in the philosophy, science, and the art of caring. She contrasts the core of nursing with what she terms the “trim ,” a term she uses to refer to the practice setting, procedures, functional tasks, clinical dis­ ease 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, p. 50). Regarding the value system that is blended with these 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 subjective-internal world of the experiencing person and how the person (both patient and nurse) is perceiving and experiencing health-illness conditions. An emphasis is placed upon helping a person gain more self-knowledge, self control, and readiness for self-healing. (pp. 34, 35) The carative factors described by Watson provide guidelines for nurse-patient interactions; however, the theory does not furnish instructions about what to do to achieve authentic caring-healing relationships. W atson’s theory is more about being than doing, but it provides a useful framework for the delivery of patient-centered nursing care (Neil & Tomey, 2006).

Patricia Benner's Clinical Wisdom in Nursing Practice Benner’s work has focused on the understanding of perceptual acuity, clinical judgment, skilled know-how, ethical comportment, and ongoing experiential learning (Brykczynski, 2010, p. 141). Also important in Benner’s philosophy is an understanding of ethical comportment. According 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. Benner’s original domains and competencies of nursing practice were derived inductively from clinical situation interviews and observations of nurses in actual practice. From these interviews and observations, 31 compe­ tencies and 7 domains were identified and described. The 7 domains are the helping role, the teaching-coaching function, the diagnostic and patient moni­ toring function, effective management of rapidly changing situations, admin­ istering and monitoring therapeutic interventions and regimens, monitoring and ensuring the quality of healthcare practices, and organizational work role competencies (Benner, 1984/2001). Along with the identification of the com­ petencies and domains of nursing, Benner identified five stages of skill acqui­ sition 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 colleagues 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 criti­ cally ill, caring for patients’ families, preventing hazards in a technological environment, facing death: end-of-life care and decision making, communi­ cating and negotiating multiple perspectives, monitoring quality and managing breakdown, using the skilled know-how of clinical leadership and the coaching and mentoring of others (Benner, Hooper-Kyriakidis, & Stannard, 1999). In addition, the nine domains of critical care nursing practice are used as broad themes in data interpretation for the identification and description of six aspects of clinical judgment 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 performance; 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: O ne’s 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 notions of good outcomes for patients and families (Benner et al., 1999).

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M etaparadigm Concepts as Defined in Benner's Philosophy

Person Embodied person living in the world who is a “self-interpreting being, that is, the per­ son does not come into the world pre-defined but gets defined in the course of living a life” (Benner & Wrubel, 1989, p. 41) Environment (situation) A social environment with social definition and meaningfulness

Health The human experiencee of health or wholeness Nursing A caring relationship that includes the care and study of the lived experience of health, illness, and disease

Benner identifies and defines the four metaparadigm concepts of nursing in addition to the concepts previously discussed. The concepts of person, environ­ ment, health, and nursing as defined by Benner are summarized in Table 2-4.

■ Selected Conceptual Models and Grand Theories of Nursing Conceptual models provide a comprehensive view and guide for nursing prac­ tice. 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, pp. 1 7 -1 8 ).

M artha Rogers's Science of U nitary Human Beings According to Rogers (1994), nursing is a learned profession, both a science and an art. The art of nursing is the creative use of the science of nursing for human betterment. Rogers’s theory asserts that human beings are dynamic energy fields that are integrated with environmental energy fields so that the person and his or her environment form a single unit. Both human energy fields and envi­ ronmental fields are open systems, pandimensional in nature and in a con­ stant state of change. Pattern is the identifying characteristic of energy fields (Table 2-5). Rogers identified the principles of helicy, resonancy, and integrality 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

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M etaparadigm Concepts as Defined in Rogers's Theory

Person An irreducible, irreversible, pandi­ mensional, negentropic energy field identified by pattern; a unitary human being develops through three principles: helicy, resonancy, and integrality (Rogers, 1992) Environment An irreducible, pandimensional, negentropic energy field, identified by pattern and manifesting characteristics different from those of the parts and encompassing all that is other than any given human field (Rogers, 1992)

Health Health and illness as part of a continuum (Rogers, 1970) Nursing Seeks to promote symphonic interac­ tion between human and environmental 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)

of change. Resonancy is depicted as a wave frequency and an energy field pattern evolution from lower to higher frequency wave patterns and is reflec­ tive 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 con­ stant interaction of the human-environment process. The Slinky illustrates the openness, rhythm, motion, balance, and expanding 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, 20 1 0 , p. 142). Rogers (1970) identified five assumptions that support and connect the concepts in her conceptual model: • M an is a unified whole possessing his own integrity and manifesting characteristics more than and different from the sum of his parts (p. 47). • M an and environment are continuously exchanging matter and energy with one another (p. 54). • The life process evolves irreversibly and unidirectionally along the space­ time 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). Rogers’s model is an abstract system of ideas but is applicable to prac­ tice, with nursing care focused on pattern appraisal and patterning activities. Pattern appraisal involves a comprehensive assessment of environmental field patterns and human field patterns of com m unication, exchange,

rhythms, dissonance, and harmony through the use of cognitive input, sensory input, intuition, and language. Patterning activities can include interventions such as meditation, imagery, journaling, or modifying sur­ roundings. Evaluation is ongoing and requires a repetition of the appraisal process (Gunther, 200 6 ).

Dorothea Orem 's S elf-C are D eficit Theory of Nursing Orem 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 Orem’s general theory of nursing known as the Self-Care Deficit Theory of Nursing (Berbiglia, 20 1 0 ; Orem, 1990; Taylor, 2006).

T h e o ry of S e lf-C a re The Theory of Self-Care describes why and how people care for themselves 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 maturing persons to know and meet their requirements for deliberate and purposive action to regulate their own human functioning and development (Orem, 2001, p. 492). The concept of self-care agency has three dimensions: development, operability, and adequacy. According to Orem (2001, p. 491), therapeutic self-care demand consists of the summation of care measures necessary to meet all of an individual’s known self-care requisites. B asic con d ition in g 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, developmental state, health state, pattern of living, healthcare system factors, family system factors, sociocultural factors, availability of resources, and external environmental factors (Orem, 2001). Orem identifies three types of self-care requisites that are integrated into the theory of self-care and 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 the following needs: • • • •

Maintenance of sufficient intake of air Maintenance of sufficient intake of water Maintenance of sufficient intake of food Provision of care associated with elimination processes and excrements

• Maintenance of a balance of activity and rest • Maintenance of a balance between solitude and social interaction • Prevention of hazards to human life, human functioning, and human well-being • Promotion of human functioning and development within social groups in accordance with human potential, known limitations, and the human desire to be normal (Orem, 1985, pp. 9 0 -9 1 ) Developmental self-care requisites are related to different stages in the human life cycle and might include events such attending college, marriage, and retirement. Broadly speaking, the development self-care requisites include the following needs: • Bringing about and maintenance of living conditions that support life processes and promote the processes of development— that is, human progress toward higher levels of organization of human structures and toward maturation • Provision of care either to prevent the occurrence of deleterious effects of conditions that can affect human development or to mitigate or overcome these effects from various conditions (Orem, 1985, p. 96) Health-deviation self-care requisites are related to deviations in structure or function of a human being. There are six categories of health-deviation requisites: • • • • • •

Seeking and securing appropriate medical assistance Being aware of and attending to the effects and results of illness states Effectively carrying out medically prescribed treatments Being aware of and attending to side effects of treatment Modifying self-concept in accepting oneself in a particular state of health Learning to live with the effects of illness and medical treatment (Orem, 1 9 8 5 ,p p .9 9 -1 0 0 )

T h e o ry of S e lf-C a re Deficit The Theory of Self-Care Deficit explains that maturing or mature adults delib­ erately 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 m aintaining an environment that supports personal development Teaching (Johnson & Webber, 2010; Orem, 1995, 2001)

T h e o ry of Nursing S y ste m s The Theory of Nursing Systems describes and explains relationships that must exist and be maintained for the product (nursing) to occur (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 w h olly com p en satory system , the patient is unable to perform any self-care activities and relies on the nurse to perform care. In the partially com p en satory system , both the patient and the nurse par­ ticipate in the patient’s self-care activities, with the responsibility 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 nurse’s role is to promote the patient as a self-care agent.

The system selected depends on the nurse’s assessment of the patient’s ability to perform self-care activities and self-care demands (Johnson & Webber, 201 0 ; Orem, 1995, 2001). There are eight general propositions for the Self-Care Deficit Theory of Nursing (although each of the three individual theories also has its own set of propositions) (Meleis, 2004): •

• • • • • • •

Human beings have capabilities to provide their own self-care or care for dependants to meet universal, developmental, and health-deviation self-care requisites. These capabilities are learned and recalled. Self-care abilities are influenced by age, developmental state, experiences, and sociocultural background. Self-care deficits should balance between self-care demands and self-care capabilities. Self-care or dependent care is mediated by age, developmental stage, life experience, sociocultural orientation, health, and resources. Therapeutic self-care includes actions of nurses, patients, and others that regulate self-care capabilities and meet self-care needs. Nurses assess the abilities of patients to meet their self-care needs and their potential of not performing their self-care. Nurses engage in selecting valid and reliable processes, technologies, or actions for meeting self-care needs. Components of therapeutic self-care are wholly compensatory, partly compensatory, and supportive-educative.

In addition to these other concepts, the four metaparadigm concepts of nursing are identified in Orem ’s theory (Table 2-6). Orem’s theory clearly differenti­ ates the focus of nursing and is one of the nursing theories that is most com­ monly used in practice.

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M etaparadigm Concepts as Defined by Orem 's Theory

Person (patient) A person under the care of a nurse; a total being with universal, developmen­ tal needs, and capable of self-care Environment Physical, chemical, biologic, and social contexts within which human beings exist; environmental components include environmen­ tal factors, environmental elements, environmen­ tal conditions, and developmental environment (Orem, 1985)

Health “A state characterized by soundness or wholeness of developed human structures and of bodily and mental functioning” (Orem, 1995,

101) Nursing Therapeutic self-care designed to sup­ plement self-care requisites. Nursing actions fall into one of three categories: wholly compensa­ tory, partly compensatory, or supportiveeducative system (Orem, 1985) p.

Callista Roy's A daptation Model The Roy Adaptation Model presents the person as an adaptive system in constant interaction with the internal and the external environments. 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 suc­ cessful adaptation (Table 2-7). According to Roy and Andrews (1999), adaptation refers to “the pro­ cess and outcome whereby thinking and feeling persons, as individuals or in groups, use conscious awareness and choice to create human and environ­ mental integration” (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 pro­ cesses. An integrated life process can change to a compensatory process, which attempts to reestablish adaptation. If the compensatory processes are not adequate, compromised processes result (Roy, 2009, p. 33). The processes for coping in the Roy Adaptation Model are categorized as “the regulator and cognator subsystems as they apply to individuals, and the stabilizer and innovator subsystems as applied to groups” (p. 33). A basic type of adaptive process, the regulator 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 affecting the fluid, electrolyte, and acid-base balance, as well as the endocrine system. This information is all channeled automatically, with the body producing an automatic, unconscious response to it (p. 41).

The second adaptive process, the cognator subsystem, responds through four cognitive-emotional channels: perceptual and inform ation processing, learning, judgment, and emotion. Perceptual and information 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 make affective appraisal and attachments through the emotions (p. 41). The cognator-regulator and stabilizer-innovator subsystems function to maintain integrated life processes. These life processes— whether integrated, compensatory, or compromised— are manifested in behaviors of the individual or group. Behavior is viewed as an output of the human system and takes the form of either adaptive responses or ineffective 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, 20 0 9 , p. 34). Behaviors can be observed in four categories, or adaptive modes: physio­ logic-physical mode, self-concept-group identify mode, role function mode, and interdependence mode. Behavior in the p h y siolog ic-p h y sical m o d e is the manifestation of the physiologic activities of all cells, tissues, organs, and systems making up the body. The se lf-c o n c ep t-g ro u p identity m o d e 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 m o d e focuses on the roles of the person in society and the roles within a group, and the interdependen ce m o d e is a category of behavior related to interdependent relationships. This mode focuses on interactions related to the giving and receiving of love, respect, and value (Roy, 2009). In the Roy Adaptation Model, three classes of stimuli form the environ­ ment: 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 factors within or outside human systems, the effects of which are unclear in the situation) (Roy, 2009, pp. 3 5 -3 6 ). The propositions of Roy’s theory include the following: • • • • •

Nursing actions promote a person’s adaptive responses. Nursing actions can decrease a person’s 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 adapta­ tion (Meleis, 2004).

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M etaparadigm Concepts as Defined in Roy's Model

Person “An adaptive system with cognator and regulator subsystems acting to maintain adapta­ tion in the four adaptive modes” (Roy, 2009, p.

12) Environment “All conditions, circumstances, and influences surrounding and affecting the development and behavior of persons and groups, with particular consideration of mutuality of person and earth resources” (Roy, 2 0 0 9 , p. 12)

Health “A state and process of being and becom­ ing an integrated and whole that reflects person and environment mutuality” (Roy, 2009, p. 12) Nursing The goal of nursing is “to promote adaptation for individuals and groups in the four adaptive modes, thus contributing to health, quality of life, and dying with dignity by assess­ ing behavior and factors that influence adaptive abilities and to enhance environmental factors” (Roy, 2009, p.12)

The Roy Adaptation M odel is commonly used in nursing practice. To use the model in practice, the nurse follows Roy’s six-step nursing process, which is as follows (Phillips, 2006): • Assessing the behaviors manifested from the four adaptive modes (phys­ iologic-physical mode, self-concept-group identity mode, role function mode, and interdependence mode) • Assessing and categorizing the stimuli for those behaviors • Making a nursing diagnosis based on the person’s adaptive state • Setting goals to promote adaptation • Implementing interventions aimed at managing stimuli to promote adaptation • Evaluating achievement of adaptive goals Andrews and Roy (1986) point out that by manipulating the stimuli rather than the patient, the nurse enhances “the interaction of the person with their environment, thereby promoting health” (p. 51).

B etty Neum an's System s Model The 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 client system in relation­ ship to stressors. The client system is a composite of interacting variables that include the physiologic variable, the psychological variable, the sociocultural variable, the developmental variable, and the spiritual variable (Neuman, 200 2 , pp. 1 6 -1 7 ). Stressors are classified as intrapersonal, interpersonal, or extrapersonal depending on their relationship to the client system (p. 22). The client system is represented structurally in the model as a series of con­ centric rings or circles surrounding a basic structure. These flexible concentric

Overview of Selected Nursing Theories

63

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 series of 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, pp. 16-18). The greater the quality of the client system’s health, the greater protection is provided by the various lines of defense (Geib, 2006). An overview and diagram of the model are provided on the Neuman Systems Model website (neumansystemsmodel.org/NSMdocs/nsm_powerpoint_overview.htm). See also Table 2-8. Basic assumptions of the Neuman Systems Model include the following (Meleis, 20 0 4 ; 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 client’s protective mechanisms and determine the client’s response. Clients present a normal range of responses to the environment that represent wellness and stability. Stressors attack flexible lines of defense and then normal lines of defense. Nurses’ 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

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M etaparadigm Concepts as Defined in Neum an's Model

Person (client system) A composite of physi­ ological, psychological, sociocultural, develop­ mental, and spiritual variables in interaction with the internal and external environment; represented by central structure, lines of defense, and lines of resistance (Neuman, 2002). Environment All internal and external factors of influences surrounding the client system. Three

relevant environments identified are the internal environment, the external environment, and the created environment (Neuman, 2002, p. 18). Health A continuum of wellness to illness; equated with optimal system stability (Neuman, 2002, p. 23). Nursing Prevention as intervention; concerned with all potential stressors.

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CHAPTER 2 Framework for Professional Nursing Practice

can be used for families, groups, and communities 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.

Im ogene King's Interacting System s Fram ew ork and Theory of Goal A tta in m e n t King, in her Interacting Systems Framework, conceptualizes three levels of dynamic interacting systems that include personal systems (individuals), inter­ personal 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 understanding 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, organiza­ tion, power, and status (King, 1981; Sieloff, 2006). King’s Theory of Goal Attainment was derived from her Interacting Sys­ tems 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 nurse-client relationship (Table 2-9). During the nursing process, the nurse and the client each perceives one another, makes judgments, and takes 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 behav­ iors, they become the criteria by which the effectiveness of nursing care can be measured (King, 1989, p. 156).

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M etaparadigm Concepts as Defined in King's Model

Person (human being) A personal system that interacts with interpersonal and social systems. Environment Can be both external and internal. The external environment is the context “within which human beings grow, develop, and perform daily activities” (King, 1981, p. 18); the internal environment of human beings transforms energy to enable them to adjust to continuous external environmental changes (King, 1981, p. 5).

Health “Dynamic life experiences of a human being, which implies continuous adjustment to stressors in the internal and external environ­ ment through optimum use of one’s resources to achieve maximum potential for daily living” (King, 1981, p. 5). Nursing A process of human interaction; the goal of nursing is to help patients achieve their goals.

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The propositions of King’s Theory of Goal Attainment are as follows (King, 1981): • • • • • • • •

If perceptual accuracy is present in nurse-client interac­ tions, transactions will occur. If the nurse and client make transactions, goals will be attained. If goals are attained, satisfactions will occur. If goals are attained, effective nursing care will occur. If transactions are made in the nurse-client interactions, growth and devel­ opment will be enhanced. If role expectations and role performance as perceived by the nurse and client are congruent, transactions will occur. If role conflict is experienced by nurse or client or both, stress in nurseclient interactions will occur. If nurses with special knowledge and skills communicate appropriate information to clients, mutual goal setting and goal attainment will occur.

King’s theory can be implemented in practice using the nursing process where assessment focuses on the perceptions of the nurse and client, com­ munication 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 King’s theory (King, 1992).

Johnson's Behavioral System Model Johnson’s model for nursing presents the client as a living open system that is a collection of behavioral subsystems that interrelate to form a behavioral system (Table 2-10). The seven subsystems of behavior proposed by Johnson include achievement, affiliative, aggressive, dependence, sexual, eliminative, and ingestive. Motivational drives direct the activities of the subsystems that are constantly changing because of maturation, experience, and learning (Johnson, 1980).

TA B LE 2 -1 0 M etaparadigm Concepts as Defined in Johnson's Theory Person (human being) A biopsychosocial being who is a behavioral system with seven subsys­ tems of behavior Environment Includes internal and external environment Health Efficient and effective functioning of system; behavioral system balance and stability

Nursing An external regulatory force that acts to preserve the organization and integrity of the patient’s 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)

The achievement subsystem functions to control or master an aspect of self or environment to achieve a standard. This subsystem encompasses intellectual, physical, creative, mechanical, and social skills. The affiliative or attachment subsystem forms the basis for social organization. Its conse­ quences are social inclusion, intimacy, and the formation and maintenance of strong social bonds. The aggressive 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 assistance. 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 “when, how, and under what conditions we eliminate,” whereas the ingestive subsystem “has to do with when, how, what, how much, and under what conditions we eat” (Johnson, 1980, p. 213). The nursing process for the behavioral system model is known as Johnson’s 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 using Johnson’s model in practice, the focus of the assessment process is obtaining information to evaluate current behavior in terms of past patterns, determining the impact of the current illness on behavioral patterns, and establishing the maximum level of health. The assessment is specifically related to gathering information related 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).

■ Selected Theories and M iddle-Range Theories of Nursing Rosem ary Parse's Hum anbecom ing Theory Parse’s theory was originally called man-living-health (Parse, 1981). In 1992, Parse changed the name to hum an becom in g, and then in 2 0 0 7 again changed the name to hu m an becom in g (Mitchell & Bournes, 2010) to coincide with Parse’s evolution of thought. The Humanbecoming Theory consists of three major themes: meaning, rhythmicity, and transcendence (Parse, 1998). Meaning is the linguistic and imagined content of something and the inter­ pretation that one gives to something. Rhythmicity is the cadent, paradoxical patterning of the human-universe mutual process. Transcendence is defined as reaching beyond with possibles or the “hopes and dreams envisioned in

multidimensional experiences powering the originating of transform ing” (Parse, 19 9 8 , p. 29 ). The three m ajor principles of the Humanbecoming Theory flow from these themes. The first principle of the Humanbecoming Theory states, “Structuring meaning multidimensionally is cocreating reality through the languaging of valuing and imaging” (Parse, 1998, p. 35). This principle proposes that per­ sons structure or choose the meaning of their realities and that the choosing occurs at levels that are not always known explicitly (Mitchell, 2006). This means that one person cannot decide the significance of something for another person and does not even understand 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, “Cocreating rhythmical patterns of relating is living the paradoxical unity of revealing— concealing and enabling— limiting while connecting— separating” (Parse, 1998, p. 42). This principle means that persons create patterns in life, and these patterns tell about personal mean­ ings 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, “ Cotrans­ cending with the possibles is powering unique ways of originating in the process of transform ing” (Parse, 1998, p. 4 6 ). This principle means that persons are always engaging with and choosing from infinite possibilities. The choices reflect the person’s ways of moving and changing in the process of becoming (Mitchell, 2006). Three processes for practice have been developed from the concepts and principles in the Humanbecoming Theory, including the following (Parse, 1998, pp. 69, 70): • •

•

Illuminating meaning is explicating what was, is, and will be. Explicating is making clear what is appearing now through language. Synchronizing rhythms is dwelling with the pitch, yaw, and roll of the human-universe process. Dwelling with is immersing with the flow of connecting-separating. 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 attentiveness on the moment at hand through immersion (Parse, 1998).

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CHAPTER 2 Framework for Professional Nursing Practice

TA B LE 2-11 M etaparadigm Concepts as Defined in Parse's Theory Person An open being, more than and different than the sum of parts in mutual simultaneous interchange with the environment who chooses from options and bears responsibility for choices (Parse, 1987, p. 160) Environment Coexists in mutual process with the person

Health Continuously changing process of becoming Nursing A learned discipline; the nurse uses true presence to facilitate the becoming of the participant

Madeleine Leininger's Cultural Diversity and U niversality Theory Leininger (1995) identified the main features of the Cultural Diversity and Universality Theory: Transcultural nursing is a substantive area of study and practice focused on comparative cultural care (caring) values, beliefs, and practices of individuals or groups of similar or different cultures with the goal of providing culture-specific and universal nursing care practices in promoting health or well-being or to help people face unfavorable human conditions, illness, or death in culturally meaningful ways. (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 (2 0 0 1 ), three modalities guide nursing judg­ ments, decisions, and actions to provide culturally congruent care that is

TA B LE 2 -1 2 M etaparadigm Concepts as Defined in Leininger's Theory Person Human being, family, group, commu­ nity, or institution Environment Totality 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)

Health A state of well-being that is cultur­ ally defined, valued, and practiced (Leininger, 1991, p. 46) Nursing Activities 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)

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beneficial, satisfying, and meaningful to the persons the nurse serves. These three modes include cultural care preservation or maintenance, cultural care accommodation or negotiation, and cultural care repatterning or restruc­ turing. Culture care preservation or maintenance refers to those assistive, supportive, facilitative, or enabling professional actions and decisions that help people of a specific culture to maintain meaningful care values for their well-being, recover from illness, or deal with a handicap or dying. Culture care accommodation or negotiation refers to those assistive, sup­ portive, facilitative, 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. Culture 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 & M cFarland, 20 0 6 ). The nurse using Leininger’s 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). Leininger developed the sunrise model, which she revised in 2004. She labeled this model as “an enabler,” to clarify that although it depicts the essential components of the Cultural Diversity and Universality Theory , it is a visual guide for exploration of cultures.

Hildegard Peplau's Theory of Interpersonal Relations In her theory, Peplau addresses all of nursing’s metaparadigm concepts (Table 2 -13), but she is primarily concerned with one aspect of nursing: how persons relate to one another. According to Peplau, the nurse-patient relationship is the center of nursing (Young, Taylor, & M cLaughlinRenpenning, 2001).

TA B LE 2-13 M etaparadigm Concepts as Defined in Peplau's Theory Person Encompasses 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) Environment Forces outside the organism within the context of culture (Peplau, 1952, p. 163).

Health “Implies forward movement of person­ ality and other ongoing human processes in the direction of creative, constructive, productive, personal, and community living” (Peplau, 1992, p.

12) Nursing The therapeutic, interpersonal process between the nurse and the patient

Peplau (1952) originally described four phases in nurse-patient relation­ ships that overlap and occur over the time of the relationship: orientation, identification, exploitation, and resolution. In 1997, Peplau 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 exploitation to be subphases of the working phase. During the orientation phase, a health problem has emerged that results in a “felt need,” 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 achievement of new goals. The resolution (termination) phase is the time when the patient gradually adopts new goals and frees himself or herself from identification with the nurse (Peplau, 1952, 1997). Peplau (1952) also describes six nursing roles that emerge during the phases of the nurse-patient 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 Peplau’s 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 physical care using clinical skills. And, as a surrogate, the nurse may take the place of another (Johnson & Webber, 2010, p. 125). Peplau (1952) also described four psychobiological experiences: needs, frustration, conflict, and anxiety. According to Peplau, these experiences “all provide energy that is transformed into some form of action” (p. 71) and provide a basis for goal formation and nursing interventions (Howk, 2002). 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 Peplau’s work, nursing practice involved acting on, to, or for the patient such that the patient was considered an object of nursing actions. Peplau’s work was the force behind the conceptualization of the patient as a partner in the nursing process (Howk, 2002, pp. 3 7 9 -3 8 0 ). Although Peplau’s book was first published in 1952, her model continues to be used extensively by clinicians and continues to provide direction to educators and researchers (Howk, 2002).

Nola Pender's Health Prom otion Model The Health Promotion Model is an attempt to portray the multidimensional­ ity 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

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functioning (Pender, 1996, p. 53). A summary of the metaparadigm concepts of nursing as defined by Pender are presented in Table 2-14. There are three major categories to consider in Pender’s health promotion model: (1) individual characteristics and experiences, (2) behavior-specific cognitions and affect, and (3) behavioral outcome. 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 factors such as self-esteem, self-motivation, and perceived health status; personal sociocultural factors include factors such as race, ethnicity, acculturation, education, and socioeconomic status. Some personal factors are amenable to change, whereas others cannot be changed (Pender, Murdaugh, & Parsons, 20 0 6 , p. 52). Behavior-specific cognitions and affect are behavior-specific variables within the Health Promotion Model. Such variables are considered 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 Promo­ tion 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. Perceived 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-promoting 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. Activityrelated affect influences perceived self-efficacy, such that the more positive the subjective feeling, the greater the perceived efficacy (Pender et al., 2006; Sakraida, 20 1 0 , p. 438). Commitment to a plan of action marks the beginning of a behavioral event. Interventions in the Health Promotion Model focus on raising con­ sciousness related to health-promoting behaviors, promoting self-efficacy,

TA B LE 2 -1 4

M etaparadigm Concepts as Defined in Pender's Theory

Person The individual, who is the primary focus of the model Environment The physical, interpersonal, and economic circumstances in which persons live Health A positive high-level state

Nursing The 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 managing barriers to change

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CHAPTER 2 Framework for Professional Nursing Practice

enhancing the benefits of change, controlling the environment to support behavior change, and managing the barriers to change. Health-promoting behavior, which is ultimately directed toward attaining positive health out­ comes, is the product of the Health Promotion Model (Pender et al., 2006, pp. 5 6 -6 3 ).

Kristen Swanson's Theory of Caring Swanson’s Theory of Caring (1991, 1993, 1999a, 1999b) offers an explana­ tion of what it means to practice nursing in a caring manner. In this theory, caring is defined as a “nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility” (Swanson, 1991, p. 162). Swanson (1993) posits caring for a person’s biopsychosocial and spiritual well-being is a fundamental and universal component of good nursing care. Five additional concepts are integral to Swanson’s Theory of Caring 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 other’s capacity to get through an event or transition and face a future with meaning. This includes believing in the other’s capacity and holding him or her in high esteem, maintaining a hope-filled attitude, offering realistic optimism, helping to find meaning, and standing by the one cared for, no matter what the situation (Swanson, 1991, p. 162). • The concept of knowing refers to striving to understand the meaning of an event in the life of the other, avoiding assumptions, focusing on the person cared for, seeking cues, assessing meticulously, and engaging both the one caring and the one cared for in the process of knowing (Swanson, 1991, p. 162). • The concept of being with refers to being emotionally present to the other. It includes being present in person, conveying availability, and sharing feelings without burdening the one cared for (Swanson, 1991, p. 162).

TA B LE 2 -1 5

Metaparadigm Concepts as Defined in Swanson's Theory of Caring

Person “Unique beings who are in the midst of becoming and whose wholeness is made manifest in thoughts, feelings, and behaviors” (Swanson, 1993, p. 352) Environment “Any context that influences or is influenced by the designated client” (Swanson, 1 9 9 3 ,p . 353)

Health Health and well-being is “to live the subjective, meaning-filled experience of whole­ ness. Wholeness involves a sense of integration and becoming wherein all facets of being are free to be expressed” (Swanson, 1993, p. 353) Nursing Informed caring for the well-being of others (Swanson, 1991, 1993)

Overview of Selected Nursing Theories

•

•

73

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 (Swanson, 1991, p. 162). The concept of enabling refers to facilitating the other’s passage through life transitions and unfamiliar events by focusing on the event, inform­ ing, explaining, supporting, validating feelings, generating alternatives, thinking things through, and giving feedback (Swanson, 1991, p. 162).

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 (W ojnar, 2010, p. 746). According to Swanson (1999b), knowing, being with, doing for, enabling, and maintaining belief are essential components of the nurse-client relationship, regardless of the context. A summary of the metaparadigm concepts of nursing as defined by Swanson are included in Table 2-15.

Katharine Kolcaba's Theory of Com fort Comfort, as described by Kolcaba (2004, p. 255) in the Theory of Comfort, is the immediate experience of being strengthened by having needs for relief, ease, and transcendence addressed in four contexts— physical, psychospiritual, sociocultural, and environmental; it is much more than simply the absence of pain or other physical discomfort. Physical comfort pertains to bodily sensa­ tions and homeostatic mechanisms. Psychospiritual comfort pertains to the internal awareness of self, including esteem, sexuality, meaning in one’s life, and one’s relationship to a higher order or being. Sociocultural comfort per­ tains 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, p. 258).

TA B LE 2 -1 6

M etaparadigm Concepts as Defined in Kolcaba's Theory of Com fort

Person Recipients of care may be individuals, families, institutions, or communities in need of health care (Kolcaba, Tilton, & Drouin, 2006). Environment The 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).

Health Health is considered optimal function­ ing of the patient, the family, the healthcare pro­ vider, or the community (Dowd, 2010, p. 711). Nuring Nursing is the intentional assessment of comfort needs, design of comfort interven­ tions to address those needs, and reassessment of comfort levels after implementation compared with baseline (Dowd, 2010, p. 711).

According to Kolcaba, comfort care encompasses three components: 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 patients’ or families’ desire for or deficit in relief, ease, or transcendence in the physical, psychospiritual, sociocultural, or environ­ mental contexts of human experience. Comfort measures refer to interven­ tions that are intentionally designed to enhance patients’ or families’ comfort (Kolcaba, 20 0 4 , p. 255). The Theory of Comfort also addresses intervening variables— 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 psychological conditions, and health habits (Kolcaba, 200 4 , p. 255). 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 uncon­ sciously 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, 200 4 , p. 255). The metaparadigm concepts of nursing as defined by K olcaba are summarized in Table 2-16.

Pam ela Reed's Self-Transcendence Theory Three m ajor 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, interpersonally, tempo­ rally, and transpersonally (Reed, 2008, p. 107). The capacity to expand self­ boundaries intrapersonally refers to a greater awareness of one’s philosophy, values, and dreams. The capacity to expand interpersonally relates to others and one’s environment. The capacity to expand temporally refers to inte­ gration of one’s past and future in a way that has meaning for the present. Finally, the capacity to expand transpersonally refers to the capacity to con­ nect with dimensions beyond the typically discernible world (p. 107). Self­ transcendence is a characteristic 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, pp. 107 -1 0 8 ). Well-being is the second major concept of Reed’s theory. Well-being is a sense of feeling whole and healthy, according to one’s own criteria for whole­ ness and health. The definition of well-being depends on the individual or pop­ ulation. Indeed, indicators of well-being are as diverse as human perceptions

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of health and wellness. Examples of indicators of well-being are life satisfac­ tion, 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). The third m ajor concept, vulnerability, is the awareness of per­ sonal mortality and the likelihood of experiencing difficult life situations. Self-transcendence emerges naturally in health experiences when a person is confronted with mortality and immortality. Life events such as illness, disability, aging, childbirth, or parenting— all of which heighten a person’s sense of mortality, inadequacy, or vulnerability— can trigger developmental progress toward a renewed sense of identity and expanded self-boundaries. According to Reed (2008, pp. 1 0 8-109), self-transcendence is evoked through life events and can enhance well-being by transforming losses and difficulties into healing experiences. Additional concepts in Reed’s theory include moderating-mediating factors and points of intervention. Moderating-mediating factors are per­ sonal and contextual variables such as age, gender, life experiences, and social environment that can influence the relationships between vulnerability and self-transcendence and between self-transcendence and well-being. Nursing activities that facilitate self-transcendence are referred to as points of interven­ tion (Coward, 2010, p. 623). Two points of intervention are intertwined with the process of self-transcendence: Nursing actions can focus either directly on a person’s 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 (p. 621). The metaparadigm concepts of nursing as defined by Reed are summarized in Table 2-17.

TA B LE 2-17

M etaparadigm Concepts as Defined in Reed's Self-Transcendence Theory

Person Persons are human beings who develop over the life span through interactions with other persons and within an environment (Coward, 20 1 0 , p. 622). Environment The environment is composed of family, social networks, physical surroundings, and community resources (Coward, 2010, p. 622).

Health Well-being is a sense of feeling whole and healthy, according to one’s own criteria for wholeness and health (Reed, 2008). Nursing The 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).

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CHAPTER 2 Framework for Professional Nursing Practice

The Am erican Association of C ritical-C are Nurses' Synergy Model for P atient Care The Synergy Model is a conceptual framework for designing practice compe­ tencies to care for critically ill patients with a goal of optimizing 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 American Associa­ tion of Critical-Care Nurses (AACN) envisioning a new paradigm for clinical practice. In 1993, the AACN Certification Corporation 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 com­ pensation, resiliency, margin of error, predictability, complexity, 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 innovator-evaluator. 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 competencies for certified practice (Hardin, 2005, pp. 3-4). In 1995, the AACN Certification Corporation decided to refine this model, to conduct a study of practice and job analysis of critical 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, vulnerability, stability, complexity, resource availability, participation in care,

TA B LE 2 -1 8

M etaparadigm Concepts as Defined in The Synergy Model for P a tien t Care

Person Persons are viewed in the context of patients who are biological, social, and spiritual entities who are present at a particular develop­ mental stage. Environment The concept of environment is not explicitly defined. However, included in the assumptions is the idea that environment is cre­ ated by the nurses for the care of the patient.

Health The 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. Nursing The 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).

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participation in decision making, and predictability. The eight nurse character­ istics are clinical judgment, advocacy, caring practices, collaboration, systems thinking, response to diversity, clinical inquiry, and facilitation of learning (Hardin, 20 0 5 , p. 4). Each patient characteristic is placed on a scale from one to five, with the level of each patient characteristic being critical in terms of the competency required of the nurse (Hardin, 2005, pp. 4 -7 ). 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 one to five (Hardin, 2005, pp. 5 -6 ). The Synergy Model delineates three levels of outcomes: outcomes derived from the patient, outcomes derived from the nurse, and outcomes derived from the healthcare system. Outcomes data derived from the patient include func­ tional 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 objectives are attained (Curley, 1998). Outcomes data derived from the healthcare system include readmission rates, length of stay, and cost uti­ lization (Hardin, 2005, pp. 8 -9 ). The metaparadigm concepts of nursing as defined in the Synergy Model for Patient Care are summarized in Table 2-18.

Nurse of the Future: Nursing Core Com petencies Although not a theory of nursing, the N urse o f the Future: N ursing C ore Competencies (Massachusetts Department of Higher Education, 2010) 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 and are presented in Table 2-19.

TA B LE 2 -1 9

M etaparadigm Concepts as Defined in The Nurse of The Future: Nursing Core Com petencies

Human being/patients The recipient of nurs­ ing care or services. Patients may be individuals, families, groups, communities, or populations (AACN, 1998, p. 2 as cited in Massachusetts Department of Higher Education, 20 1 0 , p. 7). Environment “The atmosphere, milieu, or conditions in which an individual lives, works or plays” (ANA, 2004, p. 4 7 as cited in Massachusetts Department of Higher Education, 2010, p. 7). Health “An experience that is often expressed in terms of wellness and illness, and may occur

in the presence or absence of disease or injury” (ANA, 2004, p. 5 as cited in Massachusetts Department of Higher Education, 2010, p. 8). Nursing ... “the protection, promotion, and optimization of health and abilities, preven­ tion of illness and injury, alleviation of suf­ fering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations” (ANA, 2001, p. 5 as cited in Massachusetts Department of Higher Education, 2010, p. 8).

There are 10 Nurse of the Future core competencies: • Patient-centered care: “The Nurse of the Future will provide holistic care that recognizes an individual’s preferences, values, and needs and respects the patient or designee as a full partner in providing compassion­ ate, coordinated, age and culturally appropriate, safe and effective care” (Massachusetts Department of Higher Education, 2010, p. 9). • Professionalism: “The Nurse of the Future will demonstrate accountabil­ ity for the delivery of standard-based nursing care that is consistent with moral, altruistic, legal, ethical, regulatory, and humanistic principles” (Massachusetts Department of Higher Education, 2010, p. 13). • Leadership: “The 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 goals” (Massachusetts Department of Higher Education, 2 0 1 0 , •

•

•

•

•

•

p.

17). Systems-based practice: “The 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 m icro­ system resources to provide care that is of optimal quality and value” (Massachusetts Department of Higher Education, 2010, p. 19). Informatics and technology: “The Nurse of the Future will use infor­ mation and technology to communicate, manage, knowledge, mitigate error, and support decision making” (Quality and Safety Education for Nurses [QSEN], 2007, as cited in Massachusetts Department of Higher Education, 20 1 0 , p. 22). Communication: “The 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 outcomes” (Massachusetts Department of Higher Education, 2010, p. 27). Teamwork and collaboration: “The Nurse of the Future will function effectively within nursing and interdisciplinary teams, fostering open communication, mutual respect, shared decision making, team learning, and development” (adapted from QSEN, 2007, as cited in Massachusetts Department of Higher Education, 2010, p. 31). Safety: “The Nurse of the Future will minimize risk of harm to patients and providers through both system effectiveness and individual perfor­ mance” (QSEN, 2007, as cited in Massachusetts Department of Higher Education, 20 1 0 , p. 34). Quality improvement: “The 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 systems” (QSEN, 20 07, as cited in Massachusetts Department of Higher Education, 20 1 0 , p. 36).

Relationship of Theory to Professional Nursing Practice

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Evidence-based practice: “The Nurse of the Future will identify, evalu­ ate, and use the best current evidence coupled with clinical expertise and consideration of patients’ preferences, experience and values to make practice decisions” (adapted from QSEN, 2007, as cited in Massachusetts Department of Higher Education, 20 1 0 , p. 37).

The committee that designed the N urse o f the Future: N ursing C ore C om peten cies also identified several assumptions and principles to serve as a framework. The assumptions include: (1) education and practice partner­ ships are key in developing an effective model, (2) it is imperative that leaders in nursing education and practice develop collaborative models to facilitate a minimum of a baccalaureate degree in nursing for all nurses, (3) a more effective education system must be created that will allow preparation of the nursing workforce to respond to the current and future healthcare needs of populations, (4) the nurse of the future will be proficient in a core set of competencies, and (5) nurse educators in education and practice settings will need to use different teaching strategies to integrate Nurse of the Future core competencies into the curriculum (Massachusetts Department of Higher Education, 20 1 0 , pp. 3-4). The art and science of nursing are based on a framework of caring and respect for human dignity. A compassionate approach to patient care man­ dates that nurses provide care in a competent manner. The N urse o f the Future: Nursing C ore C om petencies provides a framework for the provision of competent nursing care (Massachusetts CRiTiCAL THiNKiNG QUESTiON V Department of Higher Education, 20 1 0 , p. 7). 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? V

R e la tio n s h ip of T h e o ry to P ro fe s s io n a l N u rsin g P ra c tic e

How will theory affect your nursing practice? Using a theoretical frame­ work to guide your nursing practice assists you as you organize patient data, understand and analyze patient data, make decisions related to nursing inter­ ventions, 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 The use of a theoretical edgeable approach to nursing practice. The framework also framework provides a sys­ becomes a tool that assists you to think critically as you tematic and knowledgeable plan and provide nursing care. approach to your nursing How do you begin? Now that you know why nursing theory is important to your nursing practice, it is time to iden­ practice. tify a theoretical framework that fits you and your practice.

r

A

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CHAPTER 2 Framework for Professional Nursing 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 frame­ works. 9. Select a framework and develop its use in your nursing practice. CASE STUDY 2-1

M

r. M. is 34-year-old Caucasian male who presents to the mental health clinic with de­ pression and complaints of fatigue. An in­ terview reveals that his wife and both of his children were killed in a traffic accident 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 trans­ forming losses and difficulties into healing experiences.

1.

The nurse using Reed’s Self-Transcendence Theory focuses nursing activity for Mr. M. on facilitating self-transcendence. Based on the as­ sessment, what intrapersonal strategies might be appropriate?

2.

Which interpersonal strategies might be appropri­ ate during follow-up visits to facilitate connecting to others?

C o nclu sio n As demonstrated by the descriptions of the philosophies, conceptual models, and theories presented in this chapter, there is a wide variety of perspec­ tives 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 mul­ tiplicity 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 prescribe nursing care. Curley (2007, p. 3) describes this understand­ ing 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

Conclusion

81

characteristic of the region, such as rainfall, topography, or air currents. Although all of 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 nurse’s choice of nursing theories for practice. So, begin with whichever theoretical framework seems to “fit,” and then practice using it as you provide nursing care. “The full realization of nursing theory-guided practice is perhaps the greatest challenge that nursing as a scholarly discipline has ever faced” (Cody, 2006). So, be patient; developing your nursing practice 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 professional nursing career.

Classroom A ctivity 1 ivide into small groups and give each group a copy of the same case study. Assign a different nursing theory to each group, and ask the groups to develop a plan of care using the assigned nursing theory as the

D

basis for practice. Each group should share its plan of care with the class. Discuss the differ­ ences and similarities in the foci of care based on each of the selected theories,

Classroom A ctivity 2 hink about the metaparadigm concepts of nursing. Draw each of the concepts in relation to the other concepts to show your ideas of how each of the concepts interfaces with the others. Present your “conceptual model” 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 examples are presented in Figure 2-1 and Figure 2-2.

T

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CHAPTER 2 Framework for Professional Nursing Practice

Figure 2-1

S tu dent conceptual model

S ou rce: Used w ith permission o f Heather Grush.

Figure 2 -2

S tu dent conceptual model

R e fe re n c e s Alligood, M. R. (2006). Philosophies, models, and theories: Critical thinking structures. In M. R. Alligood & A. M. Tomey (Eds.), Nursing theory: Utilization & application (3rd ed., pp. 43-65). St. Louis, MO: Mosby. Alligood, M. R., & Tomey, A. M. (2002). Significance of theory for nursing as a discipline and profession. In A. M. Tomey & M. R. Alligood (Eds.), Nursing theorists and their work (5th ed., pp. 14-31). St. Louis, MO: Mosby. American Association of Colleges of Nursing. (1998). The essentials o f baccalaureate education for professional nursing practice. Washington, DC: Author. American Nurses Association. (2001). Nursing scope and standards o f practice. Silver Springs, MD: Author. American Nurses Association. (2004). Nursing scope and standards o f practice. Silver Springs, MD: Author. Andrews, H. A., & Roy, C., Sr. (1986). Essentials o f the Roy adaptation model. Norwalk, CT: Appleton-Century-Crofts. Andrews, H. A., & Roy, C., Sr. (1991). Essentials of the Roy adaptation model. In C. Roy Sr. & H. A. Andrews (Eds.), The Roy adaptation model: The definitive statement (pp. 2-25). Norwalk, CT: Appleton & Lange. Benner, P. (1984/2001). From novice to expert: Excellence and power in clinical nursing practice. Upper Saddle River, NJ: Prentice Hall. Benner, P., Hooper-Kyriakidis, P., & Stannard, D. (1999). Clinical wisdom and interventions in critical care: A thinking-in-action approach. Philadelphia, PA: Saunders. Benner, P., & Wrubel, J. (1989). The primacy o f caring: Stress and coping in health and illness. Menlo Park, CA: Addison-Wesley. Berbiglia, V. A. (2010). Orem’s self-care deficit theory in nursing practice. In M. R. Alligood (Ed.), Nursing theory: Utilization and application (4th ed., pp. 261-286). Maryland Heights, MO: Mosby. Bolton, K. (2006). Nightingale’s philosophy in nursing practice. In M. R. Alligood & A. M. Tomey (Eds.), Nursing theory: Utilization & application (3rd ed., pp. 89-102). St. Louis, MO: Mosby. Brykczynski, K. A. (2010). Benner’s philosophy in nursing practice. In M. R. Alligood (Ed.), Nursing theory: Utilization and application (4th ed., pp. 137-159). Maryland Heights, MO: Mosby. Cody, W. K. (2006). Nursing theory-guided practice: What it is and what it is not. In W. K. Cody (Ed.), Philosophical and theoretical perspectives for advanced nursing practice (4th ed., pp. 119-121). Sudbury, MA: Jones and Bartlett. Coward, D. D. (2010). Self-Transcendence Theory: Pamela G. Reed. In M. R. Alligood & A. M. Tomey (Eds.), Nursing theorists and their work (7th ed., pp. 618-637). Maryland Heights, MO: Mosby. Curley, M. A. Q. (1998). Patient-nurse synergy: Optimizing patients’ outcomes. American Journal o f Critical Care, 7(1), 64-72. Curley, M. A. Q. (2007). Synergy: The unique relationship between nursing and patients. Indianapolis, IN: Sigma Theta Tau International. Day, L., & Benner, P. (2002). Ethics, ethical comportment, and etiquette. American Journal o f Critical Care, 11(1), 76-79.

Dowd, T. (2010). Katharine Kolcaba: Theory of Comfort. In M. R. Alligood & A. M. Tomey (Eds.), Nursing theorists and their work (7th ed., pp. 706-721). Maryland Heights, MO: Mosby. Eckberg, D. L., & Hill, L., Jr. (1979). The paradigm concept and sociology: A critical review. American Sociological Review, 44, 925-937. Fawcett, J. (1994). Analysis and evaluation o f conceptual m odels o f nursing. Philadelphia, PA: F. A. Davis. Fawcett, J. (2005). Contemporary nursing knowledge: Analysis and evaluation o f nursing models and theories (2nd ed., pp. 553-585). Philadelphia, PA: F. A. Davis. Flaskerud, J. H., & Holloran, E. J. (1980). Areas of agreement in nursing theory development. Advances in Nursing Science, 3(1), 1-7. Furukawa, C. Y., & Howe, J. S. (2002). Definition and components of nursing: Virginia Henderson. In J. B. George (Ed.), Nursing theories: The base for professional nursing practice (5th ed., pp. 83-109). Upper Saddle River, NJ: Prentice Hall. Geib, K. M. (2006). Neuman’s systems model in nursing practice. In M. R. Alligood & A. M. Tomey (Eds.), Nursing theory: Utilization & application (3rd ed., pp. 229-254). St. Louis, MO: Mosby. Gordon, S. C. (2001). Virginia Avenel Henderson: Definition of nursing. In M. Parker (Ed.), Nursing theories and nursing practice. Philadelphia, PA: F. A. Davis. Gunther, M. (2006). Rogers’ science of unitary human beings in nursing practice. In M. R. Alligood & A. M. Tomey (Eds.), Nursing theory: Utilization & application (3rd ed., pp. 283-306). St. Louis, MO: Mosby. Hardin, S. R. (2005). Introduction to the AACN Synergy Model for Patient Care. In S. R. Hardin & R. Kaplow (Eds.), Synergy for clinical excellence: The AACN Synergy Model for Patient Care (pp. 3-10). Sudbury, MA: Jones and Bartlett. Harmer, B., & Henderson, V. (1955). T extbook o f the principles and practice o f nursing. New York, NY: Macmillan. Henderson, V. (1964). The nature of nursing. American Journal o f Nursing, 64, 62-68. Henderson, V. (1966). The nature o f nursing: A definition and its implications for practice, research, and education. New York, NY: Macmillan. Henderson, V. (1991). The nature o f nursing: Reflections after 25 years. New York, NY: National League for Nursing Press. Hickman, J. S. (2002). An introduction to nursing theory. In J. B. George (Ed.), Nursing theories: A base for professional nursing practice (5th ed., pp. 1-20). Upper Saddle River, NJ: Prentice Hall. Holaday, B. (2006). Johnson’s behavioral system model in nursing practice. In M. R. Alligood & A. M. Tomey (Eds.), Nursing theory: Utilization & application (3rd ed., pp. 157-180). St. Louis, MO: Mosby. Howk, C. (2002). Hildegard E. Peplau: Psychodynamic nursing. In A. M. Tomey & M. R. Alligood (Eds.), Nursing theorists and their work (5th ed., pp. 379-398). St. Louis, MO: Mosby. Johnson, B. M., & Webber, P. B. (2010). An introduction to theory and reasoning in nursing (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Johnson, D. (1980). The behavioral systems model for nursing. In J. Riehl & C. Roy (Eds.), Conceptual models for nursing practice (2nd ed., pp. 207-216). New York, NY: Appleton-Century-Crofts. King, I. M. (1981). A theory o f nursing: Systems, concepts, process. New York, NY: Wiley.

King, I. M. (1989). King’s general systems framework and theory. In J. P. Riehl-Sisca (Ed.), Conceptual models for nursing practice (3rd ed., pp. 149-158). Norwalk, CT: Appleton & Lange. King, I. M. (1992). King’s theory of goal attainment. Nursing Science Quarterly, 5(1), 19-26. Kolcaba, K. (2004). Comfort. In S. J. Peterson & T. S. Bredow (Eds.), Middle range theories: Application to nursing research (pp. 255-273). Philadelphia, PA: Lippincott Williams & Wilkins. Kolcaba, K., Tilton, C., & Drouin, C. (2006). Comfort theory: A unifying framework to enhance the practice environment. Journal o f Nursing Administration, 36(11), 538-544. Leininger, M. (1991). Culture care diversity and universality: A theory o f nursing. New York: National League for Nursing Press. Leininger, M. (1995). Transcultural nursing perspectives: Basic concepts, principles, and culture care incidents. In M. M. Leininger (Ed.), Transcultural nursing: Concepts, theories, research, and practices (2nd ed., pp. 57-92). New York, NY: McGraw-Hill. Leininger, M. (2001). Culture care diversity and universality: A theory o f nursing. Sudbury, MA: Jones and Bartlett. Leininger, M. M., & McFarland, M. R. (2006). Culture care diversity and universality: A worldwide theory o f nursing (2nd ed.). Sudbury, MA: Jones and Bartlett. Lippitt, G. L. (1973). Visualizing change: Model building and the change process. Fairfax, VA: NTL Learning Resources. Massachusetts Department of Higher Education. (2010). Nurse o f the future: Nursing core competencies. Retrieved from http://www.mass.edu/currentinit/documents/ NursingCoreCompetencies.pdf McBride, A. B. (Narrator). (1997). Celebrating Virginia Henderson (Video). (Available from Center for Nursing Press, 550 West North Street, Indianapolis, IN 46202). Meleis, A. I. (2004). Theoretical nursing: D evelopment & progress (3rd ed.). Philadelphia, PA: Lippincott. Meleis, A. I. (2007). Theoretical nursing: D evelopment & progress (4th ed.). Philadelphia, PA: Lippincott. Mitchell, G. J. (2006). Rosemarie Rizzo Parse: Human becoming. In A. M. Tomey & M. R. Alligood (Eds.), Nursing theorists and their work (6th ed., pp. 522-559). St. Louis, MO: Mosby. Mitchell, G. J., & Bournes, D. A. (2010). Rosemarie Rizzo Parse: Humanbecoming. In M. R. Alligood & A. M. Tomey (Eds.), Nursing theorists and their work (7th ed., pp. 503-535). Maryland Heights, MO: Mosby. Neil, R. M., & Tomey, A. M. (2006). Jean Watson: Philosophy and science of caring. In A. M. Tomey & M. R. Alligood (Eds.), Nursing theorists and their work (6th ed., pp. 91-115). St. Louis, MO: Mosby. Neuman, B. (1995). The Neuman systems m odel (3rd ed.). Norwalk, CT: Appleton & Lange. Neuman, B. (2002). The Neuman systems model. In B. Neuman & J. Fawcett (Eds.), The Neuman systems model (4th ed., pp. 3-34). Upper Saddle River, NJ: Prentice Hall. Nightingale, F. (1969). Notes on nursing: What it is and what it is not. New York, NY: Dover. (Original work published 1860).

Norris, D., & Frey, M. A. (2006). King’s system framework and theory in nursing practice. In M. R. Alligood & A. M. Tomey (Eds.), Nursing theory: Utilization & application (3rd ed., pp. 181-205). St. Louis, MO: Mosby. Orem, D. (1985). Nursing: Concepts o f practice (3rd ed.). St. Louis, MO: Mosby. Orem, D. (1990). A nursing practice theory in three parts, 1956-1989. In M. E. Parker (Ed.), Nursing theories in practice (pp. 47-60). New York, NY: National League for Nursing. Orem, D. (1995). Nursing: Concepts o f practice (5th ed.). St. Louis, MO: Mosby. Orem, D. (2001). Nursing concepts o f practice (6th ed.). St. Louis, MO: Mosby. Parse, R. R. (1981). Man-living-health: A theory o f nursing. New York, NY: Wiley. Parse, R. R. (1987). Nursing science: Major paradigms, theories, and critiques. Philadelphia, PA: Saunders. Parse, R. R. (1998). The human becoming school o f thought: A perspective for nurses and other health professionals. Thousand Oaks, CA: Sage. Pender, N. J. (1996). Health promotion in nursing practice (3rd ed.). Stamford, CT: Appleton & Lange. Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2006). Health promotion in nursing practice (5th ed.). Upper Saddle River, NJ: Prentice Hall. Peplau, H. (1952). Interpersonal relations in nursing. New York, NY: G. P. Putnam’s Sons. Peplau, H. E. (1992). Interpersonal relations: A theoretical framework for application in nursing practice. Nursing Science Quarterly, 5, 13-18. Peplau, H. E. (1997). Peplau’s theory of interpersonal relations. Nursing Science Quarterly, 10(4), 162-167. Pfettscher, S. A. (2006). Florence Nightingale: Modern nursing. In A. M. Tomey & M. R. Alligood (Eds.), Nursing theorists and their work (6th ed., pp. 71-90). St. Louis, MO: Mosby. 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. 355-385). St. Louis, MO: Mosby. Quality and Safety Education for Nurses. (2007). Quality and safety competencies. Retrieved from http://www.qsen.org/competencies.php Reed, P. G. (2008). Theory of self-transcendence. In M. J. Smith & P. R. Liehr (Eds.), Middle range theory for nursing (2nd ed., pp. 105-129). New York, NY: Springer. Rogers, M. E. (1970). An introduction to the theoretical basis o f nursing. Philadelphia, PA: F. A. Davis. Rogers, M. E. (1992). Nursing science and the space age. Nursing Science Quarterly, 5, 27-34. Rogers, M. E. (1994). The science of unitary human beings: Current perspectives. Nursing Science Quarterly, 7, 33-35. Roy, C., Sr. (2009). The Roy adaptation m odel (3rd ed.). Upper Saddle River, NJ: Pearson. Roy, C., Sr., & Andrews, H. A. (1999). The Roy adaptation model (2nd ed.). Stamford, CT: Appleton & Lange. Sakraida, T. J. (2010). The health promotion model. In A. M. Tomey & M. R. Alligood (Eds.), Nursing theorists and their work (7th ed., pp. 434-453). St. Louis, MO: Mosby.

Sieloff, C. L. (2006). Imogene King: Interacting systems framework and middle range theory of goal attainment. In A. M. Tomey & M. R. Alligood (Eds.), Nursing theorists and their work (6th ed., pp. 297-317). St. Louis, MO: Mosby. Swanson, K. M. (1991). Empirical development of a middle range theory of caring. Nursing Research, 40(3), 161-166. Swanson, K. M. (1993). Nursing as informed caring for the well-being of others. Image: The Journal o f Nursing Scholarship, 25(4), 352-357. Swanson, K. M. (1999a). The effects of caring, measurement, and time on miscarriage impact and women’s well-being in the first year subsequent to loss. Nursing Research, 48(6), 288-298. Swanson, K. M. (1999b). What’s known about caring in nursing: A literary meta­ analysis. In A. S. Hinshaw, J. Shaver, & S. Freetham (Eds.), Handbook o f clinical nursing research (pp. 31-60). Thousand Oaks, CA: Sage. Taylor, S. G. (2006). Self-care deficit theory of nursing. In A. M. Tomey & M. R. Alligood (Eds.), Nursing theorists and their work (6th ed., pp. 267-296). St. Louis, MO: Mosby. Tomey, A. M. (2006). Nursing theorists of historical significance. In A. M. Tomey & M. R. Alligood (Eds.), Nursing theorists and their work (6th ed., pp. 54-67). St. Louis, MO: Mosby. Watson, J. (1979). Nursing: The philosophy and science o f caring. Boston, MA: Little, Brown. Watson, J. (1985). Nursing: Human science and human care: A theory o f nursing. Sudbury, MA: Jones and Bartlett. Watson, J. (1989). Watson’s philosophy and theory of human caring in nursing. In J. P. Riehl-Sisca (Ed.), Conceptual m odel for nursing practice (3rd ed., pp. 219-236). Norwalk, CT: Appleton & Lange. Watson, J. (1996). Watson’s philosophy and theory of human caring in nursing. In J. P. Riehl-Sisca (Ed.), Conceptual models for nursing practice (pp. 219-235). Norwalk, CT: Appleton & Lange. Watson, J. (1997). The theory of human caring: Retrospective and prospective. Nursing Science Quarterly, 10, 49-52. Watson, J. (2001). Jean Watson: Theory of human caring. In M. E. Parker (Ed.), Nursing theories and nursing practice (pp. 343-354). Philadelphia, PA: F. A. Davis. Watson, J. (2008). Nursing: The philosophy and science o f caring (rev. ed.). Boulder, CO: 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. 741-752). Maryland Heights, MO: Mosby. Young, A., Taylor, S. G., & McLaughlin-Renpenning, K. (2001). Connections: Nursing research, theory, and practice. St. Louis, MO: Mosby.

Philosophy of Nursing Mary W. Stewart

W hat is truth? Where do our ideas about truth originate? Why does truth matter? In a previous chapter, information was presented about the four principal domains of nursing: person, environment, health, and nursing. These concepts are the building blocks for all philosophies 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 understanding of professional nursing is impressive. More than impressive, nursing theory is necessary. In this chapter, we look more closely at nursing philosophy and its sig­ nificance to professional nursing. We study the difference between beliefs and values and investigate the importance of values clarification. Finally, we examine guidelines for creating a personal philosophy of nursing.

Learning Objectives A f t e r c o m p le tin g th is c h a p te r, th e s tu d e n t should be a b le to : 1. 2. 3. 4.

Id e n tify vario u s philosophical vie w s of tru th . D iffe re n tia te b e tw e e n v alu e s and beliefs. Discuss th e pro cess of v alu e c la rific a tio n . E x p la in th e m a jo r c o m p o n e n ts o f n u rs in g philosophy.

5 . A rtic u la te th e p u rp o se fo r having a pe rso n al philosophy o f nursing. 6 . Begin th e develo p m en t of a personal philosophy o f nursing.

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Key Terms and Concepts » » » » »

P a ra d ig m Realism Idealism Values Values clarification

CHAPTER 3 Philosophy of Nursing

P h ilo so p h y Though no single definition of p h ilosop h y is uncontroversial, philosophy is defined in the following ways by the A m erican H eritage D ictionary o f the English L an gu age (2000): • Love and pursuit of wisdom by intellectual means and moral self-discipline • Investigation of the nature, causes, or principles of reality, knowledge, or values, based on logical reasoning rather than empirical methods • A system of thought based on or involving such inquiry; for example, the philosophy of Hume • The critical analysis of fundamental assumptions or beliefs • The disciplines presented in university curriculums of science and the liberal arts, except medicine, law, and theology • The discipline comprising logic, ethics, aesthetics, metaphysics, and epis­ temology • A set of ideas or beliefs relating to a particular field or activity; an underly­ ing theory; for example, an original philosophy of advertising • A system of values by which one lives; for example, has an unusual phi­ losophy of life Examples of philosophies can be found in university catalogs, clinical agency manuals, and nursing school handbooks— and 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 values to others by implying what “should be.” However, each person or group of persons is responsible for delineating their particular philosophy. At the same time, how the insider’s philosophy fits with the outsider’s view is also important, particularly in situations such 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. So, how do we please everyone all the time? The answer is simple: We don’t. We do, however, consider our own values and beliefs, which are interdependent of society, as we convey our professional philosophy 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. H ow did we ever get started on this journey? A brief look at the beginnings o f philosophy can help answer that question.

E a rly P h ilo so p h y As society and individuals change, our philosophy of nursing changes to be congru­ ent with new and renewed understanding. In the beginning, the Greeks moved from seeking supernatural to natural explanations. One assumption by the early Greek philosophers was that “something” had always existed. They did not question how something could come from nothing. Rather, they wanted to know what the “something” was. The pre-Socratics took the first step toward science in that they abandoned mythological thought and sought reason to answer their questions. Heraclitus, a pre-Socratic philosopher, is well known for his thesis, Every­ thing Is in Flux. He moved from simply looking at “being” to “becoming.” A popular analogy he used was that of a river, saying, “You cannot step into the same river twice, for different and again different waters flow.” 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 perceptions are unreliable. He is called the first metaphysician, a “hard-core philosopher.” Metaphysics is the study of reality as a whole, including beyond the natural senses. What is the nature of reality? The universe? 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. Parmenides 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 (4 6 9 -3 9 9 b . c . ), famous for the “know thyself ” philosophy that focused on man, not nature. Plato wrote about his teacher, “Socrates ... believed in the immortal soul— all natural phenomena are merely shadows of the eternal forms or ideas. The soul, which existed before the body, longs to return to the world of ideas.” Plato was a rationalist— we know with our reason. Aristotle (3 8 4 -3 2 2 b . c . ) followed Socrates and Plato. His father was a phy­ sician, apparently framing his own 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 substance. Aristotle said happiness was man’s 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 soul’s vehicle to return to its intelligible roots. There was an extrarational approach to reach union with the One. Thinking was that truth,

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and certainty was not found in this world. This was a revival of the “other worldliness” thinking of Plato. The birth of Christianity and Western philosophy came at the death of classicism. Augustine of Hippo (a . d . 3 5 4 -4 3 0 ) became a Christian and was attracted to Neoplatonism, where existence is divine. In that period, evil was defined as an absence or incompleteness. Saint Thomas Aquinas (a . d . 1 2 2 5 -1 2 7 4 ) is credited with bringing theology and philosophy together. Throughout the centuries, from the Greeks to the present day, people have debated the same questions: W hat is man? W hat 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 asking 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 com fortable with the questioning. Table 3-1 provides an overview of the perspectives of truth through the ages. From the pre-Socratics to the

T

T A B L E 3-1

Overview of the P ersp ective s of Truth Through the A g e s

School of Thought

Meaning of Truth (Philosophers)

Classical philosophers

Truth corresponds with reality, and reality is achieved through our perceptions of the world in which we live. Truth could be found in the natural world— through our sensory experiences. (Heraclitus, Aristotle) Truth can be found in the natural world— through our rational intellect. (Parmenides, Plato) Truth is found when one knows self. (Socrates) Truth is not of this world. (Plotinus)

Theocratics

Truth comes through an understanding of God. Truth can be found through both the senses and the intellect. (St. Thomas Aquinas)

Empiricists

Truth is based on experience and relating to our experiences. (Bacon, Locke, Hume, Mill)

Rationalists

All things are knowable by man’s deductive reasoning. (Descartes, Spinoza)

Idealists

Truth exists only in the mind. (Berkeley, Hegel, Kant)

Positivists

Truth is science and the facts that science discovers. (Comte, Mill, Spencer)

Early existentialists

Truth is found through man’s faith in his existence as it relates to God. (Kierkegaard)

'

Paradigms

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School of Thought

Meaning of Truth (Philosophers)

Pragmatists

Truth is relative and practical— if it works, then it is truth. (James, Peirce, Dewey) Truth is always dependent on the knower and the knower’s context. (Kuhn, Laudan)

Relativists Phenomenologists

Truth is in human consciousness. (Husserl, Heidegger)

Existentialists

If truth can be found, it can be found only through man’s search for self. (Sartre, Merleau-Ponty, Gadamer)

Poststructuralists/ Postmodernists

Truth (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 outcome of events. (Foucault) Truth is created through dialogue with a purpose of emancipatory action. (Habermas, Freire) Truth is unique to gender. (Feminists)

poststructuralists and postmodern thinkers, ways of knowing and finding truth have changed. Now, back to the real world: W hat is the purpose for this dialogue in a text on professional nursing? One of the critical theorists, Habermas, would say, “Communication is the way to truth.” We have this discussion because it leads us to truth. In this case, the dialogue leads us to truth about nursing. W hat we hold as truth does not come through mere reading, studying, or debating. The truth comes through dialogue. Let’s continue.

P a ra d ig m s How do you see the world? Whether you know it or not, you have an estab­ lished worldview or p a ra d ig m . A paradigm is the lens through which you see the world. Paradigms are also philosophical foundations that support our approaches to research (Weaver & Olson, 2006). The continuum of re a lis m and id ea lism explains bipolar paradigms (Box 3-1). M ost people today would agree that “somewhere in the middle” of these dichotomies lies truth. Our philosophies are established from a lifelong process of learning 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 envi­ ronment provide structure to our thinking. Ultimately, our philosophies are demonstrated in the outcomes of our day-to-day living. Nurses’ values and beliefs about the profession come from observation and experience (Buresh & Gordon, 2000).

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BOX 3-1 THE CONTiNUUM OF REALiSM AND iDEALISM

Realism • 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.

Your worldview of nursing began long before you enrolled in nursing school. As far as you can remember, think back on your understanding 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? W hat images of the nurse did you see on television or in the movies? WWWI c r it ic a l t h in k in g q u e s t io n v Since that time, your worldview of nursing has changed. What experiences in school have changed your perspective Where do you see yourself and your under­ of nursing? Undoubtedly, how you see nursing now will standing of truth on the continuum of realism differ from your worldview in a few years— or even a few and idealism? V months.

B e lie fs A chief goal in 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. B eliefs indicate what we value, and according to Steele (1979), beliefs have a faith component. Rokeach (1973) identifies 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 morning. 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 undesirable or proscriptive belief is that people should not be dishonest. Beliefs demonstrate a personal confidence in the validity of a person, object, or idea.

Beliefs

95

How would you define p erso n ? Look at the following W W W I CRITiCAL THiNKING QUESTION V attributes given to a person: (1) the ability to think and con­ What are your beliefs about the major con­ ceptualize, (2) the capacity to interact with others, (3) the cepts in nursing—person, environment, need for boundaries, and (4) the use of language (Doheny, health, nursing? V Cook, & Stopper, 1997). Would you agree? W hat about M aslow’s description 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? Consider a second concept in nursing: environm ent. How do you define the internal (within the person) and external (outside the person) environ­ ments? Is it important that nurses look beyond the individual toward the sur­ roundings and structures that influence quality of human life? If yes, then how do you see the relationship between the internal and external environments? Is one dimension more important than the other? How do they interact with each other? Martha Rogers, a grand theorist in nursing, described the envi­ ronment as continuous with the person, no boundaries, in constant exchange of energy. Would you agree? H ea lth 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 “healthy.” W ould 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 one’s potential as well as maintaining physical, psychosocial health. (p. 19) Maybe that definition is sufficient, but probably not. All definitions— including yours— have limitations. Definitions merely give us a way to express our beliefs. Finally, consider common beliefs about nursing. Clarke (2006) posed that question in “So W hat Exactly Is a N urse?” an article addressing the problematic nature of defining nursing. The American Nurses Association (ANA) provided a much used definition of nursing in 1980: “Nursing is the diagnosis and treatment of human responses to actual and potential health problem s” (p. 9). Fifteen years later, the ANA (1 9 9 5 , p. 6) expanded its basic definition of nursing to include four fundamental aspects. Nursing is the following: • •

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

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• Application of scientific knowledge to the processes of diagnosis and treatment • Provision of a caring relationship that facilitates health and healing How would you define nursing? Understanding our beliefs and articu­ lating them in definitions are beginning steps for developing a personal phi­ losophy. Definitions tell us what things are. Our philosophy tells us how things are. One other piece must be addressed before we begin writing our personal philosophy: the topic of values.

V a lu e s V a lu e s refer to what the normative standard should be, not necessarily 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 “an affective disposition towards a person, object, or idea” (p. 1). The values of nursing have been articulated by groups such as the ANA in the C od e o f Ethics (2001) and the American Association of Colleges of Nursing’s (AACN) (2008) essentials for baccalaureate nursing education. The AACN essentials document calls for integration of professional nursing values in bac­ calaureate education; they are altruism, autonomy, human dignity, integrity, and social justice. Ways of teaching these values have been addressed in recent literature (Fahrenwald, 2003). Nursing values have been identified as the fundamentals that guide our standards, influence practice decisions, and provide the framework used for evaluation (Kenny, 20 0 2). Nevertheless, nursing has been criticized as not clearly articulating what our values are (Kenny, 2002). If nursing is to engage in the move to “interprofessional working,” which is beyond uniprofessional and multiprofessional 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 collaboration. 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 one else does, but that som ethin g must first be clear to those of us in nursing. “It is not enough just to argue that caring is never value-free, and that values are a fundamental aspect of nursing. W hat is required is greater precision and clarity so that values can be identified by those within the pro­ fession and articulated beyond it” (Kenny, 2002, p. 66). Statements such as those by the ANA and the AACN mentioned earlier are a step in the right direction. Others have identified nursing values using different language. Antrobus (1997) sees nursing values as humanistic and included (1) a nurturing response to someone in need, (2) a view of the whole

individual, (3) an emphasis on the individual’s perspective, (4) concentration on developing human potential, (5) an aim of well-being, and (6) maintenance of the nurse-patient 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, 2 0 0 1 ). To choose a value is an intellectual stage in which a person selects a value from identified alterna­ tives. Second, prizing values involves the emotional or affective dimension of valuing. When we “feel” 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 includes behavior or action that demonstrates our value. Ideally, a genuine 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 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 M ust 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 lifestyle

Value acquisition refers to when a new value is assumed, and value aban ­ don m en t is when a value is relinquished. Value redistribution occurs when society changes views about a particular value. Values are more dynamic than attitude because values include motivation as well as cognitive, affective, and behavioral components. Therefore, people have fewer values than attitudes (feelings or dispositions toward a person, object, or idea). In the end, values determine our choices.

According to Steele (1979), values can compete with each other on our “hierarchy of values.” We typically have values that we hold about educa­ tion, politics, gender, society, occupations, culture, religion, 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 responsibilities and religious beliefs conflict, the solution is not as simple as “right versus wrong.” 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 patient’s 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 explanations represented a distinct way of thinking. A list of definitions and descriptions of the different ways of thinking includes the following: •

C ontextualism : Understanding is embedded in context; meaning is subjec­ tive and open to change and dependent on the moment in time and the person’s perspective. • F orm ism : Understanding events in relationship to their similarity to an ideal or objective standard comes from categorization (e.g., the classifica­ tion of plants and animals in biology). • M echanism : Understanding is in terms of cause-and-effect relationships, the common approach used by modern medicine. • O rganicism : Understanding comes from patterns and relationships; must understand the whole to understand the parts (e.g., cannot look at a child’s 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 thinking sig­ nificantly more than all other ways of thinking and chose contextualistic 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. W hat 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 for multiple options. Nursing claims to respond to these contextual needs, but do we?

■ Values Clarification

w w wj CRITICAL THINKING QU ESTIO N S*

Clarifying our values is an eye-opening experience. The Do you believe there is more than one right answer to situations? How do you value the process of v alu e s c la rific a tio n can occur in a group or indi­ whole individual? What barriers prevent us vidually and helps us understand who we are and what is from responding to the contextual needs of most important to us. The outcome of values clarification is our patients? V 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 statements such as “Patients have a right to know everything that is in the medical record.” W hat 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: “Everyone should have equal access to health care— regardless of income.” Ask yourself the same questions. Other exercises involve real or hypothetical clinical situations. For example, a 19-year-old male with HIV disease 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 sclerosis. 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? Reflect. W hat questions do you have? Why are these people in these situations? Does that matter? W hat in the patient’s life choices conflicts with your choices? Share this with your peers, your friends, and your teachers. In values clarification, one should consider the steps identi­ fied 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 to 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 allows us to be more open to accepting others’ 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 “W hat is health?” we would get different responses because it means different things to different people. M ost 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 ailment, whereas others wait until the situation is critical. Maintaining a nonjudgmental attitude about the values of others is crucial to the nurse-patient relationship. In health care, we need to clarify values for both the consumer and pro­ vider in society. Referring once again to health, we recognize that although the

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majority of our society states that health is a right, not a privilege, everyone does not have health care. Is health positioned at the top of society’s hierarchy of values? We also have to assess the individual’s values for congruency with the societal values. As research gives us new options to consider, continual reas­ sessment of values is essential. A questioning attitude is healthy and necessary. As a profession, nursing is responsible for clarifying W W W ] CRITICAL THINKING QUESTIONS V our values on a regular basis. Just as society places a value on health, society also determines the value of nursing in Do I believe in health care for everyone? Does the provision of health. Additionally, nurses need to be health care for everyone have value to me as a involved in all levels where decisions based on values are person? Does it have value to me as a nurse? made, particularly with ethical decisions. The values that What value does universal health care have nursing supports need to be communicated clearly to those to my patients? V making the policies that affect the health of our society. Values clarification is done for the purpose of understanding self— to 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.

KEY COMPETENCY 3-1 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Professionalism: Knowledge (K7) Understands ethical principles, values, concepts, and decision making that apply to nursing and patient care Attitudes/Behaviors (A7c) Clarifies personal and professional values and recognizes their impact on decision making and profes­ sional behavior Skills (S7c) Identifies and responds to ethical con­ cerns, issues, and dilemmas that affect nursing practice Source: Massachusetts Department of Higher Education (2010, p. 14).

D evelo p in g a P e rs o n a l P h ilo so p h y of N u rsin g Before we begin writing our individual nursing philosophies, consider the following comments about philosophy. According to Doheny et al. (1997), philosophy is defined as “beliefs of a person or group of persons” and “reveals underlying values and attitudes regarding an area” (p. 259). In this concise definition, these authors mentioned the building blocks of philosophy that we have discussed thus far: attitudes, beliefs, and values. Another definition that is not as concise reads, “Nursing philosophy is a statement of foundational and universal assumptions, beliefs, and principles about the nature of knowledge and truth (epistemology) and about the nature of the entities— nursing practice and human healing processes— represented in the metaparadigm (ontology)” (Reed, 1999, p. 483). Finally, philosophy “looks at the nature of things and aims to provide the meaning of nursing phenomena” (Blais, Hayes, Kozier, & Erb, 2002, p. 90). In N ursing’s A genda fo r the Future, the ANA (2002) identified the need for nurses to “believe, articulate, and demonstrate the value of nursing” (p. 15). To do that, each professional nurse is responsible for clearly articu­ lating a personal philosophy of nursing. Suggestions for developing personal professional philosophies have been presented in the literature (Brown & Gillis, 1999). The overall purpose of personal philosophy is to define how one finds truth. Because there are different ways of knowing, each person

Developing a Personal Philosophy of Nursing

has a unique way of finding truth, in other words, identifying our individual philosophy. Therefore, 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 indi­ viduals or groups. You may also choose to write an original definition, which is certainly 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 already— you 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. W hat would happen? U nfortunately, we would find ourselves doing tasks without BOX 3 -2 GUIDE FOR WRiTiNG A PERSONAL PHiLOSOPHY OF NURSING

1. Introduction a. W ho are you? b. Where do you practice nursing? 2. Define nursing. a. W hat is nursing? b. Why does nursing exist? c. Why do you practice nursing? 3. W hat 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. Person b. Health c. Environment 5. Summary a. How are the domains connected? b. W hat is your vision of nursing for the future? c. W hat are the challenges that you will face as a nurse? d. W hat are your goals for professional development?

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considering the rationale and performing routines in the absence of purpose. M ost likely, we would find ourselves devalued by our patients and fellow care providers. 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 attitudes, beliefs, and CRiTICAL THiNKiNG QUESTIONS V values. We can evaluate our efforts by reflecting on our philosophies. In the process of personal and professional How does my personal philosophy fit with reflection, we are challenged to reach global relevancy and the context of nursing? Does it fit? What to begin the development of a global nursing philosophy areas, if any, need assessing? V (Henry, 1998).

KEY COMPETENCY 3-2 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Professionalism: Knowledge (K8A) Under­ stands the responsibilities inherent in being a member of the nursing profession Attitudes/Behaviors (A8b) Values and upholds altruistic and humanistic principles Skills (S8a) Understands the history and philosophy of the nursing profession Source: Massachusetts Department of Higher Education (2010, p. 15).

C o nclu sio n In this chapter, we have discussed one of the most ambiguous concepts in pro­ fessional disciplines— nursing 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 profes­ sion. Our own values and beliefs must be clarified so that we can authentically respond to the healthcare needs o f our patients and to society as a whole. All along the way, our philosophies are changing. Therefore, we must constantly question the values of our profession, our society, and ourselves— aiming to better the health of all people worldwide. Hegel, an early philosopher, said, “History is the spirit seeking freedom.” On this path of searching for truth, we ask the same question, but in different contexts and with distinct experiences. The answers for one person do not provide the same satisfaction for another person. Through our individual and collective searching, we become truth kn ow ers. Habermas, the supporter of dialogue, would suggest that the journey does not end with communica­ tion and questioning alone. When truth is revealed, oppressive forces are acknowledged, 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.

Classroom A ctivity 1 ake about 15 minutes after the discussion related to developing a philosophy of nursing to begin answering the questions in Box 3-2. Jot down answers to the questions in

T

Box 3-2. Ask questions as necessary while still in the classroom. This simple activity will make it easier when writing a personal philosophy of nursing.

References

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Classroom A ctivity 2 Figure 3-1 fter thinking about your answers to the questions in Box 3-2 related to the metaparadigm 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 phi­ losophy of nursing. This activity works best if you use colored pencils, crayons, or markers. An example is pre­

Drawing of the concept of person

A

sented in Figure 3-1.

Body

Soul

' (em otion, intellect, and w ilt

S p irit

\ \

(conscience, intuition, com m union)

S ou rce: M asters, 2 0 0 6 , as adapted from Nee, 1968

R e fe re n c e s American Association of Colleges of Nursing. (2008). The essentials o f baccalaureate education for professional nursing practice. Washington, DC: Author. American Heritage Dictionary o f the English Language (4th ed.). (2000). Boston, MA: Houghton Mifflin. American Nurses Association. (1980). Nursing: A social policy statement. Washington, DC: Author. American Nurses Association. (1995). Nursing’s social policy statement. Washington, DC: Author. American Nurses Association. (2001). Code o f ethics for nurses with interpretive statements. Washington, DC: Author.

American Nurses Association. (2002, April). Nursing’s agenda for the future: A call to the nation. Retrieved from http://ana.nursingworld.org/MainMenuCategories/ HealthcareandPolicyIssues/HealthSystemReform/What-ANA-is-Doing/ AgendafortheFuture.aspx Antrobus, S. (1997). An analysis of nursing in context: The effects of current health policy. Journal o f Advanced Nursing, 45, 447-453. Blais, K. K., Hayes, J. S., Kozier, B., & Erb, G. (2002). Professional nursing practice: Concepts and perspectives (4th ed.). Upper Saddle River, NJ: Prentice Hall. Brown, S. C., & Gillis, M. A. (1999). Using reflective thinking to develop personal professional philosophies. Journal o f Nursing Education, 38, 171-176. Buresh, B., & Gordon, S. (2000). From silence to voice: What nurses know and must communicate to the public. New York, NY: Cornell University Press. Chitty, K. K. (2001). Philosophies of nursing. In K. K. Chitty (Ed.), Professional nursing: Concepts and challenges (pp. 199-217). Philadelphia, PA: Saunders. Clarke, L. (2006). So what exactly is a nurse? Journal o f Psychiatric and Mental Health Nursing, 13, 388-394. Doheny, M. O., Cook, C. B., & Stopper, M. C. (1997). The discipline o f nursing: An introduction (4th ed.). Stamford, CT: Appleton & Lange. Dowds, B. N., & Marcel, B. B. (1998). Students’ philosophical assumptions and psychology in the classroom. Journal o f Nursing Education, 37, 219-222. Fahrenwald, N. L. (2003). Teaching social justice. Nurse Educator, 28, 222-226. Henry, B. (1998). Globalization, nursing philosophy, and nursing science. Image: Journal o f Nursing Scholarship, 30, 302. Kenny, G. (2002). The importance of nursing values in interprofessional collaboration. British Journal o f Nursing, 11(1), 65-68. Massachusetts Department of Higher Education. (2010). Nurse o f the future: Nursing core competencies. Retrieved from http://www.mass.edu/currentinit/documents/ NursingCoreCompetencies.pdf Masters, K. (2006). Drawing o f concept o f person. Unpublished classroom exercise. Nee, W. (1968). The spiritual man. New York, NY: Christian Fellowship Publishers. 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 o f science in nursing (pp. 478-490). Philadelphia, PA: Lippincott. Rokeach, M. (1973). The nature o f human values. New York, NY: Free Press. Simon, S. B., & Clark, J. (1975). Beginning values clarification: A guidebook for the use o f values clarification in the classroom. San Diego, CA: Pennant Press. Steele, S. (1979). Values clarification in nursing. New York, NY: Appleton-CenturyCrofts. Weaver, K., & Olson, J. K. (2006). Understanding paradigms used for nursing research. Journal o f Advanced Nursing, 53, 459-469. Weis, D., & Schank, M. J. (2000). An instrument to measure professional nursing values. Journal o f Nursing Scholarship, 32, 201-204.

Foundations of Ethical Nursing Practice Karen Rich and Janie B. Butts

v________ :___________ Key Terms and Concepts

Scientific and technological advances, econom ic realities, pluralistic worldviews, and global communication make it impossible for nurses to ignore important ethical issues in the world community, their individual lives, and their work. As controversial and sensitive ethical issues continue to challenge nurses and other healthcare professionals, many professionals have begun to develop an appreciation for personal philosophies of ethics and the diverse viewpoints of others. Often ethical directives are not clearly evident, which leads some people to argue that ethics can be based merely on personal opinions. However, if nurses are to enter into the global dialogue about ethics, they must do more than practice ethics based simply on their personal opinions, their intuition, or the unexamined beliefs that are proposed by other people. It is important for nurses to have a basic understanding of the various concepts, theories, approaches, and principles used in ethics throughout history and to identify and analyze ethical issues and dilemmas that are relevant to nurses in this cen­ tury. Mature ethical sensitivities are critical to professional nursing practice.

» » » » » » » » » » » » » » » » » » » » »

E th ic s Morals Bioethics Nursing ethics Moral reasoning Wholeness of character Integrity Basic dignity Personal dignity Virtues Deontology Utilitarianism Ethic of care Ethical principlism Autonomy Beneficence Paternalism Nonmaleficence Justice Ethical dilemma Moral suffering

Learning Objectives A f t e r c o m p le tin g th is c h a p te r, th e s tu d e n t should be a b le to : 1. Discuss th e m ean in g of key te rm s ass o cia te d w ith e th ic a l nursing p ra c tic e . 2 . C o m p a re and c o n tra s t e th ic a l th e o rie s and a p p ro a c h e s t h a t m ig h t be u s ed in n u rs in g p ra c tic e . 3 . Discuss each of th e popular bioethical principles as th e y re la te to nursing p ra c tic e : a u to n o m y , b e n efice n ce , n o n m a lefic en ce , and ju s tic e .

4 . J u s tify th e im p o rta n c e o f th e Code of Ethics for Nurses fo r pro fession al nursing p ra c tic e . 5 . E xp lain how n urses can id e n tify and a n a ly z e d ilem m a s th a t o c cu r in nursing p ra c tic e .

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E th ic s in E v e ry d a y L ife E th ic s , a branch of philosophy, means different things to different people. When the term is narrowly defined according to its original use, ethics is the study of ideal human behavior and ideal ways of being. The approaches to ethics and the meanings of ethically related concepts have varied over time among philosophers and ethicists. As a philosophical discipline of study, ethics is a systematic approach to understanding, analyz­ ing, and distinguishing matters of right and wrong, good ■\ and bad, and admirable and deplorable as they exist along Mature ethical sensitivities a continuum and as they relate to the well-being of and the are critical to professional relationships among sentient beings. Ethical determinations nursing practice. are applied through the use of formal theories, approaches, and codes of conduct. As contrasted with the term e th ic s , m o ra ls are specific beliefs, behaviors, and ways of being based on personal judgments derived from one’s ethics. One’s morals are judged to be good or bad through systematic ethical analysis. Because the word eth ics is used when one might literally be referring to a situ­ ation of morals, the process-related conception of ethics is sometimes over­ looked today. People often use the word eth ics when referring to a collection of actual beliefs and behaviors, thereby using the terms eth ics and m o ra ls in essentially synonymous ways.

J

B io e th ic s The terms b io eth ics and h e a lt h c a re eth ics are sometimes used interchangeably in the literature. B io e th ic s is a specific domain of ethics that is focused on moral issues in the field of health care. Callahan (1995) calls it “the intersec­ tion of ethics and the life sciences— but also an academic discipline” (p. 248). Bioethics has evolved into a discipline all its own as a result of life-and-death moral dilemmas encountered by physicians, nurses, other healthcare profes­ sionals, patients, and families. In his book T h e B irth o f B io e th ic s , Albert Jonsen (1998) designates a span of 40 years, from 1947 to 1987, as the era when bioethics was evolving as a discipline. This era began with the Nuremberg Tribunal in 1947, when Nazi physicians were charged and convicted for the murderous and tortuous war crimes that these physicians labeled as scientific experiments during the early 1940s. The 10 judgments in the final court ruling of the Nazi trial provided the basis for the worldwide Nuremberg Code of 1947. This code became a document to protect human subjects during research and experimentation. The 1950s and 1960s were preliminary years before the actual birth of bioethics. A transformation was occurring during these years as technology

Moral Reasoning

advanced. In this era, a new ethic was emerging about life and extension of life through technology. The development of the polio vaccine, organ transplanta­ tion, life support, and many other advances occurred. Scientists and physicians were forced to ask questions: “Who should live?” “Who should die?” “Who should decide?” (Jonsen, 1998, p. 11). Many conferences and workshops during the 1960s and 1970s addressed issues surrounding life and death. By 1970, the public, physicians, and researchers were referring to these phenomena as bioethics (Johnstone, 1999). Today, bioethics is a vast interdis­ ciplinary venture that has engrossed the public’s interest from the time of its conception. The aim of bioethicists today is to continue to search for answers to deep philosophical questions about life, death, and the significance of human beings and to help guide and control public policy (Kuhse & Singer, 1998).

N u rs in g E th ic s “It is the real-life, flesh-and-blood cases that raise fundamental ethical ques­ tions” (Fry & Veatch, 2 0 0 0 , p. 1) in nursing. N u rs in g e th ic s sometimes is viewed as a subcategory of the broader domain of bioethics, just as medical ethics is a subcategory of bioethics. However, controversy continues about whether nursing has unique moral problems in professional practice. Nursing ethics, similar to all healthcare ethics, usually begins with cases or problems that are practice based. M any nursing ethicists distinguish issues of nursing ethics from broader bioethical issues that nurses encounter. These nursing ethicists view nursing ethics as a separate field because of the unique variety of ethical problems that surface in relationships between nurses and patients, families, physi­ cians, and other professionals who are a part of the healthcare team. The key criteria for distinguishing issues of nursing ethics from bioethics are that nurses are the primary agents in the scenario, and ethical issues are viewed from a nursing rather than a medical perspective.

M o ra l R easo ning In general, reasoning involves using abstract thought processes to solve problems and to formulate plans (Angeles, 1992). More specifically, m o ra l reasoning pertains to making decisions about how humans ought to be and act. Deliberations about moral reasoning go back to the days of the ancient Greeks when Aristotle, in N icom achean Ethics, discussed the intellectual virtue of wisdom as being necessary for deliberation about what is good and advanta­ geous in terms of moving toward worthy ends (Broadie, 2002).

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Moral reasoning can be described by what Aristotle (Broadie, 2002) called the intellectual virtue of wisdom (phronesis), also known as prudence. Virtue is an excellence of intellect or character. The virtue of wisdom is focused on the good achieved from being wise, that is, knowing how to act in a particular situation, practicing good deliberation, and having a disposition consistent with excellence of character (Broadie, 2002). Therefore, prudence involves more than having good intentions or meaning well. It includes knowing “what is what” but also transforming that knowledge into well-reasoned decisions. Deliberation, judgment, and decision are the steps in transforming knowledge into action. Prudence becomes truth in action (Pieper, 1966). In more recent times, Lawrence Kohlberg, in 1981, reported his landmark research about moral reasoning based on 84 boys he had followed for more than 20 years. Kohlberg defined six stages ranging from immature to mature moral development. Interestingly, Kohlberg did not include any women in his research but expected that his six-stage scale could be used to measure moral development in both males and females. When the scale was applied to women, they seemed to score only at the third stage of the sequence, a stage in which Kohlberg described morality in terms of interpersonal relationships and helping others. Kohlberg viewed this third stage of development as deficient in regard to mature moral reasoning. In light of Kohlberg’s exclusion of females in his research and the nega­ tive implications of women being placed within the third stage of moral reasoning, Carol Gilligan raised the concern of gender bias. Gilligan, in turn, published an influential book in 1982, In a D ifferen t V oice, in which she argued that women’s moral reasoning is different but is not deficient (Gilligan, 1993; Grimshaw, 1993; Thomas, 1993). The distinction that is usually made between the ethics of Kohlberg and Gilligan is that Kohlberg’s is a maleoriented ethic of justice and Gilligan’s is a more feminine ethic of care. The Kohlberg-Gilligan justice-care debate is still at the heart of feminist ethics. Often the work of nurses does not involve independent moral reasoning and decision making in regard to the well-publicized issues in bioethics, such as withdrawing life support. Independent moral reasoning and decision making for nurses usually occurs more in the day-to-day care and relationships between nurses and their patients and between nurses and their coworkers. Nurses’ moral reasoning is similar to the findings of Gilligan and is often based on caring and the needs of good interpersonal relationships. However, this does not negate what nurses can learn from studying Aristotle and his virtue of phronesis. Nurses’ moral reasoning needs to be deliberate and practically wise to facilitate patients’ well-being.

V a lu e s in N u rsin g Values are emphasized in the American Nurses Association (ANA, 2001) C o d e o f E thics fo r N urses w ith In terpretive Statem ents. Values refer to a

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group’s or individual’s evaluative judgments about what is good or what makes something desirable. Professional values are integral to moral reasoning. Values in nursing encompass appreciating what is important for both the profession and nurses personally, as well as what is important for patients. In the C o d e o f E th ics fo r N urses w ith In terp retiv e Statem ents (discussed in more detail later in this chapter), the ANA (2001) includes statements about w h o le n e s s of c h a r a c t e r , which pertains to knowing the values of the nursing profession and one’s own authentic moral values, integrating these two belief systems, and expressing them appropriately. In te g r ity is an important feature of whole­ ness of character. According to the code, maintaining integ­ rity involves acting consistently with personal values and the values of the profession. In a healthcare system often burdened with constraints and self-serving groups and organizations, threats to integrity can be a serious pitfall for nurses. When nurses are asked and pressured to do things that conflict with their values, such as to falsify records, deceive patients, or accept verbal abuse from others, emotional and moral suffering can occur. A nurse’s values must guide moral reasoning and actions, even when other people challenge the nurse’s beliefs. When compromise is necessary, the compromise must not be such that it compromises personal or professional values. Recognizing the essential dignity of oneself and each patient is another value that is basic to nursing and is given priority in moral reasoning. Pullman (1999) describes two conceptions of dignity. One type, called b asic d ig n ity , is intrinsic, or inherent, and dwells within all humans, with all humans being ascribed this moral worth. The other type, called pe rso n al d ig n ity , often mis­ takenly equated with autonomy, is an evaluative type. Judging others and describing behaviors as dignified or undignified are of an evaluative nature. Personal dignity is a socially constructed concept that fluctuates in value from community to community, as well as globally. Most often, however, personal dignity is highly valued.

E th ic a l T h e o rie s and A p p ro a c h e s Within each ethical theory or approach, a normative framework exists that includes foundational statements. Individuals who apply a particular theory or approach know what beliefs and values are right and wrong and what is and is not acceptable according to the Theory helps to provide guid­ particular ethical system. Normative ethical theories func­ ance in moral thinking and tion as moral guides in answering the question: “W hat reasoning and justification for ought I do or not do?” Theory helps to provide guidance __________moral actions._________ in moral thinking and reasoning and justification for moral actions. Optimally, ethical theories and approaches should

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help people to discern commonplace morality and strengthen moral judgments “in the face of moral dilemmas” (Mappes & DeGrazia, 2001, p. 5).

■ V irtu e Ethics Since the time of Aristotle (3 8 4 -3 2 2 b . c . ), v ir t u e s , arete in Greek, refer to excellences of intellect or character. Aristotle, the Greek philosopher, was one of the most influential thinkers in regard to virtue ethics. Virtue ethics pertains to questions of “W hat sort of person must I be to achieve my life’s purpose?” and “W hat makes one a good or excellent person?” rather than “what is right or good to do based on my duty or to achieve good consequences?” Virtues are intellectual and character traits or habits that are developed throughout one’s life. The idea behind virtue ethics is that when people are faced with complex moral dilemmas or situations, they will choose the right course of action because doing the right thing comes from a virtuous person’s basic character. Aristotle believed that for a person to develop moral character, personal effort, training, and practice must occur. Examples of virtues include benevolence, compassion, courage, justice, generosity, truthfulness, wisdom, and patience.

■ N atural Law Theory Saint Thomas Aquinas (1 2 2 5 -1 2 7 4 ), who had a great influence on natural law theory as disseminated by Roman Catholic writers of that century, was himself influenced by Aristotle’s work. M ost versions of natural law theory today have their basis in Aquinas’s basic philosophy. According to natural law theory, the rightness of actions is self-evident from the laws of nature, which in most cases is orchestrated by a law-giver God. Morality is determined not by customs and human preferences but is commanded by the law of rea­ son, which is implanted in nature and human intellect. Natural law ethicists believe that behavior that is contrary to their views of the laws of nature is immoral. Examples include artificial means of birth control and homosexual relationships.

■ Deontology D e o n to lo g y refers to actions that are duty based, not based on their rewards, happiness, or consequences. One of the most influential philosophers for the deontologic way of thinking was Immanuel Kant, an 18th-century German philosopher. In his classic work, G rou n dw ork o f the M etaphysics o f M orals, Kant (1785/2003) attempted to define a person as a rational human being with freedom, moral worth, and ideally having a good will, meaning that a person should act from a sense of duty. Because of their rationality, Kant be­ lieved, humans have the freedom to make moral judgments. Therefore, Kant argued that people ought to follow a universal framework of moral maxims,

or rules, to guide right actions because it is only through performing dutiful actions that people have moral worth. Even when individuals do not want to act from duty, Kant stated that they are required to do so if they want to be ethical. Maxims apply to everyone universally and become the laws for guid­ ing conduct. According to Kant, moral actions should be ends in themselves, not the means to ends. In fact, when people use others as a means to an end, such as deliberately using another person to reach one’s personal goals, they are not treating other people with the dignity that they deserve. Kant distinguished between two types of duties: hypothetical impera­ tives and categorical imperatives. Hypothetical imperatives are duties or rules that people ought to observe if certain ends are to be achieved. Hypothetical imperatives are sometimes called “if-then” imperatives, which are conditional: for instance, “If I want to pass my nursing course, then I should be diligent in my studies.” However, Kant stated that moral actions must be based on unconditional reasoning. Where moral actions are concerned, duties and laws are absolute and universal. Kant called these moral maxims, or duties, categorical impera­ tives. When acting according to a categorical imperative, one should ask this question: “If I perform this action, would I will that it becomes a universal law ?” No action can ever be judged as right, according to Kant, if the action cannot have the potential to become a binding law for all people. For example, Kant’s ethics would impose the categorical imperative that one can never tell a lie for any reason because if a person lies in any instance, the person cannot rationally wish that permission to lie should universally become a law for everyone.

■ U tilitarianism Contrasted with deontology, the ethical approach of u tilita ria n is m is to pro­ mote the greatest good that is possible in situations (i.e., the greatest good for the greatest number). British utilitarianism was promoted by Jeremy Bentham (1789/1988) in his book A n I n t r o d u c t io n to th e P r in c ip le s o f M o ra ls a n d L e g is la t io n . Bentham ’s thoughts on utilitarianism were that each form of happiness is equal and that each situation or action should be evaluated ac­ cording to its production of happiness, good, or pleasure. John Stuart Mill (1863/2002) challenged Bentham’s view when in his book, U tilita ria n ism , he clearly points out that experiences of pleasure and happiness do have different qualities and are not equal. For example, Mill stated that intellectual pleasures o f humans have more value than physical pleasures of nonhuman animals. Utilitarians place great emphasis on what is best for groups, not individual people. In doing so, the focus is on moral acts that produce the most good in terms of the most happiness. By aiming for the most happiness, this theory focuses on good consequences, utility (usefulness), or good ends. Although happiness is the goal, it should be kept in mind that utilitarianism is not based

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m e re ly o n s u b jec tive p referen ces o r ju d g m e n ts o f h ap p in es s . C o m m o n s e n s e e th ic a l d ire ctiv es ag ree d u p o n b y g ro u p s o f p e o p le a re u s u a lly a p p lie d .

■ Ethic of Care T h e e th ic o f c a re has a h is to ry in fe m in is t e th ics , w h ic h has a fo cus in th e m o ra l experiences o f w o m e n . In th e e th ic o f care a p p ro a c h , p e rs o n a l re la tio n ­ ships a n d re la tio n s h ip re s p o n s ib ilitie s a re e m p h a s ize d . Im p o r t a n t concepts in th is a p p ro a c h are c o m p a s s io n , e m p a th y , s y m p a th y , c o n c e rn fo r o th e rs , a n d c a rin g fo r o th e rs . C a r o l G illig a n w it h h e r s tu d y o n g e n d e r differences in m o ra l d e v e lo p m e n t (see th e M o r a l R e a s o n in g W W W J CRITICAL THINKING Q U ESTIO N S* s ectio n e a rlie r in th is c h a p te r) has h a d a n in flu e n c e o n th e Think about the ethical theories and e th ic o f c are a p p ro a c h . approaches discussed in this section and P eo p le w h o u p h o ld th e e th ic o f c are th in k in te rm s o f think about moral conflicts you have p a rtic u la r s itu a tio n s a n d in d iv id u a l c o n te x ts , n o t in te rm s experienced in the past. Have you used one of o f im p e rs o n a l u n iv e rs a l ru les a n d p rin c ip le s . I n re s o lv in g these approaches to resolve a conflict? Which m o r a l co n flicts a n d u n d e rs ta n d in g a c o m p le x s itu a tio n , a approach or approaches have you used? V p e rs o n m u s t use c ritic a l th in k in g to in q u ire a b o u t re la tio n ­ ships, c irc u m s ta n c e s , a n d th e p ro b le m a t h a n d . T h e s itu ­ a tio n m u s t be b ro u g h t to lig h t w it h “ c a rin g , c o n s id e ra tio n , u n d e rs ta n d in g , g en ero sity , s y m p a th y , help fulness, a n d a w illin g n e ss to assum e re s p o n s ib ility ” (M u n s o n , 2 0 0 4 , p . 7 8 8 ).

■ Ethical Principlism

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E th ic a l p rin c ip lis m , a p o p u la r a p p ro a c h to ethics in h e a lth care, in vo lv es using a set o f e th ic a l p rin c ip le s th a t is d r a w n fr o m th e c o m m o n o r w id e ly sh ared c o n c e p tio n o f m o r a lity . T h e fo u r p rin c ip le s th a t a re m o s t c o m m o n ly used in b io e th ic s a re a u to n o m y , beneficence, n o n m a le fic e n c e , a n d ju s tic e . In 1 9 7 9 , T o m B e a u c h a m p a n d Jam es C h ild res s p u b lis h e d th e firs t e d itio n o f P rin cip les o f B io m e d i c a l E t h ic s , w h ic h fe a tu re d these fo u r p rin c ip le s . C u r r e n tly , th e b o o k is in its s ix th e d itio n , a n d th e fo u r p rin c ip le s h a v e b e co m e an essential fo u n d a tio n fo r a n a ly z in g a n d re s o lv in g b io e th ic a l p ro b le m s . T h e s e p rin c ip le s , w h ic h a re c lo s e ly a s s o c ia te d w it h ru le -b a s e d e th ics , p ro v id e a fr a m e w o r k to s u p p o rt m o r a l b e h a v io r a n d d e cis io n m a k in g . H o w ­ ever, th e p rin c ip le s n e ith e r fo r m a th e o ry n o r p ro v id e a w e ll-d e fin e d d e cis io n ­ m a k in g m o d e l. T h e fr a m e w o r k o f p rin c ip lis m p ro v id e s a p rim a facie m o d e l. A s a p r im a fa cie m o d e l, p rin c ip le s are The four principles that are a p p lie d based o n rules a n d ju s tific a tio n s fo r m o ra l b e h a v io r. most commonly used in bio­ O f t e n , m o r e th a n o n e p r in c ip le is r e le v a n t in e th ic a l ethics are autonomy, benefi­ situ atio n s, a n d n o c o n flic t occurs. H o w e v e r, i f re le v a n t p r in ­ cence, nonmaleficence, and ciples c o n flic t in a n y s itu a tio n , ju d g m e n t m u s t be used in w e ig h in g w h ic h p rin c ip le sh o u ld ta k e precedence in g u id in g justice. actio n s.

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A utonom y T h e w o r d a u t o n o m y is a d e riv a tiv e o f “ th e G re e k a u to s ( ‘s e lf’ ) a n d n o m o s ( ‘ru le , governance, o r la w ’ )” (B e au c h am p & C hildress, 2 0 0 9 , p . 9 9 ). A u to n o m y th e n in v o lv e s o n e ’s a b ility to s e lf-ru le a n d to g e n e ra te p e rs o n a l d ecisio n s in d e p e n d e n tly . S om e p e o p le a rg u e th a t a u to n o m y has a to p p r io r ity a m o n g th e fo u r p rin c ip le s . H o w e v e r , th e re is n o g e n e ra l consensus a b o u t th is issue, a n d m a n y p e o p le arg u e th a t o th e r p rin c ip le s , such as beneficence, s h o u ld ta k e p r io r it y . Id e a lly , w h e n u s in g a fr a m e w o r k o f p rin c ip lis m , n o o n e p rin c ip le s h o u ld a u to m a tic a lly be assum ed to ru le s u p re m e. T h e p rin c ip le o f a u to n o m y som etim es is described as respect fo r a u to n o m y (B e a u c h a m p & C h ild re s s , 2 0 0 9 ) . In th e d o m a in o f h e a lth c are , respect fo r a p a tie n t’s a u to n o m y includ es s itu atio n s such as o b ta in in g in fo rm e d c onsent fo r tre a tm e n t; fa c ilita tin g p a tie n t c h o ice re g a rd in g tr e a tm e n t o p tio n s ; a cc ep tin g p a tie n ts ’ re fu s a l o f tr e a tm e n t; d is c lo s in g m e d ic a l in f o r m a t io n , d iag n o se s , a n d t r e a tm e n t o p tio n s to p a tie n ts ; a n d m a in t a in in g c o n f id e n t ia lit y . I t is im p o r t a n t to n o te th a t a p a tie n t’s r ig h t to re s p e c t fo r a u to n o m y is n o t u n q u a lifie d . In cases o f e n d a n g e rin g o r h a rm in g o th ers , fo r e x a m p le , th ro u g h c o m m u n ic a b le diseases o r acts o f v io le n c e , p e o p le lose th e ir basic rig h ts to s e lf-d e te rm in a tio n .

Beneficence T h e p rin c ip le o f b e n e fic e n c e consists o f deeds o f “ m e rc y , k in d n es s, a n d c h a r­ i t y ” (B e a u c h a m p & C h ild re s s , 2 0 0 1 , p . 1 6 6 ). B eneficence in n u rs in g im p lie s th a t nurses ta k e a ctio n s to b e n e fit p a tie n ts a n d to fa c ilita te th e ir w e ll-b e in g . B e n e fic e n t n u rs in g a ctio n s in c lu d e o b v io u s in te rv e n tio n s such as liftin g side ra ils o n th e p a tie n t’s bed to p re v e n t fa lls . M o r e s u b tle a ctio n s also m ig h t be c o n s id e re d to be b e n e fic e n t a n d k in d a c tio n s , such as ta k in g tim e to m a k e p h o n e calls fo r a fr a il, o ld e r p a tie n t w h o is u n a b le to d o so h e rse lf. O c c a s io n a lly , nurses c a n e x p e rie n c e e th ic a l c o n flic ts w h e n c o n fro n te d w it h h a v in g to m a k e a c h o ic e b e tw e e n re s p e c tin g a p a tie n t’s r ig h t to s e lf­ d e te rm in a tio n (a u to n o m y ) a n d th e p r in c ip le o f b e n efice n ce . N u rs e s m ig h t decide to a ct in w a y s th a t th e y b e lie v e a re fo r a p a tie n t’s “ o w n g o o d ” ra th e r th a n a llo w in g p a tie n ts to e x e rc is e th e ir a u to n o m y . T h e d e lib e ra te o v e rrid in g o f a p a tie n t’s a u to n o m y in th is w a y Nurses might decide to act is c a lle d p a te rn a lis m . A n e x a m p le o f a p a te rn a lis tic a c tio n in ways that they believe are is fo r a n u rse to decide th a t a p a tie n t m u s t tr y to a m b u la te for a patient's “own good" in th e h a ll, even th o u g h th e p a tie n t m o a n s a n d c o m p la in s rather than allowing patients o f b e in g to o tire d fr o m his m o rn in g w h ir lp o o l tre a tm e n t. In to exercise their autonomy. th a t case, th e n u rse is a w a re th a t th e p a tie n t w a n ts to w a it The deliberate overriding of u n til a la te r tim e b u t insists o th e rw is e . N u rs e s m u s t w e ig h a patient's autonomy in this c a re fu lly th e v a lu e o f p a te rn a lis tic a ctio n s a n d d e te rm in e way is called paternalism. w h e th e r th e y a re tr u ly in th e p a tie n t’s best in te re s t. Justified p a te rn a lis m o fte n in v o lv e s m a tte rs o f p a tie n t safety.

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KEY COMPETENCY 4-1 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Professionalism: Attitudes/Behaviors (A7a) Values the application of ethical principles in daily practice Source: Massachusetts Department of Higher Education (2010, p. 14).

CHAPTER 4 Foundations of Ethical Nursing Practice

Nonm aleficence N o n m a le fic e n c e , th e in ju n c tio n to “ d o n o h a r m ,” is o fte n p a ire d w it h b e n e fi­ cence, b u t a d iffe re n c e exists b e tw e e n th e tw o p rin c ip le s . B eneficence re q u ire s ta k in g a c tio n to b e n e fit o th e rs , w h e re a s n o n m a le fic e n c e in v o lv e s re fra in in g fr o m a c tio n th a t m ig h t h a rm o th e rs . N o n m a le fic e n c e has a w id e scope o f im ­ p lic a tio n s in h e a lth care th a t in clu d es m o s t n o ta b ly a v o id in g n e g lig e n t c are, as w e ll as m a k in g decisions re g a rd in g w ith h o ld in g o r w it h d r a w in g tr e a tm e n t a n d re g a rd in g th e p ro v is io n o f e x tr a o r d in a r y o r h e ro ic tre a tm e n t.

Justice T h e fo u rth m a jo r p rin c ip le , ju s tic e , is a p rin c ip le in h e a lth c a re ethics, a v irtu e , a n d th e fo u n d a tio n o f a d u ty -b a s e d e th ic a l fr a m e w o r k o f m o r a l re a s o n in g . In o th e r w o rd s , th e c o n c e p t o f ju stice is q u ite b ro a d in th e fie ld o f ethics. Justice refers to th e fa ir d is trib u tio n o f benefits a n d b u rd en s . In re g a rd to p rin c ip lis m , ju stice m o s t o fte n re fers to th e d is trib u tio n o f scarce h e a lth c a re resou rces. M o s t o f th e tim e , d iffic u lt resou rce a llo c a tio n decisions are based o n a tte m p ts to a n s w e r qu estio n s re g a rd in g w h o has a r ig h t to h e a lth c are a n d w h o w ill p a y fo r h e a lth c a re costs.

P ro fe s s io n a l E th ic s and Codes P ro fe s s io n a l n u rs in g b e g a n in E n g la n d in th e 1 8 0 0 s a t th e sch o o l F lo re n c e N ig h tin g a le fo u n d e d , w h e re p ro fe s s io n -s h a p in g e th ica l precepts w e re c o m m u ­ n ic a te d (K u h s e & S in g er, 1 9 9 8 ) . N ig h tin g a le ’s a c h ie v e m e n t w a s a la n d m a r k in n u rs in g even th o u g h g ra d u a te s in th e e a rly days o f th e schoo l w e re b e lo w a ve rag e (D o s se y, 2 0 0 0 ) . F o r th e firs t 3 0 to 4 0 years in N ig h tin g a le ’s schoo l, m a le physicians tra in e d th e p ro b a tio n e rs because n o t en o u g h ed u cated w o m e n w e re a v a ila b le to te a c h n u rs in g . Because o f th is stro n g m e d ic a l in flu e n ce , e a rly n u rs in g e d u c a tio n w a s fo cu s ed o n te c h n ic a l tr a in in g r a th e r th a n o n th e a rt a n d science o f n u rs in g as N ig h tin g a le w o u ld h a ve p re fe rre d . B y th e end o f th e 1 8 0 0 s , m o d e rn n u rs in g w a s established, a n d b y th e e a rly 1 8 9 0 s , ethics in n u rs in g w a s b e in g discussed s erio u s ly (D o s se y, 2 0 0 0 ; K u h s e & S in g e r, 1 9 9 8 ) . T h e N ig h tin g a le P le d g e , firs t a d m in is te re d in 1 8 9 3 , w a s w r itte n u n d e r th e c h a irm a n s h ip o f L y s tra G r e tte r, th e p rin c ip a l o f a D e t r o it n u rs in g sch o o l, a n d th e o rig in a tio n o f th e p led g e h e lp e d to e sta b lish n u rs in g as a n a rt a n d a science (D o s se y, 2 0 0 0 ) . T h e In te r n a tio n a l C o u n c il o f N u rs e s ( I C N ) , w h ic h has been a p io n e e r in d e v e lo p in g a c ode o f n u rs in g ethics, w as established in 1 8 9 9 . B y 1 9 0 0 , th e firs t b o o k o n n u rs in g ethics, N u r s in g E th ic s : F o r H o s p it a l a n d P riv a te U se, w a s w r it te n b y th e A m e ric a n n u rs in g le a d e r Is a b e l H a m p t o n R o b b (K u h s e & S in g er, 1 9 9 8 ). H is to r ic a lly , a p r im a r y c o n s id e ra tio n in n u rs in g ethics has been th e d e te r­ m in a tio n o f w h o is th e focus o f n urses’ w o r k . U n t il th e 1 9 6 0 s , th is focus w a s o n th e p h y s ic ia n , w h ic h is n o t s u rp ris in g based o n th e fa c t th a t o v e r th e years

Professional Ethics and Codes

most nurses have been women and most doctors have been men (Kuhse & Singer, 1998). The focus on nurses’ obedience to physicians remained at the forefront of nursing responsibilities into the 1960s with this assumption still being reflected in the I C N C o d e o f N u r s in g E th ic s in 1965. By 1973, however, the focus of nurses’ primary responsibility within the IC N ’s code changed from the physician to the patient, where it remains to this day. No code can provide absolute or complete rules that are free of con­ flict and ambiguity. Because codes are unable to provide exact directives for ethical decision making and action in all situations, some ethicists believe that virtue ethics provides a better approach to ethics because the emphasis is on an agent’s character rather than on rules, principles, and laws (Beauchamp & Childress, 2009). Proponents of virtue r Ultimately, one must ethics consider that if a nurse’s character is not virtuous, remember that codes do not the nurse cannot be depended on to act in good or moral eliminate moral dilemmas and ways even with a professional code as a guide. Professional are of no use without profes­ codes do serve a useful purpose in providing direction to sionals' motivation to act healthcare professionals. Ultimately, one must remember that codes do not eliminate moral dilemmas and are of no morally. use without professionals’ motivation to act morally.

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■ The Code o f Ethics fo r N u rs e s The ANA first adopted its code in 1950 (Daly, 2002). Although it has always been implied that the code reflected ethical provisions, the word eth ic s was not added to the title until the 1985 code was replaced with its sixth and latest revision in 2001 (Fowler & Benner, 2001). The ANA’s (2001) C o d e o f E th ic s f o r N u r s e s w ith I n t e rp re ta t iv e S ta te m e n ts contains general moral provisions and standards for nurses to follow, but specific guidelines for clini­ cal practice, education, research, and administration are contained within the accompanying interpretive statements. See Appendix B for ANA’s C o d e o f E th ic s f o r N u r s e s . The code is considered to be nonnegotiable in regard to nursing practice. Some of the significant positions and changes in the 2001 code include a return to the use of the word p a tie n t , rather than c lie n t ; an application of the code to nurses in all roles, not just clinical roles; conceding that research is not the only method that contributes to professional development; reaffirming a stance against nurses’ participation in eutha­ nasia; emphasizing that nurses owe the same duties to self The ANA Code o f E th ic s fo r as to others; and recommending that members who rep­ N u rs e s is considered to be resent nursing associations are responsible for expressing nonnegotiable in regard to nursing values, maintaining professional integrity, and par­ ticipating in public policy development (ANA, 2001; Fowler nursing practice. & Benner, 2001).

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F o w le r ( F o w le r & B e n n e r, 2 0 0 1 ) a n d D a ly ( 2 0 0 2 ) , n u r s in g le a d e rs in v o lv e d in re v is in g th e co d e c o m p le te d in 2 0 0 1 , h a v e p ro p o s e d th a t th e n e w c ode is c le a rly p a tie n t fo cu s ed w h e th e r th e p a tie n t is c o n s id e re d to be “ an in d iv id u a l, fa m ily , g ro u p , o r c o m m u n ity ” (D a ly , 2 0 0 2 , p . 9 8 ). T h e n u rs e ’s lo y a lty m u s t be fo re m o s t to th e p a tie n t even th o u g h in s titu tio n a l p o litic s is a fre q u e n t in flu e n c e in to d a y ’s n u rs in g e n v iro n m e n t. W it h th e e x p a n d in g ro le o f n u rse a d m in is tra to rs a n d a d v a n c e d p ra c tic e nurses, each n u rse m u s t be c o g n iz a n t o f co n flicts o f in te re s t th a t c o u ld p o te n ­ tia lly h a ve a n e g a tiv e e ffe c t o n re la tio n s h ip s w it h p a tie n ts a n d p a tie n t c are . O fte n nurses h a v e o v e rlo o k e d th e re s p o n s ib ility to th e p a tie n t b y nurses w h o a re n o t in c lin ic a l ro le s. N u rs e researchers, a d m in is tra to rs , a n d e d u ca to rs are in d ir e c tly b u t s till in v o lv e d in a ffe c tin g p a tie n t c a re . A c c o rd in g to F o w le r a n d B e n n e r (2 0 0 1 ), “ I t is n o t th e possession o f n u rs in g c re d e n tia ls , degrees, a n d p o s itio n th a t m a k e s a n u rse a nurse; r a th e r it is th is v e ry c o m m itm e n t to th e p a tie n t” (p . 4 3 5 ) . T h e re fo re , th e c ode a p p lie s to a ll nurses regardless o f th e ir ro le . O n e issue th a t c re a te d a v ig o ro u s d e b a te w it h th e 2 0 0 1 re v is io n o f th e c o d e in v o lv e d th e e th ic a l im p lic a tio n s o f c o lle c tiv e b a rg a in in g in n u rs in g (D a ly , 2 0 0 2 ) . U lt im a te ly , th e nurses w h o fo rm u la te d th e re vis io n s d e cid e d th a t it w a s im p o r ta n t fo r th e c ode to c o n ta in p ro v is io n s s u p p o rtin g nurses w h o w o r k to ensure th a t th e e n v iro n m e n t in w h ic h th e y w o r k is c o n d u c iv e to q u a lity p a tie n t c are a n d th a t nurses are a b le to fu lfill th e ir m o r a l re q u ire ­ m e n ts . C o lle c tiv e b a rg a in in g w a s d e te rm in e d to be a n a p p ro p r ia te a ve n u e fo r m o re th a n ju s t n e g o tia tin g fo r b e tte r salaries a n d b e n efits. I t also c a n be used to im p ro v e th e m o r a l le v e l o f th e e n v iro n m e n t in w h ic h nurses w o r k .

■ The IC N Code o f Ethics fo r N u rs e s In 1 9 5 3 , th e In te r n a tio n a l C o u n c il o f N u rs e s ( I C N ) a d o p te d its firs t C o d e o f E th ic s f o r N u r s e s . T h e m o s t re c e n t re v is io n a n d re v ie w o f th e co d e o c c u rre d

in 2 0 0 6 . T h e c o d e has b e e n re v is e d a n d r e a ffir m e d m a n y tim e s . T h e fo u r p rin c ip a l elem en ts c o n ta in e d w it h in th e I C N co d e in v o lv e s tan d ard s re la te d to nurses a n d p e o p le , p ra c tic e , th e p ro fe s s io n , a n d c o w o rk e rs . T h e se elem ents fo r m a fr a m e w o r k to g u id e n u rs in g c o n d u c t a n d a re e la b o ra te d w it h in th e c o d e w it h p ra c tic e a p p lic a tio n s fo r p ra c titio n e rs a n d m a n a g e rs , e d u c a to rs a n d researchers, a n d n a tio n a l n urses’ a sso ciatio n s. T h e I C N C o d e o f E th ic s f o r N u r s e s is a v a ila b le o n lin e a t w w w .ic n .c h /ic n c o d e .p d f.

■ A Common Them e of ANA and ICN Codes A th e m e c o m m o n to th e codes o f th e A N A (2 0 0 1 ) a n d I C N (2 0 0 6 ) is a focus o n th e im p o rta n c e o f nurses d e liv e rin g c o m p a s s io n a te p a tie n t c are a im e d a t a lle v ia tin g s u ffe rin g . T h is e m p h as is is th re a d e d th r o u g h o u t th e codes b u t begins w it h th e p a tie n t b e in g th e c e n tra l focus o f a n u rs e ’s w o r k . N u rs e s are to s u p p o rt p a tie n ts in s e lf-d e te rm in a tio n a n d are to p ro te c t th e m o ra l e n v iro n -

m e n t in w h ic h p a tie n ts receive care. T h e interests o f v a rio u s n u rs in g a sso ciatio n s a n d h e a lth c a re in s titu tio n s m u s t n o t A theme common to the be p la c e d a b o v e th ose o f p a tie n ts . A lth o u g h o p p o rtu n itie s codes of the ANA (2001) and in th e h e a lth c a re e n v iro n m e n t to e x h ib it c o m p a s s io n are ICN (2 0 0 6 ) is a focus on the n o t u n iq u e to nurses, nurses m u s t a lw a y s u p h o ld th e m o r a l importance of nurses deliv­ a g re e m e n t th a t th e y m a k e w it h c o m m u n itie s w h e n th e y jo in ering compassionate patient th e n u rs in g p ro fes s io n . N u r s in g care includ es th e im p o rta n t care aimed at alleviating re s p o n s ib ilitie s o f p ro m o tin g h e a lth a n d p re v e n tin g illness, suffering. b u t th e h e a rt o f n u rs in g c are has a lw a y s in v o lv e d c a rin g fo r p a tie n ts w h o a re e x p e rie n c in g v a ry in g degrees o f p h y s ic a l, p s y c h o lo g ic , a n d s p iritu a l s u ffe rin g . In th e C o d e o f E th ic s f o r N u r s e s w ith In t e rp re ta tiv e S ta te m e n ts , th e A N A ( 2 0 0 1 ) e m p h as ize s th e im p o rta n c e o f m o r a l re s p e c t fo r a ll h u m a n bein gs, in c lu d in g n u rse s ’ respect fo r th em selves. S elf-re sp e c t also c a n be th o u g h t o f as p e rs o n a l re g a rd . P e rs o n a l re g a rd in v o lv e s nurses e x te n d in g a tte n tio n a n d KEY COMPETENCY 4-2 c are to th e ir o w n re q u is ite needs. N u rs e s w h o d o n o t re g a rd th em selves as Examples of Applicable w o r th y o f c are u s u a lly c a n n o t fu lly care fo r o th ers .

N u rs e o f th e F u tu re : N u rs in g C o re C o m p e te n c ie s

Professionalism:

E th ic a l A n a ly s is and D ecisio n M akin g in N u rs in g E th ic a l issues a n d d ile m m a s a re e ve r p re s e n t in h e a lth c a re s ettin g s. M a n y tim e s, e th ic a l issues a re so p re v a le n t in p ra c tic e th a t nurses do n o t even re a liz e th a t th e y a re m a k in g m in u te -b y -m in u te e th ic a l decisions (C h a m b lis s , 1 9 9 6 ; K e lly , 2 0 0 0 ) . W h e t h e r o r n o t th e y a re c o g n iz a n t o f th e e th ic a l m a tte rs a t th e tim e th a t th e decisions are m a d e , nurses use th e ir c ritic a l th in k in g skills to re s p o n d to m a n y o f th ese e v e ry d a y d e c is io n s . P e rs o n a l v a lu e s , p ro fe s ­ s io n a l values a n d c o m p e te n c ie s , e th ic a l p rin c ip le s , a n d e th ic a l th e o rie s a n d a p p ro a ch e s are v a ria b le s th a t m u s t be c o n s id e re d w h e n a n e th ic a l d e cis io n is m a d e . A n sw ers to th e questions “ W h a t is th e rig h t th in g to d o fo r m y p a tie n t? ” a n d “ W h a t s o rt o f n u rs e d o I w a n t to b e ? ” a re im p o r t a n t to p ro fe s s io n a l n u rs in g p ra c tic e .

Attitudes/Behaviors (A7b) Values acting in accordance with codes of ethics and accepted standards of practice Skills (S7a) Incorporates American Nurses Asso­ ciation's C ode o f E th ic s into daily practice; (S7f) Applies a professional nursing code of ethics and profes­ sional guidelines to clinical practice Source: Massachusetts Department of Higher Education (2010, p. 14).

■ Ethical Dilem m as and Conflicts A n e th ic a l d ile m m a is a s itu a tio n in w h ic h an in d iv id u a l is c o m p e lle d to m a k e a c h o ice b e tw e e n tw o a ctio n s th a t w ill a ffe c t th e w e ll-b e in g o f a s e n tie n t b e in g a n d b o th a ctio n s c a n be re a s o n a b ly ju s tifie d as b e in g g o o d , n e ith e r a c tio n is re a d ily ju s tifia b le as g o o d , o r th e goodness o f th e a ctio n s is u n c e rta in . O n e a c tio n m u s t be chosen, th e re b y g e n e ra tin g a q u a n d a ry fo r th e p e rs o n o r g ro u p w h o m u s t m a k e th e ch o ice .

r Many times, ethical issues are K.

so prevalent in practice that nurses do not even realize that they are making minuteby-minute ethical decisions.

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In addition to general, situational ethical dilemmas, dilemmas can arise from conflicts between nurses, other healthcare professionals, the healthcare organization, and the patient and family. A dilemma might involve nurses making a choice between staying to work an extra shift during a situation of inadequate staffing and going home to rest after a very tiring 8 hours of work. Nurses in this situation might believe that patients will not receive safe or good care if they do not stay to work the extra shift, but these nurses also might not provide safe care if they stay at the hospital because of already being tired from a particularly hard day of work.

■ Moral Suffering Many times nurses experience disquieting feelings of anguish or uneasiness consistent with what might be called moral suffering. M o ra l s u ffe rin g can be experienced when nurses attempt to sort out their emotions when they find themselves in situations that are morally unsatisfactory or when forces be­ yond their control prevent them from influencing or changing these perceived unsatisfactory moral situations. Suffering can occur because nurses believe that situations must be changed to bring well-being to themselves and others or to alleviate the suffering of themselves and others. M oral suffering can arise, for example, from disagreements with insti­ tutional policy, such as a mandatory overtime or on-call policy that nurses believe does not allow adequate time for their psychological well-being. Nurses also might disagree with physicians’ orders that the nurses believe are not in patients’ best interest, or they might disagree with the way a family treats a patient or makes patient care decisions. These are but a few examples of the many types of encounters that nurses can have with moral suffering. Another important, but often unacknowledged, source of moral suffering involves nurses freely choosing to act in ways that they, themselves, know is not morally commendable. A difficult situation that may cause moral suf­ fering for a nurse would be covering up a patient care error made by a valued nurse best friend. On the other hand, nurses might experience moral suf­ fering when they act courageously by doing what they believe is morally right despite anticipated disturbing consequences. Sometimes, W W W ] CRITICAL THINKING QUESTIONS V doing the right thing or acting as a virtuous person would act is difficult. Has there ever been a time when you have Some people view suffering as something to accept and experienced the dilemma of having to make to transform, if possible. Others react to situations with a choice that you know will affect the well­ fear, bitterness, and anxiety. It is important to remember being of another individual? Have you ever that wisdom and inner strength are often most increased experienced moral suffering? V during times of greatest difficulty.

■ Using a Team Approach When trying to navigate ethically laden situations, patients and families can experience extreme anguish and suffering. Physicians, nurses, and other

healthcare providers might explain to a patient or family that to continue the KEY COMPETENCY 4-3 patient’s treatment would be nonbeneficial and futile while patients or fam­ Examples of Applicable ily members insist on continued treatment. When patients are weakened by Nurse of the Future: Nursing disease and illness and families are reacting to the pain and suffering of their Core Competencies loved one, decisions regarding treatment can become sensitive and challenging Professionalism: for everyone concerned. Members of the healthcare team might question the decision-making capacity of the patient or family. The patient’s or family’s Skills (S7e) Recognizes moral distress and seeks decision might conflict with the physician’s or healthcare team’s opinions resources for resolution regarding treatment. Nurses who care for patients and interact with families sometimes find themselves caught in the middle of these conflicts. Source: Massachusetts Department of Higher Education (2010, p. 14). It is important to note that most problematic ethical decisions in health care are not made unilaterally— not by physicians, nurses, or any other single person. Still, nurses are an integral part of the larger team of decision makers. Although nurses often make ethical decisions independently, many ethical dilemmas require nurses to participate interdependently with others in decision making. In analyzing healthcare ethics and decision making, nurses participate in exten­ sive dialogue with others through committees, clinical team conferences, and other channels. Nurses are part of the larger team approach to ethical analysis. Commonly, the team is called an ethics consultation team or ethics committee. Members of the team usually are physicians, nurses who represent their patients, an on-staff chaplain, nurses who regularly participate on the con­ sultative team, a social worker, administrative personnel, possibly a legal representative, a representative for the patient in question or surrogate deci­ sion maker, and others drafted by the team. The number and membership of the ethics team vary among organizations and specific cases. When ethical disputes arise among any members of a patient’s healthcare team, including disputes with patients and families, nurses often are the ones who seek an ethics consultation. It is within the right and duty of nurses to seek help and advice from the team if they encounter moral dilemmas or experience moral suffering. In healthcare settings, moral reasoning to resolve an ethical dilemma is often a case-based, or bottom-up, inductive, casuistry approach. This approach begins with relevant facts about a particular case and moves toward a resolution through a structured analysis. A practical case-based ethical analysis approach that is used commonly by nurses and other healthcare professionals is the Four Topics Method or, often called in jargon, the 4-Box Approach (Table 4-1) (Jonsen, Siegler, & Winslade, 2006, p. 11). The Four Topics Method, developed by Albert Jonsen, M ark Siegler, and William Winslade, was published first in 1982 in their book C lin ica l E t h ic s : A P ra ctica l A p p r o a c h to E th ic a l D e c i ­ In healthcare settings, moral s io n s in C lin ic a l M e d ic i n e , which is in its sixth edition. reasoning to resolve an This case-based approach facilitates critical thinking ethical dilemma is often a about the issues and problems of a particular situation case-based, or bottom-up, and facilitates construction of the case through informa­ inductive, casuistry approach. tion gathering in a structured format. Each problematic ethical case is analyzed according to four topics: medical

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TA B LE 4-1

Four Topics M ethod for A nalysis in Clinical Ethics Cases

Content removed due to copyright restrictions

S ou rce: Jonsen, A. R ., Siegler, M ., & W inslade, W . J. (2006). C lin ical ethics: A p ra ctica l a p p r o a c h to eth ica l decision s in clin ical m ed icin e (6th ed.). New York: M cGraw -H ill. Reprinted w ith permission o f The M cGraw -H ill Companies.

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indications, patient preferences, quality of life, and contextual features (Jonsen et al., 2006). Nurses and other healthcare professionals on the team gather information in an attempt to answer the questions in each of the four boxes. The Four Topics Method promotes a dialogue among the patient, family, and members of the healthcare ethics team. Each patient’s case is unique and should be considered as such, but the subject matter concerning the dilemma involves common threads among cases, such as withdrawing or withholding treatment and right to life. Applicability of the four fundamental bioethical principles— autonomy, beneficence, nonmaleficence, and justice— is consid­ ered along with data generated by using the Four Topics Method in analyzing a patient’s case. In Table 4-1, each box includes principles appropriate for each of the four topics. The additional principles of fairness and loyalty are included in the contextual features section.

CASE STUDY ■ MS. CRANFORD

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ou are a student nurse who is caring for Ms. Cranford. She is an 87-year-old mentally competent woman who has lived alone since her husband died 10 years ago. She was admitted to the hospital with chest pain, feeling faint, a pulse of 48, and a blood pressure of 98/56. The physician and nurses sta­ bilized Ms. Cranford with medications and intravenous fluids but later informed Ms. Cranford and her only son that she would need a heart pacemaker to regulate her heartbeat. After the physician explained the procedure and risks involved, Ms. Cranford pondered the situation for a long while before discussing it with her son and the physician. Her medical history includes long-term adult-onset diabetes, chronic renal failure, and arterial insufficiency. She feels very tired. She decides that she does not want a pacemaker. Once Ms. Cranford tells her son her wishes, he is quite upset, and thus, he meets with the physician to discuss the options. The physi­ cian and Ms. Cranford’s son revisited this issue with her in an attempt to persuade her to change her mind, but she continues to refuse the recommended treatment. She and her son argue. The physician tries to explain to Ms. Cranford that the pacemaker is for her benefit, in her “best interest,” and involves very minimal risks to her.

She feels as if they are “ganging up” on her. Once the registered nurse becomes aware of the problem, you and the nurse visit with Ms. Cranford and her son to assess and evaluate the ethical issues involved with her case. Case Study Questions Imagine that you are a nurse on the ethics committee consulted about Ms. Cranford’s case. Answer the fol­ lowing questions: 1.

What are the central ethical issues and questions in this case?

2.

Which principles are in conflict in this case?

3.

What did the physician mean by “best interest” for Ms. Cranford?

4.

Use the Four Topics Method to discuss issues, to identify additional information that might be needed, and to analyze this case. What are your recommendations on behalf of the ethics committee?

5.

What is the role of the nurses caring for Ms. Cranford in resolving this situation with the ethics team, her other healthcare providers, Ms. Cranford, and her son? ■

KEY COMPETENCY 4-4 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Professionalism: Knowledge (K7) Understands ethical principles, values, concepts, and decision making that apply to nursing and patient care Skills (S7b) Utilizes an eth­ ical decision-making frame­ work in clinical situations Source: Massachusetts Department of Higher Education (2010, p. 14).

Intense emotional conflicts between healthcare professionals and the patient and family can occur and hurt feelings can result. Nurses need to be sensitive and open to the needs of patients and families, particularly during these times. As information is passed back and forth among healthcare pro­ fessionals and patients and families, an attitude of respect is indispensable in keeping the lines of communication open. Nurses play an essential role in the decision-making process in bioethical cases because of their traditional roles as patient advocate, caregiver, and educator. Nurses must attempt to maximize the values and needs of patients and families. A key component in preserving patient autonomy, respect, and dignity is for the nurse to have all of the essential information necessary for wise and skillful decisions.

C o nclu sio n With any type of ethical matters in health care, a nurse must ask “W hat is good in terms of how one wants to be?” and “W hat is good in terms of what one ought to do?” Becoming ethically savvy does not just happen in nursing. Nurses must consciously cultivate ethical habits and use theoretical knowledge about how to navigate ethical dilemmas. M oral suffering cannot be eliminated from nursing practice; however, the cultivation of wisdom and skill in decision making can help to alleviate some of its effects.

R e fe re n c e s American Nurses Association. (2001). Code o f ethics for nurses with interpretive statements. Washington, DC: Author. Angeles, P. A. (1992). The Harper Collins dictionary o f philosophy (2nd ed.). New York, NY: Harper Perennial. Beauchamp, T. L., & Childress, J. F. (1979). Principles o f biom edical ethics. New York, NY: Oxford University Press. Beauchamp, T. L., & Childress, J. F. (2001). Principles o f biomedical ethics (5th ed.). New York, NY: Oxford University Press. Beauchamp, T. L., & Childress, J. F. (2009). Principles o f biomedical ethics (6th ed.). New York, NY: Oxford University Press. Bentham, J. (1988). The principles o f morals and legislation. Loughton, Essex, England: Prometheus. (Original work published 1789). Broadie, S. (2002). Commentary. In C. Rowe (Trans.), Aristotle: Nicomachean ethics: Translation, introduction, and commentary. New York, NY: Oxford University Press. Callahan, D. (1995). Bioethics. In W. T. Reich (Ed.), Encyclopedia o f bioethics: Revised edition (Vol. 1, pp. 247-256). New York, NY: Simon & Schuster Macmillan. Chambliss, D. F. (1996). Beyond caring: Hospitals, nurses, and the social organization o f ethics. Chicago, IL: University of Chicago Press.

Daly, B. J. (2002). Moving forward: A new code of ethics. Nursing Outlook, 50, 70-99. Dossey, B. M. (2000). Florence Nightingale: Mystic, visionary, healer. Springhouse, PA: Springhouse. Fowler, M. D., & Benner, P. (2001). Implementing a new code of ethics for nurses: An interview with Marsha Fowler. American Journal o f Critical Care, 10(6), 434-437. Fry, S., & Veatch, R. M. (2000). Case studies in nursing ethics (2nd ed.). Sudbury, MA: Jones and Bartlett. Gilligan, C. (1993). In a different voice: Psychological theory and w om en’s development. Cambridge, MA: Harvard University Press. Grimshaw, J. (1993). The idea of a female ethic. In P. Singer (Ed.), A companion to ethics (pp. 491-499). Oxford, England: Blackwell. International Council of Nurses. (2006). The ICN code o f ethics for nurses. Geneva, Switzerland: Author. Retrieved from http://www.icn.ch/icncode.pdf Johnstone, M. J. (1999). Bioethics: A nursing perspective (3rd ed.). Sydney, Australia: Harcourt Saunders. Jonsen, A. (1998). The birth o f bioethics. New York, NY: Oxford University Press. Jonsen, A. R., Siegler, M., & Winslade, W. J. (2006). Clinical ethics: A practical ap p roach to ethical decisions in clinical m edicine (6th ed.). New York, NY: McGraw-Hill. Kant, I. (2003). Groundwork o f the metaphysics o f morals. New York, NY: Oxford University Press. (Original work published 1785). Kelly, C. (2000). Nurses’ moral practice: Investing and discounting self. Indianapolis, IN: Sigma Theta Tau International. Kuhse, H., & Singer, P. (1998). What is bioethics? A historical introduction. In H. Kuhse & P. Singer (Eds.), A companion to bioethics (pp. 3-11). Oxford, England: Blackwell. Mappes, T. A., & DeGrazia, D. (2001). Biomedical ethics (5th ed.). Boston, MA: McGraw-Hill. Massachusetts Department of Higher Education. (2010). Nurse o f the future: Nursing core competencies. Retrieved from http://www.mass.edu/currentinit/documents/ NursingCoreCompetencies.pdf Mill, J. S. (2002). Utilitarianism (G. Sher, Trans.). Indianapolis, IN: Hackett Publishing. (Original work published 1863). Munson, R. (2004). Intervention and reflection: Basic issues in medical ethics (7th ed.). Victoria, Australia: Thomson Wadsworth. Pieper, J. (1966). The four cardinal virtues. Notre Dame, IN: University of Notre Dame Press. Pullman, D. (1999). The ethics of autonomy and dignity in long-term care. Canadian Journal on Aging, 18(1), 26-46. Thomas, L. (1993). Morality and psychological development. In P. Singer (Ed.), A companion to ethics (pp. 464-475). Oxford, England: Blackwell.

Social Context of Professional Nursing Rowena W. Elliott and Mary W. Stewart

v_______________ W h e n y o u h e a r th e w o r d n u r s e , w h a t im a g e s , th o u g h ts , p e rc e p tio n s , a n d a ss u m p tio n s c o m e to m in d ? A s k y o u rs e lf, “ W h y d id I h a v e th ose p e rc e p tio n s a n d a ss u m p tio n s a b o u t nurses?” T h e a n s w e r to y o u r q u e s tio n reveals m u c h a b o u t th e social c o n te x t o f n u rsin g o r h o w society view s nurses a n d th e n u rsin g p ro fe s s io n . F o r m a n y , th e im a g e th a t firs t com es in to v ie w is one o f a w h ite fe m a le w h o is dressed in a m e tic u lo u s ly iro n e d w h ite u n ifo r m w it h w h ite hose, w h ite shoes, a n d w e a rin g a s tiff w h ite c a p . F o r th ose o f us in n u rs in g , w e re c o g n ize th a t th is tr a d itio n a l A m e ric a n v ie w o f n u rs in g is r a re ly seen in th e re a l w o r ld o f p ro fe s s io n a l n u rs in g . S o, h o w d o w e c o m m u n ic a te th e tru e im a g e o f n u rs in g in th e 2 1 s t c en tu ry ? In th is c h a p te r, w e e x p lo re th e social c o n te x t o f p ro fe s s io n a l n u rs in g a n d id e n tify m a jo r influences th a t a ffe c t n u rs in g in to d a y ’s s o cie ty. T h is quest fo r a d e ep e r u n d e rs ta n d in g o f n u rs in g c h allen g es us to id e n tify o u r in d iv id u a l re s p o n s ib ilitie s in e d u c a tin g o u r p a tie n ts a n d th e p u b lic a b o u t p ro fe s s io n a l n u rs in g . T h e end re s u lt is n o t n e ce ss arily a n im m e d ia te ch an g e in th e p ic tu re th a t com es to m in d w h e n one says “ n u rs in g .” H o w e v e r , w e m ig h t b e g in to see n u rs in g a n d th ose o f us c o m m itte d to n u rs in g in n e w , m o re a cc u rate w a y s.

Key Terms and Concepts » » » » » » » » » » » » »

S te re o ty p e s Multiculturalism Access to care Capitalistic society Nurse-managed centers Incivility Violence Mental health Global aging Nursing shortage Consumerism Complementary and alternative medicine Disaster preparedness

Learning Objectives A f t e r c o m p le tin g th is c h a p te r, th e s tu d e n t should be a b le to : 1. D e s c rib e th e s o cia l c o n te x t o f p ro fe s s io n a l nursing. 2 . Id e n tify fa c to rs t h a t in flu e n c e th e p u b lic 's im ag e of pro fession al nursing. 3 . L is t w a y s t h a t n u r s e s c a n p r o m o te an a c c u ra te im a g e of p ro fessio n al nursing in th e m ed ia. 4 . Discuss th e g e n d e r gap in nursing.

5 . R e c o g n iz e s tra te g ie s to b ro ad e n th e c u ltu ra l and e th n ic d iv e rs ity in nursing. 6 . E v a lu a te c u rre n t b a rrie rs to h e a lth c a re in our s o c ie ty . 7 . A n a ly z e p re s e n t tre n d s in s o c ie ty th a t in flu ­ en ce p ro fessio n al nursing. 8 . S u g g e s t re s e a rc h needs re la te d to th e fu tu re o f nursing in o u r s o c ie ty . 125

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P u b lic Im a g e of N u rsin g The public values nursing. According to a Gallup poll in 2011, nurses received the top ranking for being the most trusted profession in 11 of the past 12 years (Jones, 2012). The only year when nurses did not rank number one was in 2001 when firefighters took the top spot after the September 11th 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 experiences with nurses in a clinical setting. The fact that nurses serve society seems to have an automatically positive impact on society’s value of nursing. Although the trust is evident, there remains a gap between the public’s per­ ception of the nursing profession and the reality of nursing. For example, the general public might think that it requires only 2 years of schooling to become a registered nurse (RN), with the “training” 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, master’s, and doctoral levels and work in areas of education, research, and independent clinical practice. Nurses are aware of the gaps in society’s knowledge of nursing. Hence, nurses should take the lead in making sure 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], 2010). So, where do we start? We must first begin with the realization that all nurses are not the same. As previously stated, many well-educated persons do not understand the various educational programs available to become a registered nurse. Likewise, knowledge about the differences in preparation and responsibility of licensed practical nurses (LPNs), registered nurses (RNs), and advanced practice nurses (e.g., nurse practitioners) is lacking. As you are preparing to be a professional nurse, ask yourself, “How do I clarify and communicate the signifi­ cance of professional nursing?” First, become familiar with the scope of practice of professional nurses and understand the multifaceted roles for which you are being educated. Second, be able to identify the unique place that profes­ sional nurses have in the healthcare system. This comes by acquiring knowledge of the nursing profession and being aware of the roles, responsibilities, and contributions of other healthcare professionals. Most important, it is imper­ ative 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). Without articulating more clearly and loudly

on our profession’s 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. N ot a nurse herself, Gordon writes to empower nurses to find their voice and be heard. Gordon is committed to obtaining a first-hand account from nurses as they face the real challenges of being a nurse that include (1) inconvenient problems of improving patient safety (Gordon, Buchanan, & Bretherton, 2008), (2) challenges of standing up for themselves, their patients, and the nursing profession (Gordon, 2010), and (3) the effect of cutting healthcare costs on patient care (Gordon, 2005), to name a few. If a journalist can commit to sharing “our” stories, that should provide a spark of motivation in us to share our experiences, triumphs, and defeats. When nurses are asked about the nurse’s 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 getting accomplished. Additionally, we rarely take time to become fully aware of and celebrate what our nursing colleagues are doing within the profession. Professional nursing organizations exist to communicate and support these achievements. However, only a small percentage of registered nurses are actu­ ally 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 necessary 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 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 professional nursing offers: mastery of complicated techno­ logic skills; appreciation 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 criti­ cally and connect the dots in today’s ever-changing healthcare system; and proficiency in communication. The list continues. Social change will take place one nurse at a time and one person at a time. By reflecting on the changes in racial relationships, for example, we know that transformation has not come solely because of the civil rights movement in the 1960s. Granted, that was a period of radical change to which we are all indebted. Nonetheless, real change in race relationships in our society has come from exposure and experience. Someone once said, “Ignorance is only removed by experience.” Is it any different for our image as nurses?

KEY COMPETENCY 5-1 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Professionalism: Knowledge (K5b) Understands the culture of nursing and the healthcare system Skills (S5b) Promotes and maintains a positive image of nursing Source: Massachusetts Department of Higher Education (2010, p. 14).

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M e d ia 's In flu e n c e I t is o b v io u s th a t th e m e d ia (te le v is io n , ra d io , In te rn e t) p la y a m a jo r ro le in h o w so ciety v ie w s p ro fe s s io n a l n u rs in g . H is to r ic a lly , th e nurse has been p o r ­ tra y e d in th e m e d ia in a v a rie ty o f w a y s . F irs t, th e n u rse a p p ears as a y o u n g , seductive fe m a le w h o s e p rin c ip a l q u a lific a tio n is th e le n g th o f h e r slender legs a n d th e a m o u n t o f cle av ag e s h o w in g th ro u g h h e r u n ifo r m . N ee d les s to say, th is nurse is u s u a lly d e p ic te d as one w h o is n o t e d u c a te d a n d lac ks c o m m o n sense a n d in te llig e n c e . A n o th e r p o p u la r v ie w o f th e nurse as p o r tra y e d b y th e m e d ia is a n u n a ttra c tiv e , o v e rw e ig h t, a n d m e a n fe m a le . H e r in te llig e n c e is n o t q u e s tio n e d , b u t h e r c o m p a s s io n fo r o th ers is h ig h ly d e b a ta b le . T h is n u rse is s h o w n as th re a te n in g a n d u n c a rin g . N e ith e r o f these v ie w s is a c c u ra te , a n d p ro b a b ly n o one w o u ld a rg u e w it h th is . A t th e sam e tim e , w e c o n tin u e to be p e rp le x e d w h e n ask ed to d e fin e o r describe th e p ro fe s s io n a l nurse. In th e ir b o o k F r o m S ile n c e to V o ic e : W h a t N u r s e s K n o w a n d M u s t C o m ­ m u n ic a t e to th e P u b lic , B u resh a n d G o r d o n (2 0 0 6 ) state th a t “ a p ro fe s s io n ’s p u b lic status a n d c re d ib ility a re e n h a n c e d b y h a v in g its e x p e rtis e a c k n o w l­ edged in th e jo u rn a lis tic m e d ia ” (p . 1 ). B u re sh a n d G o rd o n also c ite th e stu d y “ W h o C o u n ts in N e w s C o v e ra g e o f H e a lt h C a r e ,” w h e re th e d a ta s h o w th a t m a n y p ro fe s s io n a l g ro u p s h a d a g re a te r v o ic e o n h e a lth issues c o m p a re d to nurses. P hysicians w e re q u o te d th e m o s t in m e d ia , fo llo w e d b y g o v e rn m e n t, business, e d u c a tio n , p u b lic re la tio n s , a n d so fo r th . T h is is s ig n ific a n t a n d s h o c k in g because nurses are th e la rg e s t g ro u p o f h e a lth ­ W W W ] CRITICAL THINKING QUESTION * c are p ro fe s s io n a ls , y e t, w e a re th e m o s t s ile n t g ro u p . As How can you, as a student nurse, tell society nurses, w e h a v e been c o m p la c e n t a b o u t re fu tin g th e n e g a ­ what professional nurses do? V tiv e stereotypes p o r tra y e d in th e m e d ia . F u r th e rm o re , w e h a v e been la x in a rtic u la tin g o u r e x p e rtis e to th e m e d ia . B u re s h a n d G o r d o n ( 2 0 0 6 ) d e s c rib e th re e c o m m u n ic a tio n c h a lle n g e s fa ce d b y th e n u rs in g p ro fe s s io n th a t n e ed to be addressed: 1. N o t e n o u g h nurses are w illin g to ta lk a b o u t th e ir w o r k . 2 . W h e n nurses a n d n u rs in g o rg a n iz a tio n s d o t a lk a b o u t th e ir w o r k , to o o fte n th e y in te n tio n a lly p ro je c t a n in a c c u ra te p ic tu re o f n u rs in g b y using a “ v ir t u e ” in s te a d o f a “ k n o w le d g e ” s crip t. 3 . W h e n n u rs in g g ro u p s give voice to n u rs in g , th e y so m etim es bypass, d o w n ­ p la y , o r even d e v a lu e th e basic n u rs in g w o r k th a t occurs in d ire c t care o f th e sick w h ile e le v a tin g a n im a g e o f “ e lite ” nurses in a d v a n c e d p ra c tic e , a d m in is tra tio n , a n d a c a d e m ia . (p . 4 ) N u rs e s s h o u ld face th e s te re o ty p e s p re s e n t in o u r s ociety a n d erase th e lines th a t d e fin e us. T o d o th is , w e m u s t firs t re c o g n ize o u r v a lu e to society a n d ourselves. W h e n in tro d u c in g ourselves in th e p ro fe s s io n a l ro le , w e sh o u ld d o so w it h c o n fid e n ce a n d c la rity . F o r e x a m p le , w e c an say, “ G o o d m o rn in g , M r . S m ith . I ’m Susan Jones, y o u r reg istere d n u rs e .” T h is in tr o d u c tio n s h o u ld

be accompanied by a kind and self-assured handshake. Such day-to-day engagement is important. We must tell the world what we do. In F r o m S ile n c e to V o i c e , the authors identify the following actions to promote the real image of nursing: • • • • • • • • • • • • • • •

Educate the public in daily life. Describe the nurse’s work. Make known the agency— independent thinker— of the RN. Deal with the fear of angering the physician. 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 nurse’s 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 (2006) provide 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, present oneself on television or radio, and converse with community groups are among the guidelines provided. Being proactive is essential and it comes at a time when healthcare costs and cuts demand that only the fundamental players are left standing. Society needs to know that nurses are definitely fundamental players. Sigma Theta Tau International commissioned the 1997 Woodhull Study on Nursing and the Media, which reported the lack of representation that nurses have in the media (Sigma Theta Tau International, 1998). In approxi­ mately 2 0 ,0 0 0 articles from 16 major news publications, nurses were cited only 3% of the time. Among the healthcare industry publications, only 1% of the references were nurses. Although nurses are highly relevant participants in patients’ stories, they were neglected in almost every case. Key study recom­ mendations from the Woodhull 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. H e a lth c a re needs to be clearly identified as the umbrella term for specific disciplines, such as medicine and nursing.

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• Nurses with doctoral degrees should be identified correctly as doctors, and those with medical doctorate (MD) degrees should be identified as physicians. • Language needs to reflect the diverse options for health care by avoiding phrases such as, “ Consult your doctor.” Rather, media need to state, “ Consult your primary healthcare provider.” In recent years, we have seen more accurate portrayals of nurses supported in the media. Instead of portraying sexual prowess or disrespect and anger, nurses have been presented as intelligent, competent, and essential to patient care. Johnson & Johnson continues the Campaign of Nursing’s Future to raise public awareness of professional nursing. This positive promotion has supported student and faculty recruitment into the profession. Johnson & Johnson has taken additional 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 inac­ curate, we have a responsibility to correct it.

T h e G en d er Gap ■ Women in Nursing and the Socialization of That Tradition In Western culture, women have traditionally been socialized as the more pas­ sive of the sexes— to avoid conflict and yield to authority. The implications of this conventional thought are still evident in nursing practice today. Many nurses lack confidence in dealing with conflict and communicating with those in authority. For some, it is a matter of short supply of energy and too many other commitments. Others perceive assertiveness as clashing with people’s expectations. We should ask ourselves, “Isn’t the reward of knowing we do a good job enough?” 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 “good jo b ” 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 women’s movement in the 1960s empowered intelligent career­ seeking women to professions other than the traditional ones of teaching and nursing. After some years of competing for students, nursing saw a return of interest in the 1980s and 1990s. At this point, more women chose nursing

as a c a re e r because n u rs in g p ro v id e d a n a tu ra l c o m p le m e n t to th e ir gifts a n d n o t because it w a s o n e o f o n ly a fe w o p tio n s a v a ila b le to th e m ( C h itt y & C a m p b e ll, 2 0 0 1 ) . As th e m essage o f v a rie d o p p o rtu n itie s fo r w o m e n a n d m e n in n u rs in g is sh are d , th e social status o f a ll nurses c a n be e le v a te d . A n o th e r fa c e t o f w o m e n in n u rs in g is th e c h a n g in g d e m o g ra p h ic o f w o m e n e n te rin g th e n u rs in g p ro fe s s io n . I n th e U n ite d S tates, a la rg e r n u m b e r o f w o m e n fr o m u n d e rre p re s e n te d g ro u p s a re b e c o m in g nurses. A c c o rd in g to U .S . D e p a r tm e n t o f H e a lt h a n d H u m a n Services ( 2 0 1 0 ) , a p p ro x im a te ly 1 7 0 ,2 3 5 re g is te re d nurses liv in g in th e U n ite d S tates o b ta in e d th e ir in itia l n u rs in g e d u c a tio n in a n o th e r c o u n try o r U .S . te r r ito r y . T h e re w a s a n increase fr o m 3 .7 % in 2 0 0 4 to 5 .6 % in 2 0 0 8 . A b o u t 5 0 % o f th e in t e r n a tio n a lly e d u c a te d R N s liv in g in th e U n ite d States in 2 0 0 8 w e re fr o m th e P h ilip p in e s , 1 1 .5 % w e re fr o m C a n a d a , a n d 9 .3 % w e re fr o m In d ia . W h e th e r th e s w e ll is th e re s u lt o f an in flu x o f m in o r ity nurses fr o m o th e r c o u n trie s o r in crea se d re c ru itin g e ffo rts a im e d a t u n d e rre p re s e n te d g ro u p s , th is s h ift has a d ire c t im p a c t o n c u ltu re , v a lu e s , a n d b eliefs w h e n e d u c a tin g a n d w o r k in g w it h in d iv id u a ls fr o m d iffe re n t c u ltu re s . I t is u p to us as nurses to be c u ltu ra lly a w a re a n d sensitive to differences w h ile fo s te rin g a p ro d u c tiv e a n d p ro fe s s io n a l w o r k in g e n v iro n m e n t.

■ Men in Nursing A t th e s ta rt o f th e n e w m ille n n iu m , m e n re p re s e n te d a p p r o x im a te ly 5 .4 % o f th e re g is te re d n u rs e p o p u la tio n in th e U n ite d S tates (T ro s s m a n , 2 0 0 3 ) . B y 2 0 0 4 , m e n c o m p ris e d 5 .8 % o f th e R N p o p u la tio n , a n d th e n 6 .6 % in 2 0 0 8 (U S D H H S , 2 0 1 0 ) . T h is steady increase c an be a ttr ib u te d to re c ru itm e n t c a m p a ig n s fo cused o n a ttr a c tin g m e n in to n u rs in g . F o r e x a m p le , th e O r e g o n C e n te r fo r N u rs in g (2 0 0 3 ) c re a te d a p o s te r o f m e n in n u rs in g w it h th e slog an “ A re y o u m a n e n o u g h to be a n u rs e ? ” T h e M is s is s ip p i H o s p ita l A s s o c ia tio n p u b lis h e d a n a ll-m a le c a le n d a r w it h m o n t h ly fe a tu re s o f m e n in n u rs in g , ra n g in g fr o m m e n w h o w e re n u rs in g students to p ra c tic in g p ro fes s io n als in a v a rie ty o f ro le s. T h e c a le n d a r w a s used as a re c ru itin g to o l to h e lp en co u rag e m e n , y o u n g a n d o ld , to c o n s id e r th e e x te n s iv e o p p o r tu n itie s in n u rs in g . I t w a s d is trib u te d to n u rs in g p ro g ra m s as p a r t o f a h e a lth careers re c ru itm e n t in fo r m a tio n k it (H e a lth C areers C e n te r, 2 0 1 2 ) . T h e se strategies h e lp d im in is h th e s tig m a a ssociated w it h m e n in n u rs in g . T h e A m e ric a n N u rs e s A s s o c ia tio n ( A N A ) in d u c te d th e firs t m a n in to its H a l l o f F a m e in 2 0 0 4 (A m e ric a n N u rs es A ss o cia tio n [ A N A ] , 2 0 0 7 ) . D r . L u th e r C h ris tm a n w a s re c o g n iz e d fo r his 6 5 -y e a r c a re e r a n d c o n trib u tio n s to th e p ro fe s s io n , in c lu d in g th e fo u n d in g o f th e A m e r ic a n A s s e m b ly fo r M e n in N u r s in g . In 2 0 0 7 , th e A N A e s ta b lis h e d th e L u t h e r C h r is tm a n A w a r d to re c o g n ize th e c o n trib u tio n s o f m e n in n u rs in g . C u r r e n t lite r a tu re also helps to k ee p th e discussion o f m e n in n u rs in g a t th e fo r e fr o n t. In 2 0 0 6 , M e n in N u r s i n g jo u rn a l w a s la u n c h e d as th e firs t p ro fe s s io n a l jo u rn a l d e d ic a te d 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 (1495-1550) opened a hos­ pital in Grenada, Spain, so that he (along with friends) could provide care to the mentally ill, homeless, and abandoned children (Blais, Hayes, Kozier, & Erb, 2001). Saint Camillus de Lellis (15 5 0 -1 6 1 4 ) was the founder of the Nursing Order of Ministers of the sick. Men in this order were charged with providing care to alcoholics and 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 African American physician in the United States. However, despite her many contributions to the nursing profession, Florence Nightingale did not encourage the participation of men in nursing. She believed that traits such 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 “hard and horny” hands were not fit to “touch, bathe, and dress wounded limbs, however gentle their hearts may be” (Chung, 2001). There still remain some unsubstantiated stereotypes of men who pursue a career in nursing. Even with negative societal perceptions and stereotypes, men are now more open to pursuing nursing as a career choice (Berlin, Stennett, & Bednash, 2004). In the fall of 2003, the percentage of men enrolled in undergraduate schools of nursing was 8.4% . In 2011, the percentage increased to 15% largely as a result of diminishing misconceptions and increased recruiting efforts (National League for Nursing, 20 1 2 ). Men prefer distinct practice areas, 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 (American Society of Registered Nurses, 2008; Gibbs & Waugaman, 2004). Some speculate that men make these choices to avoid potential role strain if they were to choose other areas, such as obstetrics and pediatrics (Chitty & Campbell, 2001), and because they prefer areas that require more technical expertise (American Society of Registered Nurses, 2008). 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 percentage of men in nursing overall. This is partly because male nurses are more oriented and motivated to upgrade their professional status (American Society of Registered Nurses, 2008). As a result, women in nursing are challenged to learn how to promote themselves within the profession.

Cultural and Ethnic Diversity

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What issues and challenges do men face in nursing? According to research conducted by Armstrong (2002) and Keogh and O ’Lynn (2007), male nurses are unfairly stereotyped in the profession as homosexuals, low achievers, and feminine. These false assumptions and perceptions deter other men from entering the profession, create gender-based barriers 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, 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, a male nursing student was having difficulty answering questions on a nursing examination. 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 reluc­ tant to allow men in the nursing role to care for them (American Society of Registered Nurses, 2008; Cardillo, 2001). During 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 ordi­ nary. On the other hand, male nurses are assumed to be physically stronger and willing to do the heavier tasks of nursing care, such as W W W 1 CRITICAL THINKING QUESTIONS V lifting and moving patients (Cardillo, 2 0 0 1 ). Still, many What advantages do women have in nursing? men and women are learning to appreciate and enjoy the What advantages do men have in the pro­ emerging culture in the profession (Meyers, 2 0 0 3 ). The fession? What are the risks of being gender old biases continue to disappear as patients and providers exclusive? V become more educated about the need for gender diversity in nursing.

C u ltu ra l and E th n ic D iv e rs ity In addition to gender diversity, we are also privileged as a profession to ex­ perience a diversity of race, age, and socioeconomic backgrounds. However, this m u ltic u ltu ra lis m can lead to people feeling threatened, especially if the culture within the profession does not encourage mutual respect and accep­ tance (Waters, 2004). Even though most registered nurses are Caucasian women, more minori­ ties are being represented in schools of nursing. The American Association of Colleges of Nursing reported that in the fall of 2003 12.2% of students enrolled in baccalaureate programs were African American, which represented a 0 .9 % increase from earlier and the largest minority population in nursing. American Indians or Alaska Natives at 0 .6 % represent the lowest minority population, and their numbers revealed no change in the same time frame. The Hispanic nursing population grew slightly from 5.1% to 5.4% (Berlin, Stennett, & Bednesh, 200 3 , 2004).

In 2 0 1 1 , 12% of students enrolled in a baccalaureate program were African American, followed by 8% Asians or Pacific Islanders, 1% American Indians or Alaska Natives, 6 % , Hispanics, and 6% identified as O ther. In associate degree nursing programs, 9% were African American, 4% Asian or Pacific Islander, 1% American Indian or Alaska Native, 6% Hispanic, and 7% identified as Other. O f the remaining diploma programs in the United States, 30% of students were African American, 5% Asian or Pacific Islander, 1% American Indian or Alaska Native, 10% Hispanic, and 27% identified as Other (National League for Nursing, 2012). As the general population of healthcare consumers becomes increas­ ingly 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. Part­ nerships among healthcare agencies and other community agencies are vital to increased understanding of various cultures. The N ational Advisory Council on Nurse Education and Practice (NACNEP) was established to advise the secretary of the U.S. Department of Health and Human Services and Congress on policy issues related to Title VIII programs administered by the Health Resources and Services Adminis­ tration. NACNEP identified the need to increase racial and ethnic diversity of the RN workforce as an issue. In its third report, NACNEP recommended that the country “expand the resources available to develop models that will effectively recruit and graduate sufficient numbers of racial/ethnic students to reflect the nation’s diverse population” (National Advisory Council on Nurse Education and Practice [NACNEP], 2003). More details about the council’s advocacy of a national action agenda to address nursing workforce diversity are available at www.diversitynursing.com. The Joint Commission and the National Committee for Quality Assur­ ance identify 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 initiated 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 patients’ compre­ hension 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 treatment plan. As nursing focuses more on cultural behaviors, norms, and practices, healthcare outcomes can move in a positive direction (Levine, 2012). Dr. Madeleine Leininger, nurse theorist and anthropologist, began the field of transcultural nursing. In her work, Dr. Leininger has advanced nurs­ ing’s thinking to include individuals from all cultures and to understand the

significance of cultural context (Leininger, 1991). Being culturally competent, that is, having the ability to interact appropriately with others through cultural understanding, is an expectation for people entering the nursing profession (Grant & Letzring, 2003). Nurses should always keep in mind that there is a difference between learning o f another culture and learning from another culture.

■ Efforts to Recruit and Retain M inorities in Nursing In a recent literature review of ethnic diversity in the nurse workforce, Otto and Gurney (2006) explore two aspects: academic and career factors that influence diversity; and recruitment, retention, and other strategies to diver­ sify the workforce. Only a small amount of scholarly research investigates ethnic diversity in nursing. However, some progress is being made. In a 2000 national survey, New York State reported a minority R N population similar to the overall minority population in the state. Authors also report that in one study, 56% of hospital units had a nursing team that represented at least three different ethnic groups (Otto & Gurney, 2006). Kavanagh (2001) indicates that failure to recognize the issue of ethnic diversity ignores health issues and potential resources. Historically, ethnic minorities have experienced disparities and lack of equal opportunities for education, provision of health care, and access to health care. Jacob and Carnegie (2002) suggest the following strategies to promote minorities in the nursing workforce: •

Raise the awareness level of diversity issues through educational offerings in the workplace and through organizational meetings. • Seek experts on cross-cultural nursing issues from reputable sources, such as the Transcultural Nursing Society and professional nursing organiza­ tions that represent various minority populations. • Use mentoring programs where people are matched based on their cultural backgrounds. • Use technology and media to connect with people of different cultures. In 2012, M inority N urse M agazine recognized efforts to recruit and retain minorities by developing the TAKE PRIDE Campaign. The purpose of this campaign is to recognize and reward healthcare facilities and nursing schools for their commitment to diversity. The campaign recognizes those entities and individuals who take the following steps toward diversity: • •

Faculty and staff recruitment and retention efforts aimed at underrepre­ sented groups Collaborative hiring practices

KEY COMPETENCY 5-2 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Patient-Centered Care: Knowledge (K4) Describes how diverse cultural, ethnic, spiritual and socioeconomic backgrounds function as sources of patient, family, and community values Attitudes/Behaviors (A4b) Recognizes impact of per­ sonal attitudes, values, and beliefs regarding delivery of care to diverse clients Skills (S4b) Implements nursing care to meet holistic needs of patient on socio­ economic, cultural, ethnic, and spiritual values and beliefs influencing health care and nursing practice Source: Massachusetts Department of Higher Education (2010, p. 10).

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CHAPTER 5 Social Context of Professional Nursing

• Diversity initiative and accessible organizations on site • Cultural competency training and resources (diverse foods, translators) • Partnerships with other diversity organizations An additional strategy aimed at recruitment and retention is an increase in scholarly nursing research to demonstrate the value of a diverse workforce (Otto & Gurney, 2006). Analysis of recruitment and retention interventions is also necessary. Finally, professional nurses must be aware of the legisla­ tive process and actively engage in the political arena to influence policy and legislation, ensuring diversity in nursing (Otto & Gurney, 2006). In 2011, the U.S. Department of Health and Human Services provided $3.6 million for 11 awards to fund the Nursing W orkforce Diversity Award. These awards fund nursing education for individuals from disadvantaged backgrounds, including racial and ethnic minority populations (USDHHS, 2010). For this type of funding to continue, nurses need to have an active voice in the legisla­ tive process and communicate the need for such programs.

A c c e s s to H e a lth C are Many Americans have health insurance coverage and access to some of the best healthcare professionals in the nation. However, a large number of indi­ viduals experience disparities in our healthcare system. 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, 2010), individuals who are at greatest risk for experiencing healthcare dis­ parities are racial and ethnic minorities and those with a low socioeconomic status. Lack of health insurance was the most significant contributing factor to a decrease in disease prevention (cancer screenings, dental care, vaccina­ tions, etc.). Although lack of health insurance has a major effect on access to health care, other factors, such as continuity of care, economic barriers, geographic barriers, and sociocultural barriers, have a detrimental effect on the health and quality of life of individuals and are discussed in the follow­ ing subsections.

■ C ontinuity of Care Individuals who have a provider or facility where they receive routine care are more likely to receive preventive health care (AHRQ, 2010). These individu­ als usually have better health outcomes and experience reduced disparities. In 20 0 8 , the percentage of people with a specific source of ongoing care was significantly lower for poor people than for high-income people (77.5% com­ pared with 9 2 .1 % ). The AH RQ also notes that having a routine provider of care correlates with a greater trust in the provider and increased likelihood that the person 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 provider and/or facility.

■ Economic Barriers Undoubtedly, poverty poses the greatest risk to health W W W 1 CRITICAL THINKING QUESTION V care. The United States has a long-standing reputation for Who is entitled to health care? V providing the highest quality health care to persons in the highest 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, registered nurses can have a positive impact on the change required in this established system. Recognizing the stronghold that poverty currently has on the health care of citizens is a beginning to the much needed work in the fight for equality. Although stereotypes communicate that poverty is limited to certain groups, we understand that poverty affects people of all cultures and ethnicities. We must recognize the impact that poverty has on healthcare practices. “Universally, the greatest threat to positive health status is poverty” (Kavanagh, 2001, p. 315). Our most vulnerable could be saved if poverty was eradicated. There would be no more homeless people, no more uninsured, and no more choices between food and medicine. Until that time, nursing continues to face the challenge of meeting the needs of all people. This is especially difficult as private insurance companies, Medicare, and Medicaid cut spending. Fewer and fewer healthcare providers accept government funds as payment. Individuals are being turned away if they do not have private insurance or cash. This results in a domino effect on emergency departments and hospitals that spend millions of dollars to cover the expenses of indigent patients.

■ Geographic Barriers Those living in rural areas have unique concerns regarding a cc es s to c a re . As many rural hospitals close as a result of 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 outweighs 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 transportation 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 patients’ 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 services available to enhance the health and quality of life of patients.

■ Sociocultural B arriers The need for cultural and ethnic diversity in the nursing workforce has been discussed. Moreover, healthcare settings are challenged to provide an envi­ ronment where people of various sociocultural 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 provided 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 foreign language or too advanced. Specifically, consent forms for surgery and other procedures must be available in the client’s language. To ignore the need for language-appropriate literature leads to patient harm, as well as disrespect for the uniqueness of others. One subculture that has garnered much attention in recent years is the military patient population. The Department of Defense operates and finances health care through TRICARE, a comprehensive healthcare coverage program for members of the uniformed services, their families, and survivors. With national resources decreasing and demands for health care of our military population on the rise, nurses play a pivotal role in influencing the direction of care for this special group. In an effort to address the needs of the military population and their families specifically, First Lady Michelle Obama led the “Joining Forces” national initiative to mobilize all sectors of the community to give service members, veterans, and their families the support they deserve, especially in regard to employment, education, and wellness. According to Joining Forces (White House, 2012), military service members, veterans, and their families have made significant contributions to the nation’s safety and security. This contribution comes at great cost to each veteran and family. The profession of nursing has a long and established history of meeting and supporting the physical and mental health needs of our nation’s military service members, veterans, and their families. The profession of nursing has pledged to inspire and prepare each nurse to recognize the unique health and wellness con­ cerns of the population. One hundred fifty nursing organizations and 500 nursing schools pledged their support to help educate nurses on post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI) in the coming years. Although each organization and nursing school has its unique mission and vision, various strategies to be employed include (1) increasing nurse aware­ ness of PTSD and TBI, (2) recognizing the signs and symptoms in patients, and (3) integrating PTSD and TBI content in nursing school curricula, to name a few. The American Nurses Association, American Academy of Nurse

P ra c titio n e rs , A m e ric a n A s s o c ia tio n o f C olleges o f N u rs in g , a n d th e N a t io n a l L e ag u e fo r N u rs in g to o k th e le a d in seeking n a tio n w id e s u p p o rt fr o m n u rs in g o rg a n iz a tio n s a n d schools o f n u rs in g .

■ H ealthcare D elivery in the United S tates E c o n o m ic v a ria b le s p e rv a d e h o w o u r n a tio n values h e a lth c are . In d iv id u a ls w h o a re u n a b le to secure a h e a lth in s u ra n c e p la n a re a t g re a t ris k fo r in a d ­ e q u ate c are. F u r th e r, in su ran ce co m p an ie s n o w d ic ta te to care p ro v id e rs w h a t is p e rm is s ib le b y d e te rm in in g c o v e re d b e n e fits . T h e c o n fu s in g p a tte rn s o f p a y m e n t fo r h e a lth care a re p ro h ib itiv e a n d fu rth e r increase th e stress o f in d i­ v id u a ls in p o o r h e a lth c o n d itio n s . In a d d itio n to th e c o m p le x ity o f h e a lth c a re p a y m e n t o p tio n s , th e a v a ila b ility o f c h a rita b le care in this c o u n try is s h rin k in g . E v e n th o u g h w e live in a c a p ita lis tic s o c ie ty , n u rsin g in th e U n ite d States has been seem ingly p ro te c te d against th e details o f h e a lth c a re fin an ce. W e have fo cu s ed o u r a tte n tio n o n p a tie n ts a n d aspects o f th e ir c a re . T h e c h a n g in g e co n o m y , u n c e rta in ty o f th e A ffo rd a b le C a re A c t o f 2 0 1 0 , n e w p h a rm a c e u tic a l re g u la tio n s , a n d e v o lv in g roles o f th e registered nurse h ave fo rce d us to re c o n ­ sider a n d re s tru c tu re th e v e ry n a tu re o f o u r d e liv e ry system s. In a d d itio n to p a rtic ip a tin g in n e w , c rea tive , a n d in n o v a tiv e h e alth ca re d e liv e ry styles, nurses re p re s e n t th e in te rm e d ia ry b e tw e e n p a tie n ts a n d th e h e a lth c a re system . P a rt o f th e re s p o n s ib ility th a t com es w it h th a t ro le is b e in g k n o w le d g e a b le a b o u t h e alth care finance a n d e ducating others a b o u t the c u rre n t v o c a b u la ry in charges, reim b u rse m en t, an d coverage. M o re o v e r, nurses should be in vo lv ed in the p o licy ­ m a k in g processes th a t re g u la te th e h e a lth c a re system . W e are in a n u n p re c ­ edented tim e o f change in o u r n a tio n ’s h e a lth care. P rofessional nurses should be a t the fo re fro n t, lea d in g th e charge to ensure ad eq u ate h e a lth care fo r a ll people.

■ Nurse-M anaged Centers N u rs e -m a n a g e d c e n te rs increase access to h e a lth c are in a c o s t-e ffe c tiv e w a y (T u r k e lta u b , 2 0 0 4 ) . A ls o c a lle d n u rs in g -m a n a g e d clinics a n d nurse p ra c tic e a rra n g e m e n ts , these h e a lth c a re d e liv e ry o p tio n s m e e t needs in c o m m u n itie s across th e c o u n try . B ased o n th e p h ilo s o p h y o f p r im a r y c are a n d e d u c a tio n , nurses o ffe r v ita l services a t a lo w e r cost. N u rs e -m a n a g e d h e a lth clinics are le d b y a d v a n c e d p ra c tic e nurses, m o s t o f w h o m a re n u rse p ra c titio n e rs a c t­ in g as p r im a r y c are p ro v id e rs fo r p a tie n ts . T h e y p ro v id e p r im a r y c are , h e a lth p r o m o tio n services, a n d disease p re v e n tio n services to p a tie n ts least lik e ly to re ce ive o n g o in g h e a lth c a re services. T h is p o p u la tio n in clu d es p a tie n ts o f a ll ages w h o a re u n in s u re d , u n d e rin s u re d , liv in g in p o v e rty , o r m em b ers o f ra c ia l a n d e th n ic m in o r ity g ro u p s . P ro v is io n s in th e A ffo r d a b le C a re A c t a llo w th e a d v a n c e d p ra c tic e nurse to d e liv e r m o re p r im a r y c are services. A d d itio n a lly , th e In s titu te o f M e d ic in e R e p o r t T h e F u t u r e o f N u r s in g : L e a d i n g C h a n g e , A d v a n c in g H e a lt h (In s titu te

of Medicine Report [IOM], 2010) strongly recommends that each nurse work to the fullest extent of his or her education. Implementation of these provisions and recommendations will definitely expand the roles and responsibilities of the nurse so that patients receive the full benefit of quality health care. In addition to providing care and cure, nurse-managed centers enhance relationships with the community. Faculty performing advanced practice and community nursing provide role models for the community while making clinical experiences available for students. In 2002, 18 grants to support nursemanaged centers were funded through the Health Resources and Services Administration’s Bureau of Health Professions, Division of Nursing. As a result, 36 access points to care were provided for underserved populations. Service delivery options include school-based clinics, homeless shelters, correctional facilities, mobile health units, shelters, and public housing units (Turkeltaub, 2004). In 20 1 0 , the U.S. Department of Health and Human Services provided $14.8 million to support grants to 10 nurse-managed clinics as part of the Affordable Care Act’s Nurse-Managed Health Clinic Grant Program. The pur­ pose of the grants was to augment efforts to increase primary care access. The clinics were expected to provide primary care to more than 9 4,000 patients and train more than 900 advanced practice nurses by the end of the grant period. Unfortunately, Congress and the Obama administration elected not to renew these grants in 2011 in an effort to cut federal spending. Nurse-managed clinics provide services that are primarily preventative. The Institute of Medicine’s report on the future of nursing states, “Nursemanaged health clinics offer opportunities to expand access; provide quality, evidence-based care; and improve outcomes for individuals W W W ] CRITICAL THINKING Q U ESTIO N S* who may not otherwise receive needed care. These clinics also provide the necessary support to engage individuals What barriers to health care do you see in in wellness and prevention activities.” Because the funding your community? How are the underprivi­ was cut, it is imperative that nurses at all levels strongly leged served in our current healthcare sys­ tem? What actions should be taken to ensure voice to local, state, and federal legislators the positive universal access to health care? V impact nurse-managed clinics have on decreasing dispari­ ties and improving the lives of individuals.

T re n d s At any time in history, societal trends affect the nursing profession. M ajor current movements include incivility, violence in the workplace, mental health needs, global aging, imbalance of supply and demand of nursing profession­ als, consumerism, complementary and alternative care, technologic changes, disaster preparedness, and nursing research. Discussion of these issues allows us to see more clearly the professional landscape and some of our challenges.

■ Incivility In c iv ility , 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 instigated by harassment at the physical, verbal, and electronic levels. Incivility is seen in every area of society, including high school, college, and even on the job. Nursing is not immune to this behavior. Greater light has been shed on the incidence and prevalence of bullying in nurse-to-nurse, faculty-to-student, and even student-to-faculty interactions. Rocker (2008) reports that some of the behaviors include criti­ cism, 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 suicides. Bullying is costly to organizations because it contributes to increased leave, nurse attrition, and decreased nurse productiv­ ity, satisfaction, and morale. In light of this, it is vital that the nursing profession take an active step in preventing incivility in our nursing programs and places of employment. The American Nurses Association (2012) has taken such action by developing a booklet, B u lly in g in t h e W o r k p l a c e : R e v e r s in g a C u lt u r e , to help nurses understand and deal with bullying in the work environment. In addition, the Institute of Medicine Report T h e F u t u r e o f N u r s in g : L e a d i n g C h a n g e (IOM, 201 0 ) includes recommendations that call for healthcare professionals to establish civil and respectful relationships and interactions.

■ Violence in the W orkplace The violence in our society is evident and appears to be increasing in frequency and severity. W hat 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 gun­ shot wound to the chest. Only 30 minutes before, he was leaving work for a weekend with family when someone decided that they needed his car more than this man needed his life. We see violence at the women’s shelter when we rotate through that clinical site in community health nursing. We also see troubled individuals who take out their frustration on 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 also providing care to the injurer. Although some nursing education programs might include this topic in the curriculum, nurs­ ing academia should take an active stance in making sure nursing graduates are prepared to care for individuals who are directly and indirectly affected by violence. This same effort should be made in healthcare facilities to ensure nurses are knowledgeable of how to act and provide competent care when violent incidents occur.

Registered nurses can assume additional roles when addressing vio­ lence. The role of the nurse is not limited to providing care in the hospital or emergency department. To work aggressively to address violence, nurses can function in the role of a sexual assault nurse examiner (SANE), legal nurse consultant, or forensic nurse (Littel, 2001). To be a sexual assault nurse examiner (SANE), a registered nurse must have advanced education and preparation in forensic examination of sexual assault victims. The Office for Victims of Crime of the U.S. Department of Justice has led the development of SANE programs across the country and provides materials and resources to encourage new programs. As a result of the SANE programs, victims of sexual assault consistently receive attention and compassion without delay (Littel, 2001). Legal nurse consultants (LNCs) are registered nurses with specialized clinical expertise and education who interpret, research, analyze, and provide expert testimony or opinion on medical-related legal cases. These cases can be related to faulty equipment, malpractice, or side effects of medications (Grutkowski, 2 0 1 2 ). Forensic nurses are trained to recognize and collect evidence related to criminal acts of trauma or death (Santiago, 2012). Even though a registered nurse can work in all three areas, each one has its specific responsibilities and duties to be performed. 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 research into violence prevention and treatment. In every potential case, nurses have to use keen assessment skills to identify people at risk and to promote reporting, treatment, and rehabilitation. The national initiative to increase health for all U.S. citizens, Healthy People 2020, outlines objectives for violence and abuse prevention (Table 5-1).

■ M ental H ealth Needs As professional nurses experience the stresses that come with today’s health­ care environment, we are obliged to assess our own mental health needs. Consider the registered nurse who has worked for 20 years with the same agency. During this time, he learns the practices of his department and agency. In fact, he becomes highly specialized in his area of nursing expertise. Economic changes require workforce reductions, and he becomes a victim, released from employment as a result of downsizing. With the high demand for professional nurses, you might think securing employment would be an easy task. However, because of his specialization, he is forced to take a job outside his area to maintain an income. In addition to the stress of losing a position after a two-decade investment, he finds himself challenged with some of the fundamental aspects of nursing care. Yet, they are not fundamental to him, and there is no one to help him. People try, but after all, they are very

Trends

TAB LE 5-1

H e alth y People 2 0 2 0 Violence and Abuse P revention Objectives

Prevention Objectives

Target by 2 0 2 0

baseline Data (2 0 0 8 & 2 0 0 9 )

H o m ic id e s

5 .5 p e r 1 0 0 ,0 0 0

6 .1 p e r 1 0 0 ,0 0 0

F ire a rm -re la te d deaths

9 .2 p e r 1 0 0 ,0 0 0

1 0 .2 p e r 1 0 0 ,0 0 0

M a lt r e a tm e n t o f c h ild re n 1 7 years a n d younger

8 .5 p e r 1 ,0 0 0

9 .4 p e r 1 ,0 0 0

F a ta litie s caused b y m a ltre a tm e n t, 1 7 years and younger

2 .2 p e r 1 0 0 ,0 0 0

2 .4 p e r 1 0 0 ,0 0 0

P h y sica l assaults, persons aged 1 2 years a n d o ld e r

1 4 .7 p e r 1 ,0 0 0

1 6 .3 p e r 1 ,0 0 0

R e d u c e c h ild r e n ’s e x p o s u re to v io le n c e

5 4 .5 %

6 0 .6 %

P h y sica l fig h tin g a m o n g adolescents o n s ch o o l p ro p e rty in grades 9 th ro u g h 12

2 8 .4 %

3 1 .5 %

W e a p o n c a rry in g b y adolescents o n s ch o o l p ro p e rty in grades 9 th ro u g h 12

4 .6 %

5 .6 %

R e d u c e b u lly in g a m o n g adolescents

1 7 .9 %

1 9 .9 %

S ou rce: Healthy People 2 0 2 0 (2012).

busy fu lfillin g th e ir o w n roles. H e becom es depressed, u n fu lfille d a n d w o n d e rs w h a t his fu tu re h o ld s . F o llo w in g th e m a n y n a tio n a l crises o f th e la s t s e v e ra l y e a rs , w e h a v e w itn es se d a n increase in th e m e n ta l h e a lth needs o f o u r s o ciety. P ro fe s s io n a l nurses a re n o t im m u n e to th is r e a lity . H is to r ic a lly , m e n ta l h e a lth concerns h a v e ta k e n a b a c k s e a t to o th e r c o n ce rn s , such as c a n c e r a n d h e a rt disease. T r u e , these c o n d itio n s re q u ire o u r resou rces, b u t so d o th e less g la m o ro u s c o n d itio n s th a t a ffe c t e m o tio n a l, s p iritu a l, a n d m e n ta l h e a lth . L a te r in th is te x t, th e au th o rs e x a m in e care o f th e pro fes s io n al self a n d address k e y concepts p e rtin e n t to th is discussion.

■ Global Aging T h e Y e a r o f th e O ld e r P erson— th is is w h a t th e U n ite d N a tio n s c a lle d th e y ea r 1 9 9 9 to reco g n ize a n d re a ffirm global agin g, th e fa c t th a t o u r g lo b a l p o p u la tio n is a g in g a t a n u n p re c e d e n te d r a te (U .S . C en su s B u re a u , 2 0 0 1 ) . I n 2 0 1 0 , a d u lts 6 2 years o f age a n d o ld e r c o m p ris e d 1 6 .2 % (4 9 .9 m illio n ) o f th e U .S .

143

p o p u la tio n c o m p a re d to 1 4 .7 % (4 1 .2 m illio n ) in th e y e a r 2 0 0 0 . B y 2 0 3 0 , it is e s tim a te d th a t th e p o p u la tio n o f o ld e r a d u lts w ill rise to 7 1 m illio n (H o w d e n & M e y e r, 2 0 1 1 ). A f t e r W o r l d W a r I I , f e r t il i t y in c re a s e d , a n d d e a th ra te s o f a ll ages d e c re a s e d . N o t o n ly a re p e o p le in d e v e lo p e d c o u n trie s liv in g lo n g e r a n d h e a lth ie r b u t so a re th o s e in th e d e v e lo p in g w o r ld . I n th e 1 9 9 0 s , d e v e l­ o p e d c o u n trie s h a d e q u a l n u m b e rs o f y o u n g (p e o p le 15 years a n d y o u n g e r) a n d o ld (p eo p le 5 5 years a n d o ld e r) w ith a p p ro x im a te ly 2 2 % o f th e p o p u la tio n in e ac h c a te g o r y . O n th e o th e r h a n d , 3 5 % o f th e p e o p le in d e v e lo p in g c o u n trie s w e re c h ild re n c o m p a re d w it h 1 0 % w h o w e re o ld e r. S till, a b s o lu te n u m b e rs o f o ld e r p e rso n s a re la rg e a n d g r o w in g . In th e y e a r 2 0 0 0 , m o re th a n h a lf o f th e w o r ld ’s o ld e r p e o p le ( 5 9 % , o r 2 4 9 m illio n p e o p le ) liv e d in d e v e lo p in g n a tio n s . I n th e U n ite d S ta te s , a decre as e in f e r t ilit y , a n in c re a s e in u r b a n iz a ­ tio n , b e tte r e d u c a tio n , a n d im p ro v e d h e a lth c are a ll c o n trib u te to th is social p h e n o m e n o n . In a d d itio n , th e o ld e r b a b y b o o m e rs w h o tu rn e d 6 5 years o f age h a v e s ta rte d to a ffe c t h e a lth care s ig n ific a n tly w it h in c re a s in g n u m b e rs re c e iv in g M e d ic a r e b e n e fits . T h e im p a c t th is w i l l h a v e o n o u r h e a lth c a re sys te m is d a u n tin g . W i t h th e g r o w in g n u m b e rs o f o ld e r a d u lts w i l l c o m e a d o m in o e ffe c t o f m o re c h ro n ic c o n d itio n s to tr e a t a n d in c re a s e d g o v e rn ­ m e n t fu n d in g (e .g ., M e d ic a r e ) to p a y fo r tr e a tm e n t o f these m e d ic a l c o n d i­ tio n s . A c c o rd in g to th e U S D H H S (2 0 1 2 ), m o re th a n 6 0 % o f o ld e r a d u lts w ill m a n a g e m o re th a n o n e c h ro n ic m e d ic a l c o n d itio n , such as d iab etes , a rth ritis , h e a rt fa ilu re , a n d d e m e n tia . T h e r e is a n e e d fo r c le a r h e a lth p o lic y a t a n a tio n a l le v e l i f w e a re to be p re p a re d to care fo r o u r a g in g c itize n s . A p p ro a c h e s used in th e p a s t are in a d e q u a te . B ecause th is is a n e w c h a lle n g e fo r us, th e c o rre c t a ctio n s a re n o t c le a rly d e fin e d . S till, th e re s p o n s ib ility is o urs as a s o cie ty. N u rs in g p ro fe s ­ sion als s h o u ld be k n o w le d g e a b le o f o u r ro les a n d re s p o n s ib ility in o b ta in in g fa c tu a l in fo r m a tio n re g a rd in g h e a lth p o lic y a n d ta k e a n activ e ro le in e nsurin g th a t q u a lity h e a lth c are is a v a ila b le a n d p ro v id e d . P re v e n tiv e h e a lth services fo r o ld e r a d u lts a re d e lin e a te d as p ro v is io n s m a d e in th e A ffo r d a b le C a re A c t o f 2 0 1 0 . H e a lt h y P eo p le 2 0 2 0 e sta b lish e d o b je ctiv es s p e c ific a lly fo r o ld e r a d u lts th a t s h o u ld be used b y h e a lth c a re p r o ­ fessionals, in c lu d in g nurses, to p ro m o te h e a lth y o u tco m es fo r th is p o p u la tio n . T h e se a re ju s t tw o e x a m p le s o f h e a lth p o lic y in itia tiv e s th a t nurses s h o u ld be a w a re o f a n d use w h e n p la n n in g c are fo r th e o ld e r a d u lt. In th e la s t several years, schools o f n u rs in g h a v e in c o rp o ra te d a g re a te r n u m b e r o f g e ro n to lo g y courses a n d c o n c e p ts in to th e c u r r ic u lu m . S o m e n u rs in g p ro g ra m s h a ve in crea se d th e a m o u n t o f g e ro n to lo g y c o n te n t fr o m a fe w h o u rs to a re q u ire d course in th e c u rric u lu m . G e ria tric N u rs e P ra c titio n e r p ro g ra m s h a v e g ro w n in n u m b e r, a n d som e schools o ffe r d u a l-tr a c k A d u lt/ G e ri N u rs e P ra c titio n e r a n d G e ro -P s y c h ia tric M e n t a l H e a lt h N u rs e P ra c ti­ tio n e r p ro g ra m s in g ra d u a te p ro g ra m s . C lin ic a l e xp erien ces in a d u lt h e a lth

Trends

145

settings a re h e a v ily s a tu ra te d w it h o ld e r perso n s. S till, w e la c k a n o rg a n iz e d p la n to m a k e c e rta in th a t h e a lth c a re needs w ill be m e t— n o t ju st fo r th e agin g, b u t also fo r th o se w h o c o m e a fte r th e m . R e c e n t fe d e ra l a n d lo c a l le g is la tio n calls fo r im p ro v e m e n ts in m e d ic a tio n c o v e ra g e , in s u ra n c e re im b u rs e m e n ts , a n d re fo r m in m a lp ra c tic e la w . T h u s fa r, these a tte m p ts h a ve been in a d e q u a te to p ro v id e th e c o m p re h e n s iv e care th a t w ill be v ita l i f w e are to m a k e th e rig h t to h e a lth c are re a l fo r e v e ry o n e . O t h e r en tities h a ve m a d e a d d itio n a l e ffo rts to address th e issues a n d c h a l­ lenges o f p re p a rin g nurses to p ro v id e c o m p e te n t a n d s p ec ialize d c are to th e o ld e r a d u lt. T h e H a r t f o r d In s titu te fo r G e ria tric N u rs in g (2 0 1 2 ) p ro v id e s a w e a lth o f g e ria tric to o ls , c o n tin u in g e d u c a tio n o ffe rin g s a n d w o rk s h o p s , a n d in d iv id u a liz e d tr a in in g fo r nurses a n d n u rs in g fa c u lty in th e c are o f th e o ld e r a d u lt a n d in c o rp o ra tin g m o re g e ria tric c o n te n t in th e c u rric u lu m .

KEY COMPETENCY 5-3

■ Nursing Supply and Demand F e w to p ic s re g a rd in g nurses h a v e g a rn e re d th e le v e l o f p u b lic ity th a t th e c u r­ re n t nursing s h o rta g e has a ttra c te d in re c e n t years. A s o u r g e n e ra l p o p u la tio n ages, so does o u r n u rs in g p o p u la tio n . A s a re s u lt, th e n u m b e r o f nurses a n d n u rse fa c u lty is s h rin k in g (P e te rs o n , 2 0 0 1 ) . T h e a v e ra g e age o f R N s in th e U n ite d States is 4 5 years a n d a la rg e n u m b e r o f nurses w ill re tire in th e n e x t 10 to 15 years ( U S D H H S , 2 0 1 0 ) . T h is presents a c o n u n d ru m because as nurses re tire , th e p o p u la tio n o f o ld e r a d u lts w ill s te a d ily increase. T h is is s ig n ific a n t because th e re w ill be fe w e r nurses to care fo r a ll p a tie n ts a n d even fe w e r to c are fo r th e o ld e r a d u lt. I t is p ro je c te d th a t th e re w ill be a s h o rta g e o f 1 .2 m illio n nurses b y th e y e a r 2 0 1 4 . So, h o w w ill th is d e fic it be addressed? In re a lity , to m e e t th is n e ed , w e w o u ld n e e d to g ra d u a te d o u b le th e n u m b e r o f c u r r e n t n u rs e g ra d u a te s . A lth o u g h th is m ig h t seem a tta in a b le , th e re a re o th e r challeng es to m e e tin g this g o a l. F irs t, n u rs in g fa c u lty a re a g in g a n d w ill be re tirin g in th e n e a r fu tu re . T h is presents a n u rs in g fa c u lty s h o rta g e c o m p o u n d e d b y th e fa c t th a t fe w e r nurses p u rs u e a c a d e m ia as a c a re e r c h o ice m a in ly because o f lo w e r salaries c o m p a re d to th a t o f th e c lin ic a l n u rse . S econd , n u rs in g p ro g ra m s m ig h t n o t h a v e th e in fr a s tru c tu r e o r fa c ilitie s to a c c o m m o d a te a n in c re a s e in e n ro ll­ m e n t. T h e s e ch allen g es c a n be q u ite d is c o u ra g in g a n d th a t is w h y th is is a m a jo r issue th a t needs to be addressed s o o n e r r a th e r th a n la te r. T h e m a jo r c o n c e rn is re la te d to th e to p ic discussed in th e p re v io u s s e c tio n : W h o w ill care fo r th e old? A s p e o p le age a n d e x p e rie n c e h e a lth p ro b le m s , th e ir needs a re o fte n m o re c o m p le x a n d a cu te, th e re b y d e m a n d in g a n even m o re h ig h ly s k ille d n u rs in g fo rc e . W it h th e d o w n tu r n in th e n a tio n ’s e c o n o m y , h e a lth c a re system s tr ie d to c u t costs to stay in business. U n fo r tu n a te ly , n u rs in g care w a s n o t e x e m p t fr o m th e c u tb a c k s . In th e m id -1 9 9 0 s , nurses w e re ask ed to d o m o re w it h less, a n d th a t e x p e c ta tio n c o n tin u e s to d a y . P a tie n ts a re sic ke r because th e y are liv in g

Examples of Applicable Nurse of the Future: Nursing Core Competencies

Systems-Based Practice: Knowledge (K6) Is aware of global aspects of health care Attitudes/Behaviors (A6a) Appreciates the potential of the global environment to influence patient health; (A6b) Appreciates the poten­ tial of the global environ­ ment to influence nursing practice Source: Massachusetts Department of Higher Education (2010, p. 21).

longer, resulting in a nurse-to-patient ratio that for the nurse is often stressful, seemingly unbearable, and that leads to burnout. According to Maslach and Jackson (1986), job-related burnout is a syn­ drome of emotional exhaustion, depersonalization, and decreased personal accomplishment. Emotional exhaustion is feeling overextended and exhausted, depersonalization is an impersonal response to the recipient of one’s care, and decreased personal accomplishment is a feeling of incompetence and lack of achievement. A study by Vahey, Aiken, Sloane, Clarke, and Vargas (2004) found that an improvement in the work environment reduced levels of burnout and improved patient outcomes. It is documented that burnout in nurses has a direct effect on patient care and resulting outcomes. Nurse burnout is all too common and pervasive (Weinberg, 2003). As a result, nurses are leaving the profession (Bingham, 2002). For female nurses, 4 .1 % left the profession in 2000 compared with 2.7% in 1992. Male nurses left at a rate of 7.5% in 200 0 , up from 2% in 1992 (Nelson, 2002). According to the U.S. Depart­ ment of Health and Human Services (2010), nearly 77,000 registered nurses intended to leave the profession in 3 years, and of that number, 5 4,000 were not sure if they would remain in nursing. Nursing burnout might play a sig­ nificant role in their decision. In September 20 0 2 , the nursing shortage in the United States was labeled a national security concern (Nelson, 2002). Although the historical picture of nursing supply and demand has fluctuated, other variables influence the current shortage. In 2 0 0 0 , 9% of nurses were younger than 30 years old and more than 3 3 0 ,0 0 0 registered nurses were expected to retire by 2008. Although the rate of retirement has slowed as a result of economic conditions between 2008 and 20 1 2 , the combination of the growing number of older people requiring care with the number of nurses expected to retire when the U.S. economy recovers means that by 2020 the national nursing shortage is predicted to reach a 2 0 % deficit (Nelson, 2002). The m ajority of registered nurses work in hospitals; therefore, those facilities are responsible for discovering innovative and alternative ways of recruiting and retaining professional staff. Cooper (2003) presents some strat­ egies for nursing managers, staff, and faculty to negotiate through this crisis: • To retain older nurses, reconstruct the patient care environment to make it more ergonomically sensitive, supportive, and tailored to the physical limitations of an aging workforce. • Provide for and encourage educational pursuits. • Evaluate and modify work schedules to complement circadian rhythms. • Provide auxiliary staff around the clock. • Attend to special needs of the nighttime workers; for example, provide fresh foods and healthy snacks. • Provide a “resting room ” for sleep breaks, especially if employees have a distance to drive home.

D e s p ite th e d is h e a rte n in g s ta tis tic s a b o u t th e n u rs in g s h o rta g e , som e g re a t strides h a v e b een m a d e in d e v is in g in n o v a tiv e , c re a tiv e , a n d a lte r n a ­ tiv e a p p ro a c h e s to in c re a s in g th e p o o l o f re g is te re d n u rse s. A c c o rd in g to th e R o b e r t W o o d J o h n s o n F o u n d a tio n (2 0 0 7 ), s everal p a rtn e rs h ip s a m o n g n u rs in g p ro g ra m s , h o s p ita ls , a n d g o v e rn m e n t e n titie s h a ve e m e rg e d . S o m e o f th e in itia tiv e s in v o lv e “ fa st tr a c k s ” to p re p a re n u rs in g fa c u lty , special state fu n d a llo c a tio n fo r n u rs in g e d u c a tio n , a n d h o s p ita l lo a n p ro g ra m s . S till, o n th e s u p p ly side o f th e e q u a tio n , n u rs in g fa c u lty are also a g in g . A s s is ta n t a n d associate p ro fessors a re a n a ve rag e o f 5 2 .1 a n d 4 8 .5 years o ld , re s p e c tiv e ly (C o o p e r , 2 0 0 3 ) . T h e s h o rta g e o f d o c to r a l-p r e p a r e d fa c u lty is e ve n m o re severe. O n a ve rag e , nurses re c e iv in g n e w d o c to rates are 4 5 years o ld (C o o p e r, 2 0 0 3 ) . T h is d ile m m a presents us w it h th e q u e stio n : W h o w ill te a c h o u r fu tu re nurses? W ie c k (2 0 0 3 ) p o in ts o u t th a t p e o p le are n o t c h o o s in g n u rs in g as a p r o ­ fession. T h e y o u n g e r g e n e ra tio n is n o t a ttra c te d to th e n u rs in g c a re e r o p tio n . S om e reasons c a n be re la te d to issues c u rre n tly discussed in th e lite r a tu re — in fle x ib le w o r k e n v iro n m e n ts , lo w c o m p e n s a tio n , p o o r r e c o g n itio n , h ig h stress, a n d so o n . A n o th e r p o s s ib ility is th e te n d e n c y fo r n u rs in g e d u c a tio n to resist chang e to m e e t th e e x p e c ta tio n s o f c o lle g e -d e g re e -s e e k in g students. N u r s in g e d u c a tio n p ro g ra m s m u s t be a w a re o f w h a t th is n e w g e n e r a tio n desires in a le a rn in g e x p e rie n c e a n d be p re p a re d to re c o n fig u re a n d c re a te n e w w a y s o f in s tru c tio n : o ffe rin g courses o n lin e ; p ro v id in g p e rs o n a l, fre q u e n t fe e d b a c k ; a n d fo c u s in g o n o u tco m e s a n d n o t ju s t th e process (W ie c k , 2 0 0 3 ) . T h e e m e rg in g w o rk fo rc e c a n n o t be c o n v in c e d to e n te r n u rs in g fo r th e sam e reasons th a t once a ttra c te d p e o p le to th e p ro fe s s io n . I f w e are to d r a w fr o m th e ric h p o o l o f y o u n g p e o p le , w e h ave to fin d o u t w h a t th e y n e ed a n d fin d w a y s to p ro v id e it.

■ Consum erism Since th e A m e ric a n H o s p ita l A s s o c ia tio n ’s d e v e lo p m e n t o f “ A P a tie n t’s B ill o f R ig h ts ” in 1 9 7 3 , consum ers h a ve assum ed m o re c o n tro l o f th e ir h e a lth c a re e x ­ periences; th is s h ift is c a lle d c o n s u m e ris m . T h e 1 9 9 2 v e rs io n o f th e d o c u m e n t w a s re p la c e d b y th e b ro c h u re T h e P a tien t C a re P a rtn e r s h ip : U n d e r s t a n d in g E x p e c t a t io n s , R ig h ts , a n d R e s p o n s ib ilitie s (A m e ric a n H o s p ita l A s s o c ia tio n , 2 0 0 3 ) a n d v a rio u s h o s p ita ls h a v e a d a p te d th e d o c u m e n t s p e c ific a lly fo r th e ir p a tie n t p o p u la tio n (such as th e P ilg rim M e d ic a l C e n te r in M o n t c la ir , N e w Jersey, a n d St. A n th o n y ’s M e d ic a l C e n te r in C a r r o ll, Io w a ). A s u m m a ry o f th e o rig in a l d o c u m e n t is p re se n ted in B o x 5 -1 . G o n e a re th e days w h e n p a tie n ts b lin d ly fo llo w th e in s tru c tio n s o f th e ir p h y s ic ia n s . In p a r t, th is is cause fo r c e le b ra tio n in th e n u rs in g a re n a . P ro fe s s io n a l n u rs in g has lo n g so u g h t to e m ­ p o w e r p a tien ts to ta k e re s p o n s ib ility fo r th e ir o w n h e a lth . A lth o u g h pockets o f m e d ic a l p a te rn a lis m c o n tin u e , th e g e n e ra l s h ift is to h o ld h e a lth c a re p ro v id e rs to a h ig h e r s ta n d a rd th a n e ve r b e fo re .

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BOX 5-1 THE PATIENT CARE PARTNERSHIP W h a t to e x p e c t d u rin g y o u r h o s p ita l stay: 1. H ig h -q u a lit y p a tie n t care 2 . A c le a n a n d safe e n v iro n m e n t 3 . In v o lv e m e n t in y o u r care a. D is cu ss in g y o u r m e d ic a l c o n d itio n a n d in fo r m a tio n a b o u t m e d ic a lly a p p ro p r ia te tr e a tm e n t choices b. D is cu ss in g y o u r tr e a tm e n t p la n c. G e ttin g in fo r m a tio n fr o m y o u d. U n d e rs ta n d in g y o u r h e a lth c a re goals a n d values e. U n d e rs ta n d in g w h o s h o u ld m a k e decisions w h e n y o u c a n n o t 4 . P ro te c tio n o f y o u r p riv a c y 5 . P re p a rin g y o u a n d y o u r fa m ily fo r w h e n y o u lea ve th e h o s p ita l 6 . H e lp w it h y o u r b ill a n d filin g in s u ra n c e cla im s

O ’N e i l a n d th e P e w H e a lt h P ro fe s s io n s C o m m is s io n ( 1 9 9 8 ) p ro v id e a n o th e r e x a m p le o f a tte m p ts to re s p o n d to th e c h a n g in g n e ed s o f th e A m e ric a n h e a lth c a re system . F r o m 1 9 8 9 to 1 9 9 9 , w it h a g ra n t fr o m th e P e w C h a r ita b le T ru s ts , a c o m m is s io n w a s esta b lish e d to focus o n th e h e a lth c a re w o rk fo rc e . T o im p ro v e h e a lth care o f th e A m e ric a n p e o p le , p ro fes s io n als in th e h e a lth c a re d e liv e ry system n e e d e d g u id e lin e s to re s p o n d to tre n d s a n d d e v e lo p m e n ts . In 1 9 9 8 , th e c o m m is s io n p re s e n te d its r e p o r t T w e n t y - O n e C o m p e te n c ie s f o r th e T w en ty -F irst C e n tu ry . These com petencies are presented in B o x 5 -2 . A lth o u g h th is d o c u m e n t w a s d e v e lo p e d m o re th a n a d ecade a go, th e c o m p eten c ies a re s till a p p lic a b le to d a y .

BOX 5 -2 TWENTY-ONE COMPETENCIES FOR THE TWENTY-FIRST CENTURY 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

E m b ra c e a p e rs o n a l e th ic o f social re s p o n s ib ility a n d service. E x h ib it e th ic a l b e h a v io r in a ll p ro fe s s io n a l a c tiv itie s . P ro v id e evid e n ce -b a se d , c lin ic a lly c o m p e te n t c are . In c o rp o ra te th e m u ltip le d e te rm in a n ts o f h e a lth in c lin ic a l care. A p p ly k n o w le d g e o f th e n e w sciences. D e m o n s tra te c ritic a l th in k in g , re fle c tio n , a n d p ro b le m -s o lv in g skills. U n d e rs ta n d th e ro le o f p r im a r y c are. R ig o ro u s ly p ra c tic e p re v e n tiv e h e a lth c are. In te g ra te p o p u la tio n -b a s e d c are a n d services in to p ra c tic e . Im p ro v e access to h e a lth c are fo r th o se w it h u n m e t h e a lth needs. P ra c tic e re la tio n s h ip -c e n te re d c are w it h in d iv id u a ls a n d fa m ilie s . P ro v id e c u ltu r a lly sensitive care to a d iverse society.

Trends

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1 3 . P a rtn e r w it h c o m m u n itie s in h e a lth c a re decisions. 1 4 . U s e c o m m u n ic a tio n a n d in f o r m a t io n te c h n o lo g y e ffe c tiv e ly a n d a p p ro p r ia te ly . 1 5 . W o r k in in te rd is c ip lin a ry te am s . 1 6 . E n s u re care th a t balances in d iv id u a l, p ro fe s s io n a l, system , a n d societal needs. 1 7 . P ra c tic e le a d e rs h ip . 1 8 . T a k e re s p o n s ib ility fo r q u a lity o f care a n d h e a lth o u tco m es a t a ll levels. 1 9 . C o n tr ib u te to c o n tin u o u s im p ro v e m e n t o f th e h e a lth c a re system . 2 0 . A d v o c a te fo r p u b lic p o lic y th a t p ro m o te s a n d p ro te c ts th e h e a lth o f th e p u b lic . 2 1 . C o n tin u e to le a rn a n d h e lp o th ers le a rn . S ou rce: O ’Neil and the Pew Health Professions Commission (1998).

B u lg e r (2 0 0 2 ) states th a t fo u r m a jo r p o in ts m u s t be k e p t in m in d w h e n c o n s id e rin g th e h e a lth c a re system o f th e fu tu re . F irs t, te c h n o lo g y a n d science w ill h a ve a m a jo r im p a c t. A lth o u g h research a n d e x p e rim e n ta tio n h a v e m a d e th e U n ite d States a g lo b a l le a d e r in in fo rm a tic s , ro b o tic s , a n d genetics, w e are c a u tio n e d to pause a n d co n sid er th e fu ll p o te n tia l o f such a re v o lu tio n . Second, m u ltip ro fe s s io n a l c o lla b o ra tio n w ill d e te rm in e th e effic ie n c y a n d effectiveness w it h w h ic h w e re s p o n d to th e d e m an d s in h e a lth c are . I t is n o t fe as ib le fo r n u rs in g p ro fes s io n als to w o r k so le ly w it h o th e r nurses to solve p ro b le m s a n d address issues. In a so ciety w it h a c o n tin u a lly c h a n g in g h e a lth c a re system , it is e ss en tia l fo r nurses to c o lla b o ra te a n d p a r tn e r w it h o th e r h e a lth c a re p ro fe s s io n a ls a n d e n titie s th a t d o n o t h a v e a h e a lth -re la te d focus (e .g ., th ose in business, e c o n o m ic s , g o v e rn m e n t). T h ir d , w e m u s t e d u c a te ourselves as h e a lth c a re p ro v id e rs a n d th e p u b lic as c o n su m e rs o f h e a lth c are . F in a lly , as h e a lth c a re p ro fe s s io n a ls , w e d e p e n d o n th e rese arch b e in g c o n d u c te d , w h ic h s h o u ld g u id e o u r actio n s a n d p ra c tic e . In th e e n d , n u rs in g p ro fes s io n als h a ve a h e a v y re s p o n s ib ility to be a c tiv e ly eng ag ed in s h a p in g a n d d e te rm in in g th e fu tu re h e a lth c a re system .

■ C om plem entary and A ltern ative Approaches A s th e c o n s u m e r’s p e rs p e c tiv e g ro w s in in flu e n c e , a n d in d iv id u a ls ta k e o n g re a te r re s p o n s ib ility in th e ir h e a lth c a re decision s, th e y e x p lo re ap p ro a ch e s to h e a lth care th a t c a n a c tu a lly c o n tra s t w it h W e s te rn tr a d itio n s . D iffe r e n t te rm in o lo g y has been used s y n o n y m o u s ly to d e fin e th is g ro w in g fie ld , such as c o m p l e m e n t a r y c a r e p r a c t ic e s a n d a lt e r n a t iv e m e d i c i n e . A c c o rd in g to th e N a t io n a l C e n te r fo r C o m p le m e n ta ry a n d A lte r n a tiv e M e d ic in e (2 0 1 2 ),

KEY COMPETENCY 5-4 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Patient-Centered Care: Attitudes/Behaviors (A2b) Respects and encourages the patient's input relative to decisions about health care and services Source: Massachusetts Department of Higher Education (2010, p. 9).

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“Complementary and alternative medicine is a group of diverse medical and healthcare systems, practices, and products that are not presently considered to be part of conventional medicine.” C om p lem en tary m ed icin e refers to an approach that combines conventional medicine with less conventional options, whereas alternative m edicin e is an approach used instead of con­ ventional medicine. M ajor types of c o m p le m e n ta ry and a lte r n a tiv e m ed ic in e include the following: • Alternative medical systems (built on complete systems of practice such as homeopathic medicine or naturopathic medicine) • M ind-body interventions (techniques designed to enhance the mind’s 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 move­ ment 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 bioelectro­ magnetic-based therapies such as magnetic therapy)

KEY COMPETENCY 5-5

Alternative and complementary therapies affect the selection of traditional choices for treatment, and ignoring that they exist is not an option. People persist in the use of alternative and complementary therapies for obvious reasons: (1) the therapies have been found valuable, and (2) Western medicine has limited options. A duty of the professional nurse is to secure an accurate assessment of the patient’s needs and circumstances. Therefore, it is imperative that nurses be educated on treatment choices the patient has selected. Nurses should provide a safe, trusting atmosphere where patients feel free to discuss their healthcare routines and preferences. Additionally, nursing educational programs should incorporate more information about the research in this growing field.

Examples of Applicable Nurse of the Future: Nursing Core Competencies

Safety: Attitudes /Behaviors (A3) Recognizes that both indi­ viduals and systems are accountable for a safety culture Source: Massachusetts Department of Higher Education (2010, p. 34).

■ Technological Changes Although technology influences in professional nursing are presented in detail later in this text, mention of those changes here is warranted. Undeniably, technologic advances have affected professional nursing practice in ways never imagined. The dream of connecting with patients in their homes by remote video and satellite is now commonplace. Digital, point-of-care documenta­ tion systems are the upcoming standard for patient records. Moreover, the equipment used in treatment plans changes at an exponential rate. Although technology presents new challenges— higher costs, greater edu­ cational demands, threats to bedside care— nurses can respond proactively.

Trends

W a y s o f c a rin g th ro u g h te c h n o lo g y e x is t th a t c a n a c tu a lly e n h an ce p a tie n t s a fe ty th r o u g h m o re e ffe c tiv e system s a n d th e r e d u c tio n o f h u m a n e r r o r , w h ic h is c o n g ru e n t w it h In s titu te o f M e d ic in e (2 0 0 0 ) re c o m m e n d a tio n s . O n e e x a m p le is th e a d o p tio n o f e le c tro n ic p a tie n t re c o rd s , w h ic h p ro v id e c le a re r c o m m u n ic a tio n lin es a m o n g m e m b e rs o f th e m u ltid is c ip lin a r y te a m . A ls o , d o c u m e n ta tio n c a n be re c o rd e d in re a l tim e , th e re b y a llo w in g th e n u rse to spend tim e w it h th e p a tie n t. P a tie n t safety is n o t c o m p ro m is e d w it h p o o r h a n d ­ w r it in g a n d d e la y e d ord ers (M e a d o w s , 2 0 0 3 ) . A n o th e r e x a m p le is th e use o f te le h e a lth ap p ro a ch e s to im p ro v e h e a lth c a re service in r u r a l a n d u n d e rs e rv e d c o m m u n itie s (B u c k w a lte r, D a v is , W a k e fie ld , K ie n z le , & M u r r a y , 2 0 0 2 ) . In fo r m a t io n te c h n o lo g y has g iv e n p a tie n ts a n d care p ro v id e rs a n e n o r­ m ous re so u rce fo r g a in in g k n o w le d g e a b o u t diseases, m e d ic a tio n s , tre a tm e n t o p tio n s , a n d s u p p o rt g ro u p s . A basic p a r t o f a n y n u rs in g p la n o f c are s h o u ld in c lu d e p ro v id in g re p u ta b le a n d e vid e n ce -b a se d resources fo r th e p a tie n t th a t c a n be accessed o v e r th e In te rn e t. In to d a y ’s h e a lth c a re e n v iro n m e n t, p e o p le search fo r answ ers to th e ir h e a lth c a re q u e s tio n s . W h o b e tte r to g u id e th e m to g o o d in fo r m a tio n th a n a p ro fe s s io n a l re g is te re d nurse?

■ Disaster Preparedness P r io r to th e tu r n o f th is c e n tu ry , d is a s te r p re p a re d n e s s w a s n o t a m a jo r to p ic o f discussion in p ro g ra m s o f n u rs in g . F u r th e r, th e k e y roles th a t p ro fe s s io n a l nurses n o w p la y in p re p a rin g a n d re s p o n d in g to disasters w e re u n e x p lo re d u n t il re c e n tly . T h e W o r l d T r a d e C e n te r a tta c k in 2 0 0 1 a n d th e s h o c k o f H u rric a n e K a tr in a in 2 0 0 5 o p e n e d th e n a tio n ’s eyes to o u r v u ln e ra b ilitie s an d o u r strengths. As a re su lt, disaster m a n a g e m e n t has becom e c o m m o n lan g u ag e in o u r schoo ls, agencies, a n d c o m m u n itie s . D is a s te r m a n a g e m e n t, p la n s d e s ig n a tin g respo nses d u r in g a n e m e rg e n c y , is c o o rd in a te d b y lo c a l, s ta te , a n d fe d e ra l g ro u p s . F ire fig h te rs , p o lic e o ffice rs , a n d h e a lth c a re p ro fes s io n als are p a r t o f respo nse te a m s . D is a s te r tr a in in g is also a v a ila b le to o th e r v o lu n te e rs . W e h a v e le a rn e d th a t c a rin g fo r larg e gro ups a ffe cted b y disaster requires a n o rg a ­ n iz e d , th o u g h tfu l, u n b ia s e d a p p ro a c h b y o u r lea d e rs. P ro fe s s io n a l nurses c a r r y th e b u r d e n o f b e in g k n o w le d g e a b le a b o u t p o te n tia l disasters, such as A v ia n in flu e n z a , e d u c a tin g th e p u b lic a b o u t th e risks, a n d re s p o n d in g w h e n persons are a ffe c te d . T h e A N A m a k e s a v a ila b le policies, resources, a n d e d u c a tio n a l o p p o rtu n itie s o n disaster preparedness fo r nurses. In a d d itio n , th e In s titu te o f M e d ic in e (2 0 0 9 ) p re p a re d a d o c u m e n t th a t p ro v id e s g u id a n c e fo r en tities e s ta b lis h in g s ta n d a rd s o f c are fo r d isa s ter p re ­ pared ness. T h e C en ters fo r D is ea se C o n tr o l a n d P re v e n tio n ( C D C ) C lin ic ia n O u tre a c h a n d C o m m u n ic a tio n A c tiv ity p ro g ra m fo rm e d in 2 0 1 1 in response to th e a n th ra x a tta c k s in th e U n ite d States w it h th e m is s io n to h e lp h e a lth c a re p ro fe s s io n a ls p ro v id e o p tim a l c are b y fa c ilita tin g c o m m u n ic a tio n b e tw e e n

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CHAPTER 5 Social Context of Professional Nursing

c lin ic ia n s a n d C D C a b o u t e m e rg in g h e a lth th re a ts , id e n tify in g c lin ic a l issues d u r in g em e rg e n c ie s to h e lp in fo r m o u tre a c h s tra te g ie s , a n d d is s e m in a tin g e v id e n c e -b a s e d h e a lth in fo r m a t io n a n d p u b lic h e a lth e m e rg e n c y m essages (C D C , 2 0 1 2 ).

■ Research Needs A d d re s s in g th e c o n te x t o f p ro fe s s io n a l n u rs in g in to d a y ’s w o r ld raises im p o r ­ ta n t research q u e stio n s. K e y v a ria b le s are th e changes in p a tie n t a c u ity a n d the e ffe c t o n n u rse s ta ffin g (R o b e rt W o o d J o h n s o n F o u n d a tio n , 2 0 0 7 ) . M o d e ls o f n u rse s ta ffin g , in c lu d in g fix e d m in im u m ra tio s a n d p a y -fo r-p e r fo rm a n c e , a re b e in g te sted . A lth o u g h n o t in d e p e n d e n tly , s ta ffin g ra tio s o ffe r p ro m is e to im p r o v e n u rs in g w o r k e n v iro n m e n ts . R e s e a rc h re g a rd in g th e fu tu re o f n u rs in g m u s t c e n te r o n e ffo rts a im e d a t c re a tin g p ra c tic e e n ­ v iro n m e n ts th a t increase n u rse s a tis fa c tio n a n d im p ro v e p r o ­ d u c tiv ity . Specific areas id e n tifie d b y th e R o b e rt W o o d Johnson F o u n d a tio n ( 2 0 0 7 ) in c lu d e in c re a s in g n u rse s ’ a u th o r ity , i n ­ crea sin g tru s t b e tw e e n nurses a n d m a n a g e m e n t, re o rg a n iz in g nurses’ w o r k , a n d p ro h ib itin g m a n d a to ry o v e rtim e . A s n u rsin g specialties d e v e lo p s ta n d a rd s o f c are , it is also v ita l th a t th e s tan d ard s h a v e a n e v id e n c e d -b a s e d fo u n d a tio n . A s a p ro fe s ­ sio n , n u rs in g needs to base p ra c tic e o n re se arch a n d p r im a r ily o n e x p e rie n tia l successes.

C o nclu sio n N o w , w h e n y o u h e a r th e w o r d n u r s in g , w h a t im a g e com es to m in d ? I f th e p ic tu re is b lu r r y o r c o n fu s e d b y th e e x p a n d in g social c o n te x t p re s e n te d in th is c h a p te r— g o o d ! T h e c lou diness in d ic a te s th a t th e tr a d itio n c o n tin u e s to be q u e s tio n e d . W e h a v e lo o k e d a t som e o f th e s o cia l p h e n o m e n a th a t h e lp define n u rs in g . Because those experiences change c o n s ta n tly , w h a t w e e nvision n o w w ill also be tra n s fo rm e d . N e v e rth e le s s , w e h a v e to q u e s tio n th e im a g e a n d e x p lo re th e fa c to rs th a t in flu e n c e it. W e are c h a lle n g e d to d o th is o n a re g u la r basis. O n ly th e n c a n w e e vo lv e in m e a n in g fu l w a y s to b e tte r m e e t th e n u rs in g needs o f o u r society.

W eb R eso u rce s A m e ric a n A m e ric a n A m e ric a n A m e ric a n

A s s e m b ly fo r M e n in N u rs in g : w w w .a a m n .o r g A s s o c ia tio n o f C olleges o f N u rs in g : w w w .a a c n .n c h e .e d u H o s p ita l A s s o c ia tio n : w w w .a h a .o r g N u rs e s A s s o c ia tio n : w w w .n u r s in g w o r ld .o r g

References

C a m p a ig n fo r N u r s in g ’s F u tu re : w w w .d is c o v e rn u rs in g .c o m D iv e r s ity N u rs in g : w w w .d iv e rs ity n u rs in g .c o m H e a lt h y P eo p le 2 0 2 0 : w w w .h e a lth y p e o p le .g o v M i n o r i t y N u rs e : w w w .m in o r ity n u r s e .c o m N a t io n a l A s s o c ia tio n o f H is p a n ic N u rs e s : w w w .th e h is p a n ic n u rs e s .o rg N a t io n a l B la c k N u rs e s A s s o c ia tio n : w w w .n b n a .o r g N a t io n a l C e n te r fo r C o m p le m e n ta ry a n d A lte r n a tiv e M e d ic in e : w w w .n c c a m . n ih .g o v N a t io n a l L e a g u e fo r N u rs in g : w w w .n ln .o r g N a t io n a l S tu d e n t N u rs e s A s s o c ia tio n : w w w .n s n a .o r g O ffic e fo r V ic tim s o f C r im e , U .S . D e p a r tm e n t o f Justice: w w w .o jp .u s d o j. g o v /o v c P e w H e a lt h P ro fe s s io n s C o m m is s io n : h ttp ://fu tu r e h e a lth .u c s f.e d u /P u b lic / C e n te r-H o m e .a s p x S ex u a l A s s a u lt N u rs e E x a m in e rs : w w w .s a n e -s a r t.c o m T ra n s c u ltu ra l N u rs in g S ociety: w w w .tc n s .o rg T R IC A R E : w w w .t r ic a r e .m il U .S . B u re a u o f th e C ensus: w w w .c e n s u s .g o v U .S . D e p a r tm e n t o f L a b o r: w w w .s ta ts .b ls .g o v

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Education and Socialization to the Professional Nursing Role Melanie Gilmore

v_______________________ S o c ia liz a tio n to pro fes s io n al n u rsin g is th e process o f a c q u irin g th e k n o w le d g e , s kills , a n d sense o f id e n tity th a t a re c h a ra c te ris tic o f th e p ro fe s s io n . I t is a process b y w h ic h a s tu d e n t in te rn a liz e s th e a ttitu d e s , b eliefs, n o rm s , valu es, a n d s tan d ard s o f th e p ro fe s s io n in to his o r h e r o w n b e h a v io r p a tte rn (C o h e n , 1 9 8 1 ). P ro fe s s io n a l s o c ia liz a tio n has fo u r goals: (1 ) to le a rn th e te c h n o lo g y o f th e p ro fe s s io n — th e facts, s kills , a n d th e o ry , (2 ) to le a rn to in te rn a liz e th e p ro fe s s io n a l c u ltu re , (3 ) to fin d a p e rs o n a lly a n d p ro fe s s io n a lly a c c e p ta b le v e rs io n o f th e ro le , a n d (4 ) to in te g ra te th is p ro fe s s io n a l ro le in to a ll o f th e o th e r life roles (H e n tz , 2 0 0 9 ) . R e c e n tly , B e n n e r, S u tp h e n , L e o n a rd , a n d D a y (2 0 1 0 ) m a d e th e case fo r using th e te rm fo rm a tio n to describe this process th a t occurs o v e r tim e because it b e tte r denotes “ th e d e v e lo p m e n t o f p e rc e p tu a l a b ilitie s , th e a b ility to d r a w o n k n o w le d g e a n d s k ille d k n o w -h o w , a n d a w a y o f bein g a n d a ctin g in p ractice a n d in th e w o r ld ” (p . 1 6 6 ). W h a te v e r te rm in o lo g y is c h o sen , th e process d e s c rib e d in th is c h a p te r refers to th e tr a n s fo r m a tio n o f th e la y p e rs o n in to a s k ille d nurse w h o is p re ­ p a re d to re s p o n d s k illf u lly a n d re s p e c tfu lly to p e rso n s in n e e d o f n u rs in g care o r, as d esc rib ed b y B e n n e r et a l. (2 0 1 0 ) in th e ir discussion o f fo rm a tio n , “ th e la y s tu d e n t m o ves fr o m a c t in g lik e a nurse to b e in g a n u rs e ” (p . 1 7 7 ). T h is d e v e lo p m e n t o f p ro fe s s io n a l id e n tity occurs in itia lly th ro u g h th e fo rm a l e d u c a tio n a l process a n d c u lm in a te s in th e p ra c tic e settin g .

Key Terms and Concepts » » » » » » » » »

S o c ia liz a tio n Formation Professional values Novice Advanced beginner Competent Proficient Expert Role transition

Learning Objectives A f t e r c o m p le tin g th is c h a p te r, th e s tu d e n t should be a b le to : 1. Discuss p ro fes s io n alism and nursing. 2 . D escribe s o c ia liz a tio n to p ro fessio n al nursing. 3 . D e s c rib e how n u rsin g e d u c a tio n a ffe c ts th e s o c ia liza tio n of nurses.

4 . D e s c rib e th e s ta g e s o f s kill and k n o w le d g e a cq u is itio n as d e fin e d by B enner. 5 . Id e n tify fa c to rs th a t fa c ilita te pro fession al role d e v e lo p m e n t.

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P ro fe s s io n a l n u rs in g c o n tin u e s to e vo lv e in to a p ro fe s s io n w it h a d is tin c t b o d y o f k n o w le d g e , s p e c ia lize d p ra c tic e , s ta n d a rd s o f p ra c tic e , a n d s o cia l c o n tra c t. T h e p ro fe s s io n a l n u rse is re sp o n sib le fo r p ra c tic e th a t in c o rp o ra te s th is s p ec ialize d b o d y o f k n o w le d g e a n d s ta n d a rd s o f p ra c tic e .

P ro fe s s io n a l N u rs in g V a lu e s

KEY COMPETENCY 6-1 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Professionalism: Knowledge (K4a) Describes factors essential to the promotion of professional development Attitudes/Behaviors (A4a) Committed to life-long learning Skills (S4a) Participates in life-long learning Source: Massachusetts Department of Higher Education (2010), p. 13.

P ro fe s s io n a l v a lu e s a re beliefs o r id ea ls th a t g u id e in te ra c tio n s w it h p a tie n ts , c o lle ag u es , o th e r p ro fe s s io n a ls , a n d th e p u b lic . P ro fe s s io n a l values a re c o n ­ s id ered a c o m p o n e n t o f exc ellen c e, a n d th e existence o f a c ode is c o n sid e re d a h a llm a r k o f p ro fe s s io n a lis m . T h e d e v e lo p m e n t o f p ro fe s ­ s io n a l v alu e s begins w it h p ro fe s s io n a l e d u c a tio n in n u rs ­ in g a n d c o n tin u e s a lo n g a c o n tin u u m th ro u g h o u t th e years o f n u rs in g p ra c tic e . P ro fe s s io n a l v a lu e s a s s o c ia te d w it h n u rs in g a re o u tlin e d in th e A m e ric a n N u rs e s A s s o c ia tio n C o d e o f E t h ic s ( A N A , 2 0 0 1 ) . T h e v alu e s o f (1 ) c o m m it­ m e n t to p u b lic service, (2 ) a u to n o m y , (3 ) c o m m itm e n t to life lo n g le a rn in g a n d e d u c a tio n , a n d (4 ) a b e lie f in th e d ig ­ n ity a n d w o r th o f each p e rso n e p ito m iz e th e c a rin g , p ro fe s ­ s io n a l nurse. N u r s in g is a h e lp in g p ro fe s s io n d ire c te d to w a r d h e a lth p r o m o tio n a n d disease p re v e n tio n o f in d iv id u a ls , fa m ilie s , a n d c o m m u n itie s . C a r in g is a c o n ­ c e p t c e n tra l to th e p ro fe s s io n o f n u rs in g . In h e r e n t in th is v a lu e is a s tro n g c o m m itm e n t to p u b lic service. T h e ro le o f th e n u rse is fo cu s ed o n assessing a n d p ro m o tin g th e h e a lth a n d w e ll-b e in g o f a ll h u m a n s . R e g is te re d nurses re m a in in n u rs in g to p ro m o te , a d v o c a te , a n d s trive to p ro te c t th e h e a lth a n d safe ty o f p a tie n ts , fa m ilie s , a n d c o m m u n itie s ( A N A , 2 0 0 4 ) . A u to n o m y is th e r ig h t to s e lf-d e te rm in a tio n as a p ro fe s s io n . T h e ro le o f th e p ro fe s s io n a l n u rse is to h o n o r a n d assist in d iv id u a ls a n d fa m ilie s to m a k e in fo r m e d decisions a b o u t h e a lth care a n d p ro v id e in fo r m a tio n so th a t th e y c an m a k e in fo r m e d choices. T h e p ro fe s s io n a l n u rse respects p a tie n ts ’ rig h ts to m a k e decisions a b o u t th e ir h e a lth c are. C o m m it m e n t to life lo n g le a r n in g a n d e d u c a tio n is n e c e s s a ry in th e d y n a m ic h e a lth c a re a re n a th a t s u rro u n d s n u rs in g p ra c tic e in th is c e n tu ry . N u rs e s n e ed c o n tin u o u s e d u c a tio n to m a in ta in a safe le v e l o f p ra c tic e a n d e x p a n d th e ir le v e l o f c o m p e te n c e as p ro fe s s io n a ls . W it h n e w te c h n o lo g ie s a n d th e r a p id e x p a n s io n o f m e d ic a l a n d n u rs in g k n o w le d g e , th e n u rse m u s t c o n tin u o u s ly seek to e x p a n d th e b o d y o f p ro fe s s io n a l k n o w le d g e . P ro fe s ­ s io n a l n u rs in g in v o lv e s a c o m m itm e n t to be re s o u rc e fu l, to re s p o n d to th e d y n a m ic c h a lle n g e s o f d e liv e r in g h e a lth c a re , to in c o r p o r a te te c h n o lo g y in to th e ir a r t a n d c a rin g , a n d to r e m a in v is io n a rie s as th e fu tu re u n fo ld s (A N A , 2 0 0 4 ).

Socialization Process

H u m a n d ig n ity is re sp e ct fo r th e in h e re n t w o r th a n d u n iq u e n e s s o f in d iv id u a ls a n d c o m m u n itie s . A c c o rd in g to th e In te r n a tio n a l C o u n c il o f N u rs e s ’ ( I C N ’s) C o d e o f E t h ic s f o r N u r s e s ( I C N , 2 0 0 6 ) , “ in h e r e n t in n u r s in g is respect fo r h u m a n rig h ts , in c lu d in g c u ltu ra l rig h ts , th e rig h t to life a n d ch o ice , to d ig n ity a n d to be tre a te d w it h respect. N u r s in g c are is re s p e c tfu l o f a n d u n re s tric te d b y c o n s id ­ e ra tio n s o f age, c o lo r, c ree d , c u ltu re , d is a b ility o r illness, g e n d e r, s e x u a l o r ie n ta tio n , n a tio n a lit y , p o litic s , ra c e o r s o cia l s ta tu s ” (p . 1 ).

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w w wj CRITICAL THINKING QU ESTIO N S*

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? V

S o c ia liz a tio n P ro cess ■ Educational Socialization S o c ia liz a tio n in to a p ro fes s io n is a process o f a d a p tin g to a n d b e c o m in g a p a rt o f a c u ltu re (O u s e y , 2 0 0 9 ) . P a rt o f s o c ia liz a tio n is a b o u t in d iv id u a ls le a rn in g w h a t it m ean s to be a p ro fe s s io n a l. S tu d en ts n e w to th e n u rs in g p ro fe s s io n le a rn th e ro le in th e e d u c a tio n a l settin g . C o h e n (1 9 8 1 ) uses th e th e o rie s o f c o g n itive d e v e lo p m e n t to d evelo p a m o d e l o f p ro fes s io n al n u rsin g s o c ia liza tio n th ro u g h e d u c a tio n . T h e m o d e l describes fo u r stages students m u s t exp e rien c e as th e y b e g in to in te rn a liz e th e ro les o f a p ro fe s s io n . In stage 1, U n ila te r a l D e p e n d e n c e , th e in d iv id u a l places c o m p le te re lia n c e o n e x te rn a l c o n tro ls a n d searches fo r th e one rig h t a n s w e r (C o h e n , 1 9 8 1 , p . 1 6 ). In essence, th e s tu d e n t lo o k s to th e in s tru c to r fo r th e r ig h t answ ers a n d is u n lik e ly to q u e s tio n th e a u th o r ity . A s th e s tu d e n t gains fo u n d a tio n a l k n o w le d g e a n d s k ill, th e re begins th e process o f q u e s tio n in g th e a u th o r ity . D u r in g stage 2 , N e g a tiv e /In d e p e n d e n c e , th e s tu d e n t begins to p u ll a w a y fr o m e x te rn a l c o n tro ls a n d is c h a ra c te riz e d b y c o g n itiv e re b e llio n . T h e s tu ­ d e n t b e g in s to t h in k c r it ic a lly a n d b e g in s to q u e s tio n th e in s tr u c to r a n d re lies m o re o n his o r h e r o w n ju d g m e n ts . Stage 3 , D e p e n d e n c e /M u tu a lity , m a rk s th e b e g in n in g o f e m p a th y a n d c o m m itm e n t to o th ers (C o h e n , 1 9 8 1 , p . 1 8 ). In th is stage, th e s tu d e n t begins to a p p ly k n o w le d g e to p ra c tic e a n d th e s tu d e n t tests in fo r m a t io n a n d fa c ts . “ S tu d en ts h a v e a k n o w le d g e base u p o n w h ic h to a n c h o r c ritic a l th o u g h t a n d c a n re la te n e w m a te r ia l to th e ir p re v io u s k n o w le d g e b a s e ” (C o h e n , 1 9 8 1 , p . 1 8 ). In th is stage, th e s tu d e n t is a c tiv e ly e n g ag ed in th e le a rn in g , th in k in g th ro u g h p ro b le m s . F o r th is stage to e m e rg e , th e le a rn in g e n v iro n m e n t m u s t s u p p o rt a n d v a lu e ris k ta k in g . T h e ro le o f th e te a c h e r is th a t o f c o a c h , m e n to r , a n d s e n io r le a rn e r. T h e m e n to r h elp s th e s tu d e n t lin k th e o ry to p ra c tic e w h ile in th e c lin ic a l areas, th us h e lp in g th e s tu d e n t to le a rn fr o m exp e rien c es a n d to im p ro v e p ra ctice s to s u p p o rt p ro fe s s io n a l s o c ia liz a tio n .

KEY COMPETENCY 6-2 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Professionalism: Knowledge (K4c) Understands the importance of reflection to advancing practice and improving outcomes of care Attitudes/Behaviors (A4c) Values and is committed to being a reflective practitioner Skills (S4b) Demonstrates the ability for reflection in action, reflection for action, and reflection on action Source: Massachusetts Department of Higher Education (2010), p. 13.

Stage 4 , In te rd e p e n d e n c e , occurs w h e n n e ith e r m u tu a lity n o r a u to n o m y is d o m in a n t. L e a rn in g fr o m o th ers a n d th e a b ility to solve p ro b le m s in d e p e n ­ d e n tly a re e v id e n t. T h is is th e stage o f th e p ro fe s s io n a l life lo n g le a rn e r w h o d e m o n s tra te s re fle c tio n in p ra c tic e a n d is re sp o n sib le fo r c o n tin u e d le a rn in g . P ro fe s s io n a l s o c ia liz a tio n t o w a r d th e stage o f in te rd e p e n d e n c e re q u ire s a s u p p o rtiv e e d u c a tio n a l c lim a te th a t values a u to n o m y , in d e p e n d e n t th in k in g , a n d a u th e n tic ity . S tu dents b e co m e p ro fe s s io n a ls .

■ Professional Socialization Several m o d e ls in th e lite ra tu re describe p ro fe s s io n a l s o c ia liz a tio n . R egardless o f th e m o d e l e m b ra c e d , s o c ia liz a tio n in to th e n u rs in g p ro fe s s io n m u s t in c lu d e n e w com petencies fo r th e 2 1 s t c e n tu ry . T h e In s titu te o f M e d ic in e ( I O M , 2 0 1 1 ) re p o rte d th a t nurses n e ed re q u is ite c o m p eten c ies in c lu d in g le a d e rs h ip , h e a lth p o lic y , system im p ro v e m e n t, research a n d evid en ce-b ased p ra c tic e , a n d te a m ­ w o r k a n d c o lla b o ra tio n to m e e t th e needs o f th e c u rre n t d y n a m ic h e a lth c a re e n v iro n m e n t. N u r s in g e d u ca to rs m u s t g ive students th e re q u is ite skills a n d p ra c tic e o p p o rtu n itie s th a t e q u ip th e m fo r th e p ro fe s s io n a n d in s till in th e m th e d e sire to b e c o m e life lo n g le a rn e rs . N u rs e s n e ed c o n tin u o u s e d u c a tio n to m a in ta in a safe lev el o f p ra c tic e a n d e x p a n d th e ir le v e l o f c o m p e te n c e as p ro fes s io n als. W it h n e w te ch n o lo g ies a n d th e ra p id e x p a n s io n o f m e d ic a l a n d n u rs in g k n o w le d g e , th e nurse m u s t c o n tin u o u s ly seek to e x p a n d th e b o d y o f p ro fe s s io n a l k n o w le d g e . P ro fe s s io n a l n u rs in g in v o lv e s a c o m m itm e n t to be re s o u rc e fu l, to re s p o n d to th e d y n a m ic challeng es o f d e liv e rin g h e a lth c are, to in c o rp o ra te te c h n o lo g y in to th e ir a rt a n d c a rin g , a n d to re m a in v is io n a rie s as th e fu tu re u n fo ld s ( A N A , 2 0 0 4 ) .

■ Model of Professional Socialization: From Novice to Expert B e n n e r (1 9 8 4 ) describes th e d e v e lo p m e n t o f p ro fe s s io n a l c lin ic a l p ra c tic e o f nurses. B e n n e r’s m o d e l id e n tifie s th e stages o f n o v ic e , a d v a n c e d b e g in n e r, c o m p e te n t, p ro fic ie n t, a n d e x p e rt th a t are based o n th e n u rs e ’s e x p e rie n c e in p ra c tic e . W it h a n u n d e rs ta n d in g o f th is p ro g re s s io n o f k n o w le d g e a n d skills, e d u c a tio n a l p ro g ra m s h ave d e ve lo p ed s u p p o rtiv e c u rric u la usin g a c o n tin u u m o f e xp erien ces to enhance s kill a n d k n o w le d g e d e v e lo p m e n t. H e a lth c a re e n v i­ ro n m e n ts h a ve also in c o rp o ra te d th is m o d e l to fa c ilita te th e n u rs e ’s p ro fe s s io n a l p ra c tic e b y assessing th e n u rs e ’s stage o f d e v e lo p m e n t. T h is m o d e l is n o t lim ite d to th e s tu d e n t experience o r to th a t o f th e n e w g ra d u a te nurse. E xp erie n ce d nurses to o c an b e n e fit fr o m experiences designed to m o v e to w a r d e x p e rt.

T h e firs t stage, n o v ice , is c h a ra c te riz e d b y a la c k o f k n o w le d g e a n d e x p e ri­ ence. In th is stage, th e facts, ru le s, a n d g u id e lin e s fo r p ra c tic e are th e fo cus. R u le s fo r p ra c tic e a re c o n te x t fre e , a n d th e s tu d e n t ta s k is to a c q u ire th e k n o w le d g e a n d s k ills . T h e stage o f n o v ic e is n o t r e la te d to th e age o f th e stu d e n t b u t ra th e r to th e k n o w le d g e a n d s kill in th e area o f study. F o r e x a m p le , le a rn in g h o w to give in je c tio n s w o u ld be p re se n ted w it h th e p ro c e d u ra l g u id e ­ lin es, a n d th e n o v ic e w o u ld th e n p ra c tic e th e s k ill. A t th is stage, m u c h o f th e s tu d e n t’s en erg y a n d a tte n tio n is a im e d a t re m e m b e rin g th e ru le s. In th e n e x t stag e, a d v a n c e d b e g in n e r, th e s tu d e n t c a n fo r m u la te p r in ­ ciples th a t d ic ta te a c tio n (B e n n er, 1 9 8 4 ). F o r e x a m p le , th e a d v a n c e d b e g in n e r grasps th e ra tio n a le b e h in d w h y d iffe re n t m e d ic a tio n s re q u ire d iffe re n t in je c ­ tio n te c h n iq u e s . H o w e v e r , a d v a n c e d b e g in n e rs s till la c k th e e x p e rie n c e to k n o w h o w to p rio r itiz e in m o re c o m p le x s itu a tio n s a n d m ig h t feel a t a loss in te rm s o f w h a t th e y c an safe ly lea ve o u t. T h e y e m p h a s ize th e ru les a n d do n o t h a v e th e e x p e rie n c e to a d ju s t o r a d a p t th e ru les to th e s itu a tio n . B o th th e a d v a n c e d b e g in n e r a n d th e n o v ic e stages re q u ire g u id a n c e . T h e s e stages p a ra lle l C o h e n ’s p ro fe s s io n a l d e v e lo p m e n t stage o f d e p e n d e n c e . G iv e n th e c o m p le x ity o f n u rs in g p ra c tic e a n d th e ra n g e o f c lin ic a l e xp e rien c es , m a n y n e w g ra d u a te s c an be d esc rib ed as a d v a n c e d b eg in n ers. B e n n e r’s stage 3 , c o m p e te n t, is c h a ra c te riz e d b y th e a b ility to a n a ly z e p ro b le m s a n d p rio ritiz e . T h e nurse has a solid grasp o f th e rules a n d p rin c ip les . M o v e m e n t fr o m one stage to th e n e x t does n o t cross d is tin c t b o u n d a rie s . T h e nurse a t th is stage has h a d e x p e rie n c e in a v a rie ty o f c lin ic a l s itu a tio n s a n d c an d r a w o n p r io r k n o w le d g e a n d e x p e rie n c e . T h e n u rse has th e a b ility to p la n as w e ll as to a lte r p lan s as necessary. S tu dents w h o h a v e th e o p p o rtu n ity to h a v e e x te n d e d in te rn s h ip s in a s p e c ia lty a rea d u rin g th e ir e d u c a tio n c an g ra d u a te e n te rin g th is stage. C o h e n ’s stage o f d e p e n d e n c e /m u tu a lity c o rre ­ sponds to th is stage. Stage 4 , p ro fic ie n t, re fers to th e p ro fe s s io n a l w h o c an g ra sp th e s itu a ­ tio n c o n te x tu a lly a n d as a w h o le . T h is n u rse has a s o lid grasp o f th e n o rm s as w e ll as s o lid experiences th a t shed lig h t o n th e v a ria tio n s fr o m th e n o r m . In c o rp o ra te d in to p ra c tic e is th e a b ility to test k n o w le d g e a g a in s t s itu a tio n s th a t m ig h t n o t fit a n d to solve p ro b le m s w it h a lte rn a tiv e a p p ro a c h e s . In th is stage, th e p ro fe s s io n a l tests th e rules a n d th e o rie s a n d lo o k s a t cases th a t can le a d to d e v e lo p in g a lte rn a tiv e rules a n d th e o rie s . O n e m ig h t say th a t th is is th e stage w h e n th e p ro fe s s io n a l begins to “ b re a k th e ru le s ” because he o r she sees th a t th e ru les d o n o t a lw a y s a p p ly . B e n n e r’s fin a l stage, e x p e rt, m eans th e nurse has m o v e d b e y o n d a fix e d set o f rules. T h e e x p e rt has an in te rn a liz e d u n d e rs ta n d in g g ro u n d e d in a w e a lth o f e x p e rie n c e as w e ll as d e p th o f k n o w le d g e . T h e e x p e rt is a lw a y s le a rn in g a n d a lw a y s q u e s tio n in g usin g s u b jec tive a n d o b je c tiv e k n o w in g . B e n n e r (1 9 8 4 ) p ro p o ses th a t n o t a ll nurses c an o b ta in th is stage.

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CHAPTER 6 Education and Socialization to the Professional Nursing Role

R e a lity S ho ck P ro fes sio n a l s o c ia liz a tio n re q u ire s th a t th e s tu d e n t le a rn th e te c h n o lo g y o f th e p ro fe s s io n , le a rn to in te rn a liz e th e p ro fe s s io n a l c u ltu re , fin d a p e rs o n a lly a n d p ro fe s s io n a lly a c c e p ta b le v e rs io n o f th e ro le , a n d in te g ra te th is p ro fe s s io n a l ro le in to a ll th e o th e r life roles (C o h e n , 1 9 8 1 ) . S tu dents a re ta u g h t an id e a l, th e o re tic a l, re s e a rc h -b a s e d p ra c tic e th a t shelters th e m fr o m th e re a litie s o f th e w o r ld w h e re n u rs in g p ra c tic e consists n o t o n ly o f th e th e o ry a n d research b u t h u m a n e m o tio n a n d respo nse, a lo n g w it h p o licie s a n d p ro c e d u re s o f th e p a rtic u la r w o r k in g e n v iro n m e n t. T h is c o n c e p t o f id e a lis m is im p o r ta n t to th e p ro fe s s io n because it c o n trib u te s to a h ig h s ta n d a rd o f p ro fe s s io n a l p ra c tic e . T h e p e rc e iv e d d is c o n n e c t b e tw e e n e d u c a tio n a n d p ra c tic e is k n o w n as ro le d is c re p a n c y . T h e re fo re , w h e n s tu d e n ts e n te r th e re a l w o r ld , th e c u ltu re o f th e c la s s ro o m a n d th e c u ltu re o f c lin ic a l p ra c tic e c an seem w o rld s a p a rt. T h e tr a n s itio n fr o m n u rs in g s tu d e n t to re g is te re d n u rse is re fe rre d to as re a lity s h o ck (K ra m e r, 1 9 7 4 ). R e a lity s h o ck occurs w h e n th e p e rc e iv e d ro le (h o w a n in d iv id u a l believes he o r she s h o u ld p e r fo r m in a ro le ) com es in to c o n flic t w it h th e p e rfo rm e d ro le (C a ta la n o , 2 0 0 9 ) . M a n y n e w g ra d u a te s e x p e rie n c e th is r e a lity s h o ck o f k n o w in g w h a t to d o a n d h o w to d o it b u t e n c o u n te rin g c irc u m s ta n ce s th a t p re v e n t th e m fr o m p e rfo r m in g th e ro le in th a t w a y (B lais , H a y e s , K o z ie r, & E rb , 2 0 0 5 , p . 2 1 ). R o le tr a n s itio n s h o ck is th e e x p e rie n c e o f m o v in g fr o m th e k n o w n ro le o f s tu d e n t to th e ro le o f p ra c tic in g p ro fe s s io n a l (D u c h s c h e r, 2 0 0 9 ) . R o le c o n flic t exists w h e n a n u rse c a n n o t in te g ra te th e id e a l, th e p e r­ c e iv e d , a n d th e a c tu a l p e rfo r m e d ro le in to o n e p ro fe s s io n a l ro le . F o r m a n y n u rs in g s tu d e n ts , ro le c o n flic t occurs w h e n th e y tr a n s itio n fr o m th e ro le o f s tu d e n t to th a t o f re g is te re d n u rse (P e llic o , B re w e r, & K o v n e r, 2 0 0 9 ) . T h e n e w g ra d u a te m o ves fr o m a p e rc e iv e d ro le o f w h a t th e p ro fe s s io n a l n u rse is a n d does to th e a c tu a l p e rfo r m e d ro le w h e re his o r h e r a ctio n s a n d beliefs m ig h t be c h a lle n g e d . T h e re a lity sh o ck, o r ro le tra n s itio n sh o ck, n e w g ra d u a te s e xp e rien c e can be re d u c ed to som e e x te n t. Schools o f n u rs in g h a ve im p le m e n te d o p p o rtu n itie s fo r exte rn s h ip s o r p ro lo n g e d p re c e p to r c lin ic a l experiences CRiTICAL THiNKiNG QUESTIONS V w it h a p ro fe s s io n a l n u rse p r io r to g ra d u a tio n . R e s e a rc h What do you think are the barriers to the (R u th -S a h d , B ec k, & M c C a ll, 2 0 1 0 ) show s h o w p a rtic ip a ­ process of professional socialization or for­ tio n in e x te rn p ro g ra m s eases th e g a p b e tw e e n e d u c a tio n mation? Do you think different environments a n d p ra c tic e . O n e g o a l o f th is e x p e rie n c e is to h e lp th e might foster or hinder the process of profes­ s tu d e n t a s s im ila te th e ro le o f th e p ro fe s s io n a l n u rse ju s t sional socialization or formation? Do you p r io r to g ra d u a tio n . T h e s tu d e n t c a n e x p e rie n c e a m o re think that personal characteristics of nurses re a lis tic v ie w o f c lin ic a l p ra c tic e in th e re a l w o r ld . A s one might influence the process of professional s tu d e n t re p o r te d , “ A ll th e le c tu re s a n d a s s ig n m e n ts in socialization or formation? V n u rs in g s c h o o l c a n n o t c o m p a re w it h th e a p p lic a tio n o f

Facilitating the Transition to Professional Practice

th e o ry th a t th is e x te rn s h ip o ffe r e d ” (R u th -S a h d et a l., 2 0 1 0 , p . 8 3 ). E x te r n ­ ships a n d p re c e p to r c lin ic a l e xp erien ces c an h e lp n u rs in g students b e g in th e ro le tr a n s itio n fr o m p e rc e iv e d ro le e x p e c ta tio n s to a c tu a l ro le e x p e c ta tio n s , th u s easin g th e tr a n s itio n fr o m s tu d e n t nurse to p ra c tic in g p ro fe s s io n a l.

F a c ilita tin g th e T ra n s itio n to P ro fe s s io n a l P ra c tic e T h e A m e ric a n A s s o c ia tio n o f C olleges o f N u rs in g ( A A C N , 2 0 0 8 ) lists th e roles o f th e p ro fe s s io n a l nurse as p ro v id e r o f c are, d e s ig n e r/m a n a g e r/c o o rd in a to r o f c are, a n d m e m b e r o f a p ro fe s s io n to fa c ilita te th e d e v e lo p m e n t o f p ro fe s s io n a l n u rs in g values. T h e concepts o f p a tie n t-c e n te re d c are, in te rp ro fe s s io n a l team s, e v id e n c e -b a s e d p ra c tic e , q u a lit y im p ro v e m e n t, p a tie n t s a fe ty , in fo r m a tic s , c lin ic a l re a s o n in g /c ritic a l th in k in g , genetics a n d g e n o m ics , c u ltu ra l s e n s itiv ­ ity , p ro fe s s io n a lis m , a n d p ra c tic e across th e life s p an in a n e v e r-c h a n g in g a n d c o m p le x h e a lth c a re e n v iro n m e n t are e m p h a s ize d as th e essentials o f p ro fe s ­ s io n a l n u rs in g e d u c a tio n . P ro fe s s io n a l s o c ia liz a t io n o f n u rse s t o w a r d a p ro fe s s io n t h a t f u lly e m b races c a rin g fo r s elf a n d o th ers reflects th e in te rn a liz a tio n o f w h a t R o a c h (1 9 9 1 ) refers to as “ th e fiv e C ’s: c o m p a s s io n , c o m p e te n c e , c o n fid e n c e , c o n ­ science, a n d c o m m itm e n t” (p . 1 3 2 ), re p re s e n tin g a fr a m e w o r k fo r h u m a n response fr o m w h ic h p ro fe s s io n a l c a rin g is expressed. C a rin g as a c o re v a lu e o f n u rs in g represents th e essence o f th e h is to ry o f n u rs in g a n d th e fo u n d a tio n fo r th e fu tu re (W a ts o n , 1 9 8 8 ). T h e g o a l in th e s o c ia liz a tio n o f nurses to d a y a n d fo r th e fu tu r e is to a c h ie v e c a rin g w it h a u to n o m y . T o fa c ilita te th e s o c ia liz a tio n in to th e p r o ­ fession, h o s p ita ls o ffe r fo rm a liz e d g ra d u a te n u rse p ro g ra m s o r in te rn s h ip s th a t p ro v id e g ra d u a te s w it h ro ta tio n s th r o u g h a n u m b e r o f c lin ic a l areas th a t in c lu d e p re c e p to r s u p p o rt. A fte r th e c o m p le tio n o f such p ro g ra m s , n e w nurses g a in a sense o f b e lo n g in g a n d c a n c o m p le te th e ir s o c ia liz a tio n in to th e c lin ic a l w o rk p la c e (M c K e n n a & N e w to n , 2 0 0 9 ) . In a d d itio n to fo rm a l e d u c a ­ tio n , p re c e p to rs c an assist s tu d e n ts to d e v e lo p s kills o f a s s e rtio n , re fle c tio n , a n d c ritic a l th in k in g , w h ic h a re n e e d e d to p ro v id e h o lis tic , e vid e n ce -b a se d c a re (M o o n e y , 2 0 0 7 ) . T h e c h a lle n g e fo r th e p ro fe s s io n is c a p ita liz in g o n th e stren g th s o f e v e ry o n e a n d fin d in g a m ean s o f a c c o m m o d a tin g a ll in d iv id u a ls as a w a y o f m a in ta in in g th e v ia b ilit y o f th e p ro fe s s io n (L e d u c & K o tz e r , 2 0 0 9 ) . T o m e e t th is c h a lle n g e , it is im p e r a tiv e th a t e d u c a to rs , s tu d e n ts , a n d p ra c titio n e rs re c o g n ize a n d in te g ra te th e A N A C o d e o f E t h ic s in b o th e d u ­ c a tio n a n d p ra c tic e . T h e re s u lt w ill be a m o re a d a p ta b le w o r k e n v iro n m e n t th a t n u rtu re s each in d iv id u a l w h ile a c h ie v in g h a r m o n y a n d b a la n c e w it h in th e p ro fe s s io n .

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C o nclu sio ns: R e fle c tiv e P ro fe s s io n a l P ra c tic e N u r s in g e d u c a tio n s h o u ld be h u m a n is tic a n d c a rin g , w it h c a rin g e x p e rts as ro le m o d e ls w h o c o n trib u te to th e s o c ia liz a tio n o f fu tu re g e n e ra tio n s o f nurses a n d h e lp th e m becom e c a rin g experts in n u rs in g p ra c tic e . T h r o u g h th e ir rese arch , C o n d o n a n d S h a rts -H o p k o (2 0 1 0 ) re p o rt th a t re fle c tio n c a n be an e ffe ctive m eans o f u n d e rs ta n d in g h u m a n e m o tio n a n d responses. O n e s tu d e n t stated , “ I th in k th e m o s t im p o r ta n t tim e is a fte r th e c lin ic a l tr a in in g w h e n I go h o m e . I th in k a b o u t th e in fo r m a tio n I get fr o m th e p a tie n t. W h a t does it m ean? W h a t does it m e a n fo r th e p a tie n t? I s h o u ld c o n n e c t to i t ” (C o n d o n & S h a rts -H o p k o , 2 0 1 0 , p . 1 6 9 ). R e g a rd in g ro le d e v e lo p m e n t a n d s o c ia liz a tio n , it is im p o r ta n t to re m e m b e r th a t w e le a rn w h a t w e liv e (B e c k e r-H e n tz , 2 0 0 4 ) .

Classroom A ctivit n c o r p o r a te a c tu a l q u o te s fr o m th e n urses w h o w e re in te rv ie w e d in B e n n e r’s b o o k F r o m N o v i c e to E x p e r t (1 9 8 4 ) in class discussions to illu s tra te th e d iffere n c es b e tw e e n each o f th e

I

stages: n o v ic e , a d v a n c e d b e g in n er, c o m p e te n t, p ro fic ie n t, a n d e x p e rt. T h is a c tiv ity is s im p le b u t e n lig h te n in g to stu d en ts,

R e fe re n c e s American Association of Colleges of Nursing. (2008). The Essentials o f baccalaureate education for professional nursing practice. Washington, DC: Author. American Nurses Association. (2001). Code o f ethics for nurses with interpretive statements. Washington, DC: Author. American Nurses Association. (2004). Scope and standards o f practice. Washington, DC: Author. Becker-Hentz, P. (2004). Understanding relationships: Learning what we live. Unpublished manuscript. Benner, P. (1984). From novice to expert. Menlo-Park, CA: Addison-Wesley. Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass. Blais, K. K., Hayes, J. S., Kozier, B., & Erb, G. (2005). Socialization to professional nursing roles. In K. K. Blais, J. S. Hayes, B. Kozier, & G. Erb (Eds.), Professional nursing practice: Concepts and perspectives (4th ed.). Upper Saddle River, NJ: Prentice Hall.

Catalano, J. (2009). Nursing now! (5th ed.). Philadelphia, PA: F. A. Davis. Cohen, H. A. (1981). The nurse’s quest for a professional identity. Menlo-Park, CA: Addison-Wesley. Condon, E., & Sharts-Hopko, N. (2010). Socialization of Japanese nursing students. Nursing Education Perspectives, 31(3), 167-169. Duchscher, J. E. B. (2009). Transition shock: The initial stage of role adaptation for newly graduated registered nurses. Journal o f Advanced Nursing, 65(5), 1103-1113. doi:10.1111/j.1365-2648.2008.04898.x Hentz, P. B. (2009). Socialization of nurses: A historical view. In Role development in professional nursing practice (2nd ed.). Sudbury, MA: Jones and Bartlett. Institute of Medicine. (2011). The future o f nursing: Leading change, advancing health. Washington. DC: National Academies Press. International Council of Nurses. (2006). Code o f ethics for nurses. Retrieved from http://www.icn.ch/about-icn/code-of-ethics-for-nurses Kramer, M. (1974). Reality shock, why nurses leave nursing. St. Louis, MO: 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), 279-284. Massachusetts Department of Higher Education. (2010). Nurse o f the future: Nursing core competencies. Retrieved from http://www.mass.edu/currentinit/documents/ NursingCoreCompetencies.pdf 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), 153-162. Mooney, M. (2007). Professional socialization: The key to survival as a newly qualified nurse. International Journal o f Nursing Practice, 30, 75-80. Ousey, K. (2009). Socialization of student nurses—the role of the mentor. Learning in Health and Social Care, 8(3), 175-184. 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, 194-203. Roach, M. S. (1991). Creating communities of caring. In National League for Nursing (Eds.), Curriculum revolution: Community building and activism (pp. 123-138). New York, NY: 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), 78-83. Watson, J. (1988). Nursing: Human science and human care. New York, NY: National League for Nursing Press.

Career Management and Care of the Professional Self Luann M. Daggett

S h a ro n is a 2 3 -y e a r -o ld re g is te re d n u rse ( R N ) w h o g ra d u a te d fr o m a n as­ s o c ia te ’s d e g re e n u rs in g p r o g r a m 3 y ea rs a g o . S ince g r a d u a tio n , she has w o r k e d a t a la rg e u n iv e rs ity -b a s e d h o s p ita l in a m a jo r m e tr o p o lita n a re a . H e r firs t a s s ig n m e n t w a s in a n o n c o lo g y u n it w h e re she w o r k e d as a s ta ff nurse fo r a y e a r b e fo re tra n s fe rrin g to th e c a rd io v a s c u la r re c o v e ry u n it. S h a ro n is a n o u ts ta n d in g s ta ff n u rs e , p r o v id in g e x c e lle n t c a re to h e r p a tie n ts a n d w o rk in g w e ll as a m e m b e r o f th e h e a lth c a re te a m . H e r p e rfo rm a n c e appraisals h a v e been p o s itiv e . A lth o u g h S h a ro n w o u ld lik e to r e tu r n to sch o o l fo r h e r b a c c a la u re a te degree, w o r k in g ro ta tin g shifts w it h v a ry in g schedules has p re ­ v e n te d h e r fr o m ta k in g classes. R e c e n tly , th e re w a s a n o p e n in g o n h e r u n it fo r a n assistant n u rse m a n ­ a g er. S h a ro n h o p e d to be c o n s id e re d fo r th e p o s itio n a n d w a s d is a p p o in te d w h e n a n o th e r n u rs e w h o m she c o n s id e re d less q u a lifie d g o t th e p o s itio n . D is cu ss in g th e d e cis io n w it h h e r s u p e rv is o r, S h a ro n ask ed w h y she h a d n o t b e en g iv e n th e jo b . T o h e r s u rp ris e, th e s u p e rv is o r re p lie d , “ W h y , S h a ro n , I h a d n o id e a y o u w e re in te re s te d !” S h a ro n le ft th e m e e tin g fe e lin g h u r t, a n g ry , fru s tra te d , a n d d e v a lu e d . She c o u ld n o t u n d e rs ta n d w h y a ll o f h e r h a rd w o r k h a d g o n e u n n o tic e d (a n d u n re w a rd e d ) b y h e r s u p e rv is o r. A lth o u g h in c o n v e ­ n ie n t, S h a ro n is th in k in g a b o u t c h a n g in g jobs a n d m o v in g to a n e w h o s p ita l in a d iffe re n t p a r t o f th e c ity .

Key Terms and Concepts » » » » » » » » » » » » » » »

C a re e r m an ag e m en t Journaling Core values Mission statem ent Success Objectives 5-year plan Public speaking Networking Mentoring Feedback Lifelong learning Burnout Self-care Life management

Learning Objectives A f t e r c o m p le tin g th is c h a p te r, th e s tu d e n t should be a b le to : 1. D escribe th e d iffe re n c e b e tw ee n an occup ation and a c a re e r. 2 . A rtic u la te th e im p o rta n c e of assum ing a p ro ac ­ tiv e role in m an aging y o u r nursing c a re e r. 3 . S e t c a r e e r g o a ls an d fo r m u la te o b je c tiv e s designed to m e e t th e goals. 4 . D escribe sp ecific s tra te g ie s fo r increasing p e r­ sonal v is ib ility w ith in an o rg a n iz a tio n .

5 . E x p la in m e th o d s fo r o b ta in in g fe e d b a c k on perso nal p e rfo rm a n c e . 6 . D es crib e th e e ffe c ts o f w o rk -re la te d s tre s s on h e a lth and c a re e r lo n g e v ity . 7 . A rtic u la te th e im p o rta n c e o f life m a n a g e m e n t fo r o p tim a l perso nal and p ro fessio n al h e alth .

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S h a ro n ’s s to ry , u n fo rtu n a te ly , is ty p ic a l o f th e w a y m a n y nurses a p p ro a c h th e ir jo b s . C a re e r m a n a g e m e n t is n o t a c o n c e p t th a t is fa m ilia r to th e m . F o r m a n y , n u rs in g is s till v ie w e d as a c a llin g o r v o c a tio n ra th e r th a n as a c a re e r th a t needs m a n a g in g . D e s p ite th e in c re a s in g n u m b e r o f m e n e n te rin g n u rs in g in th e p a s t fe w y e a rs , n u rs in g is s till a fe m a le -d o m in a te d p ro fe s s io n , a n d w o m e n see c a re e r m a n a g e m e n t as s e lf-p ro m o tio n . T h e y are u n c o m fo rta b le c a llin g a tte n tio n to th e ir a c c o m p lis h m e n ts , a s k in g fo r re c o g n itio n , o r n e g o ti­ a tin g raises a n d p ro m o tio n s . A s a re s u lt, m a n y nurses d o n o t receive th e p o s i­ tiv e fe e d b a c k , re c o g n itio n , a n d c a re e r a d v a n c e m e n t o p p o rtu n itie s th a t th e y deserve. F e e lin g c h ro n ic a lly u n d e rv a lu e d a n d u n a p p re c ia te d , nurses b eco m e b u rn e d o u t, c h an g e jo b s , o r lea ve th e p ro fe s s io n a lto g e th e r.

O c c u p a tio n v s . C a re e r N u rs in g as a c a re e r is as m u c h a p h ilo s o p h ic a l a p p ro a c h as it is a p ro fe s s io n a l c h o ice . T h e d iffe re n c e is w h e th e r o n e considers n u rs in g a n o c c u p a tio n o r a c are er. O c c u p a tio n is d e fin e d as (1 ) a n a c tiv ity th a t keeps a p e rs o n b usy o r (2 ) o n e ’s jo b o r e m p lo y m e n t (O x f o r d U n iv e rs ity Press, 1 9 9 6 ). In c o m p a ris o n , a career is a course o f p ro fe s s io n a l life o r e m p lo y m e n t th a t a ffo rd s th e in d iv id u a l o p p o rtu n itie s fo r p e rs o n a l a d v a n c e m e n t, p ro g ress, o r a c h ie v e m e n t (M ille r , 2 0 0 3 ) . S om e p e o p le v ie w n u rs in g as a jo b o r a n o c c u p a tio n , w h e re a s others ta k e th e a p p ro a c h th a t n u rs in g is a p ro fe s s io n re q u irin g a life lo n g c o m m it­ m e n t. T a b le 7 -1 c o m p a re s a ttitu d e s to w a r d n u rs in g as e ith e r a n o c c u p a tio n o r a c a re e r. I f y o u choose to v ie w n u rs in g as a p ro fe s s io n a l c a re e r, y o u w ill b e h a v e d iffe re n tly th a n i f y o u c o n s id e r it as m e re ly a jo b th a t is m o s t lik e ly te m p o ra ry o r a m eans to a n end. A c a re e r is n o t s o m e th in g th a t is a u to m a tic a lly c o n ­ fe rre d a lo n g w it h a c o lle g e degree; it is a life c h o ic e th a t m u s t be a c tiv e ly p la n n e d a n d p u rs u e d . A d e g re e a n d a n u rs in g lice n se m ig h t be th e tic k e t th a t gets y o u s ta rte d o n th e jo u r n e y , b u t w it h o u t a d e s tin a tio n , a n itin e r a r y , a n d a m a p , y o u w i l l n o t tr a v e l v e ry fa r . L ik e a n y im p o r ­ ta n t jo u rn e y , a c a re e r re q u ire s re s e a rc h a n d p la n n in g ; o th e rw is e , y o u ris k m is s in g o p p o rtu n itie s a n d c r itic a l m ile s to n e s a lo n g th e w a y . O n e s h o u ld a lw a y s assess th e c u rre n t lo c a tio n b e fo re p la n n in g fu tu r e d ire c tio n s . Just as y o u tr a c k pro g ress w it h a m a p w h ile o n a ro a d tr ip , y o u s h o u ld h a v e a p la n fo r m a n a g in g y o u r c a re e r, lest y o u fin d y o u rs e lf w a n d e rin g in th e w i l ­ derness w it h o u t m a k in g a n y tr u e p ro g res s to w a r d y o u r W W W 1 CRITICAL THINKING QU ESTIO N S* c a re e r g o a ls . C a r e e r m a n a g e m e n t c a n be d e fin e d as a p la n n e d lo g ic a l p ro g re s s io n o f o n e ’s p ro fe s s io n a l life th a t Do you view nursing as a career or a job? in c lu d e s c le a r ly d e fin e d g o als a n d o b je c tiv e s a n d a p la n What are your goals related to nursing? V fo r a c h ie v e m e n t. J o el (2 0 0 3 ) advises b u ild in g a n u rs in g

Common Myths and Misconceptions

[

TA B LE 7-1 Factor

169

Com parison of A ttitu d e s : Occupation vs. C areer Occupation

Career

Longevity

T e m p o r a r y , a m ean s to a n end

L ife lo n g v o c a tio n

Educational Preparation

M i n i m a l tr a in in g th a t is re q u ire d , u s u a lly associate degree

U n iv e rs ity p ro fe s s io n a l degree p ro g ra m based o n a fo u n d a tio n o f c o re lib e ra l arts

Continuing Education

O n ly w h a t is re q u ire d fo r th e jo b o r to get a ra is e /p ro m o tio n

L ife lo n g le a rn in g , c o n tin u o u s e f­ fo rts to g a in n e w k n o w le d g e , s kills, a n d a b ilitie s

Level of Commitment

S h o rt-te rm , as lo n g as jo b m eets p e rs o n a l needs

L o n g -te rm c o m m itm e n t to o rg a n iz a tio n a n d p ro fe s s io n

Expectations

R e a s o n a b le w o r k fo r re a s o n ­ a b le p a y ; re s p o n s ib ility ends w it h s h ift

W il l assum e a d d itio n a l re s p o n s ib ili­ ties, v o lu n te e r fo r o rg a n iz a tio n a l a c tiv itie s a n d c o m m u n ity -b a s e d events

'

c a re e r c a u tio u s ly a n d d e lib e ra te ly , la y in g each b ric k in a p re d e te rm in e d p a t­ te rn . T h is re q u ire s c a re fu l c o n s id e ra tio n o f w h a t it is y o u lik e to d o , w h a t y o u a re g o o d a t, w h e re y o u w o u ld e v e n tu a lly lik e to be p ro fe s s io n a lly , a n d w h a t s kills a n d e d u c a tio n y o u w i l l n e ed to g e t th e re .

C o m m o n M y th s and M is c o n c e p tio n s T a b le 7 -2 lists a n u m b e r o f c o m m o n m y th s a n d m is c o n c e p tio n s th a t m a n y n u rse s h o ld . T h e a ttitu d e t h a t o n e ’s s u p e rv is o r is re s p o n s ib le fo r ta k in g c a re o f y o u is a c o m m o n e x a m p le o f a n e m p lo y e e ’s fla w e d th in k in g . G o o d w o rk s d o n o t s p e a k fo r th e m s e lv e s — m is Your supervisor has many ta k e s s p e a k fo r th e m s e lv e s , a n d th e y s p e a k lo u d ly a n d role responsibilities-looking c le a rly . Q u a lity p a tie n t care is a n e x p e c ta tio n o f th e n u rs e ’s out for your career is not one jo b a n d g e n e r a lly goes u n n o tic e d u n t il e ith e r a m is ta k e of them. is m a d e o r a c o m p la in t is re c e iv e d . Y o u r s u p e rv is o r has m a n y ro le re s p o n s ib ilitie s — lo o k in g o u t fo r y o u r c a re e r is n o t o n e o f th e m . M a n y nurses b e lie v e th a t because o f th e n u rs in g s h o rta g e th e y w ill be g u a ra n te e d a jo b . In fa c t, a la rg e n u m b e r o f students e n te r n u rs in g p ro g ra m s th in k in g th a t th e y w ill a lw ay s h ave jo b security. A lth o u g h g rad u ates o f n u rsin g p ro g ra m s g e n e ra lly h a v e h ig h ly m a r k e ta b le s k ills , n u rs in g p o s itio n s a re as

r

A

K.

J

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CHAPTER 7 Career Management and Care of the Professional Self

TAB LE 7 -2

Common M yth s and M isconceptions

• • •

I f I w o r k h a rd , I w ill be re w a rd e d . G o o d w o rk s sp ea k fo r th em selves. I t is m y boss’s jo b to re c o m m e n d m e fo r special assig nm ents o r p r o m o tio n . • A s a re g istere d n u rse , I w ill a lw a y s h a v e a jo b . • M y h o s p ita l w ill lo o k o u t fo r m e.

susceptible to e c o n o m ic flu c tu a tio n s as th o se in a n y o th e r fie ld . T h e n u rs in g s h o rta g e does n o t m e a n jo b s e c u rity ; a n u rs in g s h o rta g e u s u a lly leads to a p r o life r a tio n o f u n lice n s ed assistive p e rs o n n e l th a t a c tu a lly erodes th e ro le o f p ro fe s s io n a l nurses. T h e n o tio n th a t h o s p ita ls a n d h e a lth c a re agencies lo o k o u t fo r th e concerns o f nurses is u n re a lis tic . W h e th e r o p e ra te d fo r p r o fit o r n o t, h e a lth c a re fa c ilitie s a re businesses th a t a re c o n c e rn e d w it h p ro v id in g services to custom ers fo r a fee. I f p ro d u c tio n costs exceed p ro fits , a d ju stm e n ts m u s t be m a d e o r th e business w ill fo ld . N u rs in g c are is e xp e n siv e to p ro v id e , a n d th u s, it is o fte n ta rg e te d fo r cost re d u c tio n . H e a lth c a re agencies o p e ra te in th e ir o w n best in te re sts, w h ic h m ig h t n o t c o in c id e w it h th e interests o f th e n u rs in g s taff. I t is o u r re s p o n s ib ility to m a n a g e o u r o w n careers. Y o u r boss has o th e r th in g s to d o th a n to fo llo w y o u r care er. I t is y o u r re s p o n s ib ility to get th e level o f re c o g n itio n th a t y o u n e ed a n d to seek o p p o rtu n itie s th a t w ill a d v a n c e y o u r o w n c a re e r. Passive, o b e d ie n t b e h a v io r does n o t get y o u fa r in th e re a l w o r ld a n d n e ith e r does s ittin g b a c k w a itin g fo r oth ers to lo o k o u t fo r y o u . In th e re a l w o r ld , y o u c a n n o t a ffo r d to w a it y o u r tu r n fo r g o o d th in g s to h a p p e n — y o u h a v e to m a k e th e m h a p p e n .

S e ttin g P e rs o n a l G oals T h e firs t step in c a re e r m a n a g e m e n t is to k n o w w h e re y o u w a n t to go p ro fe s ­ s io n a lly . U nless y o u h a v e a c le a r u n d e rs ta n d in g o f th e fin a l d e s tin a tio n , it is im p o s s ib le to select th e best ro u te to fo llo w to get th e re . I f y o u set o u t o n a tr ip w it h o u t k n o w in g y o u r fin a l d e s tin a tio n , h o w c a n y o u p o s s ib ly choose th e best ro a d to ta k e to g e t th ere? T h is is p r o b a b ly th e m o s t d iffic u lt p a r t o f c a re e r m a n a g e m e n t. A re a s o n a b le a p p ro a c h w o u ld be to c o n s id e r w h ic h aspects o f n u rs in g are m o s t a p p e a lin g to y o u . D o y o u lik e th e in te ra c tio n o f d ire c t p a tie n t c are , o r d o y o u p re fe r to d ire c t o th ers in p ro v id in g care? A re y o u m o re c o m fo rta b le in an a cu te care settin g , o r d o y o u fa v o r th e s ta b ility o f lo n g -te rm care o r r e h a b ilita tio n settings? D o y o u lik e to te a c h others? A re y o u m o re a t ease le a d in g o r fo llo w in g ? Because p ro fe s s io n a l a ctiv itie s a lw a y s ta k e

p lac e w it h in th e c o n te x t o f p e rs o n a l needs a n d re s p o n s ib ilitie s , it is im p o r ta n t to c o n s id e r w h a t th ose m ig h t be as w e ll. F o r m a n y o f us, g o a l s ettin g a n d v is u a liz in g a d e sire d fu tu re a re d iffic u lt tasks. A t som e p o in t in o u r e a rly e d u c a tio n , w e m a d e th e d e cis io n to b e co m e a n u rse a n d set o u r sights o n p re p a rin g fo r e n tra n c e in to a n u rs in g p ro g ra m . T h e n w e fo cused o n s u rv iv in g th e rig o ro u s course o f s tu d y a n d g ra d u a tin g . A f t e r g r a d u a tio n c a m e th e c h a lle n g e o f fin d in g a n d a d ju s tin g to o u r firs t n u rs in g p o s itio n . L o n g -ra n g e goals w e re n o t s o m eth in g w e gave m u c h th o u g h t to u n til re a c h in g a p o in t w h e re b e in g a s ta ff n u rse w a s n o lo n g e r e x c itin g o r c h a lle n g in g . A t th is p o in t, m a n y nurses decid e to r e tu r n to schoo l to seek an a d v a n c e d degree in n u rs in g w it h little th o u g h t as to w h a t e x a c tly th e y w is h to s tu d y o r w h a t th e y u ltim a te ly p la n to d o w it h a n a d d itio n a l degree. T h e y choose p ro g ra m s th a t a re c o n v e n ie n t o r accessible, r a th e r th a n s ea rch in g fo r th e r ig h t e d u c a tio n a l p r o g r a m to m e e t specific le a rn in g needs. O f t e n th e y decide to a p p ly to schoo l because frie n d s o r colleagu es a re d o in g so, a n d th e y d o n o t w a n t to feel le ft b e h in d . T h e d e cis io n to r e tu r n to schoo l o r m a k e a m a jo r c a re e r c h an g e s h o u ld n e v e r be m a d e h a s tily ; ra th e r, it s h o u ld o c c u r a fte r a p e rio d o f c a re fu l in tr o ­ s p ec tio n a n d d is c e rn m e n t. C o n s id e ra tio n s h o u ld be g iv e n to issues such as th e fo llo w in g : • • • • • •

P e rs o n a l values P ro fe s s io n a l values F a m ily issues a n d re s p o n s ib ilitie s L ife s ty le choices E c o n o m ic fa cto rs C o m m u n ity a n d re c re a tio n a l in v o lv e m e n t

E d u c a tio n a l p ro g ra m s are d e m a n d in g a n d costly— fin a n c ia lly , p s yc h o lo g i­ c a lly , a n d s o c ia lly . R e tu rn in g to schoo l re q u ire s c o m m itm e n t, n o t ju s t fr o m th e in d iv id u a l w h o w ill be s tu d y in g , b u t also fr o m fa m ily m e m b e rs , frie n d s , e m p lo y e rs , a n d o th e r p e o p le in o n e ’s social n e tw o r k . L ik e w is e , jo b o r care er changes a re stressful a n d h a v e lo n g -te rm effects o n fin a n c es , p e rs o n a l h a p p i­ ness, a n d in te rp e rs o n a l re la tio n s h ip s . T h e se decisions s h o u ld n e v e r be m a d e c a s u a lly o r im p e tu o u s ly .

■ Journaling Techniques, W riting O bjectives V a rio u s exercises a n d b o o k s o n values c la rific a tio n a re a v a ila b le in bo o ksto res o r o n th e In te rn e t; h o w e v e r, one o f th e m o s t effective m eans o f in tro s p e c tio n is jo u rn a lin g . J o u rn a lin g is th e process b y w h ic h one sits d o w n q u ie tly o n a d a ily o r re g u la r basis to th in k a n d re c o rd o n e ’s th o u g h ts a n d ideas in a n o te b o o k . T h e re are m a n y suggested te ch n iq u es fo r jo u rn a lin g ; one useful m e th o d is to re c o rd th re e th in g s — events, ideas, o r th o u g h ts — th a t w e re im p o r ta n t to y o u th a t d a y . T h e se c a n in c lu d e th in g s th a t h a p p e n e d a t w o r k o r in y o u r p e rs o n a l

life . A s y o u re c o rd y o u r th o u g h ts , be sure to in c lu d e a n y p a rtic u la r insigh ts th a t o c c u r to y o u . I t is im p o r ta n t th a t y o u d o th is o n a d a ily basis o r a t least fiv e to s ix tim e s a w e e k . A t th e en d o f th e w e e k , re v ie w y o u r jo u rn a l e n tries, lo o k in g fo r th em es o r p a tte rn s in y o u r w r itin g . B e sure to w r ite these obser­ v a tio n s . O n c e a m o n th lo o k b a c k th ro u g h y o u r jo u rn a l to assess th e issues, ideas, o r events th a t w e re im p o r ta n t to y o u th a t m o n th . R e c o rd y o u r insigh ts. A s y o u w r ite , th e em p hasis s h o u ld be o n re c o rd in g y o u r th o u g h ts as th e y o c cu r to y o u . G r a m m a r , s p ellin g , sentence s tru c tu re , a n d h a n d w ritin g are n o t im p o rta n t. T h is jo u rn a l is fo r y o u r eyes o n ly , a n d substance is m o re im p o rta n t th a n fo rm . S om e p e o p le are m o re c o m fo rta b le w r itin g fra g m e n ts o f sentences o r m a k in g lists o f th e ir id ea s , w h e re a s o th ers p re fe r th e c ath ars is o f w r itin g pages o f te x t. E ith e r s tyle is e ffe c tiv e , w h ic h e v e r w o rk s best fo r y o u . T h e im p o r ta n t th in g is re g u la r ity . O n e ’s d a ily a c tiv itie s a re lik e th e fin e stitches o f a ta p e s try ; e x a m in e d c lo s e -u p th e y are in te re s tin g b u t lim ite d . B y s tep p in g b a c k a n d lo o k in g a t th e d e ta ils o f o n e ’s life o v e r a p e rio d o f tim e , y o u see a m o re c o m p le te p ic tu re a n d g a in a sense o f th e core values th a t give d e p th a n d m e a n in g to life . C ore What are your core values? Do you see con­ v a lu e s a re th o se values th a t a re m o s t im p o r ta n t to us, th e gruence between what you value and your values th a t define w h o w e are as h u m a n beings. T h e re m u s t career? V be c o n g ru e n c e b e tw e e n w h a t it is y o u v a lu e a n d w h a t it is y o u d o b e fo re s a tis fa c tio n c an be d e riv e d fr o m o n e ’s w o r k . O n c e y o u h a v e a n a p p re c ia tio n o f w h a t is tr u ly im p o r ta n t to y o u , C o v e y (1 9 8 9 ) re c o m m e n d s d e v e lo p in g a p e rs o n a l m is s io n s ta te m e n t th a t includ es a ll o f y o u r life roles a n d th e values th a t y o u a tta c h to o r express in th ose ro le s. A m ission s ta te m e n t is a c le a r, concise s ta te m e n t o f w h o y o u a re a n d w h a t y o u a re a b o u t in life . I t c an be a p o w e r fu l to o l fo r h e lp in g y o u fin d m e a n in g a n d give d ire c tio n to y o u r life . U n t il one u n d e rs ta n d s w h a t is tr u ly im p o r ta n t a n d essential to o n e ’s happiness in b o th th e p ro fe s s io n a l a n d p e rs o n a l arenas, it is im p o s s ib le to p la n a fu tu re o r m a n a g e a c a re e r e ffe c tiv e ly . U n d e rs ta n d in g y o u r values a n d life m issio n a llo w s y o u to discern w h ic h p ro fes s io n al a ctivities p ro v id e y o u w it h a sense o f a c c o m p lis h m e n t a n d re w a rd . A s y o u feel th e need to g r o w p ro fe s s io n a lly , it is im p o r ta n t th a t y o u set goals a n d m a k e choices based o n c o re values in s te a d o f c irc u m s ta n c e o r w h im . S u c ce ss in life c a n be d e fin e d as d o in g w h a t y o u w a n t, w h e re y o u w a n t, a n d w it h th e p e o p le y o u w a n t to d o it w it h . T h is im p lie s b a la n c e w it h in th e v a rio u s aren a s o f y o u r life — p ro fe s s io n a l, p e rs o n a l, s o cia l, a n d s p iritu a l. W h e n y o u h a v e d e cid e d o n a d ire c tio n fo r y o u r p ro fe s s io n a l c a re e r, it is essential th a t y o u c an v is u a liz e c le a rly th e o u tc o m e y o u desire. C o v e y (1 9 8 9 ) believes th a t v is u a liz in g s o m e th in g o rg an izes o n e ’s a b ility to a c c o m p lis h it; o n e m u s t b e g in w it h th e e n d in m in d . T h e m o re p re c is e ly y o u a re a b le to v is u a liz e e x a c tly w h a t it is y o u desire, th e m o re c le a rly y o u w ill be a b le to d is tin g u is h th e steps it w ill ta k e fo r y o u to a ch ieve y o u r g o a l. O b je c tiv e s a re specific m ea s u res th a t y o u w i l l ta k e in a c h ie v e m e n t o f y o u r g o a l. W r it in g o b je ctiv es p ro v id e s y o u w it h a p la n o n h o w y o u a re g o in g to get fr o m w h e re

Career Management Strategies

TABLE 7-3

C areer Goal: Fam ily Nurse P ra c titio n e r

G o a l: T o b e co m e a c e rtifie d F a m ily N u rs e P ra c titio n e r O b je c tiv e s : • C o n ta c t u n iv e rs ity fo r p ro g ra m in fo r m a tio n a n d a p p lic a tio n m a te ria ls . • S ch edu le th e G r a d u a te R e c o rd E x a m in a tio n . • P u rc h a se th e G r a d u a te R e c o rd E x a m in a tio n s tu d y g u id e a n d re v ie w one c h a p te r p e r w e e k . • C o n ta c t th re e p ro fe s s io n a l sources fo r re fe re n c e lette rs. • C o m p le te h e a lth in fo r m a tio n fo rm s a n d schedule p h y sic al e x a m in a tio n . • S u b m it a p p lic a tio n m a te ria ls b e fo re th e fa ll d e a d lin e . • A p p ly fo r fin a n c ia l a id . • M a k e a p p o in tm e n t w it h a c a d e m ic a d v is o r to p la n p ro g ra m o f s tu d y . • R e g is te r fo r classes.

y o u a re to y o u r d esired fu tu re . O b je c tiv e s s h o u ld be specific a n d m e a s u ra b le , serving as m ile s to n e s th a t m a r k y o u r pro gress. O b je c tiv e s m u s t in c lu d e a tim e fra m e fo r th e ir a c c o m p lis h m e n t. T a b le 7 -3 show s a n e x a m p le o f a g o a l a n d its c o n c o m ita n t o b je ctiv es fo r a nurse w h o w a n ts to b e co m e a fa m ily nurse p ra c titio n e r. I t is c le ar fr o m this e x a m p le th a t one c o u ld re a lis tic a lly a tta in this g o a l b y fo llo w in g th e o b jectives in th is p la n . T h e m o re d e ta ile d a n d specific y o u r o b je ctiv es , th e easier it w ill be to fo llo w th e steps re q u ire d to re a c h y o u r g o a l. T h e d iffe re n c e b e tw e e n p e o p le w h o a re successful in life a n d th ose w h o o n ly d re a m o f success is th e a b ility to v is u a liz e th e ir d re am s a n d c o m p le te th e steps th a t c o n n e c t th e ir p re s e n t w it h th e ir fu tu re . A lth o u g h it is h ig h ly d e sira b le to k n o w o n e ’s u ltim a te p ro fe s s io n a l goals, fo r m a n y o f us, it m ig h t be u n re a lis tic to lo o k th a t fa r in to th e fu tu re . T h a t does n o t m e a n y o u r c a re e r s h o u ld p ro c e e d w it h o u t a p la n ; ra th e r, y o u r p lan s m a y be m o re s h o rt te rm . D e v e lo p in g s h o rt-ra n g e g o als such as w h e re y o u w o u ld lik e to be in 5 years m ig h t be a m o re re a s o n a b le a p p ro a c h fo r y o u . D e fin in g a 5 -y e a r plan enables y o u to set c le a r o b je ctiv es a n d fo llo w specific steps o n h o w to m ee t those objectives w h ile a llo w in g fo r fle x ib ility in a d ju stin g to c h a n g in g life c irc u m s ta n ce s.

C a re e r M a n a g e m e n t S tra te g ie s Assessing y o u r c u rre n t p o s itio n is a g o o d place to b e g in m a n a g in g y o u r career. A re y o u eng ag ed in w o r k th a t is s o c ia lly s ig n ific a n t, c h a lle n g in g , re w a rd in g , a n d fu lfillin g ? D o y o u g e n e ra lly lo o k fo r w a r d to g o in g to w o r k a n d e n jo y th e tim e th a t y o u s pend th ere? D o y o u lik e a n d re sp e ct th e p e o p le w it h w h o m y o u w o rk ? A re th e s a la ry a n d benefits y o u re ce ive fo r y o u r w o r k re a s o n a b le

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a n d s u ffic ie n t to a c c o m m o d a te y o u r life s ty le ? A r e th e re o p p o rtu n itie s fo r a d v a n c e m e n t w it h in y o u r o rg a n iz a tio n ? I f y o u c a n n o t re s p o n d p o s itiv e ly to these q u e stio n s, y o u h a v e tw o choices: E ith e r stay w h e re y o u a re a n d w o r k to im p ro v e th e s itu a tio n , o r lo o k fo r a n o th e r p o s itio n . O n ly y o u c an m a k e th is d e cis io n , h o w e v e r; i f y o u r jo b s itu a tio n is n o t w o r k in g fo r y o u , it is up to y o u to d o s o m e th in g a b o u t i t . O n c e y o u h a v e d e cid e d th a t a jo b c h an g e is th e rig h t m o v e fo r y o u , it is im p o r ta n t th a t y o u set a b o u t fin d in g a p o s itio n th a t w ill m e e t y o u r p e rs o n a l a n d p ro fe s s io n a l need s. K n o w in g w h a t y o u a re lo o k in g fo r is v ita l to y o u r success. A c a re fu l analysis o f y o u r o ld jo b — w h a t y o u lik e d a n d d is lik e d a b o u t th e jo b a n d y o u r ro le in c re a tin g a n d s u s ta in in g th e s itu a tio n — c an h e lp y o u a v o id s im ila r p itfa lls in y o u r n e x t p o s itio n . T h is is w h e re jo u rn a lin g c an be v e ry u s efu l in c le a rly d e fin in g y o u r e x p e c ta tio n s . I f p o s sib le , n e v e r lea ve a jo b u n til y o u h a v e a fir m c o m m itm e n t fr o m a n e w e m p lo y e r. F in d in g th e p e rfe c t jo b is la b o r in te n s iv e a n d tim e c o n s u m in g . T r y in g to d o so w h e n y o u a re u n e m p lo y e d a n d fa c in g fin a n c ia l h a rd s h ip is a lm o s t im p o s s ib le . T h e o ld a d ag e “ g o o d jobs a re h a rd to fin d ” is v e ry tru e . M a n y p e o p le h u n t fo r p ro s p e c tiv e jobs in n e w s p ap ers o r v is it In te rn e t c a re e r w e b s ites . T h is s tra te g y m ig h t be th e best o p tio n i f y o u a re u n fa m ilia r w it h th e lo c a l jo b m a r k e t o r a re re lo c a tin g to a n e w a re a . K e e p in m in d , h o w e v e r, th a t m o s t o rg a n iz a tio n s firs t p o s t p o s itio n o p e n in g s in h ouse to a llo w th e ir e m p lo yees o p p o rtu n itie s fo r a d v a n c e m e n t o r la te ra l tra n s fe rs . Because it can be d iffic u lt fo r ou tsid ers to k n o w a b o u t these o p e n in g s , y o u m ig h t c o n s id e r b e g in n in g y o u r jo b search w it h in y o u r p re s e n t o rg a n iz a tio n . A lo n g w it h c o n ­ ta c tin g th e h u m a n resources d e p a rtm e n t fo r a lis tin g o f c u rre n t jo b o p en in g s, it is im p o r ta n t fo r y o u to b e g in n e tw o r k in g a n d ta lk in g to p e o p le w it h in y o u r o rg a n iz a tio n w h o m ig h t be a b le to h e lp y o u a d v a n c e y o u r c a re e r g o a ls. Y o u r u n it s u p e rv is o r, o th e r m a n a g e rs , o r y o u r n u rs in g service a d m in is tra to r are a ll p o te n tia l sources fo r lea d s . E v e n i f th e re is n o t a c u rre n t o p e n in g in th e a rea y o u seek, exp re ss in g y o u r in te re s t to in flu e n tia l p e o p le p u ts y o u in m in d if s o m e th in g becom es a v a ila b le . I f y o u r jo b search takes y o u to u n fa m ilia r te r r ito r y , m o d e rn jo b h u n tin g c an be fa c ilita te d b y te c h n o lo g y . M o s t h e a lth c a re agencies h a ve w ebsites th a t p o s t c u rre n t p o s itio n o p e n in g s a lo n g w it h a d e s c rip tio n o f th e fa c ility , th e services it o ffe rs , a n d its m is s io n s ta te m e n t a n d p h ilo s o p h y . Y o u m ig h t also c o n s id e r p o s tin g y o u r re su m e w it h a n o n lin e h e a lth careers d a ta b a s e w h e re p ro s p e c tiv e e m p lo y e rs c an search fo r q u a lifie d e m p lo ye es . B ecause th e re is n o c o n tro l o v e r w h o has access to y o u r in fo r m a tio n , use c a u tio n in lis tin g p e rs o n a l in fo r m a tio n in a n o n lin e re su m e . A lte r n a tiv e ly , y o u m ig h t w a n t to c o n ta c t colleagu es in a g e o g ra p h ic a l lo c a le b y jo in in g lo c a l c h a p te rs o f a p r o ­ fe ss io n a l o rg a n iz a tio n o r re g is te rin g fo r n e w s g ro u p s o r c h a t ro o m s to m a k e p ro fe s s io n a l c o n ta c ts . R eg a rd les s o f w h e th e r y o u choose to lo o k in te rn a lly o r e x te rn a lly fo r jo b o p p o rtu n itie s , c re a tin g a p o s itiv e firs t im p re s s io n o f y o u a n d y o u r w o r k is e x c e e d in g ly im p o rta n t.

■ First Impressions F irs t im p ressio n s— w h e th e r it is b y te le p h o n e , le tte r o f in q u iry , re su m e, e m a il, o r p e rs o n a l in te r v ie w — b e g in w it h y o u r in it ia l c o n ta c t w it h a n o r g a n iz a ­ tio n . A fa v o ra b le firs t im p re s s io n creates a h a lo e ffe c t th a t lasts a lo n g tim e . L ik e w is e , it is v e ry d iffic u lt to a lte r a n in itia l n e g a tiv e im p re s s io n , a n d th e m o re n e g a tiv e th e im p re s s io n , th e h a rd e r it is to ch an g e. Y o u w a n t to p re s ­ e n t y o u rs e lf in such a w a y th a t p e o p le ta k e y o u s erio u s ly a n d lis te n to w h a t y o u h a v e to o ffe r . I f y o u r firs t c o n ta c t is a w r it te n c o m m u n ic a tio n , e ith e r a le tte r o f in q u ir y , re s u m e , o r a jo b a p p lic a tio n fo r m , be sure y o u r w r itin g conveys a tru e re p re s e n ta tio n o f w h o y o u a re . L e tte rs s h o u ld a lw a y s be ty p e d a n d w r it te n c le a rly a n d c o n c is e ly a n d be free o f s p e llin g , p u n c tu a tio n , a n d g ra m m a tic a l e rro rs . L ik e w is e , a p p lic a tio n fo rm s s h o u ld be ty p e d o r p rin te d c le a r ly u s in g b la c k in k . T h e in fo r m a t io n m u s t be c o m p le te , a c c u ra te , a n d free o f e rro rs . I f y o u r w r it te n c o m m u n ic a tio n is s lo p p y o r g ra m m a tic a lly in c o rre c t, th e re v ie w e r w ill assum e th a t y o u a re careless o r u n e d u c a te d . T h is is n o t th e im p re s s io n y o u First impressions begin with w a n t to c o n v e y to a p ro s p e c tiv e e m p lo y e r. U s e fu l h in ts fo r your initial contact with an resu m e p re p a ra tio n c a n be fo u n d o n v a rio u s w ebsites such organization. as n u r s in g lin k .m o n s te r.c o m /b e n e fits /a rtic le s /7 3 9 4 -7 -b e s tre s u m e -tip s -fo r-n u rs e s a n d w w w .n u r s in g -e x a m s .c a /b lo g / th e -in te rn e ts -b e s t-re s u m e -p re p a ra tio n -s ite s . I f y o u r firs t c o n ta c t w it h a n o r g a n iz a tio n is a p e rs o n a l in te rv ie w , y o u m u s t p re p a re y o u rs e lf fo r th e in te r v ie w a n d p re s e n t y o u rs e lf as a s erio u s p ro s p e c t. D res s p ro fe s s io n a lly . F o r m e n th is m ea n s a c o a t a n d tie a n d fo r w o m e n a business s u it o r dress. R eg a rd les s o f y o u r p e rs o n a l style, th e g o a l is to lo o k lik e y o u w ill b e lo n g in th is o rg a n iz a tio n ; th u s, be sure to dress a p p ro ­ p ria te ly . A r r iv e a t least 5 m in u te s b e fo re y o u r s ch e d u led a p p o in tm e n t tim e . D o y o u r h o m e w o r k b y le a rn in g as m u c h as y o u c a n a b o u t th e o rg a n iz a tio n , in c lu d in g its p h ilo s o p h y a n d m is s io n s ta te m e n t. K e e p in m in d th a t y o u w ill be in te rv ie w in g th e o rg a n iz a tio n a l re p re s e n ta tiv e s as m u c h as th e y w ill be in te rv ie w in g y o u ; th u s , c o m e p re p a re d w it h q u e stio n s. D u r in g th e in te rv ie w , y o u w ill w a n t to le a rn as m u c h as p o s sib le a b o u t th e jo b e x p e c ta tio n s a n d c o n v e y in fo r m a t io n a b o u t w h a t y o u h a v e to o ffe r to th e o r g a n iz a tio n . Be p re p a re d to discuss y o u r s tre n g th s a n d lim ita tio n s . I t is c u s to m a ry n o t to in q u ire a b o u t s a la ry o r benefits u n til a jo b o ffe r has been m a d e . E m p lo y e rs ty p ic a lly in te r v ie w several p ro sp ects b e fo re d e c id in g o n a n in d iv id u a l, a n d s a la ry is based o n e d u c a tio n a n d e x p e rie n c e . T h e re is u s u a lly a s a la ry ra n g e fo r a g iv e n p o s itio n , a n d th u s, be p re p a re d to n e g o tia te i f th e in itia l o ffe r is u n a c c e p ta b le . E v e n i f th e e m p lo y e r is u n w illin g to increase th e q u o te d s a la ry , y o u w ill a t least le a rn w h e th e r y o u w e re o ffe re d th e m a x im u m a llo c a te d to th e p o s itio n fo r s o m eo n e w it h y o u r e x p e rie n c e a n d b a c k g ro u n d . T h e b e tte r th e jo b , th e m o re c o m p e titio n y o u w ill h a ve in a p p ly in g fo r it; th u s, fin d p o s itive w a y s to separate y o u rs e lf fr o m o th e r a p p lic an ts . P re p a ra tio n

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a n d a p ro fes s io n al ap p ea ra n ce are a g o o d s tart, b u t y o u m ig h t need to do m o re to s ta n d o u t fr o m th e c ro w d . D iscu ss n o t o n ly y o u r p re s e n t q u a lific a tio n s , b u t share y o u r p lan s fo r fu tu re p ro fe s s io n a l g r o w th o r a s p ira tio n s . T h e m o re y o u a lig n y o u rs e lf w it h th e m is s io n a n d goals o f th e o rg a n iz a tio n , th e m o re a cc ep tab le y o u w ill be to a n e m p lo y e r. F o llo w an in te rv ie w im m e d ia te ly w it h a w r it te n le tte r th a n k in g th e in te rv ie w e r fo r his o r h e r tim e a n d c o n s id e ra tio n o f y o u r a p p lic a tio n . T h is c ru c ia l step is o fte n o v e rlo o k e d b y a p p lic a n ts a n d c an tip th e b a la n c e in y o u r fa v o r. B e fo re c o n c lu d in g th e in te rv ie w , ask a b o u t th e tim e fra m e fo r d e cis io n m a k in g a b o u t th e p o s itio n . I f y o u k n o w w h e n th e e m p lo y e r expects to choose a c a n d id a te a n d y o u h a v e n o t been n o tifie d o f y o u r s elec tio n , y o u c an fo llo w u p w it h a te le p h o n e c a ll a t th e a p p ro p r ia te tim e . E v e n i f y o u are n o t selected fo r th is p o s itio n , m a in t a in y o u r p o s itiv e firs t im p re s s io n b y th a n k in g th e e m p lo y e r fo r in te rv ie w in g y o u a n d a s k in g to h a v e y o u r a p p lic a tio n k e p t o n file so th a t y o u m ig h t be c o n s id e re d fo r fu tu re p o s itio n s . A s s tated p re v io u s ly , th e in te rv ie w is also a tim e fo r y o u to fin d o u t m o re a b o u t th e o r g a n iz a tio n . T h e A m e ric a n A s s o c ia tio n o f C o lle g e s o f N u r s in g ( A A C N ) has id e n tifie d e ig h t k e y c h ara c te ris tic s o r h a llm a rk s th a t each nurse s h o u ld c o n sid e r w h e n screening p o te n tia l e m p lo yers ( A A C N , 2 0 0 2 ) . T o assess th e p ra c tic e e n v iro n m e n t o f th e o rg a n iz a tio n , th e A A C N suggests th a t th e nurse ask questions d u rin g th e in te rv ie w th a t re la te to th e fo llo w in g e ig h t k e y o rg a n iz a tio n a l c h ara cteris tic s: 1. D o e s th e p o te n tia l e m p lo y e r m a n ife s t a p h ilo s o p h y o f c lin ic a l care e m p h a ­ s izin g q u a lity , safe ty , in te rd is c ip lin a ry c o lla b o ra tio n , c o n tin u ity o f c are, a n d p ro fe s s io n a l a c c o u n ta b ility ? 2 . D o e s th e p o te n tia l e m p lo y e r re c o g n ize th e v a lu e o f n u rse s ’ e x p e rtis e o n c lin ic a l c are q u a lity a n d p a tie n t o u tco m e s? 3 . D o e s th e p o te n tia l e m p lo y e r p ro m o te e x e c u tiv e -le v e l n u rs in g lead ersh ip ? 4 . D o e s th e p o te n tia l e m p lo y e r e m p o w e r n u rs e s ’ p a r tic ip a tio n in c lin ic a l d e cis io n m a k in g a n d o rg a n iz a tio n o f c lin ic a l care systems? 5 . D o e s th e p o te n tia l e m p lo y e r d e m o n s tra te p ro fe s s io n a l d e v e lo p m e n t sup­ p o r t fo r nurses? 6 . D o e s th e p o te n tia l e m p lo y e r m a in t a in c lin ic a l a d v a n c e m e n t p ro g ra m s based o n e d u c a tio n , c e rtific a tio n , a n d a d v a n c e d p re p a ra tio n ? 7 . D o e s th e p o te n tia l e m p lo y e r c re a te c o lla b o r a tiv e re la tio n s h ip s a m o n g m e m b e rs o f th e h e a lth c a re team ? 8 . D o e s th e p o te n tia l e m p lo y e r u tiliz e te c h n o lo g ic a l advances in c lin ic a l care a n d in fo r m a tio n systems? O t h e r in fo r m a t io n a b o u t th e o r g a n iz a tio n th a t m ig h t be o f in te re s t to th e p o te n tia l n u rse e m p lo y e e d u r in g th e in te r v ie w is th e R N v a c a n c y a n d tu rn o v e r ra te , p a tie n t s a tis fa c tio n scores, e d u c a tio n a l m ix o f n u rs in g s ta ff, a ve rag e te n u re o f n u rs in g s ta ff, e m p lo y e e s a tis fa c tio n scores, p e rce n tag e o f tr a v e l nurses u tiliz e d , k e y h u m a n re so u rce p o lic ie s , w h e th e r th e nurses are

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u n io n iz e d ( if so, a c o p y o f th e c o n tra c t), a n d th e m o s t re ce n t J o in t C o m m is s io n re p o rt o n th e o rg a n iz a tio n ( A A C N , 2 0 0 2 ) . T h e fu ll w h ite p a p e r a n d s u m m a ry b ro c h u re a re a v a ila b le o n lin e . K n o w in g th e c h a ra c te ris tic s o f th e p ra c tic e e n v ir o n m e n t b e fo re y o u a c c e p t a p o s itio n assists y o u in m a k in g th e best d e c is io n CRiTICAL THiNKiNG QUESTION V p o s s ib le . M a k i n g a n in fo r m e d d e c is io n a b o u t w h e re to p ra c tic e n u rs in g , w h e th e r y o u a re a n e w g ra d u a te o r an What kind of first impression do you make e x p e rie n c e d n u rse , c o n trib u te s to y o u r lo n g -te rm success when searching for a new position? V a n d jo b s a tis fa c tio n as a nurse.

M a x im iz in g Y o u r V is ib ility D e v e lo p in g a n d m a n a g in g a c a re e r is v e ry d iffe re n t fr o m m e re ly s h o w in g u p a n d d o in g y o u r jo b . A c a re e r in v o lv e s a c o m m itm e n t n o t ju s t to th e w o r k o f an e m p lo y e e b u t to th e w e ll-b e in g o f th e e n tire o rg a n iz a ­ tio n . T h is m ean s th a t y o u r e ffo rts e x te n d b e y o n d th e care o f y o u r p a tie n ts o n y o u r assigned n u rs in g u n it to assum e re s p o n s ib ilitie s b e y o n d th o se fo r w h ic h y o u w e re h ire d . A d m in is te r in g h ig h - q u a lity p a tie n t c a re is a n im p o r t a n t p a r t o f th e n u rs e ’s ro le ; h o w e v e r, th is is o n ly one aspect o f th e p ro fe s s io n a l n u rs in g ro le . I f y o u w is h to a d v a n c e y o u r c a re e r in a g ive n in s titu tio n , y o u m u s t be seen as a c o m m it­ te d m e m b e r o f th a t o rg a n iz a tio n . T o d o th is , y o u m u s t be v is ib le w it h in th e o rg a n iz a tio n . R e m e m b e r th e m y th th a t g o o d w o rk s sp ea k fo r th em selves. N u rs e s w h o s h o w u p o n tim e , d o th e ir jobs w e ll, a n d go h o m e ra re ly c o m e to th e a tte n tio n o f in flu e n tia l p e o p le w it h in th e o rg a n iz a tio n unless a p ro b le m occurs. T h e n , th e nurses re ce ive a lo t o f n e g a tiv e a tte n tio n . N u rs e s a n d o th e r e m p lo ye es w h o w o r k th e n ig h t s h ift are ra re ly i f ever seen b y h o s p ita l a d m in is tra to rs a n d ris k b e in g in v is ib le w it h in th e o rg a n iz a tio n unless th e y p u rp o s e ly engage in a c tiv itie s th a t ta k e p lac e d u rin g n o r m a l business h o u rs . T h u s , h o w does one increase his o r h e r v is ib ility in a p o s itiv e w a y ? M o s t h o s p ita ls a n d h e a lth c a re ag en cies p ro v id e so m e d e g re e o f s e lf­ g o v e rn a n c e w it h in th e o r g a n iz a tio n a l s tru c tu re . C o m m itte e s c o m p o s e d o f p h y sic ia n s , nurses, a n d a d m in is tra to rs assum e im p o r ta n t fu n c tio n s o f g o v e r­ nance such as ethics c o m m itte e s , research p ro to c o l re v ie w c o m m itte e s , p a tie n t c are re v ie w c o m m itte e s (q u a lity assuran ce), a n d o th ers . V o lu n te e rin g to serve o n s e lf-g o v e rn a n c e c o m m itte e s n o t o n ly c o n trib u te s to n urses’ p ro fe s s io n a l a u to n o m y b u t also a ffo rd s o p p o rtu n itie s fo r y o u to be seen in a d iffe re n t lig h t b y p e o p le w h o c an be h e lp fu l to y o u in y o u r c are er. S im ila rly , m o s t h e a lth c a re in s titu tio n s a re c o m m itte d to s u p p o rtin g h e a lth -re la te d c o m m u n ity a ctiv itie s such as b lo o d d riv es , fu n d -ra is in g w a lk s , a n d h e a lth fa irs . T h e s e also p ro v id e

o p p o rtu n itie s fo r nurses to c o n trib u te to th e ir c o m m u n ity w h ile g e ttin g to k n o w p e o p le in o th e r areas o f th e ir o rg a n iz a tio n . A s a p ro fe s s io n a l n u rse , y o u re p re s e n t y o u r o rg a n iz a tio n b o th in a n d o u t o f th e w o rk p la c e . V o lu n te e rin g to be a spokesp erson fo r th e o rg a n iz a tio n can in crea se y o u r v is ib ility d ra m a tic a lly . P u b lic s p ea kin g is a d a u n tin g ta s k fo r m a n y nurses w h o are o th e rw is e fearless in th e ir o th e r p ro fe s s io n a l a c tiv itie s . M o s t nurses w o u ld r a th e r w o r k d o u b le shifts, m a n a g e disasters, o r c are fo r m u ltip le a c u te ly ill u n s ta b le p a tie n ts s im u lta n e o u s ly th a n s tan d u p in fr o n t o f a g ro u p a n d d e liv e r a speech. U n fo r tu n a te ly , it is h a rd to be a sp o kesp erso n fo r a n o rg a n iz a tio n w it h o u t e n g ag in g in som e p u b lic s p e a k in g . T h e h ig h e r in a n o rg a n iz a tio n y o u rise, th e m o re y o u a re g o in g to be c a lle d o n to speak in p u b lic . I f y o u a re c o m fo rta b le s p e a k in g in fr o n t o f o th e rs , it w ill be m u c h easier fo r y o u to e sta b lish y o u r a u th o r ity a n d c re d ib ility w it h a g ro u p . T h e g o o d ne w s is th a t it is n o t o n ly p ossible to b e co m e a s k ille d s p ea ke r b u t to e n jo y th a t aspect o f y o u r p ro fe s s io n a l n u rs in g ro le . T h e b a d n e w s is th a t th e o n ly w a y to b e co m e c o m fo rta b le b e in g a p u b lic s p e a k e r is to speak in p u b lic . I f y o u are in e x p e rie n c e d o r u n c o m fo rta b le s p e a k in g b e fo re a g ro u p , s ta rt s lo w ly . B e g in b y s p e a k in g o u t in a s ta ff m e e tin g o r v o lu n te e rin g to d o an in -s e rv ic e p re s e n ta tio n fo r th e s ta ff o n y o u r n u rs in g u n it. A g re e to c h a ir a h o s p ita l c o m m itte e , accep t a le a d e rs h ip p o s itio n in y o u r p ro fe s s io n a l n u rs in g o rg a n iz a tio n , o r tra v e l to lo c a l schools o r colleges to re c ru it nurses fo r y o u r in s titu tio n . S o o n y o u w ill be m a k in g p re s e n ta tio n s to c o m m u n ity o rg a n iz a ­ tio n s , c h u rc h g ro u p s , o r schools. D e v e lo p in g th is im p o r ta n t s k ill w ill increase y o u r poise a n d s elf-c o n fid e n c e , e n s u rin g th a t y o u r ideas w ill be h e a rd . W r it in g lette rs is a p o w e r fu l to o l to s u p p o rt o th ers w h ile in c re a s in g y o u r o w n v is ib ility w it h in th e o r g a n iz a tio n . W r it in g le tte rs to in d iv id u a ls w h o h a v e d o n e a g o o d jo b o r g o n e o u t o f th e ir w a y to h e lp y o u , th a n k in g th e m fo r th e ir e ffo rts , n o t o n ly s u p p o rts y o u r colleagu es b u t also ensures th a t y o u w ill receive s im ila r h ig h levels o f c o o p e ra tio n in th e fu tu re . B y d ire c tin g th e le tte r to th e s u p e rv is o r w h ile s ending a c o p y to th e in d iv id u a l, a p o w e r fu l m essage is sent th a t has th e s e c o n d a ry b e n e fit o f m a r k in g y o u as a te a m p la y e r. T h is s tra te g y m a y seem m a n ip u la tiv e a n d s e lf-s e rv in g ; h o w e v e r, m e m b e rs o f an o rg a n iz a tio n h a v e a n o b lig a tio n to s u p p o rt each o th e r. W e m u s t re fra m e o u r th in k in g to u n d e rs ta n d th a t b y a d v a n c in g th e careers o f o u r colleagu es a n d ourselves w e are in fa c t s tre n g th e n in g th e o rg a n iz a tio n . L ik e w is e , it is im p o r ta n t to get lette rs o f s u p p o rt fo r o urselves. T h in k o f a ll o f th e tim es p a tie n ts a n d fa m ily m e m b e rs h a v e c o m p lim e n te d y o u o n th e care th e y h a ve received fr o m y o u . A lth o u g h it is a lw a y s nice to k n o w th a t y o u r e ffo rts are a p p re c ia te d , w o u ld it n o t be nice i f y o u r s uperviso rs w e re a b le to h e a r th ose c o m m en ts? T h e n e x t tim e y o u re ce ive a v e rb a l c o m p lim e n t, ask th e p e rs o n to p u t it in w r itin g . G o o d w o r k co u n ts w h e n so m eo n e sees it o r k n o w s a b o u t it. T r y s ay in g , “ T h a n k y o u . I re a lly a p p re c ia te y o u te llin g m e th a t. I w is h m y boss c o u ld h e a r it. W o u ld y o u m in d p u ttin g th a t in w r itin g ? ”

Networking

M o s t p e o p le re s p o n d p o s itiv e ly a n d w o n d e r w h y th e y h a d n o t th o u g h t to do it th em selves. L e tte rs d o c u m e n t y o u r s kills a n d v a lid a te y o u r a b ilitie s . Save these le t­ ters a n d use th e m to get n e w jobs o r p ro m o tio n s . L e tte rs c an be p re s e n te d as sam ples o f y o u r w o r k . N e v e r leave a jo b w ith o u t g e ttin g a t least th ree letters o f referen ce fr o m supervisors a n d colleagu es. I f y o u are n o t im m e d ia te ly m o v in g to a n o th e r p o s itio n , h a ve th e references addressed to “ T o W h o m I t M a y C o n ­ c e rn .” O fte n , i f th e re is a gap in y o u r e m p lo y m e n t, w h e n y o u go to a p p ly fo r a n e w p o s itio n , th e p e o p le w h o k n e w y o u b e fo re a n d w h o c o u ld a tte s t to y o u r w o r k h a v e re tire d o r m o v e d to o th e r in s titu tio n s th em selves. T h e s e lette rs o f re fe re n c e a re ju s t as v a lid as th o se w r itte n c u rre n tly b y specific in d iv id u a ls .

N e tw o rk in g T h e m o re p e o p le w h o k n o w y o u a n d w h o k n o w th e q u a lit y o f y o u r w o r k a n d w h a t y o u h a v e to o ffe r, th e m o re d o o rs w ill be o p e n to y o u a n d g re a te r o p p o rtu n itie s w ill c o m e y o u r w a y . N e tw o rk in g is th e process b y w h ic h y o u get to k n o w p e o p le w it h in y o u r o rg a n iz a tio n a n d w it h in y o u r p ro fes s io n . N e t w o r k in g is im p o r ta n t because it a llo w s p e o p le to k n o w o n e a n o th e r o n a p e rs o n a l le v e l, fo rg in g re la tio n s h ip s t h a t e n h a n c e c o m m u n ic a tio n a n d in c re a s e p r o d u c t iv ity . N e t w o r k i n g c re a te s a sense o f b e lo n g in g a m o n g m e m b e rs o f a n o rg a n iz a tio n o r p ro fe s s io n a l g ro u p . O n e o f th e best w a y s to n e tw o r k w it h o th e r nurses is to jo in o r b e co m e m o re a c tiv e in y o u r p ro fe s s io n a l o rg a ­ n iz a tio n . B y a tte n d in g m e e tin g s , w o r k in g o n a c o m m itte e , c o n trib u tin g to th e n e w s le tte r, o r s p e a k in g a t a n o rg a n i­ z a tio n a l fu n c tio n , y o u increase y o u r p ro fe s s io n a l co n ta cts a n d e n h an ce y o u r r e p u ta tio n in y o u r fie ld . A tte n d re g io n a l o r n a tio n a l c o n v e n tio n s , jo in a p a n e l discussion, o r m a k e a p re s e n ta tio n . Be sure to send a c o p y o f y o u r speech to y o u r s u p e rv is o r a n d n u rs in g service a d m in is tr a to r so th a t th e y k n o w th a t y o u a re re p re s e n tin g y o u r o rg a n iz a tio n w e ll. I f y o u te n d to shy a w a y fr o m m ee tin g s because y o u are u n c o m fo rta b le in social s itu a tio n s w h e re y o u m ig h t n o t k n o w p e o p le , k ee p in m in d th a t oth ers p ro b a b ly feel th e sam e w a y . A ss u m e th a t y o u a re g o in g to be w e lc o m e d a n d a cc ep ted . T a k e o n th e ro le o f w e lc o m in g o th e r p e o p le a n d p u ttin g th e m a t ease. C o m e p re p a re d w it h s m a ll t a lk — to p ic s th a t y o u c a n share c o m fo r t­ a b ly w it h o th e rs . K e e p a b re a s t o f d e v e lo p m e n ts in y o u r fie ld , c o n tro v e rs ia l le g is la tiv e p ro p o s a ls , ne w s ite m s , o r a m u s in g a n ecd o tes. I f y o u a rriv e a t th e m e e tin g w it h ideas to share, it is m u c h easier to s trik e u p c o n v e rs a tio n s w it h re la tiv e s tran g ers. O c c a s io n a lly , y o u m ig h t fin d th a t it is d iffic u lt to d e ta c h

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CHAPTER 7 Career Management and Care of the Professional Self

TAB LE 7 -4 •

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G etting th e M ost out of M eetings

A tte n d th re e m ee tin g s b e fo re d e c id in g a b o u t a g ro u p : once to o v e rc o m e y o u r fe a r, once to le a rn a b o u t it, a n d once to decide i f y o u lik e it. In tr o d u c e y o u rs e lf b y g iv in g y o u r firs t a n d las t n a m e a n d te llin g s o m e th in g a b o u t y o u rs e lf to g e t th e c o n v e rs a tio n g o in g . S ay y o u r firs t a n d las t n a m e as y o u m e e t p e o ­ p le . E v e n p e o p le w h o k n o w y o u w e ll o r h a ve m e t y o u b e fo re c a n h a v e te m p o ra ry a m n es ia fo r n a m es .

KEY COMPETENCY 7-1 Examples of Applicable Nurse of the Future: Nursing Core Competencies

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W e a r y o u r n a m e ta g o n th e r ig h t side so th a t p e o p le c a n see it w h e n y o u shake h a n d s . W e a r c o m fo rta b le shoes a n d c lo th in g ; y o u m ig h t be s ta n d in g fo r a w h ile . P la n y o u r c o n v e rs a tio n a h e a d o f tim e . C o m e p re p a re d w it h s m a ll ta lk . K e e p y o u r business cards h a n d y ; use th e m to lea ve a ta n g ib le re m in d e r o f w h o y o u a re. R e la x a n d tr y to e n jo y y o u rs e lf. I f y o u are u n c o m fo rta b le , fin d so m eo n e w h o lo o k s n e rv o u s a n d tr y to set th a t p e rs o n a t ease.

y o u rs e lf fr o m s o m eo n e w it h w h o m y o u h a v e s ta rte d a c o n v e rs a tio n . I f th is is a c o n c e rn , s tan d b y th e d o o r a n d g re e t p e o p le as th e y a rriv e . S p e ak to th e m b rie fly b e fo re d ire c tin g th e m to o th ers o r th e re fre s h m e n ts . Y o u w ill fin d y o u g e t to m e e t a lo t o f p e o p le fo r a s h o rt tim e a n d y o u w ill n o t h a ve to w o r r y a b o u t d is e n g a g in g . T a b le 7 -4 o ffers fu rth e r h in ts o n g e ttin g th e m o s t o u t o f m ee tin g s . I f y o u a re s till u n c o m fo rta b le , g ive y o u rs e lf a n a ssig n m en t: S ta y fo r 1 h o u r , a n d sp ea k to fiv e p e o p le ; th e n y o u c an lea ve . Y o u m ig h t fin d th a t y o u re m a in fo r th e e n tire m e e tin g a n d e n jo y d o in g so. A fte r o n e o r tw o m ee tin g s , y o u ’ll a rriv e to a m e e tin g o f frie n d s a n d colleagu es ra th e r th a n strangers. T h e in fo r m a l c o n v e rs a tio n s th a t ta k e p lac e a t p ro fe s s io n a l m ee tin g s c an be m o re v a lu a b le to y o u a n d y o u r c a re e r th a n th e fo r m a l business o f th e g ro u p .

Teamwork and Collaboration: Knowledge (K7b) Identifies lateral violence as a barrier to teamwork and unit functioning Attitudes/Behaviors (A7b) Recognizes behaviors that contribute to lateral violence Skills (S7b) Practices strategies to minimize lateral violence Source: Massachusetts Department of Higher Education (2010), p. 32.

M e n to rin g Just as w e are re sp o n sib le fo r d e v e lo p in g a n d m a n a g in g o u r o w n careers, w e a re o b lig e d to e n c o u ra g e o th e rs to d e v e lo p p ro fe s s io n a lly as w e ll. T o o o fte n nurses c o m p ete to m a in ta in th e status q u o ra th e r th a n s u p p o rtin g th e a d v a n c e ­ m e n t o f c o lle ag u es . N u rs e s w h o choose to fu rth e r th e ir careers b y re tu rn in g to schoo l fo r a d v a n c e d degrees o r seeking p ro m o tio n s are s o m e h o w p e rce ive d as a th re a t a n d are fre q u e n tly d is c o u ra g e d o r even s ab o tag e d in s u b tle w a y s b y th e ir c o lle ag u es . T h e re is a s c a rc ity m e n ta lity in w h ic h a n o th e r’s progress is p e rc e iv e d as a loss in o n e ’s o w n status. T h is p h e n o m e n o n has a d e trim e n ta l e ffe c t o n th e p ro fe s s io n as a w h o le . E x p e rie n c e d nurses c a n u s u a lly re c a ll o th e r nurses w h o served as ro le m o d e ls o r m e n to rs , p ro v id in g le a d e rs h ip a n d g u id a n c e to th e m as th e y b egan th e ir n u rs in g c are ers o r fa c e d p ro fe s s io n a l c h a lle n g e s . T h e re la tio n s h ip s

b e tw e e n n e w a n d e x p e rie n c e d nurses ta k e m a n y fo rm s a n d v a ry fr o m frie n d a n d in fo r m a l a d v is o r to th a t o f a fo r m a l c o n tra c tu a l m e n to r. M e n to rin g has b e en d e fin e d as a d e v e lo p m e n ta l, e m p o w e rin g , a n d n u r tu r in g re la tio n s h ip th a t e xte n d s o v e r tim e a n d in w h ic h m u tu a l s h a rin g , le a rn in g , a n d g r o w th o c c u r in a n a tm o s p h e re o f re sp e ct, c o lle g ia lity , a n d a ffir m a tio n (V a n c e & O ls o n , 1 9 9 8 ). Id e a lly , a ll g ra d u a te nurses s h o u ld be assigned m e n to rs w h o w o r k c lo s e ly w it h th e m d u rin g th e d iffic u lt tr a n s itio n b e tw e e n th e s tu d e n t a n d s ta ff n u rs e ro le s . A tr u e m e n to r , h o w e v e r , is s o m e o n e w h o is w illin g to m a in ta in a lo n g -te rm re la tio n s h ip , a d v is in g a n d g u id in g an in d iv id u a l as n e ed e d th ro u g h o u t th e p ro fe s s io n a l c are er. U n fo r tu n a te ly , fe w o rg a n iz a tio n s are a b le to p ro v id e fo r m a l m e n to rs fo r a ll n e w e m p lo ye es . M e n to r s h ip , h o w e v e r, is such a n im p o r ta n t c o m p o n e n t o f successful care er m a n a g e m e n t th a t in d iv id u a ls s h o u ld a c tiv e ly seek o u t fo rm a l o r in fo r m a l m e n to rs to g u id e a n d s u p p o rt th e m . M e n to r in g re la tio n s h ip s can d e v e lo p th ro u g h n e tw o r k in g as y o u m e e t a n d in te ra c t w it h colleagu es w h o y o u re s p e c t a n d a d m ir e . W h e n s elec tin g a m e n to r , it is im p o r t a n t to seek s o m e o n e w it h w h o m it is easy to c o m m u n ic a te a n d w h o has th e tim e a n d in te re s t to w o r k w it h y o u to discuss v a rio u s p ro fe s s io n a l issues. A m e n to r is n o t ju s t s o m eo n e w h o o ffers a d v ic e , b u t s o m eo n e w h o challeng es y o u r ideas a n d encou rages y o u to s trive fo r excellen ce.

E v a lu a tin g Y o u r P e rfo rm a n c e W h a t d o p e o p le re a lly th in k o f y o u a n d y o u r w o r k ? A s id e fr o m a s k in g a tru s te d c o lle a g u e h o w he o r she rates y o u r p e rfo rm a n c e p ro fe s s io n a lly , y o u c a n e ith e r re ly o n th e fo r m a l pro cess o f th e p e rfo r m a n c e a p p ra is a l d o n e a n n u a lly b y y o u r s u p e rv is o r, o r y o u c an a c tiv e ly s o lic it fe e d b a c k fr o m o th ­ ers. M o s t p e o p le a re c rea tu res o f h a b it a n d w ill c o n tin u e b e h a v io rs th a t seem to h a v e b e e n e ffe c tiv e in th e p a s t u n t il s o m e o n e in fo r m s th e m o th e rw is e . I t is d iffic u lt fo r us to d ire c tly observe th e effects o f o u r w o rd s o r a ctio n s on a n o th e r p e rs o n . W e m u s t re ly o n th e social m ir r o r in w h ic h w e see ourselves re fle c te d th ro u g h th e responses o f o th e rs . F e e d b a c k is in fo r m a tio n th a t w e receive fr o m others a b o u t th e im p a c t o f o u r b e h a v io r o n th e m ; it a llo w s us to v ie w ourselves fr o m a n o th e r’s p e rsp ec tive . S o lic itin g fe e d b a c k fr o m peers is one w a y to g a in d ire c t in fo r m a t io n o n h o w p e o p le p e rc e iv e o u r w o rd s , a c tio n s , a n d a b ilitie s . F e e d b a c k d iffe rs fr o m a d v ic e in th a t it describes th e e ffe c t o f a n o th e r ’s b e h a v io r o n us. I t does n o t in c lu d e a d v ic e o n c h a n g in g th a t b e h a v io r; ra th e r, it is u p to th e in d iv id u a l s o lic itin g fe e d b a c k to decid e if ch an g e is w a r r a n te d (R ile y , 2 0 0 4 ) . F e e d b a c k c an be d iffic u lt to h e a r, e sp e cia lly i f it is u n e x p e c te d ly n e g a tiv e . Be sure th a t y o u tr u ly w a n t to h e a r th e in fo r m a tio n y o u a re a s k in g a n o th e r to give. I f y o u w a n t to receive o n ly p o s itiv e fe e d b a c k , fo rg e t a b o u t a s k in g p e o p le

KEY COMPETENCY 7-2 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Professionalism: Attitudes/Behaviors (A4b) Values the mentoring relationship for professional development Skills (S8g) Develops personal goals for professional development Source: Massachusetts Department of Higher Education (2010), pp. 13, 15.

to be h o n e s t w it h y o u . I t is ris k y a s k in g o th ers to je o p a rd iz e a re la tio n s h ip b y d iv u lg in g o p in io n s th a t m ig h t n o t be w e lc o m e d . R ile y (2 0 0 4 ) re c o m m e n d s y o u ta k e th e fo llo w in g steps w h e n y o u s o lic it fe e d b a c k : • • • • •

•

G e t f o c u s e d : E n s u re th a t y o u are n o t d is tra c te d b y o th e r issues a n d c an give y o u r fu ll a tte n tio n to th e in fo r m a tio n y o u a re re c e iv in g . A llo c a te s u ffic ie n t tim e : S ch edu le e n o u g h tim e so th a t y o u c an lis te n a n d re fle c t o n th e in fo r m a tio n w it h o u t b e in g ru s h e d . U n d e r s t a n d t h e f e e d b a c k : S eek c la r if ic a t io n o r a s k fo r r e p e t itio n o f in fo r m a tio n th a t is u n c le a r. A s k f o r g u i d a n c e : I f th e fe e d b a c k in d ic a te s th e n e e d fo r a c h a n g e in b e h a v io r, ask fo r a d vic e o r d ire c tio n s fo r c h an g e. S h o w a p p r e c ia t io n : T h e p e rs o n g iv in g fe e d b a c k has ta k e n a b ig ris k a n d m a d e an e ffo r t to p ro v id e y o u w it h u s efu l in fo r m a tio n . T h a n k h im o r h e r fo r th e e ffo r t. T h in k a b o u t th e f e e d b a c k : E v a lu a te y o u r b e h a v io r in lig h t o f th is n e w in fo r m a tio n . R e fle c t o n th e im p lic a tio n s a n d c o n s id e r changes.

A s k in g fo r a n d re c e iv in g fe e d b a c k , e s p e cia lly i f it is n e g a tiv e , is a c o u ra ­ geous a ct. R eg a rd les s o f w h e th e r y o u choose to a ct o n th e in fo r m a t io n , it is im p o r ta n t to k n o w h o w o th ers p e rc e iv e y o u . T h e process o f p e rfo rm a n c e a p p ra is a l is a m o re fo r ­ W W W J CRITICAL THINKING QU ESTIO N S* m a liz e d m eans o f o b ta in in g fe e d b a c k o n y o u r p ro fe s s io n a l Do you have the courage to ask for honest a ctiv ities . P e rfo rm a n c e appraisals are fo rm a l e va lu atio n s o f feedback? Do you have the courage to give e m p lo yees b y a s u p e rio r, u s u a lly a m a n a g e r o r s u p erviso r honest feedback to a friend or colleague? o f som e k in d , c o m p a rin g th e e m p lo y e e ’s b e h a v io r w it h a How do you respond to negative feedback? V set o f s tan d ard s (T a p p a n , 2 0 0 1 ) . W h e n d o n e c o rre c tly , th e p e rfo rm a n c e a p p ra is a l process can be a h ig h ly effective to o l fo r m o tiv a tin g em p lo yees to c o n tin u e h ig h -le v e l p e rfo rm a n c e a n d to strive fo r even g re a te r a cc o m p lis h m e n ts . T o o o fte n , h o w e v e r, th e process is p e rfu n c to ry o r, a t w o rs t, p u n itiv e , s ervin g to d isc o u rag e r a th e r th a n r e w a rd e m p lo ye es . O p tim a lly , a g o o d m a n a g e r collects d a ta fo r th e e m p lo y e e s ’ a n n u a l re vie w s th ro u g h o u t th e re v ie w in g p e rio d , w h ic h is u s u a lly 1 y e a r. C o lle c tin g a n e c d o ta l notes o n in c id e n ts o f p o s itiv e p e rfo rm a n c e as w e ll as n e g a tiv e episodes helps to p re se n t a b a la n c e d p ic tu re o f a n in d iv id u a l’s p e rfo rm a n c e . A n n u a l re vie w s a re to o o fte n based o n a n e m p lo y e e ’s p e rfo rm a n c e d u rin g th e w e e k o r w e e ks im m e d ia te ly p re c e d in g th e re v ie w , th u s c re a tin g a n a rtific ia l h a lo o r h o rn s e ffe c t (T a b le 7 -5 ) . T o c o u n te r th is p o s s ib ility , it is im p o r ta n t fo r y o u to ta k e a p ro a c tiv e ro le in th e process b y p ro v id in g y o u r s u p e rv is o r w it h a c c u ra te in fo r m a tio n a b o u t y o u r p e rfo rm a n c e a n d a c c o m p lis h m e n ts th ro u g h o u t th e re p o rtin g p e rio d . M o s t o r g a n iz a tio n s h a v e a set tim e in th e y e a r w h e n p e r fo r m a n c e a p p ra is a ls a re c o n d u c te d . C o m m o n ly , th is ta ke s p lac e e a rly in th e c a le n d a r y e a r a n d reflects e m p lo ye e p e rfo rm a n c e d u rin g th e p re v io u s 1 2 -m o n th p e rio d . N e w e r em p lo yees m ig h t be e v a lu a te d m o re fr e q u e n tly . K e e p in g in m in d th e

Evaluating Your Performance

TAB LE 7 -5

Halo vs. Horns Effect

H a lo E ffe c t: O v e r r a tin g a n e m p lo y e e ’s to ta l p e rfo rm a n c e based o n a single p o s itiv e e ve n t. • S tro n g social skills a n d a p le a s a n t p e rs o n a lity m a s k in g p o o r p e rfo rm a n c e • R a tin g based o n p a s t p o s itiv e p e rfo rm a n c e ra th e r th a n c u rre n t o b s e rv a tio n s • H is to r y o f m e d io c rity p u n c tu a te d b y a single re c e n t s te lla r p e rfo rm a n c e

F rie n d s h ip o r shared interests w it h th e m a n a g e r H o rn s E ffe c t: U n d e r ra tin g a n e m p lo y e e ’s to ta l p e rfo rm a n c e based o n a single n e g ative event. P o s itiv e p e rfo rm a n c e in te rru p te d b y a serious e rro r c o m m itte d re c e n tly C o n s is te n t g o o d w o r k b u t disagrees w it h m anager A s s o c ia tin g w it h s u b s ta n d a rd peers P o o r p h y s ic a l a p p e a ra n c e in dress, m a n n e rs , o r h y g ie n e

fa c t th a t y o u r s u p e rv is o r has m o re im p o r t a n t th in g s to d o th a n to tr a c k y o u r c a re e r, y o u c a n assist in th is process b y p ro v id in g y o u r s u p e rv is o r w it h in f o r ­ m a tio n th a t y o u b e lie v e s h o u ld be in c lu d e d in y o u r p e rfo rm a n c e a p p ra is a l such as th e fo llo w in g : • • • • • •

183

C o n tin u in g e d u c a tio n courses, w o rk s h o p s , s em in ars, o r fo rm a l p ro g ra m s o f s tu d y a tte n d e d Special pro jects c o m p le te d , such as p re p a rin g te ac h in g m a te ria ls , in-service e d u c a tio n a l p ro g ra m s , o r d e v e lo p in g p a tie n t c are p o licies S pecial assig nm ents c a rrie d o u t in o th e r areas o f th e o rg a n iz a tio n A w a rd s , letters o f c o m m e n d a tio n , o r re c o g n itio n re ce ive d fo r y o u r p ro fe s ­ s io n a l a c tiv itie s E x a m p le s o f instan ces w h e n y o u p e rfo rm e d a b o v e a n d b e y o n d w h a t w as e x p e c te d o r re q u ire d P lans fo r fu rth e r e d u c a tio n a n d /o r p ro fe s s io n a l d e v e lo p m e n t a c tiv itie s in th e n e x t y e a r

M o s t m an ag e rs a p p re c ia te this ty p e o f assistance a n d w e lc o m e h a v in g the in fo r m a tio n a t th e ir d isp o sa l as th e y fill o u t th e a p p ra is a l fo rm s . I f y o u h a ve m a d e serious e rro rs o r c o m m itte d a re c e n t p ro fe s s io n a l fa u x pas, th is m ig h t s till s h o w u p o n y o u r e v a lu a tio n ; h o w e v e r, y o u a re m o re lik e ly to receive a b a la n c e d re v ie w . O n c e th e p e rfo rm a n c e a p p ra is a l e v a lu a tio n fo r m has b e en c o m p le te d , m o s t o rg a n iz a tio n s re q u ire a co n feren ce b e tw e e n th e e m p lo ye e a n d superviso r to discuss th e re v ie w . I f y o u r u n it m a n a g e r does n o t a lre a d y d o th is , re q u e s t a m e e tin g a t a tim e th a t is c o n v e n ie n t fo r b o th o f y o u w h e n y o u can be re la tiv e ly free fr o m in te rru p tio n s . F o r m a n y o f us, these m ee tin g s c o n ju re u p p a in fu l m e m o rie s o f b e in g c a lle d to th e p r in c ip a l’s o ffice in schoo l to be re p rim a n d e d fo r som e in fr a c tio n o f th e ru le s — n o t a p le a s a n t a s s o c ia tio n . K e e p in m in d ,

184

CHAPTER 7 Career Management and Care of the Professional Self

h o w e v e r, th a t th e p u rp o s e o f th e m e e tin g is to discuss th e re v ie w ra tin g s , id e n ­ tify strength s a n d lim ita tio n s , a n d b ra in s to rm a c tiv itie s th a t w ill c o n trib u te to y o u r p ro fe s s io n a l g ro w th . M o t iv a t io n is th e g o a l. Y o u r ro le in th e m e e tin g is to liste n c a re fu lly to w h a t is b e in g said , w h e th e r o r n o t y o u agree w it h th e fin d in g s . I f th e re v ie w is p o s itiv e , th e discussion w ill be easy fo r b o th sides. I f th e re v ie w is d is a p p o in tin g , it is im p o r ta n t th a t y o u re m a in n e u tra l a n d n o t re a c t n e g a tiv e ly , m a k in g a d iffic u lt s itu a tio n w o rs e .

Coping w ith A d v e rs ity W e n e v e r lik e to h e a r n e g a tiv e th in g s a b o u t o u r p e rfo r m a n c e , e s p e c ia lly i f th e c o m m e n ts a re u n e x p e c te d o r u n w a r r a n te d . R e s p o n d in g to a n e g a tiv e p e rfo r m a n c e a p p ra is a l w it h a n g e r o r d efen siven ess is n o t g o in g to a d v a n c e y o u r c a re e r. W h e th e r o r n o t y o u agree w it h th e a p p ra is a l, th e r e p o r t reflects y o u r s u p e r v is o r’s p e rc e p tio n s o f y o u r p e rfo r m a n c e , w h ic h m ig h t o r m ig h t n o t be a c c u ra te . E ith e r w a y , y o u h a v e a p r o b le m . R e m e m b e r, y o u r ro le in th is m e e tin g is to lis te n to fe e d b a c k . Y o u r c a re e r is a t s ta k e h e re ; th u s , y o u d o n o t h a v e th e lu x u r y o f g e ttin g a n g ry a n d s to rm in g o u t o f th e m e e tin g . I f y o u b e c o m e e m o tio n a l o r fe e l th a t y o u m ig h t lose c o n tr o l, a s k fo r tim e to re fle c t o n th e r e p o r t a n d s c h e d u le a n o th e r m e e tin g to c o n tin u e th e d isc u s sio n . Be c a re fu l w h a t y o u sign a n d k n o w w h a t y o u r s ig n a tu re im p lie s . D o es it m e a n th a t y o u c o n c u r w it h th e p e rfo r m a n c e a p p ra is a l o r o n ly th a t y o u h a v e re c e iv e d th e re p o rt? I f y o u r s u p e rv is o r insists th a t y o u sign th e re p o rt, it is a p p ro p r ia te th a t y o u w r ite in w h a t y o u r s ig n a tu re in d ic a te s (e .g ., “ sig­ n a tu re reflects re c e ip t o f re p o rt o n ly , n o t c o n c u rre n c e w it h fin d in g s ” o r “ see a tta c h e d respo nse” ). I t is s tro n g ly re c o m m e n d e d th a t y o u ta k e tim e to distance y o u rs e lf a n d g a in p e rsp ec tive a b o u t a n e g a tiv e p e rfo rm a n c e a p p ra is a l b e fo re re s p o n d in g e ith e r in p e rs o n o r in w r it in g . Y o u m ig h t w a n t to v a lid a te th e fin d in g s w it h y o u r m e n to r o r tru s te d co lleag u es. I f y o u b e lie ve th e fin d in g s are in a c c u ra te , y o u n e ed to e x p lo re h o w y o u r s u p e rv is o r re a c h e d th o s e c o n c lu s io n s . T h is c a n be a c c o m p lis h e d o n ly b y h a v in g a fr a n k discussion w it h h im o r h e r a b o u t y o u r p e rfo rm a n c e a n d h o w it v arie s fr o m th e e x p e c ta tio n s . T h is discussion s h o u ld a ffo r d y o u a n e q u al o p p o r tu n ity to describe y o u r p o in t o f v ie w . I f y o u a re c o n c e rn e d a b o u t th e e m o tio n a l level o f th e m e e tin g , y o u c an re q u e st th a t a d isin terested th ir d p a rty a tte n d to m e d ia te . Y o u c a n d o a g re a t d e a l to d iffu s e a p o te n tia lly h o s tile m e e tin g b y a c k n o w le d g in g y o u r ro le in c re a tin g th e s itu a tio n : “ G iv e n th e in fo r m a tio n y o u h a v e , I c a n see w h e re y o u m ig h t d r a w th a t c o n c lu s io n ,” o r “ I see w h e re y o u m ig h t th in k t h a t .” T h is does n o t m e a n th a t y o u agree w it h y o u r s u p e rv is o r’s s tatem e n ts b u t a llo w s fo r th e p o s s ib ility th a t th e s u p e rv i­ s o r’s im p re ss io n s m ig h t be a c c u ra te g iv e n lim ite d o r e rro n e o u s in fo r m a tio n . I f th e a p p ra is a l is in a c c u ra te , y o u s h o u ld p re s e n t specific facts th a t c o n tra d ic t

Commitment to the Profession

th e fin d in g s a n d re q u e s t th a t th e ra tin g s be c h a n g e d . I t is h o p e d th e o u tc o m e o f th e in te r v ie w is th a t y o u each h a v e a g re a te r a p p re c ia tio n fo r th e o th e r’s p e rsp ec tive a n d e x p e c ta tio n s . I f y o u r s u p e rv is o r disagrees o r is u n w illin g to c h an g e th e ra tin g s , y o u s h o u ld th e n a tta c h a ty p e w r itt e n p a g e o f c o m m e n ts to th e r e p o r t s ta tin g fa c tu a lly th e events fr o m y o u r p o in t o f v ie w . Be sure to k e e p copies o f a ll d o c u m en ts fo r y o u r p e rs o n a l re co rd s. A t th e end o f th e m e e tin g , i f y o u are still d issatisfied o r b e lie ve th a t y o u h a v e been tre a te d u n fa irly , y o u n eed to seek redress b y fo llo w in g th e c h a in o f c o m m a n d in y o u r o rg a n iz a tio n . C o n s u lt y o u r e m p lo y e e h a n d b o o k o r p o lic y m a n u a l fo r in fo r m a tio n o n h o w to a p p e a l an e rro n e o u s p e rfo rm a n c e a p p ra is a l. A s m u c h as it m ig h t g ive te m p o ra ry re lie f, i f w o u ld be a g ra v e m is ta k e to go o u ts id e th e c h a in o f c o m m a n d a n d s to rm th e n u rs in g a d m in is tra to r’s o ffice . A t som e p o in t, y o u w ill h a v e to decide h o w fa r th e m a tte r is w o r th p u rs u in g . I f y o u are u n a b le to re so lv e y o u r d iffere n c es w it h th e su p erviso r, it m ig h t be tim e to lo o k fo r a n o th e r p o s itio n e ith e r w ith in th e o rg a n iz a tio n o r at a d iffe re n t agency. G iv e n th e n u m b e rs a n d typ es o f d e cis io n s th a t nurses a re re q u ire d to m a k e d a ily , it is p ra c tic a lly in e v ita b le th a t m istak es w ill be m a d e in th e c lin ic a l a re a . F o rtu n a te ly , m o s t erro rs c an be c o rre c te d w ith o u t p a tie n ts e x p e rie n c in g adverse effects. W h e n e v e r a m is ta k e is m a d e , h o w e v e r, it is im p o r ta n t th a t the n u rse n o tify th e p a tie n t a n d fa m ily i f a p p ro p r ia te , th e su p erviso r, th e p h y s i­ c ia n , a n d a n y o th e r m e m b e rs o f th e h e a lth c a re te a m w h o m ig h t be c o n ce rn e d . E v e ry o r g a n iz a tio n has a p ro c e d u re fo r d o c u m e n tin g e rro rs o r events th a t cause a ris k o f in ju r y o r p o s sib le litig a tio n . T h e m a n n e r in w h ic h m istak es a re h a n d le d o n a u n it is in d ic a tiv e o f th e re la tio n s h ip s a m o n g th e in d iv id u a ls w o r k in g th e re . E rro rs a re g e n e ra lly s y m p to m s o f m o re im p o r ta n t p ro b le m s th a t m u s t be addressed. A lth o u g h errors are o b v io u s ly u n d e s irab le , th e y create o p p o rtu n itie s fo r le a rn in g as w e ll as d e v e lo p in g p o licie s a n d p ro ce d u re s fo r p re v e n tin g th e ir occurrence in th e fu tu re . As a p ro fe s s io n a l, y o u s h o u ld alw ay s be h o n e s t a n d ta k e re s p o n s ib ility fo r y o u r a c tio n s . W h e n a n e rro r is m a d e , a d m it th a t y o u d id s o m e th in g w ro n g , a p o lo g ize , a n d d o w h a te v e r is necessary to e ith e r c o rre c t th e e rro r o r m itig a te th e consequences. T a k e steps to ensure th a t s im ila r m is ta k e s a re p re v e n te d . M a k in g excuses o r b la m in g o th ers o n ly m a k e s a n a d ve rse s itu a tio n w o rs e . H o s p it a l a d m in is tra to rs a n d m a n a g e rs w o u ld m u c h p re fe r h o n e s t em p lo yees w h o m a k e m is ta k e s a n d ta k e steps to c o rre c t th e s itu a tio n th a n in d iv id u a ls w h o lie o r a tte m p t to c o v e r u p erro rs th a t m ig h t le a d to c o s tly litig a tio n later.

C o m m itm e n t to th e P ro fe s s io n N u r s in g is m o r e th a n ju s t a jo b ; i t is a p ro fe s s io n a n d re q u ire s s e rio u s c o m m itm e n ts fr o m its m e m b e rs . O n e o f th e c h a ra c te ris tic s o f a p ro fe s s io n is a c o m m it m e n t to life lo n g le a r n in g . U n d e r g r a d u a t e n u r s in g p ro g ra m s ,

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re g a rd le s s o f w h e th e r th e y a re d ip lo m a , a ss o cia te d e g re e, o r b a c c a la u re a te d e g re e p ro g ra m s , a re d e s ig n e d to p r e ­ Nursing is more than just p a re in d iv id u a ls to fu n c tio n in e n try -le v e l n u rs in g p o s i­ a job; it is a profession and tio n s u n d e r th e s u p e rv is io n o f m o re e x p e rie n c e d n u rs e s . requires serious commitments S u c ce ss fu l c o m p le tio n o f th e N C L E X - R N e x a m in a tio n from its members. a n d q u a lify in g fo r state lic e n s u re im p ly th a t y o u h a v e m e t th e m in im a l r e q u ire m e n ts to p r a c tic e s a fe ly as a n R N . M a n y n urses say th a t th e ir re a l e d u c a tio n b e g a n n o t in s c h o o l, b u t o n th e ir firs t jo b . N u r s in g is o n e o f th e m o s t W W W ] CRITICAL THINKING QU ESTIO N S* r a p id ly d e v e lo p in g p ro fe s s io n a l d is c ip lin e s . I t is im p o s ­ Do you plan to be a part of a professional s ib le fo r a n y e d u c a tio n a l p r o g r a m to p ro v id e nurses w it h organization after graduation? Why or why a ll o f th e in fo r m a t io n t h a t th e y n e e d to k n o w to p ra c tic e not? What do you anticipate will be your o v e r th e c o u rs e o f a life tim e . T h e best th a t e d u c a tio n c a n level of involvement?* d o is to p r o v id e th e basics w h ile te a c h in g s tu d e n ts h o w to le a r n a n d h o w to access in f o r m a t io n . I t is u p to th e in d iv id u a l to c o n tin u e to d e v e lo p p ro fe s s io n a lly b y a c q u ir in g n e w s k ills a n d k n o w le d g e . KEY COMPETENCY 7-3 A s m em b ers o f a p ro fe s s io n a l d isc ip lin e, w e h a ve an o b lig a tio n to s u p p o rt Examples of Applicable o u r p ro fe s s io n . O u r re s p o n s ib ilitie s d o n o t en d a t th e close o f o u r s h ift; w e Nurse of the Future: Nursing a re re sp o n sib le fo r k e e p in g a b re a s t o f d e v e lo p m e n ts in th e fie ld a n d e n su rin g Core Competencies th a t th e c a re o u r p a tie n ts re c e iv e is th e h ig h e s t q u a lit y a n d m o s t c u rre n t Professionalism: tr e a tm e n t a v a ila b le . I t is also im p o r ta n t fo r nurses to h a v e a v o ic e in h e a lth Knowledge (K4b) Describes c are a n d re la te d issues. T h e p u b lic c o n sid ers nurses to be th e m o s t tru s te d the role of a professional o f a ll h e a lth c a re p ro v id e rs , y e t fe w p e o p le c a n describe e x a c tly w h a t nurses organization in shaping d o . T h e m e d ia m o re o fte n p o r tr a y nurses as sex o bjects th a n as c o m p e te n t the practice of nursing; c lin ic a l p ra c titio n e rs . T h e m e d ia ra re ly v ie w nurses as experts in h e a lth -re la te d (K8a) Understands the issues. I t is v ita l th a t w e a rtic u la te o u r ro le a n d e d u ca te elected o ffic ia ls a n d responsibilities inherent th e p u b lic a b o u t th e v a lu a b le c o n trib u tio n th a t nurses m a k e . N u rs e s s h o u ld in being a member of the ta k e e ve ry o p p o r tu n ity to p ro m o te th e ir p ro fe s s io n . nursing profession O n e im p o r ta n t w a y to d o th is is b y jo in in g p ro fe s s io n a l o rg a n iz a tio n s . Attitudes/Behaviors (A8a) W h a te v e r y o u r c lin ic a l interests, th e re is a p ro fe s s io n a l o rg a n iz a tio n th a t sup­ Recognizes need for po rts th e m . B y jo in in g an o rg a n iz a tio n , y o u h ave access to jo u rn a ls , c o n tin u in g personal and professional e d u c a tio n o fferin g s, p ro fes s io n al m eetings, a n d a n e tw o rk o f o th e r nurses w h o behaviors that promote the share y o u r in te re sts. T h e A m e ric a n N u rs e s A s s o c ia tio n a n d its state c h ap ters profession of nursing a re th e re c o g n ize d v o ic e o f n u rs in g in th e U n ite d States, a lth o u g h o n ly 1 0 % Skills (S8i) Assumes o f re g istere d nurses a re m e m b e rs . T h is m ean s th a t th e vast m a jo r ity o f nurses professional responsibility a re n o t h e a rd o r c o n s u lte d w h e n p u b lic p o licie s c o n c e rn in g h e a lth c a re issues through participation a re discussed. O r g a n iz a tio n s such as th e N a t io n a l L e a g u e fo r N u r s in g a n d in professional nursing th e A m e ric a n A s s o c ia tio n o f C olleges o f N u rs in g h a ve a n im p o r ta n t ro le in organizations setting e d u c a tio n a l stan dards a n d en su rin g th a t those stan dards a re m e t. These Source: Massachusetts Department o rg a n iz a tio n s d e p e n d o n th e c o n trib u tio n s o f m e m b e rs w h o v o lu n te e r th e ir of Higher Education (2010), pp. 13, 15. tim e , en erg y, a n d s u p p o rt to a d v a n c e th e goals o f n u rs in g .

C o m m itm e n t to O u rs e lv e s A s nurses, w e h a v e th e p riv ile g e o f in te ra c tin g w it h p e o p le d u rin g th e m o s t s ig n ifica n t m o m e n ts o f th e ir lives— b irth , d e ath , a n d tim es o f illness a n d in ju ry . I n th e c ourse o f o u r w o r k , w e r o u tin e ly engage in a c tiv itie s th a t a ffe c t th e lives o f o th ers a t tim es w h e n th e y a re m o s t v u ln e ra b le a n d in n e ed o f c a rin g p ro fe s s io n a ls . O u r w o r k m a tte rs , o u r a ctio n s c o u n t. A s a re s u lt, th e p u b lic v ie w s nurses v e ry p o s itiv e ly . W e h a v e th e re p u ta tio n o f b e in g h o n e s t, c a rin g , re lia b le , c o n ce rn e d , a n d a p p ro a c h a b le . A lth o u g h w e e n jo y th e status o f being m e m b e rs o f th is p re stig io u s p ro fe s s io n , th e re is a d o w n s id e to it. N u rs e s , u n fo rtu n a te ly , a re p a r tic u la r ly v u ln e ra b le to stress a n d b u rn o u t. N u r s in g is p u b lic ly p e rc e iv e d to be n o t ju s t a p ro fe s s io n , b u t a v o c a tio n to w h ic h m e m b e rs p le d g e life lo n g c o m m itm e n t. T h e r e is a n a s s u m p tio n th a t nurses s h o u ld be re a d ily a v a ila b le a t a ll tim e s to lis te n to p ro b le m s a n d dis­ cuss h e a lth issues even w h e n th e y a re n o t o n th e jo b . N u rs e s a re c a rin g a n d a p p ro a c h a b le ; th e re fo re , p e o p le o fte n seek o u t nurses fo r a d vic e a n d tr e a t­ m e n t w h e re th e y w o u ld n e v e r p re s u m e to im p o s e o n a p h y s ic ia n o u ts id e o f a w o r k in g s itu a tio n . F a m ily m e m b e rs fr e q u e n tly assum e th a t nurses w ill step fo r w a r d a n d v o lu n te e r to c a re fo r s ic k o r e ld e rly re la tiv e s s im p ly because th e y are nurses, regardless o f th e ir p ro fe s s io n a l c a re e r re s p o n s ib ilitie s — a n d w e re s p o n d as e x p e c te d . M e n a n d w o m e n w h o are a ttra c te d to th e n u rs in g p ro fe s s io n te n d to be “ p e o p le p lea s ers ” w h o are generous w it h th e ir tim e a n d re so u rce s. T h e y o fte n h a v e tr o u b le s ay in g “ n o ” to requests fo r assistance. B e in g n e ed e d m a k e s us feel v a lu e d a n d im p o r ta n t. A lth o u g h th e re is n o th in g in h e re n tly w r o n g w it h th is tr a it, it does o p e n us u p to abuse a n d d is re g a rd fo r o u r p e rs o n a l needs.

■ Stress in the Work Environm ent N u r s in g is d e m a n d in g w o r k . N u rs e s w o r k lo n g h o u rs in high-stress e n v iro n ­ m en ts c a rin g fo r clien ts w h o s e c o n d itio n s a re o fte n u n s ta b le . T h e decisions nurses m a k e h ave serious im p lic a tio n s fo r th e h e a lth a n d lives o f th e ir p a tien ts. O u r clien ts are s ic k a n d fa m ily m e m b e rs are stressed b y th e h o s p ita liz a tio n , so nurses re g u la rly in te ra c t w it h p e o p le w h o a re n o t a t th e ir best. H o s p ita ls a re fa s t-p a c e d , in ten se w o r k e n v iro n m e n ts w h e re s itu a tio n s ch an g e r a p id ly a n d nurses m u s t re s p o n d q u ic k ly a n d a c c u ra te ly to a m u ltitu d e o f c o m p e t­ in g d e m a n d s . T h e n u rs in g s h o rta g e fu rth e r c o m p lic a te s th e s itu a tio n in th a t m a n y u n its a re c h ro n ic a lly u n d e rs ta ffe d . T h e re is o fte n a r a p id tu rn o v e r o f s ta ff m e m b e rs a n d a la c k o f e x p e rie n c e d nurses. M a n y h o s p ita ls h a ve im p le ­ m e n te d 1 2 -h o u r shifts fo r nurses, a n d a lth o u g h th is s ch e d u lin g o ffers c e rta in a d v a n ta g e s , it creates a life s ty le th a t leaves little tim e fo r p e rs o n a l s elf-ca re a c tiv itie s . A 1 2 -h o u r s h ift easily stretches to 1 4 o r m o re h o u rs w h e n c o n s id ­ e rin g re p o rt tim e , p a p e r w o r k , a n d c o m m u tin g . T h e w o r k is p h y s ic a lly a n d

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m e n ta lly ta x in g a n d , a t th e end o f th e d a y , nurses a rriv e h o m e w it h little tim e o r e n erg y le ft to care fo r th e ir fa m ilie s , le t a lo n e th em selves. N u rs e s in g e n e ra l a re a re s ilie n t g ro u p c a p a b le o f d e a lin g w it h w o r k re la te d stress a n d th riv in g in th e d e m a n d in g h e a lth c a re e n v iro n m e n t. U n fo r ­ tu n a te ly , it is easy fo r o u r p ro fe s s io n a l lives to o v e rru n o u r p e rs o n a l lives w ith th e re s u lt th a t w e la c k a p o s itiv e b a la n c e b e tw e e n w o r k , h o m e , a n d p e rs o n a l in te re s ts . M a in t a in in g th is p ace fo r p ro lo n g e d p e rio d s c a n h a v e u n to w a r d effects o n o n e ’s h e a lth , re la tio n s h ip s , a n d o v e ra ll q u a lity o f life . T h e effects o f stress a re m u ltip le a n d v a rie d a n d c a n a ffe c t th e fo llo w in g : • •

• •

F e elin g s , in c lu d in g a n x ie ty , ir r ita b ilit y , fe a r, a n g er, a n d m o o d in e ss T h o u g h ts , in c lu d in g s e lf-c ritic is m , d iffic u lty c o n c e n tra tin g a n d m a k in g d ecis io n s, fo rg e tfu ln e s s o r m e n ta l d is o rg a n iz a tio n , p re o c c u p a tio n w it h th e fu tu re , re p e titiv e th o u g h ts , a n d fe a r o f fa ilu re B eh a vio rs , in c lu d in g c ry in g , actin g im p u ls iv e ly , nervo us la u g h te r, sn ap p in g a t frie n d s , te e th g rin d in g o r ja w c le n c h in g , s m o k in g , a lc o h o l o r d ru g abuse P h y s ic a l sensatio ns, in c lu d in g h e ad a ch es , tig h t m uscles, c o ld o r s w e a ty h a n d s , b a c k o r n e c k p ro b le m s , d iffic u lty sleep ing , s to m a c h aches, colds a n d in fe c tio n s , fa tig u e , ra p id b re a th in g o r p o u n d in g h e a rt, o r tre m b lin g (S ik o rs k y & M a la n e y , 2 0 0 7 )

T h e m ean s b y w h ic h w e d e al w it h stress b e co m e v e ry im p o r ta n t. A ll to o o fte n , nurses use c o p in g m e th o d s th a t a re d e trim e n ta l to th e ir o v e ra ll w e ll­ b e in g . L a c k o f exercise a n d p o o r n u t r itio n increase th e d e le te rio u s effects o f stress. A d d ic tiv e b e h a v io rs such as s m o k in g , o v e re a tin g , s e lf-m e d ic a tio n , a n d substance abuse c a n d e v e lo p . S om e nurses a re a ttra c te d to n e ed y p e o p le a n d e n te r in to to x ic re la tio n s h ip s . T h e results o f these n e g a tiv e b e h a v io rs c a n le a d to p h y s ic a l illness, in crea se d ris k o f in ju rie s , a n d b u rn o u t.

■ Burnout: An Occupational Hazard B u rn o u t occurs w h e n nurses c an n o lo n g e r cope w it h th e stresses a n d strain s o f p ro fe s s io n a l n u rs in g a n d choose to lea ve th e p ro fe s s io n to seek e m p lo y ­ m e n t e ls ew h e re. S y m p to m s o f b u r n o u t in c lu d e p h y s ic a l, p s y c h o lo g ic a l, a n d e m o tio n a l e x h a u s tio n ; la c k o f e n th u s ia s m a n d de cre as e d in te re s t in w o r k re la te d a c tiv itie s ; a n d d e p re ss io n , n e g a tiv is m , a n d a n g e r. N u rs e s e x p e rie n c in g b u r n o u t w it h d r a w e m o tio n a lly fr o m b o th clien ts a n d c o w o rk e rs . T h e y m ig h t e x p e rie n c e an in ­ crease in p h y s ic a l s y m p to m s th a t re su lts in a b s e n te e is m . N u rs e s w h o c o n tin u o u s ly give o f them selves p h y s ic a lly a n d e m o tio n a lly w it h o u t s u ffic ie n t e ffe c tiv e rest a n d re c re a tio n e v e n tu a lly b e c o m e d e p le te d a n d d e v e lo p b u r n o u t. S avvy e m p lo y e rs re c o g n ize th is d a n g e r a n d im p le m e n t m easures a n d p ro g ra m s d e sig n e d to id e n tify nurses a t ris k a n d i n ­ te rv e n e to p re v e n t b u r n o u t fr o m o c c u rrin g . A ll to o o fte n ,

h o w e v e r, th is w o rk p la c e crisis is o v e rlo o k e d u n til nurses resign in fru s tra tio n . U lt im a te ly , w e as nurses a re re s p o n s ib le fo r o u r o w n p h y s ic a l a n d m e n ta l h e a lth . I t is im p e ra tiv e th a t nurses u n d e rs ta n d th e effects o f w o rk p la c e stress a n d th e s y m p to m s o f b u r n o u t to p re v e n t th is o c c u p a tio n a l h a z a rd .

■ Stress M anagem ent and Self-Care T o su rviv e a n d th riv e in th e p ro fe s s io n , nurses m u s t be as a tte n tiv e to th e ir o w n needs as th e y are to th e needs o f th e ir c lie n ts . S e lf-c a re m ean s a c k n o w l­ e d g in g a n d m e e tin g y o u r o w n p h y s ic a l, p s y c h o lo g ic a l, s o cia l, a n d s p iritu a l needs. I t m ean s c a rin g fo r y o u rs e lf b e fo re y o u care fo r o th e rs , n o t a fte r y o u h a v e te n d e d to everyon e else. In an em ergency, a irlin e a tte n d a n ts a lw ay s advise in d iv id u a ls tra v e lin g w ith y o u n g c h ild re n to p lace th e o x y g e n m asks o v er th e ir o w n faces b e fo re p la c in g th e m o n th e c h ild re n . W e c a n n o t h e lp o th ers i f w e a re s ta rv e d a n d d e p le te d ourselves. In d iv id u a ls are h a p p ie s t a n d fu n c tio n a t th e ir best w h e n th e re is b a la n c e in th e ir lives. M e e tin g o n e ’s p h y s ic a l needs is a g o o d p lac e to b e g in . N u rs e s u n d e rs ta n d th e im p o rta n c e o f n u tr itio n o n w o u n d h e a lin g a n d illness re co v ery in th e ir clients; th e re fo re , th e y m u s t s im ila rly n o u ris h th e ir o w n bodies w it h h e a lth y , b a la n c e d , n u tritio u s m ea ls fo r o p tim a l p e rfo rm a n c e . P ro b le m s w it h o v e rw e ig h t a n d ob esity s h o u ld be addressed th ro u g h p ro g ra m s o f so und n u tr i­ tio n a n d p la n n e d exercise. O n e o f th e c ru e l iro n ie s o f n u rs in g is th a t, a lth o u g h th e w o r k is p h y s ic a lly d e m a n d in g , it is n o t p a rtic u la rly g o o d exercise. N u rs e s m u s t m a k e tim e in th e ir busy schedules fo r a e ro b ic a c tiv itie s such as w a lk in g , jo g g in g , s w im m in g , te n n is , s p in n in g , b ic y c lin g , o r d a n c in g in a d d itio n to basic w e ig h t tr a in in g to s tre n g th en m uscles a n d b u ild s ta m in a . H a b its such as s m o k in g , c o n s u m in g a lc o h o l, a n d ta k in g n o n p re s c rip tio n m e d ic a tio n s m u s t be a v o id e d . R e s t is as im p o r t a n t as d ie t a n d exe rcis e in d e a lin g w it h stress. M o s t p e o p le re q u ire a m in im u m o f 8 h o u rs o f sleep a t n ig h t. N u rs e s w h o ro ta te shifts o r w o r k n ig h ts o fte n h a v e p ro b le m s sleep ing d u rin g th e d a y a n d fa il to g e t a d e q u a te rest. Sleep aids c an o ffe r te m p o ra ry re lie f; h o w e v e r, m o s t sleepin d u c in g m e d ic a tio n s cause d e p e n d e n c y a n d h a v e side e ffects. M e la to n in is a n a tu r a lly o c c u rrin g h o rm o n e th a t induces sleep a n d c an be p u rc h a s e d o v er th e c o u n te r in d ru g sto re s o r h e a lth fo o d stores. T o d a te , m e la to n in has n o t been s h o w n to h a v e n e g ative side effects w h e n ta k e n as d ire cted fo r s h o rt-te rm re lie f o f sleeplessness. T h e m o s t e ffe c tiv e sleep a id , h o w e v e r, is g o o d n u t r i­ tio n , p h y s ic a l exercise, a n d a n e n v iro n m e n t c o n d u c iv e to rest a n d r e la x a tio n . F u lfillin g p s yc h o lo g ica l, social, a n d s p iritu a l needs is as im p o rta n t to o n e ’s w e ll-b e in g as ta k in g c are o f p h y s ic a l needs. U n fo r tu n a te ly , these a re o fte n s a c rifice d w h e n tim e a n d e n erg y a re a t a p re m iu m . W h e th e r o n e considers n u rs in g a v o c a tio n , a n o c c u p a tio n , o r a c are er, it re m a in s o n ly one aspect o f a n in d iv id u a l’s life a n d m u s t n o t b e c o m e a ll-c o n s u m in g . T im e a w a y fr o m th e jo b is as im p o r ta n t as tim e spent o n th e jo b . S o c ia liz in g w it h p e o p le w e

190

KEY COMPETENCY 7-4 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Professionalism: Knowledge (K8b) Recognizes the relationship between personal health, self renewal, and the ability to deliver sus­ tained quality care Source: Massachusetts Department of Higher Education (2010), p. 15.

CHAPTER 7 Career Management and Care of the Professional Self

lo v e a n d w h o c o n trib u te p o s itiv e ly to o u r lives is c ru c ia l; h o w e v e r, n o t a ll re la tio n s h ip s w it h frie n d s o r fa m ily m em b ers are h e a lth y . W h e n y o u re g u la rly lea ve s o cia l e n co u n te rs fe e lin g w o rs e th a n b e fo re , it is tim e to re e v a lu a te th a t re la tio n s h ip . B y a ll m ea n s , address in te rp e rs o n a l issues a n d re so lv e c o n flic t w h e n e v e r possible; seek cou n selin g i f necessary, b u t i f th e re la tio n s h ip re m ain s to x ic , y o u m u s t lim it y o u r e x p o s u re to th a t p e rs o n . W e a re s o cia l beings w h o re ly o n each o th e r fo r v a lid a tio n , stress re lie f, a n d sheer e n jo y m e n t o f life . W it h o u t p o s itiv e social re la tio n s h ip s , w e lose p e rsp ec tive a n d p ro b le m s c an ra p id ly b e co m e o v e rw h e lm in g . H u m a n beings n a tu r a lly s trive to fin d m e a n in g in th e ir e xisten ce. A ll o f us h a v e s p iritu a l needs, b u t fo r nurses w h o d e a l w it h life a n d d e a th o n a d a ily basis, s p ir itu a lity becom es p a rtic u la rly im p o r ta n t as w e s tru g g le to c o m e to te rm s w it h these issues. B e lie f in a h ig h e r b e in g , in a p la n n e d u n iv ers e, a n d in a ric h a fte rlife helps p ro v id e c o n te x t fo r th e joys a n d trag e d ies w e w itn ess re g u la rly . R egardless o f o n e ’s p e rso n al s p iritu a l beliefs, p a rtic ip a tio n in p ra y e r, re lig io u s services, a n d fe llo w s h ip w it h oth ers s h a rin g y o u r beliefs is im p o rta n t to m a in ta in b a la n c e a n d p e rsp ec tive .

■ Tim e M anagem ent Is Key to Life M anagem ent F o r m o s t o f us, th e g re ates t c h a lle n g e a n d k e y to life b a la n c e is tim e m a n a g e ­ m e n t. E a c h o f us has 2 4 h o u rs a day, 1 6 8 h o u rs p e r w e e k , o r 8 ,7 6 0 h o u rs p e r y e a r to m a n a g e . I f a th ir d o f y o u r d a ily a llo tm e n t is spent sleep in g a n d a n o th e r th ir d w o r k in g , th a t leaves o n ly 8 h o u rs to a tte n d to a ll o f th e o th e r a c tiv itie s o f d a ily liv in g — s h o p p in g , m e a l p re p a ra tio n , d in in g , h o u s e k e e p in g , la u n d ry , e rra n d s , c h ild c a re , c a rp o o lin g , c o m m u tin g , a n d so o n . P recious little tim e re m a in s a t th e end o f th e d a y fo r q u ie t re fle c tio n , re c re a tio n , re a d in g , re la x in g , o r re la tio n s h ip s ; y et, these a re th e a ctiv ities th a t are v ita l to re s to rin g o u r p h y s ic a l a n d m e n ta l h e a lth . T h e m o re a c tiv itie s w e c ra m in to o u r day, th e m o re th e stress b u ild s . I t is im p o s s ib le to d o it a ll! Y es, w e c an h a v e it a ll— career, frie n d s , fa m ily re la tio n s h ip s , c h ild re n , h o m e — w e ju s t m ig h t n o t be a b le to h a v e it a ll a t th e sam e tim e o r m a n a g e it a ll b y ourselves. M a n y p e o p le a p p ro a c h th e c h allen g e o f tim e m a n a g e m e n t b y a tte m p tin g to b e co m e m o re o rg a n iz e d , e m p lo y in g to -d o lists, d a ily p la n n e rs , o r p e rs o n a l assistive devices to g a in c o n tro l o v e r m u ltip le d e m a n d s fo r tim e a n d a tte n tio n . T h e s e s tra te g ie s c a n h e lp y o u o r g a ­ n iz e y o u r a c tiv itie s , b u t th e y c a n n o t a d d h o u rs to th e d a y . A n a lte r n a tiv e a p p ro a c h to tim e m a n a g e m e n t is life m a n a g e m e n t. L ife m a n a g e m e n t e n ta ils d e te rm in in g w h a t is t r u l y i m p o r t a n t to y o u a n d m a k in g p o s itiv e c h o ice s a b o u t h o w , w h e re , a n d w it h w h o m y o u s p en d y o u r p r e ­ c io u s h o u r s . L if e m a n a g e m e n t m e a n s le t tin g g o o f th e m in u tia e t h a t c lu t te r o u r liv e s a n d sap o u r s tre n g th . I t in v o lv e s s im p lify in g o u r e n v iro n m e n ts , o u r c o m m itm e n ts ,

Conclusion

191

a n d o u r re la tio n s h ip s to e lim in a te th e p h y s ic a l a n d p s y c h o lo g ic a l b a g g a g e t h a t w e ig h s us d o w n . T h e p o p u la r press a b o u n d s w it h b o o k s w r it te n b y life coaches a n d tim e m a n a g e m e n t specialists w ith suggestions o n h o w to id e n tify y o u r valu es, fo rm u la te p e rs o n a l m iss io n statem en ts, a n d set W W W ] CRITICAL THINKING QUESTION V p rio r itie s th a t a llo w y o u to in c o rp o ra te th e re la tio n s h ip s Think about what it is that is truly important a n d a c tiv itie s th a t n o u ris h a n d e n ric h y o u r life in to y o u r to you. Do the choices you make about how, schedule. T a k e a d v a n ta g e o f w h a te v e r to o ls a re a v a ila b le where, and with whom you spend your time to y o u to le a rn to p u t in to p la c e th e p e o p le a n d system s reflect what is important to you? V th a t assist y o u to a c c o m p lis h th a t w h ic h is tr u ly im p o rta n t.

C o nclu sio n A s nurses, o u r p ro fe s s io n a l lives a re b o th c h a lle n g in g a n d re w a rd in g . S im p ly b y in tr o d u c in g y o u rs e lf as a n u rse , y o u a re in v ite d in to th e lives o f oth ers in a w a y th a t r a re ly h a p p e n s in o th e r d isc ip lin es . P eo p le e n tru s t y o u w it h th e m o s t in tim a te d e ta ils o f th e ir lives a n d lite r a lly p lac e th e ir lives a n d th e lives o f th e ir lo v e d ones in y o u r h a n d s . O n a d a ily basis, y o u h a v e th e o p p o rtu n ity to m a k e a d iffe re n c e in th e life o f a n o th e r h u m a n b e in g . F e w pro fession s o ffe r th is lev el o f in te ra c tio n . T h is is, a t th e sam e tim e , a ra re p riv ile g e a n d a n a w e ­ som e re s p o n s ib ility . A s m e m b e rs o f a w id e ly respected p ro fe s s io n , w e m u s t keep in m in d th e re s p o n s ib ility th a t w e b e ar a n d strive to u p h o ld c o n tin u o u s ly th e s ta n d a rd s o f e xcellen ce th a t o u r p ro fe s s io n h o ld s . O n e c ru c ia l aspect o f th is re s p o n s ib ility lies in c a rin g fo r ourselves b o th p e rs o n a lly a n d p ro fe s s io n a lly . W e m u s t a tte n d to o u r o w n needs firs t so th a t w e c an address th e needs o f o u r clien ts a n d o f o u r p ro fe s s io n . T h is c h a p te r has discussed th e im p o rta n c e o f c a re e r m a n a g e m e n t, life m a n a g e m e n t, a n d p e rs o n a l s elf-ca re. A s in d iv id u a ls m a k e th e d e cis io n to e n te r th e n u rs in g p r o ­ fession, th e y also choose w h e th e r n u rs in g , fo r th e m , w ill be a n o c c u p a tio n o r a c a re e r. T h e fu tu re o f n u rs in g depen ds o n m e m b e rs c a rin g fo r them selves a n d c h o o s in g to a p p ro a c h n u rs in g as a life lo n g p ro fe s s io n . W e h o p e th a t y o u w ill choose w is e ly .

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CHAPTER 7 Career Management and Care of the Professional Self

Classroom A ctivity: Nursing School Survival Game e fo re class th e in s tru c to r w ill p re p a re the b o a rd gam e. Spaces o n the b o a rd w ill reflect s e lf-c a re a c tiv itie s a n d g ive in s tru c tio n s fo r m o v in g fo rw a rd o r b a c k w a rd d e p en d in g o n w h eth er the activity reflected in the space prom otes self-care o r is d e trim e n ta l. D iv id e students in to sm all groups to p la y the N u rs in g School S urvival G a m e . Students ro ll th e dice to d e te rm in e h o w m a n y spaces to m o v e . A s th ey m o v e a ro u n d the b o a rd , th ey w ill progress fro m nursing school ad ­ m ission to second semester, th ird semester, fo u rth semester, an d th en g ra d u a tio n . A s th e g ro u p s la n d o n d iff e r e n t sp ac es , ta k e tim e to discuss th e s e lf-c a re a c tiv ity a n d w h y it w ill h e lp th e m to be successful in n u rs ­ in g sch o o l. A c tiv itie s m ig h t in c lu d e th in g s such as b u y in g a p la n n e r to g e t o rg a n iz e d , re a d in g assignm ents b e fo re class, fin d in g a s tu d y g ro u p , g e ttin g re g u la r exercise, e a tin g n u tritio u s m eals,

B

a n d e m p lo y in g specific stress m a n a g e m e n t te c h ­ n iq u e s . T h is g a m e is a g o o d o n e to use a t th e b e g in n in g o f th e firs t sem ester to h e lp students get to k n o w one a n o th e r as w e ll as discuss w a y s in w h ic h students c an b e g in using self-care s tra t­ egies fr o m th e v e ry b e g in n in g o f th e ir n u rs in g s ch o o l c are er. Spaces o n th e b o a rd m a y a lte rn a te ly re fle c t c a te g o rie s i f v e r b a l q u e s tio n s w i l l be a s k e d d u r in g th e g a m e . I f th is a p p ro a c h is used, th e g ro u p w ill a n s w e r questions a b o u t self-care c a t­ egories to progress a ro u n d th e b o a rd . A n o th e r a p p ro a c h to th is g a m e t h a t is fu n is to h a v e d iff e r e n t c o lo r e d p iec e s o f p a p e r la b e le d as c a te g o rie s o f s e lf-c a re q u e s tio n s o n th e flo o r , c re a tin g a g a m e b o a rd e ffe c t a n d le ttin g th e s tu ­ dents (e ith e r a lo n e o r in g ro u p s ) m o v e a ro u n d th e “ g a m e b o a r d ” as th e y a n s w e r q u e s tio n s re la te d to self-ca re,

R e fe re n c e s American Association of Colleges of Nursing. (2002). White paper on the professional practice setting. Retrieved from http://www.aacn.nche.edu/Publications/positions/ hallmarks.htm Covey, S. R. (1989). The 7 habits o f highly effective people. New York, NY: Simon & Schuster. Joel, L. A. (2003). Career management. In L. A. Joel (Ed.), Kelly’s dimensions o f professional nursing (9th ed.). New York, NY: McGraw-Hill. Massachusetts Department of Higher Education. (2010). Nurse o f the future: Nursing core competencies. Retrieved from http://www.mass.edu/currentinit/documents/ NursingCoreCompetencies.pdf Miller, T. W. (2003). Work versus career. In T. W. Miller (Ed.), Building and managing a career in nursing. Indianapolis, IN: Sigma Theta Tau International. Oxford University Press. (1996). The Oxford English dictionary. New York, NY: Oxford University Press. Riley, J. B. (2004). Feedback. In J. B. Riley (Ed.), Communication in nursing (5th ed.). St. Louis, MO: Mosby.

Sikorski, E., & Malaney, K. (2007). Personal and financial health. Vermont Nurse Connection, 10(3), 9. Tappan, R. M. (2001). Individual evaluation procedures. In R. Tappen & C. Lynn (Eds.), Nursing leadership and management concepts and practice (4th ed.). Philadelphia, PA: F. A. Davis. Vance, C., & Olson, R. (1998). The mentor connection in nursing. New York, NY: Springer.

u n i t ii

Professional Nursing Practice and the Management of Patient Care

The Healthcare Delivery System and the Role of the Professional Nurse Sharon Vincent

v____________________ P erh ap s y o u w o n d e r w h y h o s p ita ls a re c a lle d h e a lth c a re d e liv e ry system s a n d n o t ju s t h o s p ita ls , o r w h y nurses are re fe rre d to as p ro fe s s io n a l nurses a n d n o t ju s t nurses? T h is c h a p te r e x p lo re s w h a t th e h e a lth c a re d e liv e ry system m ea n s to us a n d som e o f th e ro les nurses p la y th a t d e fin e w h a t it m ean s to be a p ro fe s s io n a l n u rse . V a r io u s m o d e ls o f n u rs in g c are d e liv e ry a re discussed so th a t th e g ra d u a te nurse possesses a g re a te r u n d e rs ta n d in g o f th e h e a lth c a re d e liv e ry e n v iro n m e n t. T h e m e th o d used to assign s ta ff nurses a n d te ch n ician s m ig h t seem lik e a d is ta n t c o n c e p t a t th is m o m e n t, b u t as a b a c c a la u re a te e n try -le v e l n u rse , y o u c o u ld be m a k in g assig nm ents soon a fte r g ra d u a tio n . A ll nurses to d a y a re m a n a g e rs . R e g is te re d nurses (R N s ) m a n a g e th e care o f specific gro ups o f p a tie n ts , p e rfo rm care th em selves, d ire c t others to p ro v id e c a re , a n d c o lla b o ra te w it h o th e r h e a lth c a re p ro v id e rs . N u rs e s m u s t k n o w h o w to d e le g a te , supervise, e v a lu a te , m o tiv a te , a n d c o m m u n ic a te w it h o th e r discip lin es, nurses, a n d u n lice n s ed p e rs o n n e l. N u rs e s m u s t also le a d te a m s . In th e m a n a g e m e n t o f c are , each n u rse directs th e n u rs in g c are w it h in a d e liv e ry s e ttin g to p ro te c t th e c lie n ts , s ig n ific a n t o th e rs , a n d h e a lth c a re p e rs o n n e l.

Learning Objectives A f t e r c o m p le tin g th is c h a p te r, th e s tu d e n t should be a b le to : 1. D escribe how h e a lth c a re is d e liv e re d and how th e s y s te m is changing. 2 . D escribe nursing c a re d e liv e ry m odels. 3 . A n a ly ze fa c to rs th a t a ffe c t c o lla b o ra tio n in th e h e a lth c a re d e liv e ry s y s te m . 4 . A n a ly ze th e role of th e p ro fessio n al nurse. 5 . D escribe th e a d vo c ac y role o f th e pro fession al nurse. 6 . E xp lain how e ffe c tiv e d e le g a tio n can b e n e fit b o th th e c lie n t and th e h e a lth c a re d e liv e ry s y s te m .

7 . Id e n tify th e need fo r c o n s u lta tio n and co lla b o ­ ra tio n w ith o th e r h e a lth c a re p ro vid e rs. 8 . D es crib e th e im p o rta n c e of c o n tin u ity o f c are and in te rd is c ip lin a ry c o lla b o ra tio n b e tw e e n h e a lth c a re p ro vid e rs. 9 . D is c u s s th e n e e d fo r c o n tin u o u s q u a lit y im p ro v e m e n t in th e provision of p a tie n t c are .

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Key Terms and Concepts » H e a lth c a re d e liv e ry s y s te m » Complex adaptive systems (CASs) » Models of patient care delivery » Team nursing » Total patient care » Case management » Collaborative critical pathway » Practitioner, caregiver, advocate, educator, leader, manager, collaborator, and researcher » Delegation » Interdisciplinary healthcare team » Consultations » Continuous quality improvement (CQI)

T h e p ro fe s s io n a l n u rse uses c ritic a l th in k in g s kills to assess c lie n ts a n d to e v a lu a te th e e x p e rtis e o f n u rs in g s ta ff w h e n m a k in g assig nm ents. T h e n u rs e ’s ro le encom passes c o lla b o ra tio n in th e c o n tin u ity o f c are fr o m a d m is s io n to discharge a n d re h a b ilita tio n . T h is c h a p te r c le a rly defines som e o f th e concepts th a t are needed fo r th e e n try -le v e l nurse to m a in ta in safe a n d c o m p e te n t e n try lev el n u rs in g p ra c tic e .

H e a lth c a re D e liv e ry S y s te m T h e h e a lth c a re d e liv e ry s y s te m has c h an g ed p ro fo u n d ly o v e r th e p a st several decades fo r m a n y reasons. P o p u la tio n shifts (d e m o g ra p h ic c hang es), c u ltu ra l d iv e rs ity , th e p a tte rn s o f diseases, a d va n ce s in te c h n o lo g y , a n d e c o n o m ic changes h a v e a ll a ffe c te d th e p ra c tic e o f n u rs in g . P o p u la tio n changes a ffe c t d e liv e ry o f h e a lth c are . H e a lt h c are is n e ed e d n o w m o re th a n in th e p a st be­ cause th e p o p u la tio n is g ro w in g , th e c o m p o s itio n o f th e p o p u la tio n is c h a n g ­ in g , b ir th rates a re d e cre as in g , a n d th e life s p an is le n g th e n in g . P eo p le o ld e r th a n 8 5 years o f age, w h o o fte n re q u ire h e a lth c are fo r c h ro n ic c o n d itio n s , m a k e u p one o f th e fa s te s t-g ro w in g segm ents o f th e p o p u la tio n : T h e n u m b e r w a s 3 4 tim es la rg e r in 1 9 9 9 th a n in 1 9 0 0 (S m e ltz e r, B a re , H in k l , & C h e e v e r, 2 0 1 0 ) . M o r e sen io r c itize n s, m a n y o f w h o m are w o m e n , a re a fa c to r in h e a lth c are because o f th e h e a lth c a re resources th e y c o n su m e . A ls o , a s ig n ific a n t p o r tio n o f th e p o p u la tio n n o w resides in u rb a n areas, w it h a stea d y in flu x o f e th n ic m in o ritie s . H o m e le s s perso n s, in c lu d in g h o m e ­ less fa m ilie s , are o n th e rise. C u ltu r a l d iv e rs ity increases as p e o p le fr o m d if ­ fe re n t n a tio n a litie s e n te r th e c o u n try . T h e p ro fe s s io n a l nurse m u s t k n o w h o w to p ro v id e fo r th e d iverse needs o f p e o p le fr o m v a rie d c u ltu ra l b a c k g ro u n d s . I t is p ro je c te d th a t b y 2 0 3 0 , ra c ia l a n d e th n ic m in o r ity gro u p s c o u ld a p p ro a c h 5 0 % o f th e p o p u la tio n o f th e U n ite d States (S m e ltz e r et a l., 2 0 1 0 ) . N u rs in g c are m u s t be sensitive to c u ltu ra l d iffere n c es . B e in g c u ltu ra lly a w a re w it h in th e h e a lth c a re d e liv e ry system helps th e n u rse a v o id im p o s in g p e rs o n a l v a lu e systems w h e n th e p a tie n t has a d iffe re n t p o in t o f v ie w . In th e las t 5 0 years, e v o lv in g p a tte rn s o f diseases h a v e b ro u g h t s ig n ific a n t c h an g es to th e h e a lth c a re d e liv e ry s y s te m . D is ea se s such as tu b e rc u lo s is , a c q u ire d im m u n o d e fic ie n c y s y n d ro m e ( A ID S ) , a n d s e x u a lly tr a n s m itte d in fe c tio n s a re in c re a s in g . B ecause o f th e w id e s p re a d in a p p r o p r ia te use o f a n tib io tic s , a n in c re a s in g n u m b e r o f in fe c tio u s agents are b e c o m in g resis­ ta n t to a n tib io tic th e ra p y . O b e s ity is n o w a m a jo r h e a lth c h a lle n g e as are its c o m o rb id itie s — h y p e rte n s io n , c o ro n a ry h e a rt disease, d ia b e te s m e llitu s , a n d c a n c e r. A ls o , th e im p ro v e m e n t in tech niques fo r tra u m a a n d acute care m eans th a t m o re p e o p le a re liv in g decades lo n g e r w it h c h ro n ic c o n d itio n s . T e c h n o lo g y has b o o s te d s u rg ic a l a n d d ia g n o s tic service areas so th a t p a tie n ts c an receive s o p h is tic a te d tr e a tm e n t o n an o u tp a tie n t basis. C o m m u n ic a tio n tech n iq u es

p ro v id e a m ean s to tr a in p ro v id e rs a n d d e liv e r h e a lth care to re m o te c o u n trie s o r islands b y s a te llite . T h e V e te ra n s A d m in is tr a tio n has a p ro g ra m o f p o s t­ tr a u m a tic stress d is o rd e r a n d te le m e n ta l h e a lth fo r v ete ra n s in tr ib a l re s e rv a ­ tio n s a n d o n re m o te isla n d s. T e le h e a lth uses e le c tro n ic c o m m u n ic a tio n s a n d in fo r m a t io n te c h n o lo g y to p ro v id e a n d s u p p o rt h e a lth c are w h e n d istan ce separates p a rtic ip a n ts . In th e past, th e h e a lth c a re d e liv e ry system w a s m a in ly h o s p ita l based w ith an acu te c are fo cus. C u r r e n tly , m a n y clients stay in th e h o s p ita l fo r a s h o rt tim e , ju st 2 3 h o u rs. O th e r facets o f c u rre n t h e a lth c a re d e liv e ry in clu d e h o s p ita l te s tin g a n d p re c e rtific a tio n , te le c o m m u n ic a tio n s , h o m e h e a lth , m o b ile vans, a n d m a ll c lin ic s . H is to r ic a lly , as h e a lth c a re costs b e c a m e a la r m in g ly h ig h , cost c o n ta in m e n t m a n d a te d b y C ongress in itia te d th e b e g in n in g o f d iag n o sis re la te d gro ups (D R G s ), a p la n to c u t costs re la te d to M e d ic a re re im b u rs e m e n t. T r e a tm e n t b e ca m e fo cu sed o n cost a n d p ro fit, a n d th e q u a lity o f n u rs in g care d e c lin e d . N u rs e s e x p e rie n c e d w o r k -r e la te d stress a n d b u rn o u t, a n d m a n y le ft n u rsin g as h o sp itals o p e ra te d w it h fe w e r resources. Because o f cost con strain ts a n d a s h o rta g e o f a v a ila b le nurses, cross tr a in in g b ecam e a c o m m o n p ra c tic e . F o r e x a m p le , one n u rse c o u ld be cross tr a in e d to w o r k in th e o p e ra tin g ro o m a n d th e p o s ta n e s th e s ia c a re u n it a n d th u s possess th e s p e c ia lize d s kills to w o r k in e ith e r u n it w h e n th e n eed arises (B lais , H a y e s , K o z ie r, & E rb , 2 0 0 6 ) . N u rs e s a re tr a in e d to fill tw o d e p a rtm e n ts o r m o re because fe w e r nurses are b e in g h ire d as a re s u lt o f cost c o n s tra in ts . N u rs e s are c h a lle n g e d m o re th a n ever to p ro v id e q u a lity care w it h fe w e r resources. T w o m a jo r issues a re a t th e fo r e fr o n t o f h e a lth c a re d e liv e ry : cost c o n ta in m e n t a n d access to c are. R e d u c tio n s in h e a lth c a re p e rs o n n e l h a ve been a m a jo r ch allen g e to p ro v id in g q u a lity care in a n era o f re s tru c tu re d resources. M a n y p e o p le h a v e lim ite d o r n o access to h e a lth c a re . F e w e r p a tie n ts a re c o v e re d b y in s u ra n c e , a n d m a n y h a v e lo w e r p ercen tag es o f c o ve rag e, c o p a y ­ m e n t p ro b le m s , o r n o in s u ra n c e c o v e ra g e a t a ll. T h e u n in s u re d seg m en t o f th e p o p u la tio n is in crea sin g : A b o u t 4 0 m illio n A m e ric a n s are e s tim a te d to be u n in s u re d a t a tim e , a n d 6 0 m illio n A m e ric a n s a re w it h o u t h e a lth in s u ra n c e fo r a p o r tio n o f th e y e a r (B lais et a l., 2 0 0 6 ) . M a n y m o re are u n d e rin s u re d , th us lim itin g th e m fr o m re c e iv in g h e a lth c are. T h e c h a in o f c o m m a n d refers to th e h ie ra rc h y o f a u th o r ity a n d re s p o n ­ s ib ility in a n o r g a n iz a tio n . L in e a u th o r it y is a ty p e o f a u th o r it y in t r a d i ­ tio n a l h e a lth c a re d e liv e ry system s in w h ic h th e s u p e rv is o r d ire cts a c tiv itie s o f e m p lo yees he o r she supervises. A c h a in o f c o m m a n d a llo w s e m p lo ye es to u n d e rs ta n d th e ir tasks a n d to m a n a g e s u p e rv is o ry re la tio n s h ip s w it h in th e o rg a n iz a tio n . T h is s tru c tu re p ro v id e s an ave n u e fo r re p o rtin g issues th a t need m a n a g e m e n t’s a tte n tio n . N u rs in g students s h o u ld fo llo w c h a in o f c o m m a n d , firs t w it h n u rs in g in s tru c to rs a n d th e n sch o o l p ro g ra m d ire c to rs . O r g a n iz a ­ tio n a l c h a rts w it h c h a in o f c o m m a n d illu s tr a te flo w o f re s p o n s ib ility fr o m s ta ff n u rse to nurse m a n a g e rs a n d o n u p to th e c h ie f n u rs in g o ffic e r. T h is is th e c e n tra liz e d /d e c e n tra liz e d a p p ro a c h (S m e ltz e r et a l., 2 0 1 0 ) .

O th e r m o d e ls o f h e a lth c a re d e liv e ry are e m e rg in g as o rg a n iz a tio n s face in c re a s in g u n p r e d ic ta b ility a n d th e n e ed fo r c h a n g e . H e a lth c a r e o rg a n iz a ­ tio n s ( H C O s ) a re e x a m p le s o f c o m p le x system s. T h e te rm c o m p le x a d a p tiv e s y s te m s (C A S s ) refers to a c o lle c tio n o f in d iv id u a l agents w h o a re free to act in w a y s n o t to ta lly p re d ic ta b le a n d w h o s e a ctio n s a re in te rc o n n e c te d so th a t o n e a c tio n chang es th e c o n te x t fo r o th e r agents o r u n its (W ils o n & H o l t , 2 0 0 1 ) . A C A S is h ig h ly a d a p tiv e a n d is c h a ra c te riz e d b y s e lf-o rg a n iz a tio n , e m ergence o f n e w p a tte rn s o r b e h a v io rs , a n d d is trib u te d r a th e r th a n c e n tra l­ ize d c o n tro l. P atte rn s a n d b e h a v io rs e n ab le u n d e rs ta n d in g o f C A S s . P lsek an d W ils o n (2 0 0 1 ) a d v o c a te a p p ly in g C A S concepts to o rg a n iz a tio n a l s tru c tu re . S uch a p p lic a tio n to h e a lth c a re o rg a n iz a tio n s w o u ld describe a z o n e o f c o m ­ p le x ity in w h ic h C A S s ra n g e fr o m a d a p ta b ility o f h ig h o rd e r to a n a re a o f e m e rg e n c e, w it h th e a b ility to a d a p t to d iffe re n t c o n d itio n s (B u tts & R ic h , 2 0 1 1 ) . O n e u n it o r a g e n t c an ch an g e th e o rd e r o f b e h a v io r, a n d th is chang e does n o t n ecessarily fo llo w a lin e a r h ie ra rc h y s tru c tu re . I n H C O s , th e C A S im p lic a tio n s a re th a t h o s p ita ls are e x a m p le s o f h ig h o rd e r c o m p le x system s, a n d th e y ty p ic a lly c o n ta in system s e m b e d d e d w it h in systems. N e w m o d els o f o rg a n iz a tio n a l d e v e lo p m e n t are needed to u n d e rs ta n d th e d y n a m ic a n d fa s t-p a c e d u n p r e d ic ta b ility o f h e a lth c a re d e liv e ry . T h e se n e w m o d e ls m u s t re p lac e o u td a te d ones, in c lu d in g m o d e ls o f o rg a n iz a tio n a l d e v e lo p m e n t a n d change based o n lin e a rity , v e rtic a l o rg a n iz a tio n , h ie ra rc h ic a l d e cis io n m a k in g , a n d c o n tro lle d ch an g e strategies, w h ic h a re o u tm o d e d a n d n o lo n g e r w o r k fo r c o n te m p o ra ry H C O s . C o m p le x it y science o ffe rs n e w m e n ta l m o d e ls . C o m p le x it y science is a v e h ic le fo r c h a n g e a n d also c reates a lens th ro u g h w h ic h w e c a n u n d e r­ s tan d o rg a n iz a tio n s a n d ch an g e. M e n t a l m o d e ls are g e n e ra liz a tio n s w e m a k e a b o u t re a lity th a t fo r m p a tte rn s th a t o rg a n iz e h o w w e u n d e rs ta n d th e w o r ld . H e a lth c a re p ro fes s io n als m u s t b e g in to a b a n d o n lin e a r m o d e ls , accep t u n p re ­ d ic ta b ility a n d c re a tiv ity , a n d re s p o n d to e m e rg in g o p p o rtu n itie s (P ls ek & W ils o n , 2 0 0 1 ) . F o r e x a m p le , nurses c an a d o p t a n e w p a ra d ig m o f c o m p le x ity o f h u m a n p h y s io lo g y a n d c a n th e n p ro v id e m o re in d iv id u a liz e d c a re th a t a u g m en ts a d a p tiv e c o m p o n e n ts o f th e h u m a n b o d y . A s o rg a n iz a tio n s s tru g g le to be m o re re sp o n siv e to issues, th e a b ility to be fle x ib le , a d a p tiv e , a n d in n o v a tiv e becom es essential fo r s u rv iv a l. N u rs e s m u s t u n d e rs ta n d th e fr a m e w o r k o f C A S s i f th e y a re to s u s ta in a d y n a m ic o rg a n iz a tio n re a d y fo r in n o v a tio n a n d ch an g e in th e c o m p le x h e a lth e n v iro n ­ m e n t (B u tts & R ic h , 2 0 1 1 ) . N e w e r h e a lth c a re d e liv e ry systems use in te rd is c ip lin a ry te am s , c o lla b o ra ­ tio n te ch n iq u es , a n d case m a n a g e m e n t, w h ere as in p re v io u s eras th e p h y s ic ia n d ire c te d a ll p a tie n t care, a n d e v e ry o n e else fo llo w e d th e p h y s ic ia n ’s le a d . C u r ­ re n tly , p ro fe s s io n a l nurses a re c a re e r fo cu s ed , w it h a n in te re s t in c o n tin u in g th e ir e d u c a tio n fo r s p e c ia lty tr a in in g a n d jo in in g p ro fe s s io n a l o rg a n iz a tio n s , w h e re a s nurses o f th e p a st w e re s im p ly jo b -fo c u s e d e m p lo ye es . T h e care o f

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c lie n ts has s h ifte d fr o m care o f th e sick to h e a lth p r o m o tio n a n d p re v e n tio n p ro g ra m s , c o n tin u ity o f c a re , a n d c o m p le m e n ta ry h e a lth a lte rn a tiv e s . T h e fo cu s o n b illin g w it h c o s t c o n ta in m e n t has s h ifte d to a fo cus o n a c c o u n t­ a b ility o f c are g ive rs , c o n tin u o u s q u a lity im p ro v e m e n t ( C Q I ) , a n d c a re m ap s o r c ritic a l p a th w a y s (B lais et a l., 2 0 0 6 ) . R e p re s e n tin g a step in th e s h ift fr o m a c e n tra liz e d b io m e d ic a l m o d e l o f c a rin g , c o m m u n ity n u rs in g c e n te rs a re a c re a tiv e h e a lth c a re d e liv e ry m o d e l w it h a m o re h o lis tic n u rs in g m o d e l o f c a rin g . O v e r th e p a s t c e n tu ry , th e fo cus o f th e t r a d itio n a l b io m e d ic a l m o d e l o f illness has b een o n d is c o v e rin g th e p a th o lo g y o r th e c u re to o n e p ro b le m , r a th e r th a n o n u n d e rs ta n d in g th e illn e s s a n d its v a rio u s c o m p o n e n ts (W a d e & H a llig a n , 2 0 0 4 ) . C o m m u n ity n u r s in g c e n te rs lo c a te d in c h u rc h e s , m o b ile u n its , s h e lte rs , a n d s ch o o ls a re set u p to m e e t th e u n d e rs e rv e d p o p u la tio n s b y p r o v id in g a ra n g e o f services to th e p u b lic t h a t a re n o t n o r m a lly a v a ila b le . T h e n e ed s o f th e p a tie n t b e c o m e th e fo c u s , in s te a d o f a m e d ic a l d ia g n o s is a n d a s in g le c u re . T h e s e c e n te rs o ffe r e d u c a tio n a n d p re v e n tiv e m e a s u re s fo r to p ic s o f in te re s t to th e lo c a l c o m m u n ity . A n u rs e o r W W W ) CRITICAL THINKING Q U E S TIO N * g ro u p o f c a re g iv e rs m ig h t go to c o m m u n ity c e n te rs to Positive health promotion is a process of assess a n d te a c h h e a lth p r o m o tio n a n d p re v e n tio n s tra te ­ enabling people to improve and increase gies fo r c a n c e r o r h y p e r te n s io n . T h is re p re s e n ts a s h ift control of their maximum health potential. fr o m s e e k in g a s in g le c u re to th e p r o m o tio n o f h e a lth , Think of positive health promotion behaviors w e lln e s s , a n d w e ll-b e in g (B la is et a l., 2 0 0 6 ) . that you have demonstrated (or not) since T h e h e a lth c a r e d e liv e r y s y s te m is c o n t in u o u s ly beginning nursing school. What have you c h a n g in g a n d e v o lv in g . W it h i n th e h e a lth c a re d e liv e ry noticed since using these behaviors in your daily routine? V system th e re are sev era l m o d e ls o f p a tie n t c a re d e liv e ry , discussed n e x t.

N u rs in g M odels of P a tie n t C are N u rs es are leaders a n d m an agers w ith in v ario u s m odels of p a tie n t c are d e liv e ry . T h e m e th o d s o f c are d e liv e ry m ig h t d iffe r s ig n ific a n tly fr o m one o rg a n iz a ­ tio n to a n o th e r. T h e p u rp o s e o f a n u rs in g care d e liv e ry system is to p ro v id e a fr a m e w o r k fo r nurses to d e liv e r c are to a specific g ro u p o f p a tie n ts . T h e d e liv ery o f care im p lem e n ts th e n u rsin g process a n d includes assessing a n d tria g in g clients so th a t th e o rd e r o f care can be p rio r itiz e d , a c are p la n fo rm u la te d , a n d c lie n t responses to n u rs in g in te rv e n tio n s e v a lu a te d in c o lla b o ra tio n w it h o th e r h e a lth te a m m e m b e rs (W e n d t, K e n n y , & A n d e rs o n , 2 0 0 7 ) . T h e m e th o d s a n d m o d e ls o f n u rs in g c a re h a v e e v o lv e d o v e r th e years a n d h a v e in c lu d e d fu n c tio n a l n u rs in g (ta s k n u rs in g ), te a m n u rs in g , to ta l p a tie n t care, p rim a ry n u rs in g , an d case m a n a g e m e n t. T e a m n u rsin g , to ta l p a tie n t care, an d

KEY COMPETENCY 8-1 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Systems-Based Practice: Knowledge (K3a) Under­ stands the concept of patient care delivery models Attitudes/Behaviors (A3a) Acknowledges the tension that may exist between a goal-driven and a resourcedriven patient care delivery model Skills (S3a) Considers resources available on the work unit when contributing to the plan of care for a patient or group of patients Source: Massachusetts Department of Higher Education (2010), p. 20.

case m a n a g e m e n t m o d els o f n u rs in g care d e liv e ry a re discussed in this c h a p te r. T h e c o n tin u a l e v a lu a tio n o f n u rs in g m o d e ls o f c are has b een p ro m p te d b y changes in n u rs in g s ta ff a v a ila b ility , re d u c tio n in h o s p ita l re v e n u e a n d r e im ­ b u rs e m e n t, changes in a c u ity levels (c ritic a l illness lev els ), s h o rte r stays in the h o s p ita l, c o n s u m e r d e m an d s fo r q u a lity care a n d lesser charges, a n d d em an d s b y h e a lth c a re w o rk e rs fo r im p ro v e m e n ts .

■ Team Nursing T h e te a m n ursing m o d e l o f c are is used in th e U n ite d States m o s t fre q u e n tly in h o s p ita ls a n d in lo n g -te rm a n d e x te n d e d care fa c ilitie s . T h is a rra n g e m e n t e v o lv e d a fte r th e fu n c tio n a l n u rs in g o f th e 1 9 4 0 s . W it h th is a p p ro a c h , th e n u rs in g s ta ff is d iv id e d in to te am s a n d to ta l p a tie n t c a re is p ro v id e d to a g ro u p o f p a tie n ts w h o m ig h t be g ro u p e d a c c o rd in g to th e ir diagnoses. A te a m m ig h t co n sist o f a n R N , L P N , a n d tw o u n lice n s ed assistive p e rs o n n e l (U A P s ). T h e R N is th e te a m le a d e r re sp o n sib le fo r m a k in g assig nm ents a n d w h o has o v e ra ll re s p o n s ib ility fo r p a tie n t c a re b y te a m m e m b e rs . T h e te a m w o rk s c o lla b o r a tiv e ly , w it h e ac h m e m b e r p e r fo r m in g a c tiv itie s he o r she is best tra in e d to d o . T h e te a m c o m m u n ic a te s c lie n t care needs a n d possible changes in th e c are p la n to th e te a m le a d e r. T h e te a m acts as a w h o le w it h a h o lis tic p e rs p e c tiv e o f th e p e rs o n a l needs o f each c lie n t. T h e te a m le a d e r takes th e le a d to reso lve p ro b le m s th a t th e te a m en co u n te rs b y u p d a tin g care p lan s a n d c o m m u n ic a tin g w it h p h y s ic ia n s a n d o th e r h e a lth c a re p e rs o n n e l. O f te n th e te a m lea d e r m akes ro u n d s w it h physicians. T h e n u rs in g re p o rts c o m m u n ic a te d a t th e b e g in n in g o f each s h ift a re a k e y fe a tu re to h ig h -q u a lity te a m n u rs in g . T e a m n u rs in g has s everal a d v a n ta g e s . O n e is th a t U A P s c a n c a rry o u t som e o f th e fu n c tio n s th a t d o n o t re q u ire a re g is te re d n u rs e ’s e x p e rtis e . T e a m n u rs in g also a llo w s fo r tasks to be c a rrie d o u t th a t re q u ire s everal persons because an assigned te a m is re a d ily a v a ila b le . S everal d isa d v an tag e s c an s u r­ face w ith a te a m . I f c o m m u n ic a tio n skills are n o t a d e q u a te , th e h o listic v ie w o f th e p a tie n t m ig h t be fra g m e n te d . A ls o , U A P s a n d L P N s m ig h t feel re s e n tm e n t i f th e y perceive th e R N to be focused to ta lly o n p a p e r w o rk a n d d o c u m e n ta tio n a n d less o n th e p h y s ic a l needs o f th e c lie n t. F o r a te a m le a d e r to be e ffe c tiv e , d e le g a tio n , c o m m u n ic a tio n , a n d p ro b le m -s o lv in g skills a re essential.

■ Total Patient Care A p p e a rin g as e a rly as th e 1 9 2 0 s , th e firs t m o d e l o f p a tie n t c are d e liv e ry w a s t o t a l p a tie n t c a re (S u lliv a n & D e c k e r , 2 0 0 5 ) . In th is m o d e l, th e R N has re s p o n s ib ility fo r a ll aspects o f c are o f th e p a tie n t o r p a tie n ts . T h e R N w o rk s d ire c tly w it h th e c lie n t, o th e r n u rs in g s ta ff, a n d p h y sic ia n s in im p le m e n tin g a p la n o f care. T h e o b je c tiv e o f to ta l p a tie n t care is to h a ve one nurse p ro v id e a ll c are to th e sam e p a tie n t o r p a tie n ts fo r th e e n tire s h ift. C u rre n tly , th is m o d e l is p ra c tic e d in areas such as c ritic a l care u n its o r postanesth esia re c o v e ry units w h e re a h ig h lev el o f e x p e rtis e is re q u ire d . T h is sys te m ’s a d va n ta g e s a re th a t

nurses p ro v id e h o lis tic c o n tin u o u s c are , th e re is c o n tin u ity o f c o m m u n ic a ­ tio n fr o m clien ts to o th e r h e a lth c a re te a m m e m b e rs , a n d th e n u rse has to ta l a c c o u n ta b ility fo r th a t s h ift. T h e d is a d v a n ta g e is th a t som e o f th e tasks c o u ld be p e rfo rm e d b y les s e r-s k ille d perso n s, w h ic h m ig h t be m o re cost e ffe c tiv e .

■ Case M anagem ent A c u rre n t n u rs in g m o d e l o f n u rs in g c are d e liv e ry is c as e m a n a g e m e n t, w h ic h relies o n c lin ic a l p a th w a y s to e v a lu a te c a re . T h e c lin ic a l p a th w a y re fe rs to e x p e c te d o u tc o m e s a n d in te rv e n tio n s t h a t th e c o lla b o ra tiv e p ra c tic e te a m establishes (S u lliv a n & D e c k e r, 2 0 0 5 ) . T h e p ro fe s s io n a l n u rse is resp o n sib le fo r in itia tin g a n d u p d a tin g th e p la n o f c a re , c are m a p , o r c lin ic a l p a th w a y th a t is used to g u id e a n d e v a lu a te c lie n t c are . T h e c lin ic a l p a th w a y p ro v id e s a tim e fra m e fo r e x p e c te d o u tco m e s o f c are a n d in v o lv e s a n in te rd is c ip lin a ry te a m o f c areg ivers w h o use th e p a th w a y to p ro v id e c o n sis te n t c are. N u r s in g case m a n a g e m e n t focuses o n m a n a g in g a g ro u p (c a s e lo a d ) o f clien ts a n d th e m e m b e rs o f th e h e a lth c a re te a m c a rin g fo r th ose clie n ts . T h e case m a n a g e r o rg an izes p a tie n t care b y m a jo r diagnoses o r D R G s a n d focuses o n specific tim e fram es to achieve p re d e te rm in e d p a tie n t outcom es a n d c o n ta in costs. T h e case m a n a g e r m ak e s re fe rra ls to o th e r h e a lth c a re p ro v id e rs a n d m an ag es th e q u a lity o f c are . Im p o r t a n t c h ara c te ris tic s to th e ro le o f n u rs in g case m an ag e rs a re c o lla b o ra tio n , id e n tific a tio n o f p a tie n t o u tco m e s w it h tim e fra m e s , a n d th e use o f c o n tin u o u s q u a lity im p ro v e m e n t ( C Q I ) a n aly sis. T h e case m a n a g e r does n o t u s u a lly p ro v id e d ire c t p a tie n t care b u t supervises th e p ro v is io n o f c are b y U A P s a n d licensed p e rs o n n e l. A case m a n a g e r’s ro le in a n a cu te c are settin g in v o lv e s th e m a n a g e m e n t o f a c as elo a d o f 1 0 to 1 5 p a tie n ts . C ase m a n a g e rs fo llo w p a tie n t p ro g re s s io n fr o m a d m is s io n th r o u g h d is c h a rg e a n d s o lve p ro b le m s o f v a ria n c e s fr o m th e e x p e c te d o u tc o m e s . A v a ria n c e w o u ld be, fo r e x a m p le , th a t a to ta l h ip su rg e ry p a tie n t d id n o t g e t d isc h a rg e d o n d a y 6 (e x p e c te d o u tc o m e b y tim e fra m e ) as p la n n e d . In s te a d , th a t p e rs o n w a s h o s p ita liz e d fo r 1 0 d ays. T h e case m a n a g e r in te rv en e s a n d c o m m u n ic a te s w it h th e te a m to a n a ly z e specific p a tie n t p ro g re s s io n a n d o u tc o m e s a n d d e te rm in e w h y th e p a tie n t w a s n o t d is c h a rg e d . U s u a lly , case m a n a g e rs h a v e c o n s id e ra b le n u rs in g e x p e rie n c e a n d an a d v a n c e d degree. T o m a n a g e th e cases o f a g ro u p o f clien ts, a te a m is selected th a t includes c lin ic a l e x p e rts fr o m th e d is c ip lin e s n e e d e d such as n u rs in g , m e d ic in e , o r p h y sic al th e ra p y . T h e k e y features o f a case m a n a g e m e n t te a m a re s u p p o rt b y a d m in is tra tio n a n d p h y sic ia n s , a q u a lifie d case m a n a g e r, c o lla b o ra tio n o f th e team s, a C Q I system in p lac e , a n d c ritic a l p a th w a y s . A ll m em b ers o f th e te a m m u st agree o n th e c ritica l p a th w a y s a n d accept re sp o n sib ility a n d a c c o u n ta b ility fo r in te rv e n tio n s a n d p a tie n t o u tco m e s. Case m a n a g e m e n t c o n trib u te s to th e re d u c tio n o f c o m p lic a tio n s th a t arise d u rin g h o s p ita liz a tio n . Specific m e a s u r­ able p a tie n t outcom es w ith tim e fram es fo r th e g ro u p o f clients are d e te rm in e d .

KEY COMPETENCY 8-2 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Systems-Based Practice: Knowledge (K3b) Understands role and responsibilities as a member of the health care team in planning and using work unit resources to achieve quality patient outcomes Attitudes/Behaviors (A3b) Values the contributions of each member of the health care team to the work unit Skills (S3b) Collaborates with members of the health care team to prioritize resources, including one's own work time and activi­ ties delegated to others, for the purposes of achieving quality patient outcomes Source: Massachusetts Department of Higher Education (2010), p. 20.

T h e c a s e lo a d s e le c te d fo r case m a n a g e m e n t in c lu d e s h ig h - v o lu m e , h ig h -c o s t, a n d h ig h -ris k cases. O n e such e x a m p le is th e to ta l h ip re p la c e m e n t c lie n t p o p u la tio n in o rth o p e d ic s . T h e n u m b e r o f h ip re p la c e m e n t surgeries p e rfo r m e d is h ig h e r th a n th e n u m b e r o f m a n y o th e r p ro c e d u re s ; th e y cost m o re a n d in c lu d e h ig h e r risks such as p u lm o n a r y e m b o li a n d s u rg ic a l site in fe c tio n s . T h e to ta l cost to th e c lie n t a n d re la te d d e p a rtm e n ts is h ig h e r, so c a re fu l m o n ito r in g is necessary. O t h e r h ig h -ris k c lie n ts are th o se in c ritic a l c o n d itio n , in I C U m o re th a n 2 days, o r o n a v e n tila to r. B aseline d a ta such as le n g th o f stay, cost o f c are , a n d c o m p lic a tio n s are c o lle c te d o n these g ro u p s a n d a n a ly ze d . T h e c ritic a l p a th q u ic k ly o rie n ts th e s ta ff to th e e x p e c te d o u tco m e s th a t s h o u ld be a c h ie v e d fo r th a t d a y . N u r s in g diag noses id e n tify th e o u tc o m e s needed. I f these a re n o t a ch ie ve d , th e case m a n a g e r is n o tifie d a n d th e s itu a tio n a n a ly z e d . A n e x a m p le o f a c o lla b o ra tiv e c ritic a l p a th w a y fo r a p a tie n t h a v in g a to ta l h ip re p la c e m e n t is d esc rib ed h e re . A c ritic a l p a th fo r a to ta l h ip c lie n t o n days 1 a n d 3 p o s to p e ra tiv e ly m ig h t in c lu d e th e fo llo w in g : •

D a y 1 O p e ra tin g R o o m a n d P o s to p e ra tiv e C a re A c tiv ity : B ed rest, tu rn /c o u g h /d e e p b re a th q 2 hrs N S G : V S q h x 4 , th e n q 4 hrs, c irc u la tio n /n e u ro checks q h x 4 , th e n q 4 h rs , H e m o v a c : C h e c k q h r x 4 , th e n q 4 h rs , I & O M e d ic a tio n s : A n tib io tic s , p a in c o n tro l N u tr it io n : N P O to c le a r liq u id s as to le ra te d T e a c h in g : P a in c o n tro l, assist devices, in c e n tiv e s p iro m e try , m o b ility p la n , D /C p la n , h o m e h e a lth e v a lu a tio n

•

D a y 3 P o s to p e ra tiv e ly A c tiv ity : C o n tin u e m o b ility p la n , tu rn /c o u g h /d e e p b re a th q 2 h rs , s k in p ro to c o ls N S G : V S q 8 h rs , D /C assessm ent, D /C h e m o v a c , c k d ra in a g e , I & O q 8 h rs , D /C F o le y , c o n tin u e elastic hose M e d ic a tio n s : A n tib io tic s , p .o . p a in c o n tro l, c o n tin u e s to o l so fte n e rs, I V to h e p lo c k , c o n tin u e C o u m a d in N u tr it io n : D ie t as to le ra te d , re p e a t te a c h in g as needed D /C p lan s: R e v ie w tra n s fe r o rd e rs , D /C needs

N o r m a lly , a to ta l h ip c lie n t w o u ld be e x p e c te d to be d isc h a rg e d o n th e s ix th d a y a fte r s u rg e ry. T h e c ritic a l p a th c o n tin u e s a ll 6 days, w it h p o te n tia l n u rs in g diagnoses a tta c h e d , such as p a in c o n tro l d e fic it o r im p a ire d m o b ility . T h e c ritic a l p a th is also g iv e n to th e p a tie n t’s fa m ily so th a t th e y k n o w w h a t to e x p e c t d u r in g a n u n c o m p lic a te d to ta l h ip s u rg e ry h o s p ita liz a tio n . C ase m a n a g e m e n t is one ro le o f p ro fes s io n al n u rsin g . T h e fo llo w in g sections fu rth e r d e fin e som e o f th e m a n y ro les th a t nurses assum e.

Role of the Professional Nurse

203

R ole of th e P ro fe s s io n a l N u rs e T h e r o le o f th e p r o fe s s io n a l n u rs e is o n e o f th e m o s t e x c it in g a re a s to discuss fo r e n tr y -le v e l n u rs e s . T h i n k a b o u t it . Y o u g o f r o m h ig h s c h o o l s tu d e n t to p r o fe s s io n a l in z e r o to 4 y e a rs o r so! T h e r o le o f th e p r o ­ fe s s io n a l n u rs e has e x p a n d e d in re s p o n s e to c h a n g in g p o p u la tio n s a n d th e p h ilo s o p h ic a l s h ift t o w a r d h e a lth p r o m o tio n r a th e r th a n illn e s s c u re . S e v e ra l ro le s o f nurses in c lu d e p r a c titio n e r , c a re g iv e r, a d v o c a te , e d u c a to r, le a d e r, m a n a g e r, c o lla b o ra to r , and r e s e a r c h e r . P la c in g R N a fte r y o u r n a m e m e a n s t h a t y o u a re c o m m itte d to th e le g a l, e th ic a l, a n d m o r a l r e s p o n s ib ili­ tie s t h a t d e fin e p ro fe s s io n a l ro le s . T h e s e re s p o n s ib ilitie s a re b a se d o n th e A m e r ic a n N u rs e s A s s o c ia tio n ’s ( A N A ’s) N u r s i n g S c o p e a n d S t a n d a r d s o f P r o fe s s i o n a l P r a c t i c e , th e A N A ’s N u r s i n g C o d e o f E t h i c s , a n d th e A N A ’s N u r s i n g S o c ia l P o lic y S t a t e m e n t . Y o u a re th e fu lc r u m o f p a tie n t c a re a n d p a tie n ts ’ s a fe ty n e t as w e ll as th e ir a d v o c a t e . Y o u h a v e a le g a l o b lig a t io n to e x p la in th e The role of the professional p h y s ic ia n ’s o rd e rs to y o u r p a tie n ts ! D o c u m e n ta tio n is a nurse has expanded in le g a lly im p o r t a n t r o le o f th e re g is te re d n u rs e (S m e ltz e r response to changing e t a l., 2 0 1 0 ) . populations and the T h is sec tio n e x a m in e s th e m o s t im p o r t a n t aspects o f philosophical shift toward th e e n try -le v e l n u rse ro le a n d also defines basic concepts o f health promotion rather than c are m a n a g e m e n t. N u rs e s p ra c tic e h e a lth p r o m o tio n (p r i­ illness cure. m a r y p re v e n tio n o r illness p re v e n tio n ) th ro u g h e d u c a tio n o f clien ts a n d th e ir fa m ilie s .

r

■ C aregiver T h e ro le o f th e n u rs e as c a re g iv e r has c h a n g e d tr e m e n d o u s ly d u r in g th e p a s t c e n tu ry . T h e ro le as a d e p e n d e n t p e rs o n to th e p h y s ic ia n w h o o n ly p ro v id e d p e rs o n a l c a re has e v o lv e d to t h a t o f th e e d u c a te d n u rs e w h o is an a u to n o m o u s a n d in fo r m e d p ro fe s s io n a l. A s a c a re g iv e r, th e n u rse p ra c tic e s n u rs in g as a s cien ce. T h e n u rs e p ro v id e s in te r v e n tio n s to m e e t p h y s ic a l, p s y c h o s o c ia l, s p ir it u a l, a n d e n v ir o n m e n ta l needs o f c lie n ts a n d fa m ilie s u s in g th e n u r s in g p ro c e s s a n d c r it ic a l t h in k in g s k ills . H o lis t ic c a re is a p h ilo s o p h ic a l a p p ro a c h th a t e m p h a s ize s th e u n iq u e n e s s o f th e in d iv id u a l a n d in w h ic h in te r a c tin g w h o le s a re m o re im p o r t a n t th a n th e s u m o f each p a r t. T h a t is, th e w h o le p e rs o n is g re a te r th a n m e r e ly e ac h c o m p o n e n t p a r t o f th e c lie n t— b io p h y s ic a l, p s y c h o lo g ic a l, s o c ia l, a n d s p ir itu a l p a rts . T h e science (k n o w le d g e base) o f n u rs in g b e co m e s th e a r t o f n u rs in g th r o u g h c a rin g , w h e re th e n u rse is c o n c e rn e d fo r th e c lie n t. T h e n u rse a n d c lie n t are c o n n e c te d . T h e n u rs e as a c a re g iv e r is s k ille d a n d e m p a th e tic , k n o w le d g e ­ a b le a n d c a rin g .

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KEY COMPETENCY 8-3 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Patient-Centered Care: Knowledge (K6) Demon­ strates understanding of the diversity of the human condition Attitudes/Behaviors (A6) Values the inherent worth and uniqueness of individ­ uals and populations Skills (S6b) Provides holistic care that addresses the needs of diverse populations across the life span Source: Massachusetts Department of Higher Education (2010), p. 10.

■ Advocate A s th e n u rs e -c lie n t re la tio n s h ip develops, th e nurse needs p ro fe s s io n a l k n o w l­ edge to assist clien ts in th e ir d e cis io n m a k in g . T h e n u rse fills th e ro le o f c lie n t a d v o c a te in h e a lth c a re d e liv e ry , in te rv e n in g in crises o f A ID S , hom elessness, d ru g a n d a lc o h o l abuse, teen ag e p re g n a n c y , c h ild a n d spouse abuse, a n d in ­ creasin g h e a lth c a re costs. A c lie n t a d v o c a te is a p e rs o n w h o plead s th e cause fo r c lie n ts ’ rig h ts . T h e p u rp o s e o f th is ro le is to respect c lie n t decisions a n d b o o s t c lie n t a u to n o m y . C lie n t a d v o c a c y in c lu d e s d e v e lo p in g a th e ra p e u tic n u r s e -c lie n t re la tio n s h ip to secure p a tie n t s e lf-d e te rm in a tio n , p ro te c tio n o f p a tie n ts ’ rig h ts , a n d a c tin g as a n in te rm e d ia ry a m o n g p a tie n ts a n d th e ir sig­ n ific a n t o th ers a n d h e a lth c a re p ro v id e rs (B lais et a l., 2 0 0 6 ) . A c lie n t a d v o c a te is m a in ly c o n c e rn e d w it h e m p o w e rin g th e c lie n t th ro u g h th e n u r s e -p a tie n t re la tio n s h ip . T h e nurse represents th e interests o f th e c lie n t, w h o has needs th a t are u n m e t a n d a re lik e ly to re m a in u n m e t w it h o u t th e n u rs e ’s sp ecial in te r v e n tio n . T h e p ro fe s s io n a l n u rse speaks fo r th e c lie n t as i f th e c lie n t’s interests w e re th e n u rs e ’s o w n . In n u m e ro u s s itu a tio n s th e n u rse c an speak u p fo r th e p a tie n t. E x a m p le s a re p a in c o n tro l, th e c lie n ts ’ re fu s a l o f tre a tm e n t, o r issues o f re s u s c ita tio n status. E th ic a l challeng es face th e n u rse as c lie n t a d v o c a te . T o be a n e ffe ctive c lie n t a d v o c a te , th e n u rse m u s t d o th e fo llo w in g : • •

KEY COMPETENCY 8-4

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Examples of Applicable Nurse of the Future: Nursing Core Competencies

Systems-Based Practice: Knowledge (K4) Understands the role and responsi­ bilities as patient advocate, assisting patient in navi­ gating through the health care system Attitudes/Behaviors (A4a) Values role and responsibili­ ties as patient advocate Skills (S4a) Serves as a patient advocate Source: Massachusetts Department of Higher Education (2010), p. 20.

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Be assertive. R e c o g n iz e th e c lie n t ’s v a lu e s as m o re im p o r t a n t th a n th e h e a lth c a re p ro v id e rs ’. E n s u re a d e q u a te in f o r m a t io n so t h a t c lie n ts a n d fa m ilie s c a n m a k e decisions. Be a w a re th a t m o ra l o r e th ic a l c o n flicts c an arise th a t re q u ire c o n s u lta tio n o r n e g o tia tio n a m o n g h e a lth c a re p ro v id e rs .

N u rs e s n e ed to assist c lie n ts in th e c la rific a tio n o f th e ir v alu e s as th e y re la te to a p a rtic u la r h e a lth p ro b le m o r e n d -o f-life issue. T h e n u rse a n d th e c lie n t are e q u a lly resp o n sib le fo r th e o u tco m es o f care, b u t th e nurse is re s p o n ­ sible fo r assisting th e c lie n t to use his o r h e r strength s to o b ta in th e h ig h e st lev el o f h e a lth p o s sib le . A d v a n c e d ire ctiv es s h o u ld be addressed e a rly in th e course o f p a tie n t h o s p ita liz a tio n s w h ile th e p a tie n t is c a p a b le o f m a k in g p e r­ s o n al choices.

■ M anager In e x p lo rin g th e c o n c e p t o f m a n a g e m e n t in p ra c tic e , a ll nurses a re m a n a g e rs . T h e y d ire c t th e w o r k o f professionals a n d n o n p ro fessio n als to achieve expected o u tc o m e s o f c are . A ll nurses n e ed to le a rn m a n a g e m e n t a n d le a d e rs h ip skills to be e ffic ie n t a n d e ffe c tiv e in th e ir re s p e c tiv e fie ld s. In th e h e a lth c a re set­ tin g , a m a n a g e r is a n in d iv id u a l w h o is e m p lo y e d b y a n o rg a n iz a tio n a n d is

re s p o n s ib le a n d a c c o u n ta b le fo r th e goals o f th a t o rg a n iz a tio n (S u lliv a n & D e c k e r, 2 0 0 5 ) . In p ra c tic e , nurses a re e x p e c te d to m a n a g e th e c are o f each p a tie n t assig ned to th e m fo r th a t s h ift. So, im a g in e y o u ’ve ju s t re c e iv e d a r e p o r t o n y o u r p a tie n ts . W h e r e d o y o u b eg in ? A ssessm ents a n d m e d ic in e s a re d u e . P a tie n ts n e ed to go to s u rg e ry a n d ra d io lo g y . B re a k fa s t tra y s are b e in g d is trib u te d . In s u lin is p a s t d u e . C h a r tin g is n e e d e d . S tu d e n t nurses w a n t re p o rt. So m u c h to d o , a n d so little tim e ! H o w c an y o u g e t e v e ry th in g d o n e , p ro v id e q u a lity c are , a n d s till be s tan d in g ? W e ll, d e le g a t io n is a te rrific c o n c e p t! I t is easy to say d e le g a te , b u t d e le g a tio n is a d iffic u lt le a d e rs h ip ro le fo r nurses to a d o p t a n d one th a t is n o t r e a d ily le a rn e d d u rin g n u rs in g e d u c a tio n . B o th e x p e rie n c e d nurses a n d e n try -le v e l nurses strugg le to d e v e lo p d e le g a tio n a n d p r io r it iz a tio n s k ills . N u rs e m a n a g e rs m u s t c o n tin u a lly e x p a n d d e le g a ­ tio n s kills to s u rv iv e . N u rs e s m u s t also le a rn to d e le g a te w it h o u t th e th re a t o f litig a tio n . W it h cost c o n ta in m e n t, it is necessary n o w m o re th a n ever to d e le g a te e ffe c tiv e ly . D e le g a tio n is d e fin e d as th e process b y w h ic h re s p o n s i­ b ilit y a n d a u th o r ity fo r p e rfo r m in g a c e rta in ta s k a re tra n s fe rre d to a n o th e r in d iv id u a l. T h is in d iv id u a l accepts th a t a u th o r ity a n d re s p o n s ib ility (S u lliv a n & D e c k e r, 2 0 0 5 ) . W h e n a c c e p tin g re s p o n s ib ility , a n u rs e has th e o b lig a ­ tio n to in te rv e n e a n d a c c o m p lis h a ta s k . N u rs e s b e c o m e a c c o u n ta b le w h e n th e y a c c e p t o w n e rs h ip fo r th e re s u lts , o r th e la c k o f re s u lts , d e p e n d in g o n th e s itu a tio n . W h e n d e le g a tin g , re s p o n s ib ility c an be tra n s fe rre d to a n o th e r in d iv id u a l a n d b o th in d iv id u a ls a re h e ld a c c o u n ta b le . A c c o u n ta b ility is a s h a re d c o n c e p t. I t is th e q u a lity o r state o f b e in g a c c o u n ta b le , e s p e c ia lly th e o b lig a tio n o r w illin g n e s s to a c c e p t re s p o n s ib ility o r to a c c o u n t fo r o n e ’ s a c tio n s . T o d e le g a te , th e p e rs o n d e le g a tin g (d e le g a to r) m u s t be th e o n e w h o is re s p o n s ib le fo r th e ta s k . I t is im p o r ta n t to u n d e rs ta n d th e a cc ep tan c e o f d e le g a tio n . T h e o n e to w h o m a ta s k is b e in g d e le g a te d (d eleg ate e ) m u s t re a lis tic a lly decid e w h e th e r he o r she has th e skills a n d a b ilitie s fo r th e ta s k b e in g assigned a n d th e tim e to d o it. I f n o t, th e in d iv id u a l m u s t in fo r m th e p e rs o n d e le g a tin g th a t he o r she does n o t h a v e th e s kills . T h e n e x t step is to see i f th e d e le g a to r has th e tim e a n d w illin g n e s s to t r a in a n d assist in a c c o m p lis h in g th e ta s k . I f th e d e le g a to r c a n n o t d o th is , th e d e le g a te e m u s t re fu s e th e a s s ig n m e n t. W h e n d e le g a tio n is a c c e p te d , re s p o n s ib ility is a c c e p te d fo r o u tc o m e b en efits a n d also fo r lia b ilitie s . T h e d e le g a to r has th e o p tio n to delegate p a rts o f a ta s k , b u t th e one d e le g a te d to also has th e o p tio n to n e g o tia te fo r th e p a rts o f th e ta s k th a t c an be a c c o m p lis h e d . N e w skills c an be o b ta in e d in th e process. A fte r th e p a rtic ip a n ts agree o n th e re s p o n s ib ilitie s to be assum ed, th e y m u s t c la rify th e tim e fra m e a n d o th e r e x p e c ta tio n s . T h e d e le g a te e m u s t c o m m u n ic a te w it h th e d e le g a to r e ffe c tiv e ly th r o u g h o u t th e c o m p le tio n o f th e ta s k . I f a n u rse declines a ta s k , he o r she s h o u ld th a n k th e d e le g a to r a n d in d ic a te a desire to h e lp h im o r h e r in th e fu tu re .

KEY COMPETENCY 8-5 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Leadership: Knowledge (K6) Understands the principles of account­ ability and delegation Attitudes/Behaviors (A6a) Recognizes the value of delegation; (A6b) Accepts accountability for nursing care given by self and del­ egated to others Skills (S6b) Assigns, directs, and supervises ancillary per­ sonnel and support staff in carrying out particular roles/ functions aimed at achieving patient care goals Source: Massachusetts Department of Higher Education (2010), p. 18.

I t is im p o r ta n t to e x a m in e th e lia b ility issues o f d e le g a tio n . T h e N a t io n a l C o u n c il o f S tate B o a rd s o f N u rs in g suggests fiv e “ rig h ts o f d e le g a tio n ” : • • • • •

R ig h t R ig h t R ig h t R ig h t R ig h t

ta s k circ u m s ta n ce s p e rs o n d ire c tio n a n d c o m m u n ic a tio n s u p e rv is io n (S u lliv a n & D e c k e r, 2 0 0 5 )

I t is im p o rta n t to use these five rights o f deleg atio n . A c c o rd in g to th e A N A (2 0 0 1 ) C o d e o f E th ic s f o r N u r s e s w ith I n t e rp re tiv e S ta te m e n ts , th e nurse is responsible fo r using in fo rm e d ju d g m e n t an d basing the decision to delegate o n the perso n ’s com petencies a n d q u a lifica tio n s . I f the nurse fails to do this, it is consid­ ered negligence. So, the delegating nurse m u st fo llo w the steps o f delegation w h e n d efining the task. T h e pro cedure should be co m m u n ic a te d w ith clear instructions an d guidelines. T h e nurse m u s t delegate to accom plish the goals o f care. A fte r tasks h ave been delegated, the nurse m u s t e va lu ate th e tasks to ensure c o rrect c o m p le tio n o f each a c tiv ity . D e le g a tio n is d e fin ite ly a s kill th a t can be learn ed an d requires practice. Successful nurses le a rn the process o f deleg atio n . N urses accom plish m o re b y delegating th a n if th ey try to do e veryth in g them selves. T o s u m m a riz e th e c o n c e p t o f d e le g a tio n , it is a c o n tra c tu a l a g re e m e n t in w h ic h a u th o r ity a n d re s p o n s ib ility fo r a ta s k are tra n s fe rre d b y th e d e le g a to r, w h o is a c c o u n ta b le fo r th e ta s k , to a n o th e r p e rs o n . D e le g a tio n necessitates p ro fic ie n c y in d e te rm in in g th e ta sk an d level o f re sp o n s ib ility , d e te rm in in g w h o has th e skills re q u ire d , c o m m u n ic a tin g e x p e c ta tio n s c le a rly to assigned p e r­ so n n el, a n d m o n ito rin g th e p e rfo rm a n c e o f assigned tasks. W h e n nurses c a re ­ fu lly select a q u a lifie d p e rs o n as a delegatee a n d p ro v id e s u p ervisio n , lia b ility is m in im iz e d . A ll nurses a n d m an ag e rs m u s t le a rn to de le g a te to be successful.

■ C ollaborative Practice H e a lt h care has b e co m e so c o m p le x to d a y th a t it takes several p ro fe s s io n a l p ro v id e rs d e liv e rin g c are in a c o lla b o ra tiv e e n v iro n m e n t to im p ro v e c lie n t h e a lth o u tc o m e s . A ll m e m b e rs o f th e h e a lth c a re te a m m u s t c o m b in e th e ir s k ills , k n o w le d g e , a n d reso u rces to im p ro v e o u tc o m e s ; nurses a n d p h y s i­ cians m u s t m o d ify th e ir tr a d itio n a l ro les a n d w o r k m o re c o lla b o ra tiv e ly as c o lle ag u es . O n e o f th e m a n y ro les o f th e p ro fe s s io n a l n u rse is p a rtic ip a tin g in c o lla b o ra tiv e p ra c tic e . T h e p u rp o s e o f c o lla b o r a tio n is to a ch ie ve h ig h q u a lity c lie n t c are a n d c lie n t s a tis fa c tio n . A c o lla b o ra tiv e fr a m e w o r k w it h a n in te rd is c ip lin a ry te a m c a n also lim it costs. O t h e r goals o f c o lla b o ra tio n a re to th e fo llo w in g : •

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E n h a n c e c o n tin u ity across th e c o n tin u u m o f c are fr o m w ellness a n d p re ­ v e n tio n , th ro u g h a cu te episodes o f illn ess, to d is c h a rg e o r tra n s fe r a n d re h a b ilita tio n Im p ro v e c lie n t a n d s ig n ific a n t o th e rs ’ s a tis fa c tio n w it h care

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P ro v id e re search -b ased , h ig h -q u a lity , c o s t-e ffe ctive care th a t is d riv e n b y e x p e c te d o u tco m e s P ro m o te m u tu a l re s p e c t a n d c o m m u n ic a tio n a m o n g c lie n t, n u rse , a n d c a re g iv e r to fo r m a c o a litio n P ro v id e o p p o rtu n itie s to solve issues a n d p ro b le m s

T h e le v e l o f c o lla b o r a t io n a c h ie v e d a n d n a tu r e o f decisions are th e p rim a ry o u tco m e s. T h is leads to secondary o u tco m e s o f g o a l a tta in m e n t a n d a u to n o m y . C o lla b o ra tiv e p r a c t ic e in c a r e g iv in g c a n in c lu d e n u r s e - p h y s ic ia n in te ra c tio n , n u rs e -n u rs e in te ra c tio n , o r th e in te ra c tio n o f in te rd is c ip lin a ry te am s o r c o m m itte e s (B lais et a l., 2 0 0 6 ) . C o lla b o ra tiv e team s p ro v id e exten sive care b y p ro v id in g a fu ll ra n g e o f e x p e r­ tise th ro u g h each o f th e te a m m e m b e rs , a n d th us c o n trib u tin g to o u tco m e s. N u rs e -p h y s ic ia n c o lla b o ra tio n is essential to m a x im iz e q u a lity p a tie n t care a n d re q u ire s k n o w le d g e s h a rin g w it h jo in t re s p o n s ib ility fo r p a tie n t c are . O n som e o c casio n s, c o lla b o r a tio n b e tw e e n nurses a n d p h y s ic ia n s c a n in v o lv e fle e tin g en co u n ters in p a tie n t areas. In th is s itu a tio n , th ere is n o second chance to c o lla b o ra te e ffe c tiv e ly o n a c o m m itte e , b u t th e v o lu m e o f these p ro fe s ­ s io n al en co u n te rs m ig h t be in c re a s in g . T h e c h a lle n g e is to m a k e th e m o s t o f a ll in te ra c tio n s to use th e best k n o w le d g e a n d a b ilitie s o f a ll h e a lth c a re te a m m e m b e rs a n d p ro d u c e p o s itiv e c lie n t o u tco m e s (L in d e k e & S e ic k e rt, 2 0 0 5 ) . B o tto m -lin e a tte n tio n is g iv e n to c o m p a s s io n a te a n d h u m a n ita r ia n p a tie n t c are . In te rd is c ip lin a ry c o lla b o ra tio n c a n k e e p th is c e n tra l despite e c o n o m ic pressures. M o t iv a te d te am s m u s t w o r k to g e th e r to th riv e b y b e in g o p tim is tic a n d p o s itiv e , th us in s p irin g h o p e in o th ers . As discussed p re v io u s ly , c ritic a l p a th w a y s are im p le m e n te d b y c o lla b o ra ­ tio n w it h in p u t fr o m v a rio u s d e p a rtm e n ts . C ritic a l p a th w a y s a re also c a lle d in te rd is c ip lin a ry p lan s, o r a c tio n p lan s. T h e in te rd is c ip lin a ry h e a lth c a re te a m c an be e s p e cia lly e ffe c tiv e in o u tp a tie n t services. T h e te am s d e al w it h c lie n tre la te d p ro b le m s a n d h e lp th e p a tie n t progress th ro u g h th e c lin ic a n d h o s p ita l e ffic ie n tly . T h e p h y s ic ia n o r n u rs e p r a c titio n e r sees th e c lie n t a n d re c o m ­ m en d s c o n s u lta tio n s as n e ed e d . P ro fe s s io n a l nurses p ra c tic e c o n s u lta tio n s o n a d a y -to -d a y basis. T h e p r im a r y n u rs e ’s ro le is to assess th e n eed fo r c o n s u l­ ta tio n s a n d id e n tify e x p e c te d o u tco m e s o f c o n s u lta tio n , a lo n g w it h th e need fo r re v is in g c are as c lie n t needs ch an g e. F o r e x a m p le , n u rs e -n u rs e c o n s u ltin g m ig h t o c c u r b e tw e e n a s ta ff nu rse a n d a n e n te ro s to m a l th e ra p is t fo r th e care o f a c lie n t’s e x c o ria te d o s to m y site s e c o n d a ry to ra d ia tio n a n d c h e m o th e ra p y . T h is ty p e o f c o n s u lta tio n is d o c u m e n te d in th e p a tie n t re c o rd b y o b ta in in g a p h y s ic ia n ’s o rd e r fo r an e n te ro s to m a l th e ra p is t consu lt; th e n , th e e n te ro s to m a l nurse intervenes a n d d o c u m en ts th e care re n d e re d . T h e p rim a ry nurse changes th e c u rre n t p la n o f c are w it h c o n tin u o u s e v a lu a tio n o f o u tco m e s. T h e a b ilit y to c o lla b o r a te is p a r t ic u la r ly im p o r t a n t fo r s ta ff n u rs e s . C o lla b o r a tio n is o n e o f th e k e y s k ills re q u ir e d in n u rs in g . T h e a d v e n t o f g ro u p p ra c tic e , m a n a g e d c are , a n d p ra c tic e s tan d ard s has d riv e n th e n e ed fo r

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CHAPTER 8 The Healthcare Delivery System and the Role of the Professional Nurse

c o lla b o ra tio n a n d c o n s u lta tio n . O n a c o n tin u u m , c o lla b o ra tio n a t th e lo w e s t level begins w it h c o m m u n ic a tio n a m o n g a ll in v o lv e d disciplines a n d th e c lie n t, w it h e v e ry o n e a s k in g s im ila r qu estio n s (B lais et a l., 2 0 0 6 ) . E a c h p ro fe s s io n a l has separate in te rv e n tio n s w it h a separate p la n o f c are, a n d decision m a k in g is in d e p e n d e n t. C o o r d in a tio n a n d c o n s u lta tio n re p re se n t a m id d le -ra n g e level o f c o lla b o ra tio n , w h e re th e p ro fes s io n als seek to m a k e best use o f th e resources. C o m a n a g e m e n t a n d re fe rra l re p re s e n t th e h ig h e s t le v e l o f c o lla b o ra tio n , in w h ic h p ro v id e rs a re re s p o n s ib le a n d a c c o u n ta b le fo r th e ir o w n aspects o f c are , a n d th e n p a tie n ts are d ire c te d to o th e r p ro v id e rs w h e n th e p ro b le m is b e y o n d a p a rtic u la r p r o v id e r ’s e x p e rtis e . T h e m a in levels o f th e c o n tin u u m o f c o lla b o ra tio n a re re p re s e n te d in F ig u re 8 -1 . Successful c o n s u lta tio n becom es a p p a re n t w h e n each p e rs o n m a k in g a c o n tr ib u tio n is re c o g n iz e d so t h a t a u n ifie d p la n c a n be p u t in to p ra c tic e . N u rs e s c o lla b o ra te w it h c lie n ts , peers, a n d o th e r perso ns in th e h e a lth c a re d e liv e ry system . S p e c ific a lly , th e n u rs e ’s ro le as a c o lla b o ra to r w it h th e c lie n t in c lu d e s a c k n o w le d g in g a n d s u p p o rtin g th e c lie n t in h e a lth c a re d ecisio n s, e n c o u ra g in g c lie n t a u to n o m y , h e lp in g clients set goals fo r c are, a n d p ro v id in g c lie n t c o n s u lta tio n in a c o lla b o ra tiv e fa s h io n . W it h o th e r h e a lth c a re p ro fe s ­ s io n als, th e n u rs e ’s ro le is to re c o g n ize th e c o n trib u tio n a n d e x p e rtis e o f each m e m b e r o f th e in te rd is c ip lin a ry te a m , listen, share re sp o n sib ilities in e x p lo rin g o p tio n s a n d s ettin g goals, a n d p a rtic ip a te in c o lla b o ra tiv e in te rd is c ip lin a ry re se arch to increase k n o w le d g e o f a p a rtic u la r c lin ic a l p ro b le m . A n u rse c an also c o lla b o ra te w it h in p ro fe s s io n a l o rg a n iz a tio n s b y serv in g o n c o m m itte e s a t th e lo c a l, s tate, n a tio n a l, o r in te rn a tio n a l le v e l to c rea te s o lu tio n s fo r p r o ­ fe ss io n a l a n d h e a lth c a re concerns. K e y e le m en ts n e e d e d fo r c o lla b o r a tio n o f th e in te rd is c ip lin a ry h e a lth ­ c are te a m in c lu d e e ffe c tiv e c o m m u n ic a tio n s kills , m u tu a l re sp e ct a n d tru s t, th e a b ility to give a n d re ce ive fe e d b a c k , d e c is io n -m a k in g s k ills , a n d c o n flic t re s o lu tio n skills. E a c h p ro fe s s io n a l g ro u p m u s t focus o n c o m m o n g ro u n d : the c lie n t’s needs. A p e rs o n -c e n te re d a p p ro a c h is essential B ro w n , 2 0 0 5 ) . M u t u a l

Figure 8-1 Levels of th e continuum of collaboration Information exchange

Consultation

Lowest level -«----------------------Communication between client and each professional

Referral ------------------ ► Highest level

Coordination of care

Comanagement

Role of the Professional Nurse

209

respect d evelops in th e te a m w h e n in d iv id u a ls s h o w h o n o r CRITiCAL THiNKING QUESTiON V o r give c re d it to one a n o th e r. W h e n one te a m m e m b e r is One of the most difficult challenges in pro­ c o n fid e n t in th e a ctio n s o f a n o th e r, tru s t occurs. H o s p ita ls moting collaboration among professionals is h a ve n o t a lw a y s fo ste re d m u tu a l c a rin g a n d respect a m o n g giving and receiving feedback. What is your p ro fe s s io n a ls , so nurses m u s t s triv e to p ro m o te p o s itiv e experience in giving and receiving timely re la tio n s h ip s w it h te a m m e m b e rs d esp ite lin g e rin g n e g a ­ and helpful feedback with a team? Think of tiv e a ttitu d e s fr o m th e p ast. A ls o , w h e n pro fessio n als w o r k an example of receiving both negative and c lo s e ly to g e th e r o n a te a m , g iv in g a n d re c e iv in g tim e ly positive feedback. Compare the effect of the a n d re le v a n t fe e d b a c k a re som e o f th e m o s t d iffic u lt c h a l­ negative and positive feedback. Compare the experiences. V lenges b u t im p o r t a n t to th e te a m pro cess. T y p e o f fe e d ­ b a c k g ive n c an be a ffe c te d b y a p e rs o n ’s p e rc e p tio n s , roles, c o n fid e n c e , b e lie fs , a n d e n v iro n m e n t. H e lp f u l fe e d b a c k is c h a ra c te riz e d b y w a r m , c a rin g , a n d re sp e ctfu l c o m m u n ic a tio n . O p p o rtu n itie s to p ra c tic e lis te n in g a n d g iv in g a n d re c e iv in g fe e d b a c k c a n e n h an ce p ro fe s ­ s io n a l c o m m u n ic a tio n s kills . G iv in g a n d re c e iv in g fe e d b a c k help s th e p ro fe s ­ s io n a l c o lla b o ra tiv e te a m d e v e lo p a n u n d e rs ta n d in g a n d e ffe c tiv e w o r k in g re la tio n s h ip . A n o th e r k e y e le m e n t o f c o lla b o r a tio n b y th e in te r d is c ip lin a r y te a m in v o lv e s re s p o n s ib ility fo r th e e x p e c te d o u tc o m e . T o a ch ieve a s o lu tio n , te a m d e c is io n m a k in g m u s t b e g in w it h a c le a r d e fin itio n o f th e p r o b le m a n d be d ire c te d a t th e o b je c tiv e s o f th e specific e ffo r t. B y fo c u s in g o n th e c lie n t’s KEY COMPETENCY 8-6 p r io r it y needs firs t, o r g a n iz a tio n o f in te rv e n tio n s c a n be p la n n e d a c c o rd ­ in g ly . T h e d is c ip lin e best a b le to a d d ress th e c lie n t’ s h ig h e s t needs a t th e Examples of Applicable m o m e n t is g iv e n p r io r it y in p la n n in g a n d is re s p o n s ib le fo r p r o v id in g its Nurse of the Future: Nursing in te rv e n tio n s in a tim e ly m a n n e r . O fte n , nurses c a n h e lp th e te a m id e n tify Core Competencies p rio ritie s a n d focus o n areas th a t re q u ire fu rth e r re fe rra l o r a tte n tio n . T a k e , Teamwork and Collaboration: fo r e x a m p le , a te rm in a l o n c o lo g y p a tie n t w h o re q u ire s c are p o s t a b d o m in a l Knowledge (K2) Describes su rg e ry to c o rre c t a b o w e l o b s tru c tio n caused b y an in v a s iv e tu m o r . C a n c e r scope of practice and roles has a ffe c te d th e p a tie n t’s spine, c au sin g n e u ro lo g ic d eficits o f th e e x tre m itie s . of interdisciplinary and T h e p a tie n t has a n im p la n te d p o r t fo r c h e m o th e ra p y , p a re n te ra l n u tr itio n , nursing health care team a n d re q u ire s m u ltip le a n tib io tic in fu s io n s . S everal d e c u b iti h a v e d e v e lo p e d . members T h e p rim a ry nurse ensures to ta l p a tie n t care b y c o m m u n ic a tin g w it h th e c lie n t Attitudes/Behaviors (A2) a n d s ig n ific a n t o th ers . T h e nurse th e n c o lla b o ra te s w it h th e p h y s ic ia n fo r p a in Values the perspectives and c o n tro l a n d p o s to p e ra tiv e c are . T h e n u rse ensures e x p e rt in tra v e n o u s lines expertise of all health care team members fo r c h e m o th e ra p y a n d m u ltip le a n tib io tic in fu s io n s , c o lla b o ra tin g w it h peers i f necessary. T h e n u rse consu lts p e r p h y s ic ia n ord ers w it h th e e n te ro s to m a l Skills (S2) Functions compe­ th e ra p is t fo r w o u n d c are o f th e d e c u b iti a n d consu lts w it h th e d ie tic ia n fo r tently within own scope of practice as a member of the h y p e r a lim e n ta tio n (to ta l p a re n te ra l n u tr itio n ) needs. T h e n u rse c o lla b o ra te s health care team w it h p h y s ic a l th e ra p y fo r re s u m p tio n o f a c tiv ity fo r n e u ro lo g ic d eficits. E ac h m e m b e r o f th e in te rd is c ip lin a ry te a m c o n trib u te s his o r h e r o w n e x p e rtis e to Source: Massachusetts Department of Higher Education (2010), p. 31. c o m m o n goals o f care. In te rp e rs o n a l c o n flic t m ig h t o c cu r w h e n in d iv id u a ls a re w o r k in g to g e th e r a n d th e ir e x p e c ta tio n s are in c o m p a tib le . C o n flic ts b e tw e e n p e o p le c an a ffe c t in te rd is c ip lin a ry c o lla b o ra tio n . T o reduce c o n flic t, te a m m em b ers can c o n d u c t

KEY COMPETENCY 8-7 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Communication (Collegial Communication and Conflict Resolution): Knowledge (K4b) Discusses effective strategies for com­ municating and resolving conflict Attitudes/Behaviors (A4b) Recognizes that each indi­ vidual involved in a conflict has accountability for it and should work to resolve it Skills (S4b) Contributes to resolution of conflict Source: Massachusetts Department of Higher Education (2010), p. 28.

in te rd is c ip lin a ry co n fe re n ce s, ta k e p a r t in in te rd is c ip lin a ry e d u c a tio n a l p r o ­ g ra m s , a n d re co g n ize a n d accept p e rs o n a l re s p o n s ib ility fo r te a m w o rk . S o m e ­ tim e s th e fa ilu re o f p ro fes s io n als to c o lla b o ra te is because th e y la c k th e skills necessary to c o n trib u te to e ffe c tiv e te a m w o r k . In th e p a st, n u rs in g has been in te re s te d in e m p h a s izin g n u rs in g rese arch a n d n u rs in g p ra c tic e . A tte n tio n is n o w s h iftin g to focus o n in te rd is c ip lin a ry c o lla b o ra tio n a n d th e re c o g n itio n o f d iffe r e n t p o in ts o f v ie w . C o lla b o r a tio n a m o n g d is c ip lin e s re q u ire s th a t nurses h a v e th e a b ility to a rtic u la te th e ir o w n th e o rie s w h ile c o n s id e rin g d if­ fe re n t p ersp ectives, a m u tu a l g iv e -a n d -ta k e to d e te rm in e th e best a p p ro a c h to specific p ro b le m s . S o m e tim e s o rg a n iz a tio n a l s tru c tu re a ffe cts ro le c o n ­ flic t. D e liv e r y systems th a t m a in ta in a h ie ra rc h y o f a u th o r ity d o n o t s u p p o rt in te rd is c ip lin a ry c o lla b o r a tio n . In s itu a tio n s w h e re a tr a d itio n a l a u th o r ity fig u re is s tro n g , th e o rg a n iz a tio n c an p ro m o te c o lla b o ra tio n b e tw e e n p h y s i­ cians a n d nurses. W h a te v e r th e o rg a n iz a tio n a l h ie ra rc h y o r d e liv e ry system , th e re la tio n s h ip a m o n g a ll m e m b e rs o f a n e ffe c tiv e c o lla b o ra tiv e te a m m u s t re fle c t tru s t a n d respect. C o n flic t c an be o v e rt o r c o v e rt. R e a c tiv e b e h a v io rs in c lu d e w h in in g , c o m ­ p la in in g , passive-aggressive b e h a v io r, a n d gossiping. C o n flic t c an be an engine o f in n o v a tio n a n d c h an g e i f nurses c o n fro n t it p ro p e rly . P ossible causes o f c o n flic t in c lu d e in c o rre c t fa cts, la c k o f tru s t, u n c le a r p o s itio n d e s c rip tio n s , u n c le a r goals, in a d e q u a te a c tio n p lan s, un s ta b le lea d e rsh ip , la c k o f lea d e rsh ip , o r lim ite d s ta ff p a rtic ip a tio n in d e cis io n m a k in g . N u rs e s n e ed to ta k e steps to a v o id c o n flic ts . R e c o g n iz in g causes o f c o n flic t c a n assist o rg a n iz a tio n s to d evelo p strategies to p re v e n t c o n flic t. N u rs e s s h o u ld deal w it h conflicts as th ey o c c u r. C o lla b o r a tio n is a p o s itiv e a p p ro a c h to c o n flic t. S trategies fo r c o n flic t re s o lu tio n c an be to firs t id e n tify th e p ro b le m a n d c o lle c t facts, d o c u m e n tin g each fa c t a n d its sources. A n e x p la n a tio n o f b e h a v io rs s h o u ld g ive o p p o r tu ­ n ity fo r d isc u s sio n o f issues a n d e x p e c ta tio n s . C o u n s e lin g sessions s h o u ld give o p p o rtu n ity fo r g ro w th w it h e n c o u ra g e m e n t o f a ctiv e p a rtic ip a tio n . T h e c o u n s e lin g session a n d a c tio n p la n w it h a tim e lin e s h o u ld be re p o rte d to th e a p p ro p ria te superviso r w ith a p p ro p ria te d o c u m e n ta tio n o f a ll events a n d facts.

C o n tin u o u s Q u a lity Im p ro v e m e n t C ontinuo us q u a lity im p ro v e m e n t (C Q I) is d efin ed as a s tru c tu red o rg a n iz a tio n a l process th a t in vo lv es p e rs o n n e l in p la n n in g a n d im p le m e n tin g th e c o n tin u o u s flo w o f im p ro v e m e n ts in th e p ro v is io n o f q u a lity h e a lth c are th a t m eets o r exceeds e x p e c ta tio n s . C Q I g e n e ra lly in c lu d e s th e fo llo w in g c o m m o n set o f c h ara c te ris tic s : a lin k to k e y elem ents o f th e o r g a n iz a tio n ’s s tra te g ic p la n , a q u a lity c o u n c il c o m p o s e d o f th e o rg a n iz a tio n ’s le a d e rs h ip , tr a in in g p ro g ra m s fo r p e rs o n n e l, m ec h a n ism s fo r th e selectio n o f im p ro v e m e n t o p p o rtu n itie s , fo r m a tio n o f process im p ro v e m e n t te a m s , s ta ff s u p p o rt fo r process analysis a n d red esig n , p o licie s th a t m o tiv a te a n d s u p p o rt s ta ff p a rtic ip a tio n in process

im p ro v e m e n t, a n d a p p lic a tio n o f c u rre n t a n d rig o ro u s te ch n iq u es o f scientific m e th o d a n d s ta tis tic a l process c o n tro l (S o lle c ito & J o h n s o n , 2 0 1 3 , p p . 4 - 5 ) . T h e n u rs e ’s ro le in C Q I is especially im p o rta n t in h o s p ita ls th a t p ro m o te a c u ltu re o f p a tie n t safe ty a n d v ie w q u a lity -re la te d a c tiv itie s as p r io r ity “ safe ty c h e c k s .” E n s u rin g h ig h -q u a lity p a tie n t care a n d safe ty c a n n o t be o v e rs ta te d . Q u a lity care results fr o m c areg ivers d o in g th e rig h t th in g th e r ig h t w a y th e firs t tim e . C o lla b o ra tio n a n d e vid e n ce -b a se d p ra c tic e are k e y elem ents o f successful q u a lity im p ro v e m e n t p ro g ra m s (C a ra m a n ic a , C o u s in o , & P etersen , 2 0 0 3 ) . In th e 1 9 8 0 s , h o s p ita ls a n d agencies im p le m e n te d o n g o in g q u a lity assurance p ro g ra m s . Q u a lity assurance p ro g ra m s w e re re q u ire d fo r re im b u rs e m e n t o f services a n d fo r a c c re d ita tio n b y th e J o in t C o m m is s io n . In 1 9 9 2 , th e re vised J o in t C o m m is s io n s ta n d a rd s id e n tifie d c o n tin u o u s q u a lity im p ro v e m e n t as a m e c h a n is m o f h e a lth c are . T h is d iffe re d fr o m p re v io u s q u a lity p ro g ra m s b y p u rp o s e ly id e n tify in g th e causes o f p ro b le m s o r systems th a t n eed ed im p ro v e ­ m e n t in h e a lth c a re . In 2 0 0 2 , th e J o in t C o m m is s io n s ta n d a rd a m e n d m e n ts fu rth e r specified th a t p a tie n ts h a v e th e r ig h t to ag e-specific a n d c o n s id e ra te h e a lth c are th a t preserves d ig n ity a n d respects c u ltu r a l, p s y c h o s o c ia l, a n d s p iritu a l values (S m e ltz e r et a l., 2 0 1 0 ) . E v id e n c e -b a s e d p ra c tic e in p e rfo rm a n c e im p ro v e m e n t in c lu d e s th e use o f s ta n d a rd iz e d c are p la n s a n d o u tc o m e assessm ents such as c lin ic a l p a th ­ w a y s o r a lg o rith m s . A c u rre n t n a tio n a l in itia tiv e is th e b u n d lin g o f c are fo r v a rio u s p ro b le m s th a t h ave been id e n tifie d b y th e N a t io n a l Q u a lity F o r u m an d o th e r o rg a n iz a tio n s . T h e se p ro b le m s in c lu d e v e n tila to r-a s s o c ia te d p n e u m o n ia (V A P ), sepsis p ro to c o ls , a n d in fe c tio n s re la te d to c e n tra l v en o u s c a th e te rs . B u n d lin g is a lis tin g o f care c rite ria necessary to re d u c e in fe c tio n s such as a c h e c k lis t o r g ra p h fo r nurses to use a t th e b edside. T h e se d a ta a re tra c k e d b y th e p e rfo rm a n c e im p ro v e m e n t c o u n c il. T h e m o n th ly exc h an g e (c o lla b o r a tio n ) a m o n g p h ysician s a n d nurses a n d o th e r h e a lth c a re p erso n n el fosters m u tu a l tru s t a n d respect. W h e n th e need fo r q u a lity im p ro v e m e n t is id e n tifie d b y th e p e rfo rm a n c e im p ro v e m e n t c o u n c il, th e re g is te re d n u rs e a t th e b e d s id e uses q u a lity te c h n iq u e s th a t w e re once e m p lo y e d o n ly b y q u a lity assurance p e rs o n n e l. T h e n u rse m ig h t u tiliz e E x c e l spreadsheets, flo w d ia g ra m s , c o m p u te r p ro g ra m s , o r c o n tro l ch arts to re c o rd d a ta w h e n a n a ly z in g a c lin ic a l p ro b le m o r s itu a tio n . T re n d e d d a ta c o lle c te d b y nurses are p ro v id e d b y th e ris k m a n a g e m e n t d e p a rtm e n t o r p e rfo rm a n c e im p ro v e m e n t c o u n c il a n d d is s e m in a te d to th e u n its . Q u a lity im p ro v e m e n t is tie d in to each n u rs e ’s p e rfo rm a n c e . In d iv id u a l n u rse a n d te a m g o als fo r q u a lity a n d s a fe ty a re im p o r t a n t c o m p o n e n ts o f each s ta ff m e m b e r’s a n n u a l re v ie w . A s n u rs in g le a d e rs h ip a n d s ta ff fo s te r a c u ltu re o f safe ty a n d q u a lity , th e y e m p h a s ize re p o rtin g n e a r misses a n d u n in ­ te n d e d o u tco m e s as a m ea n s to id e n tify a n d fix th e w e a k lin k in processes o f c are . F o r e x a m p le , th e a n o n y m o u s re p o rtin g o f m e d ic a tio n a d ve rse events in som e in s titu tio n s has le d to a n in c re a s e d n u m b e r o f in c id e n t re p o rts b e in g

KEY COMPETENCY 8-8 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Quality Improvement: Knowledge (K1) Describes the nursing context for improving care Attitudes/Behaviors (A1) Recognizes that quality improvement is an essential part of nursing Skills (S1a) Actively seeks information about quality in their own settings and organization; (S1b) Actively seeks information about quality improvement in the care setting from relevant institutional, regulatory and local/national sources Source: Massachusetts Department of Higher Education (2010), p. 36.

m a d e b y bedside c are g ive rs . T h is has re s u lte d in th e id e n tific a tio n o f areas o f th e m e d ic a tio n use system th a t n e ed im p ro v e m e n t, a n d th is u ltim a te ly leads to p re v e n tio n o f o th e r p ossible n e a r misses a n d m o re serious u n in te n d e d o r n e g a tiv e o u tco m e s in m e d ic a tio n a d m in is tra tio n (C a ra m a n ic a et a l., 2 0 0 3 ) . C o n tin u o u s q u a lity im p ro v e m e n t has p ro v e d to be b en eficial in p ro m o tin g c lie n t s afe ty , b u t c o n flicts in v o lv in g g ro u p s o r in d iv id u a ls m ig h t o c cu r. In te r ­ g ro u p co n flicts c an o c c u r w h e n th e g ro u p disagrees a b o u t p o licie s g o v e rn in g p ra c tic e , such as w h e n a nurse is asked to flo a t to a n o th e r u n it. W h a te v e r th e c o n flic t, re s o lu tio n strategies a re essential to success. P ro b le m s o lv in g c a n be a ch ie ve d w it h o p e n discussion a n d a n in v e s tig a tio n o f a ll d im e n s io n s o f th e c o n flic t. W h e n each p ro fe s s io n a l’s g o a l has a p o s itiv e o u tc o m e , success is m o re lik e ly . N e g o tia tin g o r b a rg a in in g occurs w h e n th e to p p r io r ity need an d o p tim a l o u tc o m e a re id e n tifie d fo llo w e d b y re a c h in g a fin a l a g re e m e n t th a t is close to each p e rs o n ’s p o s itio n . A ll p a rtie s m u s t be sincere in th e e ffo r t to n e g o tia te , a n d th e goals o f n e g o tia tio n s h o u ld be seen as fa ir a n d re a s o n a b le to each side. F o r e x a m p le , th e nurses w o r k in g in a n o u tp a tie n t su rg e ry u n it p la n th e o n -c a ll schedule a t a m o n th ly s ta ff m e e tin g w it h th e ir nurse m a n a g e r. W h e n a chang e in schedule is needed, th e nurses m u s t p la n a m e e tin g to discuss strategies a n d n e g o tia te th e ch an g e. Successful n e g o tia tio n occurs w h e n th e nurses re a c h a fa v o ra b le schedule a n d v ie w th e o u tc o m e as fa ir, re a s o n a b le , a n d a lig n e d w it h th e ir p e rs o n a l goals. P ro fe s s io n a l nurses h a v e e x p e rtis e in a w id e v a rie ty o f roles to p ra c tic e c lie n t-d riv e n c are. T h e concepts o f c o n s u lta tio n , c o n tin u ity o f care, c o lla b o ra ­ tio n , a n d re fe rra l are in te rre la te d . T o p ro v id e c o n tin u ity o f care fr o m a d m is ­ sion to discharge a n d re h a b ilita tio n , th e nurse c o lla b o ra te s w it h o th e r services a n d agencies to p ro v id e c are . T h e o ld clic h e th a t d isc h a rg e p lan s b e g in w it h a d m is s io n m a k e s m o re sense n o w th a n ever b e fo re , even fo r th e a cu te care p a tie n t. W it h s h o rte n e d len g th s o f h o s p ita l stay, nurses m u s t e v a lu a te a ll c li­ ents fo r th e ir a b ility to m a n a g e a t h o m e . T h e re fe rra l source p r io r to discharge m ig h t be a p h y s ic ia n , n u rse , s o cia l w o r k e r , o r d isc h a rg e p la n n e r. T h is p e rso n supplies th e ag en cy w it h d e ta ils a b o u t th e c lie n t’s needs. T h e n u rs e ’s ro le is to assess th e need to re fe r clien ts fo r assistance w it h a c tu a l o r p o te n tia l p r o b ­ lem s a n d id e n tify c o m m u n ity resou rces, such as re sp ite c are , social services, o r shelters, fo r th e c lie n t, fa m ily , a n d s ig n ific a n t o th ers (W e n d t et a l., 2 0 0 7 ) . I f th e n u rse re fers th e p a tie n t to a h o m e h e a lth a gency a n d th e agency believes th a t th e c lie n t q u a lifie s fo r services, th e agency u s u a lly c o n ta cts th e c lie n t’s p h y s ic ia n a n d requests a re fe rra l o n th e c lie n t’s b e h a lf (L e M o n e & B u rk e , 2 0 0 7 ) . T h e n u rse c an re fe r a c lie n t to h o s p ice , a c o m m u n ity re so u rce , o r s u p p o rt g ro u p . T h e k in d s o f agencies th a t p ro v id e care in th e c o m m u n ity a n d h o m e h a v e in c re a s e d because o f th e m o re c o m p le x needs o f p a tie n ts . T e c h n o lo g ie s th a t w e re once lim ite d to th e a cu te care settin g such as v e n tila ­ to r y s u p p o rt, d ia ly s is , a n d in tra v e n o u s o r p a re n te ra l n u tr itio n th e ra p y h a ve been a d a p te d to th e h o m e c are settin g . H o m e c are nurses fu n c tio n as acu te care nurses in th e h o m e , p ro v id in g “ h ig h -te c h , h ig h -to u c h ” services to p atien ts

w it h a cu te h e a lth c a re needs. T h e y are resp o n sib le fo r fa m ily te a c h in g a n d c o l­ la b o ra tin g w it h c o m m u n ity resources in th e c o n tin u ity o f care to p ro m o te an d m a in ta in p a tie n t s elf-ca re m a n a g e m e n t. T h e n u rse c an c o n s id e r th e fo llo w in g q u e stio n s w h e n assessing th e c lie n t b e in g d isc h a rg e d fr o m a cu te care to h o m e c are (L e M o n e & B u rk e , 2 0 0 7 ): • • • • • • • • •

D o e s th e c lie n t n e ed fo llo w -u p tre a tm e n ts o r a d d itio n a l ed u ca tio n ? W h a t e q u ip m e n t o r supplies a re necessary? W h a t te a c h in g m a te ria ls d o th e clien ts n e ed , a n d are th e y a t an acc ep tab le re a d in g lev el fo r th e client? A re th e re a n y sensory d e p riv a tio n s th a t m ig h t im p e d e lea rn in g ? W h o is g o in g to be th e p rin c ip a l c a re g iv e r in th e hom e? I f h e o r she is n o t c o m fo rta b le , w h a t s u p p o rt does th e c a re g iv e r need? W a s th e c a re g iv e r p re s e n t d u rin g in s tru c tio n s in th e h o s p ita l setting? D id he o r she c o m p re h e n d th e in s tru c tio n s ? H a s a d e v a s ta tin g p ro g n o s is ju s t been d e te rm in e d ? Is h ig h -te c h n o lo g y in te rv e n tio n necessary? A re c o m m u n ity resources a v a ila b le w h e re th is p a tie n t lives?

In e very in stan ce , th e nurse s h o u ld n o t m a k e a s s u m p tio n s . W e ll-e d u c a te d o r fin a n c ia lly secure clients c an be ju s t as o v e rw h e lm e d b y illness as clients w h o a p p e a r less e d u c a te d o r p o o r . E v e ry c lie n t is a re fe rra l c a n d id a te . I f th e fa m ily believes th a t n o h e lp is necessary b u t th e n u rse believes o th e rw is e , th e nurse c a n suggest a n e v a lu a tio n v is it b y a n agency once th e c lie n t is a t h o m e . I f a re fe rra l is m a d e to a h o m e care a g en c y, it m u s t p ro c e e d w it h a p h y s ic ia n a p p ro v e d tr e a tm e n t p la n , w h ic h is a le g a l re q u ire m e n t. I f p h y s ic a l th e ra p y o r o th e r services are n e ed e d , th e n u rse o r social w o r k e r a rran g es fo r these visits. T h e n u rs in g process used in h o m e c are settings is th e sam e as th a t p ra c ­ tic e d in a n y o th e r h e a lth c a re settin g . T h e n u rse is resp o n sib le fo r m a in ta in in g c o n tin u ity o f c a re b e tw e e n a n d a m o n g h e a lth c a re ag en cies. T h is in c lu d e s p ro v id in g a n d re c e iv in g re p o rts o n assig ned c lie n ts a n d u s in g a p p ro p r ia te d o c u m e n ts such as m e d ic a l re c o rd s o r tr a n s fe r fo rm s to re c o r d a n d c o m ­ m u n ic a te c lie n t in fo r m a tio n . A c c u ra te tr a n s c r ip tio n o f p r im a r y h e a lth c a re p ro v id e r ord ers is also necessary. H o m e c are n u rs in g is a s p e c ia lty a rea th a t re q u ire s a d v a n c e d k n o w le d g e a n d h ig h -le v e l assessm ent s kills , c ritic a l th in k in g , a n d d e c is io n -m a k in g skills w h e re o th e r h e a lth c a re p ro fes s io n als are n o t a v a ila b le to v a lid a te conclusions a n d decision s a b o u t c a re . B ecause o f th is , th e scope o f h o m e c a re n u rs in g encom passes n o t o n ly th e acu te c are settin g in th e h o s p ita l b u t also th e a cu te care settin g as it e xp a n d s in to th e c o m m u n ity . C o lla b o r a tiv e p ra c tic e s h o u ld be a p r im a r y g o a l fo r n u rs in g . T h is g o a l p ro m o te s sh ared p a rtic ip a tio n , re s p o n s ib ility , a n d a c c o u n ta b ility in a h e a lth ­ c are e n v iro n m e n t th a t is s triv in g to m e e t th e c o m p le x h e a lth c a re needs o f th e p u b lic . N u rs e s w it h a s ig n ific a n t p ra c tic e th a t e m p o w e rs o th ers a re those w h o v a lu e c o lla b o ra tio n a n d d e v e lo p th e a b ility to associate e ffe c tiv e ly a n d

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CHAPTER 8 The Healthcare Delivery System and the Role of the Professional Nurse

p o s itiv e ly w it h o th e r h e a lth c a re p e rs o n n e l (P o n te et a l., 2 0 0 7 ) . A n in flu e n tia l p ro fe s s io n a l n u rse w o rk s w e ll w it h o th e rs , is fa ir , a n d has p ersp ectives th a t a re s o u g h t o u t b y o th e r h e a lth c a re p e rs o n n e l. L e a d in g a n d p a rtic ip a tin g in in te r d is c ip lin a r y te a m s a n d p a r tn e r in g w it h o th e rs a re e ss e n tia l to s o u n d n u rs in g p ra c tic e .

C o nclu sio n T h is c h a p te r has in tro d u c e d h e a lth c a re d e liv e ry system s a n d th e ro le o f th e p ro fe s s io n a l n u rse . I t e x p lo re d v a rio u s m o d e ls o f n u rs in g c are d e liv e ry . A ll nurses are m an ag e rs o f th e care o f a specific g ro u p o f p a tie n ts a n d c o lla b o ra te w it h o th e r h e a lth c a re p ro v id e rs in th e d e liv e ry o f c lie n t-c e n te re d a n d s a fe ty fo cused c are. N u rs e s m u s t possess th e skills o f c ritic a l th in k in g , d e le g a tio n , s u p e rv is io n , c o lla b o ra tio n , e v a lu a tio n , m o tiv a tio n , a n d c o m m u n ic a tio n to w o r k w it h o th e r d is c ip lin e s o f c a re . T h is c h a p te r has d e fin e d som e o f th e c o n ce p ts th a t a re n ecessary fo r th e e n try -le v e l n u rse to m a in t a in safe a n d c o m p e te n t e n try -le v e l n u rs in g p ra c tic e .

Classroom A ctivit o u a re p la n n in g th e d is c h a rg e o f a n 8 2 -y e a r-o ld m a n w h o has h e a rt fa ilu re a n d c h ro n ic o b s tru c tiv e p u lm o n a ry d is ­ ease (C O P D ) . D iv id e th e class in to s m a ll gro u p s o f s tu d e n ts to discuss h o w th e case m a n a g e r

Y

w o u ld in te rv e n e fo r th e c lie n t a n d fa m ily a n d p ro v id e c o n tin u ity o f c are fr o m I C U to h o m e . H a v e a s p o k e s p e rs o n fo r e a c h g ro u p b rie fly p re se n t each g ro u p ’s p la n ,

R e fe re n c e s American Nurses Association. (2001). Code o f ethics for nurses with interpretive statements. Washington, DC: Author. Blais, K. K., Hayes, J. S., Kozier, B., & Erb, G. (2006). Professional nursing practice concepts and perspectives (5th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Brown, F. (2005). Nurse consultations: A person-centered approach. Retrieved from http://tcmdiscovery.com/2007/6-24/200762416820.html Butts, J., & Rich, K. (2011). Philosophies and theories for advanced nursing practice. Sudbury, MA: Jones & Bartlett Learning.

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), 336-343. LeMone, P., & Burke, K. (2007). Medical-surgical nursing critical thinking in client care (4th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Lindeke, L. L., & Seickert, A. M. (2005). Nurse-physician workplace collaboration. Retrieved from http://www.nursingworld.org/ojin Massachusetts Department of Higher Education. (2010). Nurse o f the future: Nursing core competencies. Retrieved from http://www.mass.edu/currentinit/documents/ NursingCoreCompetencies.pdf North Carolina Concept-Based Learning Editorial Board. (2011). Nursing: A conceptbased approach to learning (Vols. 1 and 2). Upper Saddle River, NJ: Pearson. Plsek, P. E., & Wilson, T. (2001). Complexity, leadership and management in healthcare organisations. British Medical Journal, 323, 746-749. Ponte, P. R., Glazer, G., Dann, E., McCollum, K., Gross, A., Tyrrell, R., . . . Washington, D. (2007). The power of professional nursing practice: An essential element of patient and family centered care. Online Journal o f Issues in Nursing, 12. Retrieved from http://nursingworld.org/ojin Smeltzer, S. C., Bare, B. G., Hinkl, J. L., & Cheever, K. H. (2010). Brunner & Suddarth’s textbook o f medical-surgical nursing (12th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Sollecito, W. A., & Johnson, J. K. (2013). McLaughlin and Kaluzny’s continuous quality improvement in health care (4th ed.). Burlington, MA: Jones & Bartlett Learning. Sullivan, E. J., & Decker, P. J. (2005). Effective leadership and management in nursing (6th ed.). Upper Saddle River, NJ: Pearson Prentice Hall. Wade, D. T., & Halligan, P. W. (2004). Do biomedical models of illness make for good healthcare systems [Electronic version]? British Medical Journal, 329, 1398-1401. Retrieved from http://www.bmj.com/content/329/7479/1398.full Wendt, A., Kenny, L., & Anderson, J. (2007). National Council of State Boards of Nursing 2007 NCLEX-RN detailed test plan. Retrieved from https://www.ncsbn. orgZ2007_NCLEX_RN_Detailed_Test_Plan_Candidate.pdf Wilson, T., & Holt, T. (2001, September). Complexity and clinical care. British Medical Journal, 323, 685-688.

Critical Thinking and Clinical Judgment in Professional Nursing Jill Rushing

v_____________________ T h e re s p o n s ib ilitie s o f a p r o fe s s io n a l re g is te re d n u rs e h a v e in c re a s e d s ig n ific a n tly o v e r th e y e a rs . N u rs e s a n d n u rs in g s tu d e n ts m u s t be a b le to fu n c tio n w it h in th e c o m p lic a te d e n v iro n m e n t o f th e h e a lth c a re system . T h e im p a c t o f a d v a n c e d te c h n o lo g y , th e in crea se d a c u ity lev el a n d c o m p le x ity o f p a tie n ts , c o m b in e d w it h th e a c c o u n ta b ility a n d re s p o n s ib ility nurses h a v e in th e d e liv e ry o f safe a n d e ffe c tiv e c are , m a k e it essential, m o re n o w th a n ever, fo r nurses to possess th e a b ility to th in k c ritic a lly . I n n u rs in g , c ritic a l th in k ­ in g is th e a b ility to th in k in a s ys te m a tic a n d lo g ic a l m a n n e r, solve p ro b le m s , m a k e decisions, a n d establish p rio ritie s in th e c lin ic a l setting. C r itic a l th in k in g is th e c o m p e te n t use o f th in k in g s kills a n d a b ilitie s to m a k e s o u n d c lin ic a l ju d g m e n ts a n d safe d e cis io n m a k in g . C r it ic a l th in k in g in n u rs in g is a n ess en tia l c o m p o n e n t o f p ro fe s s io n a l a c c o u n ta b ility a n d q u a lity n u rs in g care. C o n c e rn fo r p a tie n t safe ty has g ro w n as h ig h rates o f e rro r a n d in ju r y c o n tin u e to be re p o rte d . T o im p ro v e p a tie n t s afety, nurses m u s t be a b le to re co g n ize changes in p a tie n t c o n d itio n , p e rfo r m in d e p e n d e n t n u rs in g in te rv e n tio n s , a n tic ip a te o rd ers , a n d p rio r itiz e . N e w nurses n e ed to be p re p a re d to p ra c tic e s afe ly, a c c u ra te ly , a n d c o m ­ p a s s io n a te ly , in v a rie d settings, w h e re k n o w le d g e a n d in n o v a tio n increase a t asto n ish in g rates (B e n n er, S u tp h en , L e o n a rd , & D a y , 2 0 1 0 ) . N u rs in g students m u s t use a c o m p le x a rra y o f n u rs in g skills a n d k n o w le d g e a t th e sam e tim e a n d p ra ctice th in k in g in c h an g in g situ atio n s, a lw ay s fo r th e g o o d o f th e p a tie n t (B e n n e r et a l., 2 0 1 0 ) .

Key Terms and Concepts » » » » » »

C ritic a l th in k in g Clinical judgment Reflective thinking Nursing process Concept mapping Journaling

Learning Objectives A f t e r c o m p le tin g th is c h a p te r, th e s tu d e n t should be a b le to : 1. 2. 3. 4.

D efine c ritic a l th in k in g . D escribe im p o rta n t c ritic a l th in k in g skills. E xp lo re c h a ra c te ris tic s of c ritic a l th in k in g . D escribe th e ch ara cteris tic s of a critical th inker.

5 . E x p la in w h y c ritic a l th in k in g is im p o rta n t in nursing p ra c tic e . 6 . Explore th e process involved in critical thinking.

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R e c e n t s tu d ie s in d ic a te n e w n u r s in g g r a d u a te s h a v e d e fic ie n c ie s in c r it ic a l t h in k in g a b ilit y in c lu d in g r e c o g n itio n o f p ro b le m s , r e p o r t in g o f e ss e n tia l c lin ic a l d a ta , in itia t in g in d e p e n d e n t n u rs in g in te rv e n tio n s , a n tic i­ p a tin g re le v a n t m e d ic a l o rd e rs , p ro v id in g re le v a n t r a tio n a le to s u p p o rt deci­ sion s, a n d d iffe r e n tia tin g u rg e n c y (F e r o , W its b e r g e r , W e s m ille r , Z u l l o , & H o f f m a n , 2 0 0 9 ) . N e w g ra d u a te nurses p ra c tic e a t th e n o v ic e o r a d v a n c e d b e g in n e r le v e l (B e n n e r, 1 9 8 4 ) . N e w g ra d u a te n urses a re a t th e e a rly stage o f d e v e lo p in g a s k ill set a n d a p p ly in g c r it ic a l t h in k in g . F o r th e n o v ic e , th e b e g in n in g n u rs in g s tu d e n t, th e d iffic u lty e n c o u n te re d in s e ttin g p r i o r i ­ ties is th a t a ll ta s k s , re q u e s ts , a n d c o n c e rn s seem to be o f e q u a l w e ig h t o r im p o r ta n c e a n d th e y m u s t a ll be d o n e (B e n n e r et a l., 2 0 1 0 ) . D e t e r m in in g w h ic h ta s k s a re m o s t i m p o r t a n t o r u r g e n t re q u ire s d e lib e r a te th o u g h t b e ca u se th e s tu d e n t has n o t y e t le a r n e d to see th e b ig p ic tu r e o r g a in e d th e s k ill to re c o g n iz e q u ic k ly w h a t is m o s t u rg e n t, m o s t im p o r t a n t in each c lin ic a l s itu a tio n ; th is le v e l o f th in k in g is o fte n d iffic u lt fo r th e n o v ic e , th e b e g in n in g n u rs in g s tu d e n t (B e n n e r et a l., 2 0 1 0 ) . F o r e x a m p le , y o u a re a b o u t to a d m in is te r m e d ic a tio n s to a p a tie n t. W h a t is th e b ig g e r p ic tu re ? W h y is th e p a tie n t b e in g g iv e n th ese m e d ic a tio n s ? O r y o u h a v e a p a tie n t w h o has ju s t re tu r n e d fr o m s u rg e ry . W h a t s h o u ld be c a rrie d o u t in th e firs t h o u rs p o s t o p e ra tio n ? T o ensure q u a lity care fo r p a tie n ts , w e m u s t im p le m e n t strategies to h e lp n u rs in g students d e v e lo p th e essential s k ill o f c ritic a l th in k in g . T h e re s h o u ld be a p ro g re s s io n th ro u g h th e ir e d u c a tio n te n u re in n u rs in g s tu d e n ts ’ a b ility to th in k c ritic a lly .

W h a t Is C ritic a l T h in k in g ? C r itic a l th in k in g is a n in te g ra l p a r t o f n u rs in g p ra c tic e a n d p ro m o te s q u a l­ ity n u rs in g care a n d p o s itiv e p a tie n t o u tc o m e s . A lth o u g h c ritic a l th in k in g is w id e ly re g a rd e d as a c o m p o n e n t o f c lin ic a l re a s o n in g a n d d e cis io n m a k in g , it is d iffic u lt to d e fin e , a n d th e re is n o sing le, s im p le d e fin itio n th a t e x p la in s c ritic a l th in k in g . In n u rs in g , c ritic a l th in k in g fo r c lin ic a l decisio n m a k in g is the a b ility to th in k in a s ystem atic a n d lo g ic a l m a n n e r, w it h openness to q u e s tio n a n d re fle c t o n th e re a s o n in g process used to ensure safe n u rs in g p ra c tic e a n d q u a lity care. I t is p ro v id in g e ffe ctive care based o n s o und re as o n in g (S criven & P a u l, 2 0 1 1 ) . C r itic a l th in k in g in n u rs in g is a n essential c o m p o n e n t o f p r o ­ fe s s io n a l a c c o u n ta b ility a n d q u a lity n u rs in g c a re . C r itic a l th in k e rs e x h ib it th e fo llo w in g h a b its o f m in d : c o n fid e n c e , c o n te x tu a l p e rsp ec tive , c re a tiv ity , fle x ib ility , in q u is itiv e n e s s , in te lle c tu a l in te g rity , in tu itio n , o p e n -m in d e d n e s s , perseverance, a n d re fle c tio n . In n u rs in g , c ritic a l th in k e rs p ra c tic e th e c o g n itiv e s k ills o f a n a ly z in g , a p p ly in g s ta n d a rd s , d is c rim in a tin g , in fo r m a t io n s ee k ­ in g , lo g ic a l re a s o n in g , p re d ic tin g , a n d tra n s fo r m in g k n o w le d g e (S c h e ffe r & R u b e n fe ld , 2 0 0 0 ) .

What Is Critical Thinking?

T h e r e is a s tro n g lin k b e tw e e n c r itic a l th in k in g a n d c lin ic a l ju d g m e n t. T h e fo llo w in g d e fin itio n o ffe rs a c o m ­ p re h e n s iv e d e s c rip tio n o f e le m e n ts in c o r p o r a tin g c ritic a l th in k in g fr o m a n u rs in g p ro s p e c tiv e . C r itic a l th in k in g a n d c lin ic a l ju d g m e n t in n u rs in g : (1 ) are p u rp o s e fu l, in fo rm e d , o u tc o m e -fo c u s e d t h in k in g ; (2 ) c a r e f u lly id e n t if y k e y p ro b le m s , issues, a n d risks; (3 ) are based o n p rin c ip le s o f n u rs in g process, p ro b le m solving, a n d th e scientific m e th o d ; (4 ) a p p ly lo g ic , in tu itio n , a n d c re a tiv ity ; (5 ) a re d riv e n b y p a tie n t, fa m ily , a n d c o m m u n ity needs; (6 ) c a ll fo r strategies th a t m a k e th e m o s t o f th e h u m a n p o te n tia l; a n d (7 ) re q u ire c o n s ta n t re e v a lu a tin g (A lfa ro -L e fe v re , 2 0 0 9 ) . T h u s , c ritic a l th in k in g , p ro b le m s o lv in g , a n d d e cis io n m a k in g a re p r o ­ cesses th a t a re in te rre la te d . D e c is io n m a k in g a n d c ritic a l th in k in g need to o c c u r c o n c u rre n tly to p ro d u c e re as o n in g , c la rific a tio n , a n d p o te n tia l s o lu tio n s . C o m p e t e n c e in c r i t i c a l t h i n k i n g is o n e o f th e e x p e c ta tio n s o f n u rs in g e d u c a tio n . C r itic a l th in k e rs are d e sc rib ed as w e ll in fo r m e d , in q u is itiv e , o p e n m in d e d , a n d o rd e rly in c o m p le x m a tte rs . C r itic a l th in k in g c o m p e te n c e is a n o u tc o m e fo r q u a lity n u rs in g c a re a n d fo r th e d e v e l­ o p m e n t o f c lin ic a l ju d g m e n t. T h e a b ility to th in k c ritic a lly is a ls o d e s c rib e d as re d u c in g th e re s e a r c h -p ra c tic e g a p a n d fo s te r in g e v id e n c e -b a s e d n u r s in g (W a n g e n s te e n , J o h a n s s o n , B jo r k s tr o m , & N o r d s tr o m , 2 0 1 0 ) . L e a rn in g to be a nurse re q u ires m o re th a n m e m o riz in g fa c ts . I t re q u ire s th a t y o u le a rn to th in k lik e a n u rs e , to th in k th ro u g h a n d re a s o n o n a g re a te r d e p th , a n d to d r a w a m o re s o p h is tic a te d o r d eep er u n d e rs ta n d in g o f w h a t y o u a re d o in g in c lin ic a l p ra c tic e so th a t y o u p r o v id e safe, q u a lity p a tie n t c a re . N u r s in g is n o t a careless, m in d le s s a c tiv ity . A ll acts in n u r s in g a re d e e p ly s ig n ific a n t a n d re q u ire th e n u rs e ’s m in d to be fu lly engag ed. T h e fo llo w in g illu s tr a tio n show s n u rs in g is b o th th in k in g a n d d o in g : T h e p h y s ic ia n has o rd e re d a n I V to be p la c e d in a p a tie n t. H o w d o y o u c h o o s e b e tw e e n a b u tte r fly o r a n I V in tra c a th ? F irs t, y o u h a v e to c o n s id e r w h y th e lin e is b e in g p la c e d . Y o u ta k e in to c o n s id e ra tio n w h e th e r it is a s h o r t-te r m , k e e p -o p e n I V w it h lim ite d m e d ic a tio n s ; i f so, th e n th e b u t­ te rfly I V is m o re c o m fo rta b le a n d presents less o f a th re a t o f p h le b itis . D o c to rs v a ry in th e ir pre fe re n ce s as w e ll, a n d th is has to be c o n s id e re d . A ls o , th e c o n d itio n o f th e p a tie n t a n d his o r h e r veins m a k e s a g re a t d e a l o f d iffe re n c e . F o r e x a m p le , w it h o ld e r p a tie n ts special s k ill is re q u ire d . T h e

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www^} CRITICAL THINKING Q U E S TIO N *

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/minute. 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.” What 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 to 75 to 85 degrees

Based on knowledge you have learned, you realize the patient’s symptoms indicate acute hypoxemia, so improving oxygen delivery is the priority. The other actions also are appropriate, but they are not as critical as the initial action. V

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M

What do all of the following scenarios have in common? • An elderly male becomes acutely confused and refuses to follow directions for his safety. • A teen comes into an urgent care setting requesting information about STDs. • A mother visits a school nurse and requests information about how the school handles sex education. • A team leader needs to rearrange assignments when one team member goes home sick. • Nursing staff in an ICU need to develop an evacuation plan. Answer: They all require critical thinking skills. V

veins lo o k as th e y a re g o in g to be easy to get because th e y lo o k larg e, b u t th e y are v e ry fra g ile . I f y o u d o n o t use a v ery s lig h t to u rn iq u e t, th e v e in w ill p o p o p e n (B e n n e r, 1 9 8 4 ).

C h a ra c te ris tic s of C ritic a l T h in kin g H o w d o y o u k n o w w h e n c ritic a l th in k in g is ta k in g place? C r itic a l th in k in g has som e o f th e fo llo w in g c h ara c te ris tic s (W ilk in s o n , 2 0 0 7 ): • • • • • •

C ritic a l th in k in g is r a tio n a l a n d re a s o n a b le . C ritic a l th in k in g in v o lv e s c o n c e p tu a liz a tio n . C ritic a l th in k in g re q u ire s re fle c tio n . C ritic a l th in k in g in vo lv es c o g n itiv e (th in k in g ) skills a n d a ttitu d e s (fee lin g s). C ritic a l th in k in g in v o lv e s c re a tiv e th in k in g . C ritic a l th in k in g re q u ire s k n o w le d g e .

C ritic a l th in k in g is r a tio n a l a n d re a s o n a b le . I t is based o n reasons ra th e r th a n pre fe re n ce s, p re ju d ic e , o r s e lf-in te re s t. I t uses facts a n d o b s e rv a tio n s to d r a w c o n c lu s io n s . F o r e x a m p le , suppose d u r in g a n e le c tio n y o u d e cid e to v o te fo r th e D e m o c ra tic c a n d id a te because y o u r fa m ily has a lw a y s v o te d fo r D e m o c ra ts . T h is decision is based o n p re fe re n ce , p re ju d ic e , a n d , p o s sib ly , self­ in te re st. B y c o n tra s t, suppose y o u to o k tim e to re flec t o n w h a t th e c a n d id a te in th e e le c tio n said a b o u t th e issues a n d based y o u r c h o ice o n th a t. E v e n th o u g h y o u s till m ig h t v o te fo r th e D e m o c ra t, y o u w o u ld be th in k in g r a tio n a lly , using facts a n d o b s e rv a tio n s to d r a w y o u r c o n clu s io n s (W ilk in s o n , 2 0 0 7 ) . C ritic a l th in k in g in v o lv e s c o n c e p tu a liz a tio n . C o n c e p ­ W W W J CRITICAL THINKING QUESTION V tu a l th in k in g is th e a b ility to u n d e rs ta n d a s itu a tio n b y id e n tify in g p a tte rn s o r c o n n e c tio n s , a n d fo c u s in g o n k e y You will be taking care of a patient in a nurs­ u n d e rly in g issues a n d in te g ra tin g th e m in to a c o n c e p tu a l ing home for the first time. Your assignment is to care for an older man who has heart fr a m e w o r k . I t in v o lv e s u s in g p ro fe s s io n a l tr a in in g a n d disease. In addition, he has five other medical e x p e rie n c e , c r e a tiv ity , a n d in d u c tiv e re a s o n in g th a t le a d problems and takes 20 medications. While to s o lu tio n s o r a lte rn a tiv e s th a t m a y n o t be easily id e n ti­ developing a plan of care for this patient, you fie d . C o n c e p tu a l th in k in g in vo lv es a w illin g n e s s to e x p lo re can identify 8 to 10 nursing problems. You a n d h a v in g a n openness to a n e w w a y o f seeing th in g s o r have no previous experience with nursing “ lo o k in g o u ts id e o f th e b o x .” C o n s id e r, fo r e x a m p le , a homes, and most of what you have heard case in w h ic h a p a tie n t w it h h e a rt fa ilu re is c o u g h in g up and read about them is negative. Will you y e llo w s p u tu m . I f th e n u rs e suspects th a t th e p a tie n t is find yourself dreading the clinical day and s h o rt o f b re a th fr o m in fe c tio n , he o r she w ill e v a lu a te o th e r expecting a negative experience before you in d ic a to rs o f in fe c tio n . T h e n u rse w ill c h e c k th e p a tie n t even begin? V fo r a n e le v a te d te m p e ra tu re a n d w ill assess th e la s t w h ite

b lo o d c ell c o u n t in th e p a tie n t’s c h a rt to see i f it is e le v a te d . T h e n u rse w ill also c o n s id e r fa c to rs th a t m a y p lac e th e p a tie n t a t ris k fo r in fe c tio n , such as im m o b ility , p o o r n u tritio n , o r im m u n e suppression (C ra v e n & H ir n le , 2 0 0 7 ) . C ritic a l th in k in g uses re fle c tio n . R e fle c tiv e th in k in g is d e lib e ra te th in k in g a n d c a re fu l c o n s id e ra tio n . I t is th e process o f a n a ly z in g , m a k in g ju d g m e n ts , a n d d r a w in g c o n c lu s io n s . R e fle c tiv e th in k in g in v o lv e s c re a tin g a n u n d e r­ s ta n d in g th ro u g h o n e ’s e xp erien ces a n d k n o w le d g e a n d e x p lo rin g p o te n tia l a lte rn a tiv e s — assessing w h a t y o u k n o w , w h a t y o u n eed to k n o w , a n d h o w to b rid g e th a t g a p . Processes o f re fle c tiv e th in k in g in v o lv e th e fo llo w in g : • • • • • •

D e te r m in e w h a t in fo r m a t io n is n e e d e d (w h a t y o u n e e d to k n o w ) fo r u n d e rs ta n d in g th e issue. E x a m in e w h a t y o u h a v e a lre a d y e x p e rie n c e d a b o u t a n issue. G a th e r th e a v a ila b le in fo r m a tio n . S yn thesize th e in fo r m a tio n a n d o p in io n s . C o n s id e r th e synthesis fr o m d iffe re n t perspectives a n d fram e s o f referen ce. C re a te som e m e a n in g fr o m th e re le v a n t in fo r m a tio n a n d o p in io n s .

R efle ctive th in k in g is im p o rta n t d u rin g c o m p le x p ro b le m -s o lv in g situations because it p ro v id e s an o p p o rtu n ity to step b a c k a n d th in k a b o u t h o w to a c tu ­ a lly solve p ro b le m s a n d h o w p ro b le m -s o lv in g strategies a re used fo r ach ie vin g set goals. R e fle c tio n a llo w s students to observe a n d re fle c t, p u llin g to g e th e r w h a t th e y le a rn in th e c lin ic a l a n d cla ss ro o m settings in ta k in g care o f p a tien ts. S tudents c an b u ild a n d in te g ra te k n o w le d g e a n d skills. R e fle c tin g o n a n u rs in g e xperience o r s itu a tio n can assist nurses in c ritic a lly re flec tin g o n th e ir p ra ctice . C h o o s e a c lin ic a l s itu a tio n a n d ask y o u rs e lf som e o f th e fo llo w in g questions: • • • • • • • •

W h a t w a s m y ro le in th is s itu a tio n ? D id I feel c o m fo rta b le o r u n c o m fo rt­ able? W h y ? W h a t actions d id I take? H o w d id I an d others respond? W a s it a p p ro p ria te ? H o w c o u ld I h a ve im p ro v e d th e s itu a tio n fo r m ys e lf, th e p a tie n t, an d others in v o lv e d ? W h a t c an I ch an g e in th e fu tu re ? W h a t h a v e I le a rn e d th ro u g h th is s itu atio n ? D id I e x p e c t a n y th in g d iffe re n t to h a p p e n ? W h a t a n d w h y? H a s th is s itu a tio n c h a n g e d m y w a y o f th in k in g in a n y w a y ? W h a t k n o w le d g e fr o m th e o ry a n d rese arch c a n I a p p ly in th is s itu a tio n ? W h a t b ro a d e r issues, fo r e x a m p le , e th ic a l, s o cia l, o r p o litic a l, arise fr o m th is s itu a tio n ?

T h r o u g h re fle c tio n , students m a n a g e to be m o re o rg a n iz e d a n d e ffe ctive because th e y h a v e a b e tte r u n d e rs ta n d in g o f w h o th e p a tie n t is a n d w h a t his o r h e r care needs a re . R e fle c tio n o n p ra c tic e h elp s th e s tu d e n t d e v e lo p a s elf­ im p ro v in g p ra c tic e (B e n n e r et a l., 2 0 1 0 ) . C ritic a l th in k in g invo lves c o g n itive (th in k in g ) skills a n d attitu d es (feelings). C r itic a l th in k in g in v o lv e s h a v in g th in k in g skills as w e ll as th e m o tiv a tio n to use th e m . I t in v o lv e s th e w illin g n e s s to u tiliz e c o m p le x th o u g h t processes

KEY COMPETENCY 9-1 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Leadership: Knowledge (K2) Under­ stands critical thinking and problem-solving processes Attitudes/Behaviors (A2) Values critical thinking pro­ cesses in the management of client care situations Skills (S2a) Uses systematic approaches in problem solving Source: Massachusetts Department of Higher Education (2010), p. 17.

c o m p a re d to e as ily u n d e rs to o d ones. C r itic a l th in k e rs d o n o t o v e rs im p lify . C r itic a l th in k in g is a b o u t b e in g w illin g a n d a b le to th in k . C ritic a l th in k in g involves creative th in k in g . C re a tiv ity is p a rt o f the th in k in g process. W h e n y o u b ra in s to rm p o te n tia l p ro b le m solutions o r possible decisions, y o u are using c re a tiv ity . C re a tiv e a n d c ritic a l th in k e rs c o m b in e ideas a n d in fo r­ m a tio n in w ays th a t fo rm n e w solu tions o r in n o v a tiv e ideas. A c rea tive th in k e r is a n o p e n -m in d e d th in k e r. N u rs e s can u tiliz e c re a tiv e th in k in g w h e n en co u n ­ te rin g a p a tie n t s itu a tio n in w h ic h tr a d itio n a l m eth o d s a re n o t e ffe ctive . F o r e x a m p le , a p e d ia tric nurse is c a rin g fo r 9 -y e a r-o ld P a u lin e , w h o has in effe ctiv e re sp ira tio n s fo llo w in g a b d o m in a l surgery. T h e p h y sic ia n has o rd e re d in ce n tiv e s p iro m e try b re a th in g tre a tm e n ts , b u t P a u lin e is frig h te n e d by th e e q u ip m e n t a n d she q u ic k ly tires d u rin g th e tre a tm e n ts . T h e nurse offers P a u lin e a b o ttle o f soap bubb les a n d a b lo w in g w a n d . T h e nurse k n o w s th a t th e re s p ira to ry e ffo rt in b lo w in g bubb les w ill p ro m o te a lv e o la r e x p a n s io n a n d suggests th a t P a u lin e b lo w bubb les b e tw e e n in c e n tiv e s p iro m e try tre a tm e n ts (W ilk in s o n , 2 0 0 7 ). C r itic a l th in k in g re q u ire s k n o w le d g e . I n m o s t a c a d e m ic d isc ip lin es , th e e d u c a tio n a l system uses a n e x p e rt to d e liv e r a b o d y o f k n o w le d g e to th e u n p ra c tic e d n o v ic e , w h o w ill la te r be e xp e cted to go o u t a n d a p p ly th e k n o w l­ edge a n d ru le s le a rn e d in s ch o o l to v a rio u s w o r k s itu a tio n s . I n n u rs in g , a specific e d u c a tio n a l k n o w le d g e base is re q u ire d b e fo re a p p ly in g th a t k n o w l­ edge in p a tie n t c are . I t is im p o r ta n t to k n o w th a t th e process is b e in g a p p lie d c o rre c tly . In essence, to becom e a nurse y o u m u s t le a rn th e k n o w le d g e to th in k lik e a n u rse . O n th e “ flip s id e ” o f th is , as th e lev el o f e x p e rie n c e o f th e nurse in creases, so w ill th e s cie n tific k n o w le d g e base th a t th e n u rse a p p lie s . F o r e x a m p le , y o u are c a rin g fo r a p a tie n t w it h h e a rt fa ilu re . A fte r o b ta in in g th e v ita l signs, w h a t h e a rt ra te w o u ld p re v e n t y o u fr o m p e rfo r m in g a m b u la tio n o n th is p a tie n t? I f y o u d id n o t h a v e k n o w le d g e re g a rd in g h e a rt fa ilu re o r d id n o t k n o w th a t th e n o r m a l h e a rt ra te w a s 6 0 - 1 0 0 beats p e r m in u te , y o u c o u ld n o t m a k e th e g o o d d e cis io n th a t a m b u la tio n s h o u ld be p o s tp o n e d i f th e h e a rt ra te is a b o v e 1 0 0 beats p e r m in u te fo r th is p a tie n t.

W h a t A re th e C h a ra c te ris tic s of a C ritic a l T h in k e r? N u rs e s a re re q u ire d to th in k c ritic a lly in a ll settings. N u rs e s ’ a b ility to th in k c ritic a lly is one o f th e ir m o s t im p o r t a n t s kills , a n d a c o m m itm e n t to th in k c r it ic a lly b e n e fits th e n u rs e ’s a b ility to c a re fo r p a tie n ts m o s t e ffe c tiv e ly . A c ritic a l th in k e r has m a n y c h a ra c te ris tic s , in c lu d in g th e fo llo w in g : • •

C ritic a l th in k e rs a re fle x ib le — th e y can to le ra te a m b ig u ity a n d u n c e rta in ty . C r itic a l th in k e rs base ju d g m e n ts o n facts a n d re a s o n in g , n o t p e rs o n a l fe elin g s . T h e y id e n tify in h e re n t biases a n d a s s u m p tio n s . C r itic a l th in k e rs s ep a rate facts fr o m o p in io n s .

Approaches to Developing Critical Thinking Skills

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C r itic a l th in k e rs d o n ’t o v e rs im p lify . C r itic a l th in k e rs e x a m in e a v a ila b le evid en ce b e fo re d ra w in g c o n clu s io n s. C r itic a l th in k e rs th in k fo r th em selves a n d d o n o t s im p ly go a lo n g w it h th e c ro w d . C r itic a l th in k e rs re m a in o p e n to th e n e e d fo r a d ju s tm e n t a n d a d a p ta tio n th ro u g h o u t th e in q u ir y stages. C r itic a l th in k e rs accep t c h an g e. C ritic a l th in k e rs e m p a th iz e ; th e y a p p re c ia te a n d tr y to u n d e rs ta n d o th e rs ’ th o u g h ts , fe e lin g s , a n d b e h a v io rs . C ritic a l th in k e rs w e lc o m e d iffe re n t vie w s a n d v a lu e e x a m in in g issues fr o m e ve ry a n g le. C r itic a l th in k e rs k n o w th a t it is im p o r t a n t to e x p lo re a n d u n d e rs ta n d p o s itio n s w it h w h ic h th e y disagree. C r it ic a l th in k e rs d is c o v e r a n d a p p ly m e a n in g to w h a t th e y see, h e a r, a n d re a d .

A p p ro a c h e s to D evelo p in g C ritic a l T h in k in g S kills A s s tu d e n ts d e v e lo p in th e ir n u r s in g r o le , th e y le a r n a n d b u ild c r it ic a l t h in k in g s k ills a n d a p p ly th e m to re a l h e a lth c a re s itu a tio n s . C r itic a l t h in k ­ in g re q u ire s c o n s c io u s , d e lib e r a te e ffo r t. C r it ic a l t h in k in g does n o t ju s t c o m e n a tu r a lly , a n d p e o p le te n d to b e lie v e w h a t is easy to b e lie v e o r w h a t th o s e a r o u n d th e m b e lie v e ( W ilk in s o n , 2 0 0 7 ) . W i t h e ffo r t a n d p ra c tic e , e v e ry o n e c a n a c h ie v e s o m e le v e l o f c r itic a l th in k in g to b e c o m e a n e ffe c tiv e p r o b le m s o lv e r a n d d e c is io n m a k e r . A s th e e le m e n ts o f c r itic a l th o u g h t d e ­ v e lo p in to a h a b it, nurses im p ro v e th e ir a b ility to assess c o m p le x s itu a tio n s a n d en g ag e in th e p ra c tic e o f n u rs in g . T h e o b je c tiv e s fo r c r itic a l th in k in g in n u rs in g in c lu d e th e a b ility to ask p e r tin e n t q u e s tio n s , a n a ly z e m u ltip le fo rm s o f e v id e n c e , a n d e v a lu a te o p tio n s b e fo re c o m in g to a c o n c lu s io n . F o llo w in g a re e x a m p le s th a t c a n be used as a p p ro a c h e s to d e v e lo p in g c r it i­ c a l th in k in g s k ills .

KEY COMPETENCY 9-2 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Professionalism: Knowledge (K1b) Justifies clinical decisions Attitudes/Behaviors (A1b) Shows commitment to provi­ sion of high quality, safe, and effective patient care Skills (S1b) Exercises critical thinking within standards of practice Source: Massachusetts Department of Higher Education (2010), p. 13.

■ The Nursing Process T h e A m e ric a n N u rs e s A s s o c ia tio n s ta n d a rd s h a v e set fo r th th e fr a m e w o r k n e ce ss ary fo r c r itic a l th in k in g in th e a p p lic a t io n o f th e n u rs in g p ro ce ss . T h e n u rs in g p ro c e s s is th e to o l b y w h ic h a ll n u rse s c a n b e c o m e e q u a lly p ro fic ie n t a t c ritic a l th in k in g . T h e n u rs in g process c o n ta in s th e fo llo w in g c r ite r ia : (1 ) a ssessm en t, (2 ) id e n tify in g th e p r o b le m (n u rs in g d ia g n o s is ), (3 ) p la n n in g , (4 ) im p le m e n ta tio n , a n d (5 ) e v a lu a tio n . T h r o u g h th e a p p lic a ­ tio n o f each o f these c o m p o n e n ts th e nurse c an b e co m e p ro fic ie n t a t c ritic a l

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th in k in g . N u rs e s use c ritic a l th in k in g in each stage o f th e n u rs in g process. T h is a p p ro a c h to c ritic a l th in k in g e n ta ils p u r p o s e fu l, in fo r m e d , o u tc o m e -fo c u s e d th in k in g , w h ic h re q u ire s id e n tific a tio n o f n u rs in g a n d h e a lth c a re needs o f clien ts (K n a p p , 2 0 0 7 ) . T h e n u rs in g process is a s y s te m a tic p ro b le m -s o lv in g a p p ro a c h to w a r d g iv in g n u rs in g c are th a t a llo w s th e nurse to b e a c c o u n ta b le b y usin g c ritic a l th in k in g b e fo re ta k in g a ctio n s . N u rs e s p ro v id e e ffe c tiv e c are b a se d o n s o u n d re a ­ s o n in g , w h ic h is th e re a s o n a b le re fle c tio n a b o u t n u rs in g p ro b le m s b e fo re s e le c tin g o n e o f a v a r ie ty o f s o lu tio n s . T h is is a c c o m p lis h e d b y re g u la r ly e m p lo y in g th e elem ents o f c ritic a l th o u g h t, such as d e fin in g th e p ro b le m , id e n tify in g th e g o a l, a n d a n a ly z in g th e evid en ce (C a p u ti, 2 0 1 0 ) . E a c h o f th e th in k in g skills lis te d in th is c a te g o ry is c o m m o n ly used w h e n a n u rse g ath ers d a ta (C a p u ti, 2 0 1 0 ) . T h e se skills in c lu d e th e fo llo w in g :

KEY COMPETENCY 9-3 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Patient-Centered Care: Knowledge (K1) Identifies components of nursing process appropriate to individual, family, group, community, and population health care needs across the life span Attitudes/Behaviors (A1a) Values use of scientific inquiry, as demonstrated in the nursing process, as an essential tool for provision of nursing care Skills (S1a) Provides prioritybased nursing care to indi­ viduals, families, and groups through independent and collaborative application of the nursing process Source: Massachusetts Department of Higher Education (2010), p. 9.

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Assessing s y s te m a tic a lly a n d c o m p re h e n s iv e ly C h e c k in g a c c u ra c y a n d re lia b ility C lu s te rin g re la te d in fo r m a tio n C o lla b o r a tin g w it h c o w o rk e rs D e te rm in in g th e im p o rta n c e o f in fo r m a tio n D is tin g u is h in g re le v a n t fr o m irre le v a n t in fo r m a tio n G a th e rin g c o m p le te a n d a c c u ra te d a ta a n d th e n a c tin g o n th a t d a ta J u d g in g h o w m u c h a m b ig u ity is a cc ep tab le R e c o g n iz in g inco nsistencies U s in g d ia g n o s tic re a s o n in g

E a c h one o f th e fo llo w in g th in k in g skills is c o m m o n ly used w h e n nurses p ro v id e c are to p a tie n ts (C a p u ti, 2 0 1 0 ) : • • • • • • •

A p p ly in g th e n u rs in g process to d e v e lo p a tr e a tm e n t p la n C o m m u n ic a tin g e ffe c tiv e ly P re d ic tin g a n d m a n a g in g p o te n tia l c o m p lic a tio n s R e s o lv in g c o n flicts R e s o lv in g e th ic a l d ile m m a s S e ttin g p rio ritie s T e a c h in g oth ers

■ Assessm ent T h e n u rs in g assessm ent a n s w e rs th e q u e s tio n s : “ W h a t is h a p p e n in g ? ” o r “ W h a t c o u ld h a p p e n ? ” I t in v o lv e s s y s te m a tic a lly c o lle c tin g , o rg a n iz in g , a n d a n a ly z in g in fo r m a t io n a b o u t th e c lie n t. O n c e d a ta o r in fo r m a t io n has b een c o lle c te d a n d it is d e te rm in e d th a t th e d a ta a re a c c u ra te a n d c o m p le te ,

th e n u rs e p e rfo rm s d a ta a n a ly s is o r d a ta in te r p r e ta tio n . W h a t a re th e c li­ e n t’s a c tu a l a n d /o r p o t e n t ia l p ro b le m s ? A p r o b le m lis t is th e n d e v e lo p e d b a se d o n th e d a ta , a n d th e n u rs e p rio r itiz e s th e c lie n t’s p ro b le m s . T h e n u rse p e r fo r m s a n o n g o in g ass es sm e n t t h r o u g h o u t th e im p le m e n ta tio n o f th e n u rs in g pro cess.

■ Diagnosis T h e n u rse a n a ly ze s a n d d erives m e a n in g fr o m th e assessm ent in fo r m a t io n a n d selects a d ia g n o s is . D ia g n o s is is th e id e n tific a tio n o f a p ro b le m . I t is a s ta te m e n t th a t describes a specific response to an a c tu a l o r p o te n tia l h e a lth p ro b le m . F o r e x a m p le , a n u rs in g d iag n o sis fo r a selected p a tie n t m ig h t be “ decreased c a rd ia c o u tp u t re la te d to in a b ility o f th e h e a rt to p u m p e ffe c tiv e ly , a n d o c c lu s io n a n d c o n s tric tio n o f vessels im p a irin g b lo o d f lo w .”

■ Planning D u r in g p la n n in g , th e nurse d evelops a p la n to p ro v id e co n sis te n t, c o n tin u o u s c a re t h a t m ee ts th e c lie n t ’s u n iq u e n e ed s . P la n n in g in c lu d e s d e v e lo p in g e x p e c te d o u tc o m e s a n d w o r k in g w it h th e c lie n t to id e n tify g o a ls a n d to d e te rm in e a p p ro p r ia te n u rs in g a ctio n s a n d in te rv e n tio n s th a t w ill re d u c e th e id e n tifie d p r o b le m . T h e n u rs e uses c r itic a l th in k in g to d e v e lo p g o a ls a n d n u rs in g in te rv e n tio n s fo r p ro b le m s th a t re q u ire a n in d iv id u a liz e d a p p ro a c h . N u rs e s use ju d g m e n t to d e te rm in e w h ic h in te rv e n tio n s h a v e a p r o b a b ility o f a ch ie vin g desired o u tco m e s. T o c o n tin u e w it h th e p re vio u s e x a m p le , exp ected o u tc o m e s m ig h t in c lu d e th e fo llo w in g : 1. P a tie n t w ill be free o f chest p a in d u rin g m y s h ift. 2 . P a tie n t w ill m a in ta in O 2 sat o f 9 0 % d u rin g m y s h ift. 3 . V it a l signs w ill re m a in stab le: T < 9 9 .0 ° F , H R > 6 0 < 1 1 0 b e a ts /m in , R > 1 2 < 2 4 b re a th s /m in , a n d SBP > 9 0 m m H g w h ile u n d e r m y c are. 4 . P a tie n t w ill h a ve n o fu rth e r w e ig h t g a in a n d w ill h a v e a decrease in ed em a d u rin g m y s h ift.

■ Im plem entation Im p le m e n ta tio n is c a rry in g o u t th e p la n o f c are a n d depends o n th e firs t th re e steps o f th e n u rs in g process. T h e se steps p ro v id e th e basis fo r n u rs in g actio n s p e rfo rm e d d u rin g th e im p le m e n ta tio n phase o f th e n u rs in g process. T h e nurse carries o u t n u rs in g in te rv e n tio n s in d iv id u a liz e d to th e p a tie n t, reassesses th e c lie n t, a n d v a lid a te s th a t th e p la n o f care is a c c u ra te a n d successful. In th is stage, to each p a tie n t c are s itu a tio n th e n u rse ap p lie s k n o w le d g e a n d p r in ­ ciples fr o m n u rs in g a n d fr o m re la te d courses. T h e a b ility to a p p ly , n o t ju st m e m o riz e , p rin c ip le s is a c o m p o n e n t o f c ritic a l th in k in g (W ilk in s o n , 2 0 0 7 ) .

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F o r th e p a tie n t w it h de cre as e d c a rd ia c o u tp u t, th e n u rse c o u ld im p le m e n t som e o f th e fo llo w in g in d iv id u a liz e d in te rv e n tio n s : • • • • • • • • • • • • • • • •

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Assess L O C — c o n fu s io n , a n x ie ty . P ro v id e reassurance to th e p a tie n t. M o n i t o r v ita l signs e ve ry 4 h o u rs . Assess h e a rt ra te a n d rh y th m ; m o n ito r te le m e try o r e le c tro c a rd io g ra p h y . M o n i t o r fo r ju g u la r v e in d isten sio n . M o n i t o r fo r chest p a in . M o n i t o r p e rip h e ra l pulses; assess c a p illa ry re fill. A u s c u lta te lu n g sounds; m o n ito r re s p ira to ry ra te a n d rh y th m ; m o n ito r o x y g e n s a tu ra tio n ; assess fo r c o u g h a n d s p u tu m . L o o k a t s k in c o lo r a n d te m p e ra tu re . M o n i t o r fo r fa tig u e a n d a c tiv ity to le ra n c e . Assess in ta k e a n d o u tp u t, d a ily w e ig h t, a n d e d e m a in d e p e n d e n t areas. Assess a b d o m e n fo r d is te n s io n o r b lo a tin g , ascites, a n d b o w e l fu n c tio n . M o n i t o r la b a n d X -r a y s : C B C , P T /P T T , e le c tro ly te s , c a rd ia c e n zy m es , a rte ria l b lo o d gases, a n d chest X - r a y . E le v a te h e a d o f b e d to im p ro v e gas exc h an g e. A d m in is te r o x y g e n as o rd e re d to im p ro v e gas e x c h an g e. A d m in is te r m o rp h in e s u lfa te as p re s c rib e d to re lie v e chest p a in , p ro v id e s e d a tio n a n d v a s o d ila tio n , a n d m o n ito r fo r r e s p ira to r y d e p re ss io n a n d h y p o te n s io n a fte r a d m in is tra tio n . A d m in is te r d iu re tic s as p re s c rib e d to reduce p re lo a d , enhan ce re n a l e x c re ­ tio n o f s o d iu m a n d w a te r, re d u c e c irc u la tin g b lo o d v o lu m e , a n d re d u c e p u lm o n a r y c o n g e s tio n ; c lo s e ly m o n it o r p o ta s s iu m le v e l, w h ic h m ig h t decrease as a re s u lt o f d iu re tic th e ra p y . P ro v id e teaching: Id e n tify p re c ip ita tin g ris k factors o f h e a rt fa ilu re a n d p re ­ scribed m e d ic a tio n re g im en ; n o tify p h y s ic ia n i f u n a b le to ta k e m e d ic a tio n s because o f illness; a v o id larg e a m o u n ts o f caffein e ; c a rd ia c d ie t in s tru c tio n ; signs o f e x a c e rb a tio n ; m o n ito r flu id s ; b a la n c e p e rio d s o f a c tiv ity a n d rest; a v o id is o m e tric a c tiv itie s th a t increase pressure in th e h e a rt.

■ Evaluation D u r in g e v a lu a tio n , th e n u rs e c o m p a re s th e p a tie n t’s c u rre n t s tatu s to th e p a tie n t goals. W e re th e goals achieved? T h e nurse analyzes o u tco m es to d e te r­ m in e i f th e in te rv e n tio n s w o r k e d , a n d i f n o t, w h y ? T h e in fo r m a tio n p ro v id e d d u rin g e v a lu a tio n c an be used to b e g in a n o th e r p la n o f c are s u ffic ie n t to m ee t p a tie n t needs. C o n tin u in g w it h th e p re v io u s e x a m p le , th e e v a lu a tio n m ig h t in c lu d e th e fo llo w in g : • •

P a tie n t denies chest p a in o n m y s h ift. P a tie n t rates p a in 0 o n p a in scale. P a tie n t’s O 2 s a tu ra tio n d ro p p e d to 8 5 % w h e n o x y g e n a t 3 L n asal c a n n u la w a s re m o v e d . W it h o x y g e n o n , p a tie n t’s O 2 s a tu ra tio n re m a in e d 9 2 % .

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V it a l signs w e re : T , 1 0 1 .0 ° F ; H R , 1 0 0 - 1 1 0 b e a ts /m in ; R , 3 2 b re a th s /m in a n d la b o re d ; B P , 9 0 /5 0 m m H g . P a tie n t’s w e ig h t w a s 2 4 1 lbs w it h 2 + e d em a in lo w e r e x tre m itie s .

■ Concept Mapping C o n ce p t m ap ping is a v is u a l re p re s e n ta tio n o f th e re la tio n s h ip s a m o n g c o n ­ cepts a n d id ea s . T h e concepts a re re p re s e n te d b y boxes a n d lin k e d w it h lines. In n u rs in g , c o n c e p t m ap s a re used to o rg a n iz e a n d lin k in fo r m a tio n a b o u t a p a tie n t’s h e a lth p ro b le m s . T h is a llo w s th e n u rse to see re la tio n s h ip s a m o n g th e p a tie n t’s p ro b le m s a n d h elp s p la n in te rv e n tio n s th a t c an address m o re th a n one p ro b le m . T o b e g in a c o n c e p t m a p , s ta rt in th e c e n te r o f th e page w it h th e m a in id e a o r c e n tra l th e m e , a n d w o r k o u tw a r d in a ll d ire c tio n s , p ro d u c in g a g ro w in g o rg a n iz e d s tru c tu re co m p o se d o f k e y w o rd s o r p ic tu re s . P lace w o rd s o r pictures a ro u n d th e m a in id e a to illu s tra te h o w th e y re la te to each o th e r a n d th e c e n tra l th e m e . P ictu res, w o rd s , o r a c o m b in a ­ tio n o f b o th c an be used to c rea te a m a p . C o n c e p t m ap s are useful fo r s u m m a riz in g in fo rm a tio n , c o n s o lid a tin g in fo r m a tio n fr o m d iffe re n t sources, th in k in g th ro u g h c o m p le x p ro b le m s , a n d presen tin g in fo r m a tio n in a fo rm a t th a t shows th e o v e ra ll stru ctu re o f y o u r subject. Figure 9 - 1 illu s trates m in d m a p p in g tech n iq u es used by students w it h a p a tie n t case.

■ Journaling K e e p in g a jo u rn a l o f c lin ic a l e xp erien ces th a t w e re m e a n in g fu l o r tr o u b lin g to y o u is a re c o m m e n d e d w a y to h e lp e n h an ce a n d d e v e lo p re a s o n in g skills. T h in k a b o u t a n d re c o rd e xp erien ces th a t b o th e r y o u , a n d c o n s id e r w h a t y o u c o u ld a n d w o u ld d o d iffe re n tly in th e fu tu re . T h is is a fo r m o f re fle c tio n a n d a llo w s y o u to v ie w y o u r o w n th in k in g , re a s o n in g , a n d a ctio n s . I t helps crea te a n d c la rify m e a n in g a n d n e w u n d e rs ta n d in g s o f a p a rtic u la r exp e rien c e. W h e n y o u e n c o u n te r a s im ila r s itu a tio n , y o u s h o u ld be a b le to re c a ll w h a t y o u d id o r w o u ld d o d iffe re n tly as w e ll as th e re a s o n in g b e h in d y o u r actio n s (R a in g ru b e r & H a ffe r , 2 0 0 1 . Som e suggestions y o u s h o u ld tr y to address w h e n jo u rn a lin g y o u r n u rs in g e x p e rie n c e in c lu d e th e fo llo w in g : • • • • • •

W h a t h a p p e n ed ? W h a t a re th e facts? W h a t w a s m y ro le in th e event? W h a t feelings a n d senses s u rro u n d e d th e event? W h a t d id I do? H o w a n d w h a t d id I feel a b o u t w h a t I did? W h y ? W h a t w a s th e setting?

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Figure 9-1

Mind mapping techniques

1. D e c re a s e d c a rd ia c o u tp u t re la te d to in a b ility o f th e h e a rt to p u m p e ffe c tiv e ly , o c c lu s io n a n d c o n s tr ic tio n o f v e s s e ls Dx; Exacerbation of CHF Sacral edema HX; HTN, CAD, MI, CABG Yellow secretions Family HX: CVA, MI, diabetes HX; Smoking x 20 years C/O SOB, productive/congested cough, Wt. 240 lbs. Swelling in legs, chest pain HR 100, BP 88/60 Obese pt, K+ 2.9 3+ edema RBC 4.0 Lungs w rales H & H 11.0 & 35 O2 sat 86% Glucose 210 JVD PT 31.0, PPT 80

ALB 3.0 PC02 32 EKG NSR old infarct CXR - Bil. inflt, enlarged heart BR w BRP HOB 40° 1800 cal ADA, low, NA, low chol, & low fat Fluid restriction 1200cc Daily wt. VS Q4h

I& O Digoxin Foley Lasix Tele Potassium D - stick’s Prinivil Egg crate Humulin R & NPH Ted hose Heparin O2 3 L/NC Albuterol O2 Sat Morphine EKG for CP Colace Daily lab; H & H, PT/PTT

3. A lte r e d N u tritio n r e la te d to in a b ility o f p a n c re a s t o s e c r e te in s u lin C h ie f m e d ic a l d ia g n o s is : Exacerbation of CHF & pneumonia S e c o n d a r y d ia g n o s is Type I diabetes HTN CAD Hypothyroidism PVD

Dx; Exacerbation of CHF Hx: Diabetes type I, CAD, PVD, MI Family Hx: Diabetes, MI, CABG, CVA C/O SOB, CP Obese - 240 Ibs. Labored resp, chest pain T - 99° WBC 14,000 K+ 2.9 H & H 11.0 & 35

RBC 4.0 Glucose 210 ALB 2.9 Prot. 5.6 BR 1800 cal ADA, low, NA low chol, & low fat FR 1200 cc Daily wt. VS Q4 Daily H & H BC for T > 101

I& O Foley D - Stick’s Egg crate Ted hose Morphine Colace Potassium Humulin R & N Lasix

2 . Im p a ir e d g a s e x c h a n g e re la te d to m u c o u s b u ild -u p in a lv e o li im p a ir in g o x y g e n m o v e m e n t DX exacerbation of CHF & pneumonia Hx: CAD, PVD, CABG C/O SOB, productive cough, chest pain Obese 3+ Edema Lungs w rales O2 Sat 86% JVD Yellow secretions Hx: Smoking x 20 yrs. Wt. 240 Ibs. HR - 100, R - 34

• • •

HGB 11.0 Daily H & H PC02 32 BC for T > 101 CXR - Bil Infl & enlarged heart O2 3L/NC BR w BRP O2 Sat HOB 40° EKG prn CP Fluid Rest 1200 cc Lasix Daily Wt. Heparin I& O Albuterol via HHN Foley Morphine Telemetry Egg crate Ted hose

W h a t w e re th e im p o r ta n t elem ents o f th e event? W h a t p re c e d e d th e e ve n t, a n d w h a t fo llo w e d it? W h a t s h o u ld I be a w a re o f i f th e e ve n t recurs?

I t is im p o r t a n t th a t y o u w r ite in y o u r jo u r n a l as so o n as p o s sib le a fte r a n e ve n t to c a p tu re th e essence o f w h a t h a p p e n e d in th e c lin ic a l e x p e rie n c e . T h e fo llo w in g is a n e x a m p le o f a jo u r n a l e x c e rp t th a t illu s tra te s re fle c tio n o n

events a n d th e feelings e lic ite d b y those events o v e r th e course o f m a n y p a tie n t c are en co u n te rs d u rin g th e c a re e r o f a nurse.

KEY COMPETENCY 9-4

I h a v e le a rn e d , n o t so easily, th a t m y jo b is n o t ju s t a b o u t savin g a life , tr y in g to k e e p p e o p le w e ll, o r h e lp in g th e m get w e ll w h e n th e y are ill, b u t im p o r ta n tly , it also e n ta ils p ro v id in g th a t sam e d e d ic a te d c are to th e m as th e y ta k e th e ir las t b re a th s in life . I t is m y jo b , m y d u ty , a n d I h a ve le a rn e d , m y p riv ile g e . A s I care fo r a d y in g p a tie n t, lis te n in g to the rise a n d fa ll o f m e th o d ic a l m ac h in e s im ita tin g life , I h o p e I n e ve r get c allo u se d to th e p o in t th a t I say, “ I d o th is e ve ry d a y . I t is ju s t a n o th e r p a tie n t.” I w a n t to a p p re c ia te th a t e very in d iv id u a l’s life has been re m a rk a b le in som e w a y — th a t th e y a re r e m a rk a b le in som e w a y . I w a n t to m a k e m y p a tie n t’s jo u rn e y th ro u g h th is las t c h a p te r in th e ir life a little easier, p ro v id e c o m fo rt, re c o g n ize th e ir fears, h o ld th e ir h a n d , a n d a lw a y s re a liz e th is is n o t a n o th e r p a tie n t, b u t a p erso n .

Nurse of the Future: Nursing Core Competencies

■ Group Discussions and Reflection A n o th e r w a y to enhance c ritic a l th in k in g skills is b y using g ro u p discussions to e x p lo re a ltern ativ es a n d a rriv e a t c o nclusions. G r o u p discussions a m o n g n u rs ­ in g students a n d teachers c an ta k e p lace in th e c la ss ro o m o r fo llo w in g c lin ic a l experiences. D u r in g discussions, students are e n co u rag e d to fo rm u la te a lte r­ n a tive s to c lin ic a l o r e th ic a l decisions. T e a c h e r a n d le a rn e r g ro u p discussions o v e r c lin ic a l a n d e th ic a l scenarios s h o u ld e n co u rag e q uestions, analysis, a n d re fle c tio n . G r o u p discussions c an assist n u rs in g students in c o n n e c tin g c lin ic a l events o r decisions w it h in fo r m a tio n o b ta in e d in th e cla ss ro o m . T h is fo rm o f c o o p e rativ e le a rn in g occurs w h e n gro ups w o r k to g e th e r to m a x im iz e th e ir o w n a n d each o th e r’s le a rn in g . F o r e x a m p le , fo llo w in g a c lin ic a l experience, students a n d te ac h e r use re fle c tio n a n d discussion o n a c e rta in c lin ic a l e xp e rien c e th a t a s tu d e n t e n c o u n te re d . T o g e th e r th e y discuss d iffe re n t scenarios o f “ W h a t if? ,” “ W h a t else?,” a n d “ W h a t th e n ? ” to e n co u rag e th e fo rm u la tio n o f a ltern ativ es o r c lin ic a l decisions. O th e r exa m p le s o f th is process in c lu d e th e fo llo w in g : Y o u a re g o in g in to a p a t ie n t ’s r o o m — w h a t a re y o u g o in g to do? W h e n y o u go in th e re , w h a t are y o u g o in g to do? W a l k y o u rs e lf th ro u g h it step b y step. W h a t a re y o u g o in g to d o first? W h a t s h o u ld y o u get d o n e first? W h ic h one takes im p o rta n c e a n d th e n w h e re d o y o u go fr o m there? T h is is th e p a tie n t, a n d th is h a p p e n s . W h a t d o y o u do next? T h e se are y o u r assessm ent fin d in g s . W h a t else d o y o u n eed to k n o w ?

Examples of Applicable

Professionalism: Knowledge (K4c) Understands the importance of reflection to advancing practice and improving outcomes of care Attitudes/Behaviors (A4c) Values and is committed to being a reflective practitioner Skills (S4b) Demonstrates ability for reflection in actions, reflection for action, and reflection on action Source: Massachusetts Department of Higher Education (2010), p. 13.

www^1 CRITICAL THINKING QU ESTIO N S*

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. V

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W h y Is C ritic a l T h in k in g Im p o rta n t in N u rsin g P ra c tic e ? N u r s in g c o m p e te n c e p la y s a la rg e ro le in e n s u rin g p a tie n t s a fe ty . In 2 0 0 8 , th e R o b e r t W o o d J o h n s o n F o u n d a tio n a n d th e In s titu te o f M e d ic in e ( I O M ) la u n c h e d a 2 -y e a r in itia t iv e to re s p o n d to th e n e e d to assess a n d tr a n s fo r m th e n u rs in g p ro fe s s io n . T h e I O M re p o rt p o in ts o u t nurses a re g o in g to h a v e a c ritic a l ro le in th e fu tu r e , e s p e c ia lly in p ro d u c in g safe, q u a lit y c a re a n d c o v ­ e rag e fo r a ll p a tie n ts in o u r h e a lth c a re system (In s titu te o f M e d ic in e [ I O M ] , 2 0 1 1 ) . T h e A g e n c y fo r H e a lth c a r e R e s e a rc h a n d Q u a lit y ( 2 0 0 8 ) ( A H R Q ) a n d th e R o b e r t W o o d J o h n s o n F o u n d a tio n d e v e lo p e d a h a n d b o o k fo r nurses o n p a tie n t s a fe ty a n d q u a lit y . T h is is a w e a lt h o f in fo r m a t io n fo r n u rs in g th a t p ro v id e s b a c k g ro u n d re s e a rc h a n d to o ls fo r im p r o v in g th e q u a lit y o f c a re . In 2 0 0 8 , th e A m e ric a n A s s o c ia tio n o f C o lle g e s o f N u r s in g ( A A C N ) re ­ vised its T h e E ssen tia ls o f B a c c a la u re a t e E d u c a t io n f o r P ro fe s s io n a l N u r s in g P ra c tic e based o n e a rly discu ssio n o f I O M re p o rts a n d th e ne ce ss ity o f b u ild in g a s afe r h e a lth c a re system (A m e r ic a n A s s o c ia tio n o f C o lle g e s o f N u r s in g [ A A C N ] , 2 0 0 8 ) . A m a ­ jo r it y o f s en tin el even ts, u n e x p e c te d o ccu rren ces in v o lv in g d e a th o r serious p h y s ic a l o r p s y c h o lo g ic a l in ju r y , o c c u r in a c u te c a re s ettin g s, w h e re n e w g ra d u a te nurses t r a d it io n ­ a lly b e g in th e ir p ro fe s s io n a l n u rs in g care ers. T h e in a b ility o f a n u rse to set p rio ritie s a n d w o r k s a fe ly , e ffe c tiv e ly , a n d e ffic ie n tly c a n d e la y p a tie n t tr e a tm e n t in a c ritic a l s itu a ­ tio n a n d re s u lt in s erio u s life -th r e a te n in g co n se q u e n ce s . C r itic a l th in k in g is ess en tia l to p r o v id in g safe, c o m p e te n t, q u a lit y n u rs in g c are . N e w re a litie s o f h e a lth c a re re q u ire nurses to m a s te r c o m p le x in f o r m a t io n , to c o o rd in a te a v a r ie ty o f c a re e x p e rie n c e s , to use a d v a n c e d te c h n o lo g y fo r h e a lth c a re d e liv e ry a n d e v a lu a tio n o f p a tie n t o u t­ com es, as w e ll as assist p a tie n ts w it h m a n a g in g a n d n a v ig a tin g a n in c re a s in g ly c o m p le x system o f care. Som e o f th e trends th a t h ave a d d e d to th e c o m p lex ities o f th e h e a lth c a re e n v iro n m e n t, a n d n u rs in g sp ecifically, in c lu d e increases in lo n g e v ity ; m a r k e d ly s h o rte n e d h o s p ita l stays, w h ic h a re m o v in g p a tie n ts o u t o f th e h o s p ita l “ q u ic k e r a n d s ic k e r” ; scien tific advances; m a jo r advances in te c h n o lo g y ; a n increase in p o p u la tio n ; in crea se d d iv e rs ity in th e U .S . p o p u la ­ tio n ; a n d a n in crea se d in c id e n c e o f c h ro n ic diseases a n d in fe c tio u s diseases (A A C N , 2 0 0 8 ). T o p re p a re n u rs in g s tu d e n ts fo r th e m u ltifa c e te d ro le o f p ro fe s s io n a l n u rs e , th e le a rn in g pro cess in v o lv e s c o m p o n e n ts th a t w i l l p ro v id e a s o lid fo u n d a tio n fo r d e v e lo p in g c lin ic a l ju d g m e n t s kills. O n e o f these c o m p o n e n ts o r c o re co m p eten c ies is c ritic a l th in k in g . C o u rs e w o r k o r c lin ic a l e x p e rie n c e

s h o u ld p ro v id e th e n u rs in g s tu d e n t a n d g ra d u a te w it h k n o w le d g e a n d skills to d o th e fo llo w in g : • • • • • •

U s e a p p r o p r ia te n u rs in g th e o rie s a n d m o d e ls a n d a p p r o p r ia te e th ic a l fr a m e w o rk s in p ra c tic e . U se re se arch -b as ed k n o w le d g e fr o m n u rs in g a n d th e sciences as th e basis fo r p ra c tic e . U se s o u n d c lin ic a l ju d g m e n t a n d d e c is io n -m a k in g skills. E ngage in processes such as s elf-re fle c tio n a n d shared e d u c a tio n a l d ia lo g u e a b o u t p ro fe s s io n a l p ra c tic e . E v a lu a te n u rs in g c are o u tco m e s th ro u g h a c q u irin g d a ta a n d th e q u e s tio n ­ in g o f in co n sis te n cie s, a llo w in g fo r th e re v is io n o f a ctio n s a n d goals. E n g a g e in c re a tiv e th in k in g a n d p ro b le m so lv in g .

Y o u a re w o r k in g in a n a cu te care c lin ic a l s itu a tio n . A fte r re c e iv in g re p o rt, y o u h a v e s ta rte d y o u r m o rn in g ro u tin e s . E v e ry th in g is g o in g as p la n n e d , a n d y o u a re a b o u t to s ta rt p re p a rin g y o u r m e d ic a tio n s . T h e w ife o f one o f y o u r p a tie n ts re p o rts th a t th e o x y g e n is b u rn in g his nose a n d w a n ts y o u to get an o x y g e n h u m id ifie r. A ll o f a su d d e n , th e d a u g h te r o f y o u r o th e r p a tie n t, M r . P eary, rushes to w a r d y o u a n d in fo rm s y o u th a t h e r fa th e r is s p ittin g u p b lo o d . H e lo o k e d fin e w h e n y o u o b s erve d h im a fe w m in u te s ag o . Y o u w a lk ra p id ly to w a r d th e p a tie n t’s ro o m , th in k in g , “ W h a t a m I g o in g to do w h e n I get there? I h a v e to get th e o x y g e n h u m id ifie r fo r ro o m 2 0 2 . H is nose w a s b u rn in g , a n d his w ife w a s w a itin g fo r m e . W h a t c o u ld be h a p p e n in g w it h M r . P e a ry ? ” Y o u e n te r th e r o o m , a n d th e firs t th in g y o u th in k is: “ H e ’ s ly in g f l a t , ” a n d y o u t h in k to y o u rs e lf, “ I n e e d to e le v a te his h e a d . T h a t is w h a t I d id o n th e re s p ira to r y u n it w h e re I re c e n tly w o r k e d .” T h e d a u g h te r te lls y o u th a t M r . P e a ry c o u g h e d u p som e b lo o d in th e em esis b a s in . T h e re is a s m a ll a m o u n t o f b r ig h t re d b lo o d in it . Y o u d o n o t k n o w w h a t to d o n e x t. A n R N stops b y th e r o o m a n d te lls y o u th a t th e w ife o f th e p a tie n t in r o o m 2 0 2 is a s k in g a b o u t th e b u r n in g in h e r h u s b a n d ’s nose a g a in . Y o u r m in d d o e s n ’t seem to be a b le to th in k a b o u t a n y th in g . D o y o u fe el s c a tte re d a n d th in g s seem o u t o f c o n tr o l a t th is p o in t? D o y o u fe el a little o v e r­ w h e lm e d a n d c a n ’t th in k w h a t to d o n e x t? T h e R N says wwwj CRITICAL THINKING QUESTIONS V she w ill ta k e o v e r w it h M r . P e a ry w h ile y o u fo llo w u p w ith Beginning nursing students often tend to th e p a tie n t in r o o m 2 0 2 . L a te r , y o u re c a ll th e s itu a tio n a n d focus primarily on their routines, such as to c a n ’t b e lie v e y o u d id n ’t th in k to ta k e M r . P e a ry ’s b lo o d get their list of tasks done, such as assess­ p re ss u re , c o u n t re s p ira tio n s , ask a b o u t p a in , o r lis te n to ments, ordered treatments, daily care, and his lu n g s o r a n y th in g else. A ll y o u d id w a s ju s t ra is e his charting. What if an unexpected situation h e a d . Y o u w o n d e r w h y y o u m issed so m a n y th in g s . •

W h a t d o y o u th in k w a s g o in g o n in th e s itu a tio n th a t in flu e n c e d w h a t w a s h a p p e n in g a n d caused y o u to lose y o u r a b ility to th in k a n d p la n w h a t to d o next?

occurred during the day? Do you think you would be able to reason, plan, and take appropriate action—think critically? V

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W h a t w o u l d y o u d o d i f f e r e n t ly in th is s it u a t io n a f t e r h a v in g a ch an c e to re fle c t o n it? P rio ritiz e th e o rd e r in w h ic h y o u w o u ld h a ve d o n e th in g s . I f th is h a d h a p p e n e d to y o u a n d n o one h e lp e d y o u th ro u g h it, w h a t w o u ld y o u h a v e d o n e to m o b iliz e y o u rs e lf to th in k a b o u t w h a t to do?

C o nclu sio n In n u rs in g , c ritic a l th in k in g is th e a b ility to th in k in a sys te m a tic a n d lo g ic a l m a n n e r, solve p ro b le m s , m a k e decisions, a n d establish p rio ritie s in th e c lin ic a l s ettin g . N u rs e s n eed to d e v e lo p c ritic a l th in k in g skills to m a k e s o u n d c lin i­ c a l ju d g m e n ts a n d to p ro v id e safe, c o m p e te n t p a tie n t c a re . N u r s in g re q u ire s c o n s ta n t d ecision m a k in g . W h a t s h o u ld I do first? W h a t is th e m o s t im p o rta n t th in g to d o a t th is tim e ? P r io ritiz in g n u rs in g actio n s in v o lv e s re c a llin g im p o r ­ ta n t n u rs in g in fo r m a tio n as w e ll as usin g c o m p le x p ro b le m -s o lv in g skills to m a k e decisions in p ro v id in g safe a n d e ffe c tiv e p a tie n t c a re . A s a n u rse , y o u w ill c o n s ta n tly h a v e to d e m o n s tra te g o o d ju d g m e n t in a n a ly z in g facts a n d s itu a tio n s a n d a p p ly in g n u rs in g k n o w le d g e .

Classroom A ctivity 1 r itic a l th in k in g gives y o u th e p o w e r to m a k e sense o f s o m e th in g b y d e lib e r ­ a te ly c h o o s in g h o w to re s p o n d to events t h a t y o u e n c o u n te r. Y o u ta k e in in fo r m a t io n , e x a m in e a n d ask questions a b o u t it, lo o k a t n e w p ersp ectives, a n d id e n tify a p la n . Y o u use p r o b ­ le m -s o lv in g a n d d e c is io n -m a k in g strategies.

C

• •

C h o o s e a d e c is io n t h a t y o u n e e d to m a k e s o o n , a n d w r ite it d o w n . W h a t g o a l o r d esired o u tco m e s d o y o u seek fr o m th is decision? P rio ritiz e goals o r desired o u tc o m e s , a n d w r ite th e m d o w n .

•

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Id e n tify w h o a n d w h a t w i l l be a ffe c te d b y y o u r d e c is io n , a n d in d ic a te h o w y o u r d e c i­ sio n w ill a ffe c t th e m . Id e n t if y a n y a v a ila b le o p tio n s y o u m ig h t h a ve . T a k in g in to a c c o u n t a n d e v a lu a tin g y o u r in fo r m a tio n , id e n tify a p la n o r decid e w h a t y o u are g o in g to d o . A fte r y o u h a v e m a d e y o u r d e cis io n , e v a lu a te th e re s u lt, i'.'ffl'l

Conclusion

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Classroom A ctivity 2

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o u a re re c e iv in g m o rn in g re p o rts o n th e fo llo w in g p a tie n ts fr o m th e n ig h t-s h ift n u rs e . A f t e r r e c e iv in g th e f o llo w in g re p o rt, w h ic h p a tie n t w o u ld y o u choose to see first? A s y o u m a k e y o u r d e cis io n , th in k a b o u t y o u r th o u g h t processes a n d h o w y o u m a d e y o u r d e cis io n . 1. A w o m a n w h o is s ch e d u led to h a v e a b io p s y o n a b re a s t lu m p th is m o rn in g , a n d w h o is scared a n d c ry in g 2 . A n 8 5 - y e a r - o l d m a n w h o w a s a d m it te d d u r in g th e n i g h t b e c a u s e o f in c r e a s e d c o n fu s io n w h o re m a in s d is o r ie n t e d th is m o rn in g

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3 . A w o m a n w h o h a d lu n g s u rg ery th e p re vio u s d a y , a n d w h o has tw o chest tu b es in p lac e w it h m in im a l d ra in a g e 4 . A m a n w h o is s c h e d u le d to h a v e a c o lo n re s e c tio n in 2 h o u rs a n d is c o m p la in in g o f c h ills A n s w e r : Y o u s h o u ld h a v e a n s w e re d th e c lie n t w h o is s c h e d u le d f o r s u rg e ry a n d is e x h ib itin g s y m p to m s o f in fe c tio n . T h is p a tie n t needs to be assessed im m e d ia te ly fo r in fe c tio n , a n d th e d o c to r n o tifie d . I f a n in fe c tio n is p re s ­ e n t, th e s u rg e ry n e ed s to be p o s tp o n e d . T h e o th e r p a tie n ts a re s ta b le , a n d th e ir needs d o n o t h a v e to be a d d re ss ed im m e d ia te ly .

TUDY ■ JIM FULLER

im Fuller is a 40-year-old male patient. He is cur­ rently 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 per minute.

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Case Study Questions • Are Mr. Fuller’s vital signs within normal limits? List normal adult ranges. • What factors might affect body temperature? • List sites where a nurse might take a patient’s pulse. What sites are most commonly used? • 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. Case Study Questions • What could Mr. Fuller’s vital signs indicate? • What nursing interventions are indicated? What should the nurse assess in Mr. Fuller at this time? • What clinical signs associated with an elevated tem­ perature might the nurse assess? • If Mr. Fuller’s fever persists and increases, what might the nurse suspect is happening, and what might be done? ■

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R e fe re n c e s Agency for Healthcare Research and Quality. (2008). Patient safety and quality: An evidence-based handbook for nurses (Vols. 1,2, 3). Rockville, MD: U.S. Department of Health and Human Services. Retrieved from www.ahrq.gov/qual/nurseshdbk Alfaro-Lefevre, R. (2009). Critical thinking and clinical judgment: A practical approach to outcome-focused thinking (4th ed.). St. Louis, MO: Saunders Elsevier. American Association of Colleges of Nursing. (2008). The essentials o f baccalaureate education for professional nursing practice. Washington, DC: Author. Benner, P. (1984). From novice to expert. Menlo Park, CA: Addison-Wesley. Benner, P. E., Malloch, K., & Sheets, V. (2010). Nursing pathways for patient safety, NCSBN. St. Louis, MO: Mosby Elsevier. Benner, P. E., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass. Caputi, L. (2010). Developing critical thinking in the nursing student. In L. Caputi (Ed.), Teaching nursing: The art and science (2nd ed.). Glen Ellyn, IL: College of DuPage Press. Craven, R. F., & Hirnle, C. J. (2007). Fundamentals o f nursing: Human health and function (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Fero, L., Witsberger, C., Wesmiller, S., Zullo, T., & Hoffman, L. (2009). Critical thinking ability of new graduate and experienced nurses. Journal o f Advanced Nursing, 65(1), 139-148. Institute of Medicine. (2011). The future o f nursing: Leading change, advancing health. Washington, DC: National Academies Press. Knapp, R. (2007). Nursing education—the importance of critical thinking. Retrieved from http://www.articlecity.com/articles/education/article_1327.shtml Massachusetts Department of Higher Education. (2010). Nurse o f the future: Nursing core competencies. Retrieved from http://www.mass.edu/currentinit/documents/ NursingCoreCompetencies.pdf Raingruber, B., & Haffer, A. (2001). Using your head to land on your feet: A beginning nurse’s guide to critical thinking. Philadelphia, PA: F. A. Davis. Scheffer, B. K., & Rubenfeld, M. G. (2000). A consensus statement on critical thinking in nursing. Journal o f Nursing Education, 39(8), 352-359. Scriven, M., & Paul, R. (2011). Defining critical thinking. Retrieved from http://www. criticalthinking.org/pages/defining-critical-thinking/410 Wangensteen, S., Johansson, I. S., Bjorkstrom, M. E., & Nordstrom, G. (2010). Critical thinking dispositions among newly graduated nurses. Journal o f Advanced Nursing, 66(10), 2170-2181. Wilkinson, J. (2007). Nursing process and critical thinking (4th ed.). Upper Saddle River, NJ: Pearson.

Evidence-Based Professional Nursing Practice Kathleen Masters

v______________________ E v id e n c e -B a s e d P ra c tic e : W h a t Is It?

Key Terms and Concepts

» R esearch E vid e n c e-b as ed p ra ctice — it is m o re th a n th e m o s t recent b u z z w o rd in n u rsin g . u tiliz a tio n E v id e n c e -b a s e d p ra c tic e a llo w s nurses to p ro v id e h ig h -q u a lity p a tie n t care » Quality improvement b a se d o n re s e a rc h e v id e n c e a n d k n o w le d g e r a th e r th a n t r a d it io n , m y th s , » Evidence-based h u n c h e s , a d v ic e f r o m p e e rs , o u td a te d te x tb o o k s , o r e ve n w h a t th e n u rse practice le a rn e d in sch o o l 5 , 1 0 , o r 15 years a go. E v id e n c e -b a s e d p ra c tic e p ro v id e s a » PICO » Clinical practice s tra te g y to ensure th a t n u rs in g c are reflects th e m o s t u p -to -d a te k n o w le d g e guidelines a v a ila b le . N u rs in g p ra c tic e th a t is based o n evidence is n o w th e a ccepted s tan ­ d a rd fo r p ra c tic e as w e ll as one o f th e s ix c o re co m p eten cies fo r a ll re g is te re d nurses id e n tifie d in th e Q u a lity a n d S afety E d u c a tio n fo r N u rs e s p ro je c t (C r o n e n w e tt et a l., 2 0 0 7 ) . Nursing practice that is N u rs e s are a c c o u n ta b le fo r in te rv e n tio n s th e y p ro v id e to based on evidence is now p a tie n ts . E v id e n c e -b a s e d p ra c tic e p ro v id e s a s ystem atic a p ­ the accepted standard for p ro a c h fo r d e cis io n m a k in g a n d p ro v id e s a fr a m e w o r k fo r practice. th e n u rse to use to in c o rp o ra te best n u rs in g p ra ctice s in to th e c lin ic a l c are o f p a tie n ts (P u g h , 2 0 1 2 ) .

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Learning Objectives A f t e r c o m p le tin g th is c h a p te r, th e s tu d e n t should be a b le to : 1. D e s c rib e th e im p o rta n c e o f e v id e n c e -b a s e d nursing c are . 2 . Id e n tify b a rrie r s to th e im p le m e n ta tio n of e vid e n ce -b a se d nursing p ra c tic e . 3 . Id e n tify s tra te g ie s fo r th e im p le m e n ta tio n of e vid e n ce -b a se d nursing p ra c tic e .

4 . D escribe how and w h ere to search fo r evidence. 5 . Id e n tify m eth o d s to e v a lu a te th e e vid e n ce . 6 . D iscu ss a p p ro a c h e s to in te g ra tin g e v id e n c e in to p ra c tic e . 7 . Id e n tify m o d e ls o f e v id e n c e -b a s e d n u rs in g p ra c tic e .

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M o s t nurses w a n t to p ro v id e c a re fo r th e ir p a tie n ts based o n th e m o s t c u rre n t k n o w le d g e , b u t fo r m a n y nurses try in g to in te g ra te e vid e n ce -b a se d p ra c tic e in to p a tie n t care in th e c lin ic a l e n v iro n m e n t it raises m a n y q uestions: • • •

KEY COMPETENCY 10-1 Examples of Applicable Nurse of the Future: Nursing Core Competencies

A lth o u g h th e y m a y be w id e ly used a n d re la te d processes, e vid e n ce -b a se d p ra c tic e is n o t re se arch u tiliz a tio n o r q u a lity im p ro v e m e n t. •

Evidence-Based Practice: Knowledge (K2) Describes the concept of evidencebased practice (EBP), including the components of research evidence, clinical expertise, and patient/ family values Attitudes/Behaviors (A2) Values the concept of EBP as integral to determining best clinical practice Skills (S2) Bases individual care on best current evi­ dence, patient values, and clinical expertise Source: Massachusetts Department of Higher Education (2010), p. 37.

W h a t e x a c tly is evid e n ce -b a se d p ra c tic e , a n d h o w is it re le v a n t to m y p ra c tic e ? Is e v id e n c e -b a s e d p r a c tic e d if f e r e n t f r o m re s e a rc h u tiliz a tio n ? Is e v id e n c e -b a s e d p r a c t ic e d if f e r e n t f r o m q u a lit y im p ro v e m e n t?

•

R e s e a rc h u tiliz a tio n in v o lv e s c ritic a l analysis a n d e v a lu a tio n o f research fin d in g s a n d th e n d e te rm in in g h o w these fin d in g s fit in to c lin ic a l p ra c tic e . In research u tiliz a tio n , th e research finding s are th e o n ly source o f evidence. In e vid e n ce -b a se d p ra c tic e , rese arch is o n ly o n e o f th e sources o f evidence (L e v in , 2 0 0 6 a ). Q u a lity im p ro v e m e n t focuses o n system s, pro cesses, s a tis fa c tio n , a n d c o s t o u tc o m e s , u s u a lly w it h in a s p ecific o r g a n iz a tio n . T h e s e p ro je c ts c a n c o n tr ib u te to u n d e r s ta n d in g b e st p ra c tic e s fo r th e pro cesses o f c a re in w h ic h nurses a re in v o lv e d , b u t ty p ic a lly q u a lit y im p r o v e m e n t e ffo rts a re n o t designed to d e v e lo p n u rs in g p ra c tic e s ta n d a rd s o r n u rs in g science.

E vid e n c e-b as ed p ra c tic e is a fr a m e w o rk fo r c lin ic a l p ra c tic e th a t in c o rp o ­ rates “ th e conscientious, e x p lic it, a n d ju d icio u s use o f th e c u rre n t best evidence in m a k in g decisions a b o u t th e c are o f in d iv id u a l p a tie n ts ” (B eyea & S la tte ry , 2 0 0 6 ) . P u t a n o th e r w a y , e vid e n ce -b a se d p ra c tic e is “ th e in te g ra tio n o f best re se arch evid en ce w it h c lin ic a l e x p e rtis e a n d p a tie n t v a lu e s ” (S a c k e tt, S traus, R ic h a rd s o n , R o s e n b e rg , & H a y n e s , 2 0 0 0 ) . In o th e r w o rd s , e vid e n ce -b a se d p ra c tic e assum es th a t evid en ce is used in th e c o n te x t o f p a tie n t p re feren ces, th e c lin ic a l s itu a tio n , a n d th e e x p e rtis e o f th e c lin ic ia n . E v id e n c e -b a s e d p ra c tic e is re le v a n t to n u rs in g p ra c tic e because it does th e fo llo w in g : • • • • •

H e lp s re so lv e p ro b le m s in th e c lin ic a l settin g R esu lts in b e tte r p a tie n t o u tco m e s C o n trib u te s to th e science o f n u rs in g th ro u g h th e in tr o d u c tio n o f in n o v a ­ tio n to p ra c tic e K eeps p ra c tic e c u rre n t a n d re le v a n t b y h e lp in g nurses d e liv e r care based o n c u rre n t best research D ecreases v a ria tio n s in n u rs in g c are a n d increases c o n fid e n ce in d e cis io n m a k in g

Strategies to Promote Evidence-Based Practice

S u p p o rts J o in t C o m m is s io n re a d in e s s b e ca u se p o l i ­ cies a n d p ro c e d u re s a re c u rre n t a n d in c lu d e th e la te s t research E ss e n tial fo r h ig h -q u a lity p a tie n t care a n d a c h ie v e m e n t o f m a g n e t status (Beyea & S latte ry, 2 0 0 6 ; S pector, 2 0 0 7 )

wwwj CRITICAL THINKING QUESTIONS V

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? V

B a rrie rs to E v id e n c e -B a s e d P ra c tic e B ecause e vid e n ce -b a se d p ra c tic e is n o w th e s ta n d a rd fo r p ro fe s s io n a l n u rs in g p ra c tic e , o n e w o u ld th in k th a t p ra c tic e based o n evid e n ce is c o m m o n p la c e . H o w e v e r , th is is n o t th e case. P ra c tic in g nurses cite m a n y b a rrie rs to evidencebased p ra c tic e . C o m m o n b a rrie rs to im p le m e n tin g e vid e n ce -b a se d p ra c tic e in c lu d e th e fo llo w in g : • • • • • • • • • • • • • • • • •

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L a c k o f v a lu e fo r re se arch in p ra c tic e D iffic u lty in c h a n g in g p ra c tic e L a c k o f a d m in is tra tiv e s u p p o rt L a c k o f k n o w le d g e a b le m e n to rs In s u ffic ie n t tim e L a c k o f e d u c a tio n a b o u t th e rese arch process L a c k o f aw areness a b o u t rese arch o r e vid e n ce -b a se d p ra c tic e R e s e a rc h re p o rts a n d a rticle s n o t re a d ily a v a ila b le D iffic u lty accessing rese arch re p o rts a n d articles N o tim e o n th e jo b to re a d research C o m p le x ity o f research re p o rts L a c k o f k n o w le d g e a b o u t e vid e n ce -b a se d p ra c tic e L a c k o f k n o w le d g e a b o u t th e c ritiq u e o f a rticles F e e lin g o v e rw h e lm e d b y th e process L a c k o f sense o f c o n tro l o v e r p ra c tic e L a c k o f c o n fid e n ce to im p le m e n t chang e L a c k o f le a d e rs h ip , m o tiv a tio n , v is io n , s tra te g y, o r d ire c tio n a m o n g m a n ­ agers (B eyea & S la tte ry , 2 0 0 6 ; S p e c to r, 2 0 0 7 )

S tra te g ie s to P ro m o te E v id e n c e -B a s e d P ra c tic e D e s p ite b a rrie rs , nurses a re m a k in g a d iffe re n c e in p a tie n t o u tco m e s th ro u g h th e use o f evid e n ce -b a se d p ra c tic e . S trategies th a t c an be u s efu l in th e p r o m o ­ tio n o f evid en ce in p ra c tic e g e n e ra lly fa ll in to tw o c a te g o rie s : strategies fo r in d iv id u a l nurses a n d o rg a n iz a tio n a l s trateg ies.

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CHAPTER 10 Evidence-Based Professional Nursing Practice

S trategies fo r in d iv id u a l nurses in c lu d e th e fo llo w in g : • •

•

•

E d u c a te y o u rs e lf a b o u t evid e n ce -b a se d p ra c tic e th ro u g h avenues such as o n lin e sites, b o o k s , a rtic le s , a n d c o n feren ces. C o n d u c t fa c e -to -fa c e o r o n lin e jo u rn a l clubs th a t c an be used to e d u cate y o u rs e lf a b o u t c ritiq u in g a rtic le s , share n e w re se arch re p o rts a n d g u id e ­ lines w it h peers, a n d p ro v id e s u p p o rt to o th e r nurses. S h a re y o u r results th ro u g h po s te rs , n e w s le tte rs , u n it m ee tin g s , o r a p u b ­ lished a rtic le to s u p p o rt a c u ltu re o f evidence-based n u rs in g p ra c tic e w ith in th e o rg a n iz a tio n a n d th e p ro fe s s io n . A d o p t a re fle c tiv e a n d in q u ir in g a p p ro a c h to p ra c tic e b y c o n tin u o u s ly a s k in g y o u rs e lf a n d o th e rs w it h in y o u r o rg a n iz a tio n q u e stio n s such as, “ W h a t is th e e vid e n ce fo r th is in te rv e n tio n ? ” o r “ H o w d o m y p a tie n ts re s p o n d to th is in te rv e n tio n ? ” (B eyea & S la tte ry , 2 0 0 6 ) S trategies fo r o rg a n iz a tio n s in c lu d e th e fo llo w in g :

cr it ic a l t h in k in g

D e v e lo p in g a c e n te r fo r e vid e n ce -b a se d p ra c tic e A d m in is tr a tiv e s u p p o rt fo r e vid e n ce -b a se d p ra c tic e b y p ro v id in g th e tim e a n d th e fu n d s fo r necessary resources Access to e le c tro n ic resources in th e w o rk p la c e E n h a n c e m e n t o f jo b d e s c rip tio n s to in c lu d e c rite ria re la te d to evid en cebased p ra c tic e O ffe r in g in ce n tiv es such as a p a id re g is tra tio n to a c o n fe re n c e fo r th e best c lin ic a l q u e s tio n in a u n it-w id e o r fa c ility -w id e c o n te st • P ro v id in g o p p o rtu n itie s fo r nurses to c o lla b o ra te w it h n u rs e re s e a rc h e rs o r fa c u lt y w i t h n u r s in g re s e a rc h q u e s t io n s v e xp e rtis e

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? V

W h ic h e v e r s tra te g ie s a re in c o r p o r a te d , i t is im p o r ­ ta n t to n o te th a t passive d is s e m in a tio n o f results w it h in a n o rg a n iz a tio n is in e ffe c tiv e in c h a n g in g p ra c tic e . M u l ­ tifa c e te d in te rv e n tio n s are m u c h m o re lik e ly to be e ffe c ­ tiv e in f a c ilit a t in g e v id e n c e -b a s e d p r a c tic e w i t h i n a n o rg a n iz a tio n .

S e a rc h in g fo r E vid en ce ■ Asking the Question N u rs e s m u s t le a rn to ask questions in a fo r m a t th a t fa c ilita te s sea rch in g fo r e vid e n c e . I t has been suggested th a t a ll nurses s h o u ld le a rn h o w to use th e P IC O fo r m a t to ask c lin ic a l q u e stio n s. P IC O is s im p ly a n a c ro n y m th a t assists in th e fo rm a ttin g o f c lin ic a l questions. U s in g th is fo rm a t helps th e nurse to ask

Searching for Evidence

p e rtin e n t c lin ic a l q u estio n s, focus o n a s k in g th e r ig h t q u estio n s, a n d choose re le v a n t g u id e lin e s . P = P a tie n t, P o p u la tio n , o r P ro b le m • H o w w o u ld I d escribe a g ro u p o f p a tie n ts s im ila r to m ine? • W h a t g ro u p d o I w a n t in fo r m a tio n on? I = In te rv e n tio n o r E x p o s u re o r T o p ic o f In te re s t • W h ic h m a in in te rv e n tio n a m I con sid erin g ? • W h a t e v e n t d o I w a n t to s tu d y th e e ffe c t of? C = C o m p a ris o n o r A lte r n a te In te rv e n tio n ( i f a p p ro p ria te ) • W h a t is th e m a in a lte rn a tiv e to c o m p a re w it h th e in te rv e n tio n ? • C o m p a r e d to w h a t? B e tte r o r w o rs e th a n n o in te rv e n tio n a t a ll, o r th a n a n o th e r in te rv e n tio n ? O = O u tc o m e • W h a t c a n I h o p e to a c c o m p lis h , m e a s u re , im p ro v e , o r affect? • W h a t is th e e ffe c t o f th e in te rv e n tio n ? (L e v in & F e ld m a n , 2 0 0 6 ) S o m e researchers also a d d th e e le m e n t o f tim e o r tim e fra m e to th e P IC O q u e s tio n fo r m a t a n d re fe r to th e fo r m a t as P I C O T , a lth o u g h th e tim e fra m e m ig h t n o t be a p p lic a b le to a ll q u estio n s. T = T im e o r T im e F ra m e • H o w m u c h tim e is re q u ire d to d e m o n s tra te a n o u tco m e ? • H o w lo n g are p a rtic ip a n ts observed? A fte r d e te rm in in g th e p a tie n t, in te rv e n tio n , c o m p a ris o n , a n d o u tc o m e o f in te re s t, th e n u rse th e n c o m b in e s these fo u r elem en ts in to a single q u e s tio n in c o m b in a tio n s such as th e fo llo w in g e x a m p le s : • •

In (p a tie n t o r p o p u la tio n ), w h a t is th e e ffe c t o f (in te rv e n tio n o r e x p o s u re ) o n (o u tc o m e ) c o m p a re d w it h (c o m p a ris o n )? (L e v in , 2 0 0 6 b ) F o r (p a tie n t o r p o p u la tio n ) , does th e in tr o d u c tio n o f (in te r v e n tio n o r e x p o s u re ) re d u c e th e ris k o f (o u tc o m e ) c o m p a re d w it h (c o m p a ris o n in ­ te rv e n tio n )? (L e v in , 2 0 0 6 b )

■ Electronic Indexes E le c tro n ic in d e xe s p ro v id e o p tio n s fo r n a r r o w in g o r b ro a d e n in g a to p ic to id e n tify re le v a n t lite r a tu re . M o s t e le c tro n ic in d e x e s p ro v id e c ita tio n in f o r ­ m a tio n a n d w ill in d ic a te i f th e selected articles are a v a ila b le lo c a lly in p r in t fo r m o r i f th e item s are a v a ila b le in an e le c tro n ic fo rm a t. T h r e e o f th e m o s t c o m m o n e le c tro n ic in d e xe s used in h e a lth c are are th e C u m u la tiv e In d e x to N u r s in g a n d A llie d H e a lt h L ite ra tu re ( C I N A H L ) , a v a ila b le a t w w w .c in a h l. c o m ; M E D L I N E , a v a ila b le a t w w w .n lm .n ih .g o v ; o r P u b M e d , a w e b -b a s e d fo r m a t o f M e d lin e a v a ila b le a t w w w .p u b m e d .g o v .

239

■ Electronic Resources M a n y o th e r h e lp fu l In te rn e t resources a re a v a ila b le th a t c a n assist th e nurse in u n c o v e rin g th e m o s t c u rre n t evid en ce fo r p ra c tic e . S om e o f th e m o s t c o m ­ m o n ly used in c lu d e these: • • • • •

KEY COMPETENCY 10-2 Examples of Applicable Nurse of the Future: Nursing Core Competencies

• • •

N a t io n a l L ib r a r y o f M e d ic in e : w w w .n lm .n ih .g o v C o c h ra n e L ib ra ry : w w w .c o c h ra n e .o rg N a t io n a l G u id e lin e C le a rin g h o u s e : w w w .n g c .g o v J o a n n a B riggs In s titu te : w w w .jo a n n a b rig g s .e d u .a u A g e n c y fo r H e a lth c a re R e s e a rc h a n d Q u a lity : w w w .e ffe c tiv e h e a lth c a r e . a h rq .g o v C e n tre fo r H e a lt h E v id e n c e : w w w .c c h e .n e t R e g is te re d N u rs e s ’ A s s o c ia tio n o f O n ta r io : rn a o .c a /b p g M c G i l l U n iv e rs ity H e a lt h C e n tre ’s R e s e a rc h a n d C lin ic a l R esources fo r E v id e n c e B ased N u rs in g : w w w .m u h c -e b n .m c g ill.c a

Evidence-Based Practice: Knowledge (K3) Describes reliable sources for locating evidence reports and clinical practice guidelines Attitudes/Behaviors (A3) Appreciates the importance of accessing relevant clinical evidence Skills (S3) Locates evi­ dence reports related to clinical practice topics and guidelines Source: Massachusetts Department of Higher Education (2010), p. 37.

T h e C o c h r a n e L ib r a r y is a c o lle c tio n o f d a ta b a s e s th a t c o n ta in h ig h q u a lity , in d e p e n d e n t evidence to in fo r m h e a lth c a re decision m a k in g . C o c h ra n e re v ie w s re p re s e n t th e h ig h e s t lev el o f evid en ce o n w h ic h to base c lin ic a l tr e a t­ m e n t decisions. In a d d itio n to the C o c h ra n e s ystem atic re v ie w s , the C o c h ra n e L ib r a r y also o ffe rs o th e r sources o f in f o r m a t io n , in c lu d in g th e C o c h ra n e D a ta b a s e o f S ystem atic R e v ie w s , D a ta b a s e o f A b s tra c ts o f R e v ie w s o f E ffects, C o c h ra n e C o n tr o lle d T ria ls R e g is te r, C o c h ra n e M e th o d o lo g y R e g is te r, N H S E c o n o m ic E v a lu a tio n D a ta b a s e , H e a lt h T e c h n o lo g y A ssessm ent D a ta b a s e , a n d th e C o c h ra n e D a ta b a s e o f M e th o d o lo g y R e v ie w s ( C D M R ) . T h e N a t io n a l G u id e lin e C le a rin g h o u s e in c lu d e s s tru c tu re d s u m m a rie s c o n ta in in g in fo r m a tio n a b o u t each g u id e lin e , in c lu d in g c o m p a ris o n s o f g u id e ­ lin es c o v e rin g s im ila r to p ic s th a t s h o w areas o f s im ila r ity a n d d iffe re n c e s ; fu ll te x t o r lin k s to fu ll te x t; o rd e rin g d e ta ils fo r fu ll g u id e lin e s ; a n n o ta te d b ib lio g ra p h ie s o n g u id e lin e d e v e lo p m e n t, e v a lu a tio n , im p le m e n ta tio n , a n d s tru c tu re ; w e e k ly e m a il u p d a te s; a n d g u id e lin e arch iv es .

E v a lu a tin g th e E vid en ce R eg a rd les s o f th e source, w e a lw a y s n e ed to e v a lu a te th e e vid e n ce . B eg in b y a s k in g such questions as fo llo w : • • • • •

W h a t is th e source o f th e in fo rm a tio n ? W h e n w a s it d eveloped ? H o w w a s it developed ? D o e s it fit th e c u rre n t c lin ic a l e n v iro n m e n t? D o e s it fit th e c u rre n t s itu atio n ?

Evaluating the Evidence

241

r

B est evid e n ce fo r p ra c tic e in clu d es e m p iric a l evidence fr o m ra n d o m iz e d c o n tro lle d tria ls , evid en ce fr o m d e s c rip ­ Regardless of the source, we tiv e a n d q u a lita tiv e re s e a rc h , a n d in fo r m a t io n fr o m case always need to evaluate the re p o rts , s c ie n tific p rin c ip le s , a n d e x p e rt o p in io n . W h e n evidence. in s u f f ic ie n t re s e a rc h is a v a ila b le , h e a lth c a r e d e c is io n m a k in g is d e riv e d p r in c ip a lly fr o m n o n re s e a rc h evid en ce sources such as e x p e rt o p in io n a n d s c ie n tific p rin c ip le s (T it le r , 2 0 0 8 ) . S ev e ral c la s s ific a tio n systems e xist to e v a lu a te th e lev el o r s tre n g th o f th e evid en ce. T h e A g e n c y fo r H e a lth c a re R e s e a rc h a n d Q u a lit y ( A H R Q ) serves as th e re c o g n ize d a u th o r ity re g a rd in g th e assessm ent o f c lin ic a l rese arch in th e U n ite d States. T h e A H R Q levels o f evid e n ce in c lu d e cla ss ifica tio n s 1 - 5 lis te d h e re (M e ln y k & F in e o u t-O v e r h o lt, 2 0 0 5 ) . O th e r sources ( D i C esenso, G u y a tt, & C ilis k a , 2 0 0 5 ) also in c lu d e a d d itio n a l c la ss ifica tio n s o r levels o f evid e n ce ( 6 - 7 ) . • • • • • • • •

1 A M e ta -a n a ly s is o r s y s te m a tic re v ie w s o f m u ltip le w e ll-d e s ig n e d c o n ­ tr o lle d studies 1 W e ll-d e s ig n e d ra n d o m iz e d c o n tro lle d tria ls 2 W e ll-d e s ig n e d n o n r a n d o m iz e d c o n tro lle d tria ls (q u a s i-e x p e rim e n ta l) 3 O b s e rv a tio n a l studies w it h c o n tro ls (re tro s p e c tiv e , in te r r u p te d tim e , c a s e -c o n tro l, c o h o rt studies w it h c o n tro ls ) 4 O b s e rv a tio n a l studies w ith o u t c o n tro ls (c o h o rt studies w ith o u t c o n tro ls a n d case series) 5 S ys te m atic re v ie w o f d e s c rip tiv e , q u a lita tiv e , o r p h y s io lo g ic studies 6 S ingle d e s c rip tiv e , q u a lita tiv e , o r p h y s io lo g ic s tu d y 7 O p in io n s o f a u th o ritie s , e x p e rt c o m m itte e s

U s in g th is c la s s ific a tio n s y s te m , th e s tro n g e s t e v id e n c e c o m es fr o m th e fir s t le v e l, r e p r e s e n tin g s y s te m a tic re v ie w s t h a t in te g r a te fin d in g s fr o m m u lt ip le w e ll-d e s ig n e d c o n tr o lle d s tu d ie s . T h e w e a k e s t e v id e n c e is re p re s e n te d b y th e s even th le v e l a n d is based o n o p in io n (P o lit & B ec k, 2 0 0 8 ). In a d d itio n , g ra d in g th e s tre n g th o f a b o d y o f evid e n ce s h o u ld in c o rp o ­ ra te th re e d o m a in s th a t in c lu d e q u a lity , q u a n tity , a n d c o n sisten cy. Q u a lity has to d o w it h th e e x te n t to w h ic h a s tu d y m in im iz e s b ias in th e d esig n , im p le m e n ta tio n , a n d a n aly sis. Q u a n t ity refers to th e n u m b e r o f studies th a t h a v e e v a lu a te d th e re se arch q u e s tio n , as w e ll as th e s a m p le size across th e studies a n d th e s tre n g th o f th e fin d in g s . T h e c a te g o ry o f co n sis te n cy refers to b o th th e s im ila r ity a n d d iffe re n c e s o f s tu d y designs th a t in v e s tig a te th e s am e re s e a rc h q u e s tio n a n d r e p o r t s im ila r fin d in g s (A g e n c y fo r H e a lt h ­ c a re R e s e a rc h a n d Q u a lit y [ A H R Q ] , 2 0 0 2 ; L o B io n d o - W o o d , H a b e r , & K r a in o v ic h - M ille r , 2 0 0 6 ) .

J

KEY COMPETENCY 10-3 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Evidence-Based Practice: Knowledge (K4) Differenti­ ates clinical opinion from research and evidence summaries Attitudes/Behaviors (A4) Appreciates that the strength and relevance of evidence should be determi­ nants when choosing clinical interventions Source: Massachusetts Department of Higher Education (2010), p. 37.

U sing th e E vid en ce ■ Clinical Practice Guidelines C lin ic al p ra c tic e g u id elin es a re d e v e lo p e d to g u id e c lin ic a l p ra c tic e a n d re p re ­ sent a n e ffo r t to p u t a la rg e b o d y o f evidence in to a m a n a g e a b le fo rm . C lin ic a l p ra c tic e g u id e lin e s are u s u a lly based o n sys te m a tic re v ie w s a n d give specific re c o m m e n d a tio n s fo r c lin ic ia n s . G u id e lin e s u s u a lly a tte m p t to address a ll the issues re le v a n t to a c lin ic a l d e cis io n , in c lu d in g risks a n d ben efits. T h e re is a n o n g o in g c o lla b o ra tio n th a t focuses o n im p ro v in g th e q u a lity a n d effectiveness o f c lin ic a l p ra c tic e g u id e lin e s . T h e g ro u p has esta b lish e d a fr a m e w o r k fo r d e te rm in in g th e q u a lit y o f g u id e lin e s fo r d iag n o ses, h e a lth p ro m o tio n , tre a tm e n ts , o r c lin ic a l in te rv e n tio n s . T h e in s tru m e n t can be used w it h n e w , e x is tin g , o r u p d a te d g u id e lin e s a n d is k n o w n as th e A p p ra is a l o f G u id elin es fo r R esearch a n d E v a lu a tio n (A G R E E ) in s tru m e n t. T h e in s tru m e n t, firs t p u b lis h e d in 2 0 0 3 b y th e A G R E E C o lla b o r a tio n , has been re vis ed a n d is n o w k n o w n as A G R E E I I (A G R E E N e x t Steps C o n s o rtiu m , 2 0 0 9 ) . T h e A G R E E I I replaces th e o rig in a l in s tru m e n t a n d is th e p re fe rre d to o l. T h e fu ll v e rs io n o f th e A G R E E I I in s tru m e n t a n d tr a in in g m a te ria ls a re a v a ila b le a t: w w w .a g re e tru s t.o rg . T h e A G R E E in s tru m e n t is c o m p o se d o f s ix categories c o m p ris in g th e 2 3 ite m s lis te d here: •

Scope a n d p u rp o s e • • •

•

S ta k e h o ld e r in v o lv e m e n t • • •

•

O v e r a ll o b jectives o f th e g u id e lin e are s p e c ific a lly d e scrib ed . T h e h e a lth questions c o ve red b y th e g u id e lin e are specifically described. T h e p o p u la tio n (p a tie n ts , p u b lic , e tc.) to w h o m th e g u id e lin e is m e a n t to a p p ly is s p ec ifica lly d e scrib ed .

G u id e lin e d e v e lo p m e n t g ro u p in c lu d e s in d iv id u a ls fr o m a ll re le v a n t p ro fessio n s. T h e v ie w s a n d p referen ces o f th e ta rg e t p o p u la tio n (p a tie n ts , p u b lic , e tc.) h a v e been so u g h t. T a rg e t users o f th e g u id e lin e a re c le a rly d e fin e d .

R ig o r o f d e v e lo p m e n t • • • • •

S ys te m atic m e th o d s w e re used to search fo r evid en ce. T h e c rite ria fo r selecting th e e vid e n ce a re c le a rly d e scrib ed . T h e s tre n g th s a n d lim it a t io n s o f th e b o d y o f e v id e n c e a re c le a r ly d escrib ed . T h e m e th o d s used fo r fo r m u la tin g th e re c o m m e n d a tio n s a re c le a rly d escrib ed . T h e h e a lth b e n e fits , side e ffe cts, a n d risk s h a v e b e e n c o n s id e re d in fo rm u la tin g re c o m m e n d a tio n s .

Models of Evidence-Based Nursing Practice

• • • •

C la r ity a n d p re s e n ta tio n • • •

•

R e c o m m e n d a tio n s are specific a n d u n a m b ig u o u s . D if fe r e n t o p tio n s fo r m a n a g e m e n t o f th e c o n d itio n o r h e a lth issue are c le a rly p re se n ted . K e y re c o m m e n d a tio n s are e asily id e n tifia b le .

A p p lic a tio n • • • •

•

T h e r e is a n e x p lic it l in k b e tw e e n th e r e c o m m e n d a tio n s a n d th e s u p p o rtin g evid en ce. T h e g u id e lin e ha s b e e n e x t e r n a lly r e v ie w e d b y e x p e rts p r io r to p u b lic a tio n . A p ro c e d u re fo r u p d a tin g th e g u id e lin e is p ro v id e d .

T h e g u id e lin e describes fa c ilita to rs a n d b a rrie rs to its a p p lic a tio n . T h e g u id e lin e p ro v id e s a d vic e a n d /o r to o ls o n h o w th e re c o m m e n d a ­ tio n s c an be p u t in to p ra c tic e . T h e p o te n tia l re so u rce im p lic a tio n s o f a p p ly in g th e re c o m m e n d a tio n s h a ve been c o n sid e re d . G u id e lin e presents m o n ito rin g a n d /o r a u d itin g c rite ria .

E d ito r ia l in d e p e n d e n c e • •

T h e v ie w s o f th e fu n d in g b o d y h a v e n o t in flu e n c e d th e c o n te n t o f th e g u id e lin e . C o m p e tin g interests o f g u id e lin e d e v e lo p m e n t g ro u p m e m b e rs h a ve b e en re c o rd e d a n d addressed (A G R E E N e x t Steps C o n s o rtiu m , 2 0 0 9 , pp. 2 -3 ).

T h e usefulness o f a g u id e lin e depends o n w h e th e r th e a c tu a l re c o m m e n d a ­ tions in th e g u id e lin e a n d m e a n in g fu l a n d p ra c tic a l. R e c o m m e n d a tio n s sh o u ld be p ra c tic a l in re la tio n to im p le m e n ta tio n , be as u n a m b ig u o u s as p ossible, address fre q u e n c y o f screening a n d fo llo w -u p , a n d address c lin ic a lly re le v a n t a c tio n s . O th e r questions th a t th e c lin ic ia n m u s t address in re la tio n to g u id e ­ lines m u s t in c lu d e such fa cto rs as th e s e ttin g o f c are , th e p a tie n t p o p u la tio n , a n d th e s tre n g th o f th e re c o m m e n d a tio n s (B eyea & S la tte ry , 2 0 0 6 ) .

M odels of E v id e n c e -B a s e d N u rsin g P ra c tic e D iffe re n c e s e xist a m o n g e vid e n ce -b a se d p ra c tic e m o d e ls , b u t m o s t m o d els do h a ve c o m m o n elem ents th a t in c lu d e s elec tio n o f a p ra c tic e to p ic , c ritiq u e a n d synthesis o f e vid e n ce , im p le m e n ta tio n , e v a lu a tio n o f th e im p a c t o n p a tie n t care a n d p ro v id e r p e rfo rm a n c e , a n d c o n s id e ra tio n o f th e c o n te x t in w h ic h th e p ra c tic e is im p le m e n te d (T it le r , 2 0 0 8 ) . N o o n e m o d e l o f e vid e n ce -b a se d

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p ra c tic e is a p e rfe c t fit fo r e v e ry o r g a n iz a tio n . S o m e m o d e ls fo cu s o n th e p ersp ective o f th e in d iv id u a l c lin ic ia n , o r th e re se arch e r, w h ile oth ers focus o n in s titu tio n a l e ffo rts . T h e re fo re , b e fo re e m b a rk in g o n th is jo u rn e y , th e nurse o r o rg a n iz a tio n s h o u ld c o n s id e r several m o d e ls a n d select o r a d a p t o n e th a t fits th e n u rs e ’s o r o r g a n iz a tio n ’s needs.

■ ACE S tar Model of Knowledge Transform ation T h e A c a d e m ic C e n te r fo r E v id e n c e -B a s e d N u r s in g ( A C E ) S ta r M o d e l o f K n o w le d g e T r a n s fo r m a tio n , d e v e lo p e d b y D r . K a th le e n S tevens, is a v a il­ a b le a t w w w .a c e s ta r .u th s c s a .e d u /a c e s ta r -m o d e l.a s p . T h e m o d e l in v o lv e s fiv e steps th a t in c lu d e k n o w le d g e d is c o v e ry , e vid e n ce s u m m a ry , tr a n s la tio n in to p ra c tic e re c o m m e n d a tio n s , in te g r a tio n in to p ra c tic e , a n d e v a lu a tio n . D is c o v e ry re fe rs to th e o rig in a l re s e a rc h . D u r in g th e second step , th e ta s k is to syn th es ize a ll th e re la te d re s e a rc h in to a m e a n in g fu l w h o le . I t is d u rin g th is step th a t in fo r m a t io n is re d u c e d to a m a n a g e a b le fo r m . D u r in g th e step o f tr a n s la tio n , th e s cie n tific e vid e n ce is c o n s id e re d in th e c o n te x t o f c lin ic a l e xp e rtis e a n d v alu es. T h is results in c lin ic a l p ra c tic e g u id e lin e s , best p ractices, p ro to c o ls , s ta n d a rd s , o r c lin ic a l p a th w a y s . D u r in g th e stage o f im p le m e n ta ­ tio n , chang es ta k e p la c e in p ra c tic e . D u r in g e v a lu a tio n , th e im p a c t o f th e c h an g e is m e a s u re d . V a r ia b le s such as specific h e a lth o u tc o m e s , le n g th o f s tay , o r p a tie n t s a tis fa c tio n a re e x a m p le s o f p o s sib le o u tc o m e s th a t m ig h t be e x a m in e d .

■ The Iowa Model of Evidence-Based Practice T h e Io w a M o d e l o f E v id e n c e -B a s e d P ra c tic e re sem b les a d e c is io n -m a k in g tre e th a t id e n tifie s e ith e r p ro b le m -fo c u s e d o r k n o w le d g e -fo c u s e d trig g e rs th a t in itia t e th e pro cess in th e o r g a n iz a tio n . A d d itio n a l in fo r m a t io n a n d a d ia g ra m o f th e Io w a M o d e l o f E v id e n c e -B a s e d P ra c tic e a re a v a ila b le a t w w w .c o n e h e a lth .c o m /d o c u m e n ts /p u b lic /N u r s in g % 2 0 R e s e a r c h /Io w a % 2 0 M o d e l% 2 0 1 9 9 8 .p d f . P ro b le m -fo c u s e d trig g ers w it h in a n o rg a n iz a tio n c a n in c lu d e ris k m a n ­ a g e m e n t d a ta , process im p ro v e m e n t d a ta , b e n c h m a rk in g d a ta , fin a n c ia l d a ta , o r th e id e n tific a tio n o f c lin ic a l p ro b le m s . K n o w le d g e -fo c u s e d trig g ers w it h in a n o rg a n iz a tio n c an in c lu d e th e p u b lic a tio n o f n e w re se arch o r lite r a tu re , a chang e in o rg a n iz a tio n a l stan d ard s a n d g u id e lin e s , changes in p h ilo s o p h ie s o f care w it h in th e p ro fe s s io n o r o rg a n iz a tio n , o r questions fr o m a n in s titu tio n a l s tan d ard s c o m m itte e . O n c e th e re is e ith e r a p ro b le m -fo c u s e d o r k n o w le d g e -fo c u s e d trig g e r w it h in th e o rg a n iz a tio n , a te a m m u s t id e n tify w h e th e r th e to p ic is a p r io r ity fo r th e o rg a n iz a tio n . I f th e to p ic is in d e e d a p r io r ity , evid e n ce is e x a m in e d , a n d th e c h an g e in p ra c tic e c a n be p ilo te d . T h is process is fo llo w e d b y m o n i­ to rin g a n d analysis o f b o th th e process a n d th e o u tc o m e d a ta a n d fin a lly b y d is s e m in a tio n o f th e results.

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■ Agency for Healthcare Research and Quality Model A m o d e l fo r m a x im iz in g a n d a c c e le ra tin g th e tr a n s fe r o f re s e a rc h re su lts fr o m th e A g e n c y fo r H e a lt h c a r e R e s e a rc h a n d Q u a lit y ( A H R Q ) p a tie n t s afe ty rese arch p o r tfo lio to h e a lth c a re d e liv e ry has re c e n tly been d e v e lo p e d . T h e th re e m a jo r stages o f k n o w le d g e tra n s fe r in th e A H R Q m o d e l in c lu d e : (1 ) k n o w le d g e c re a tio n a n d d is tilla tio n , (2 ) d iffu s io n a n d d is s e m in a tio n , a n d (3 ) o rg a n iz a tio n a l a d o p tio n a n d im p le m e n ta tio n . M o r e s p e c ific a lly , k n o w l­ edge c re a tio n a n d d is tilla tio n refers to th e c o n d u c tin g o f rese arch a n d th en p a c k a g in g re le v a n t research fin d in g s in to usab le fo rm such as p ra c tic e re c o m ­ m e n d a tio n s . T h e d iffu s io n a n d d is s e m in a tio n stage in v o lv e s p a rtn e rin g w ith p ro fe s s io n a l le a d e rs , p ro fe s s io n a l o rg a n iz a tio n s , a n d h e a lth c a re o rg a n iz a ­ tio n s to d is s e m in a te k n o w le d g e to p o te n tia l users such as n u rses, p h y s ic a l th e ra p is ts , o r p h y s ic ia n s . D u r in g th e fin a l stage o f th e process, th e fo cus is o n o rg a n iz a tio n a l a d o p tio n a n d im p le m e n ta tio n o f e vid e n ce -b a se d research fin d in g s a n d in n o v a tio n s in p ra c tic e . In th is m o d e l, th e stages o f k n o w le d g e tra n s fe r a re v ie w e d fr o m th e p e rsp ec tive o f th e re se arch e r o r th e c re a to r o f n e w k n o w le d g e a n d b e g in w it h decision s a b o u t w h a t rese arch fin d in g s o u g h t to be d is s e m in a te d (T it le r , 2 0 0 8 ) .

■ Johns Hopkins Nursing Evidence-Based Practice Model T h e process used in th e Johns H o p k in s N u rs in g E vidence-B ased P ractice M o d e l is k n o w n as P E T , w h ic h refers to a s k in g a p ra c tic e q u e s tio n , fin d in g th e e v i­ den ce, a n d tr a n s la tin g th e e vid e n ce to p ra c tic e (N e w h o u s e , D e a r h o lt, P oe, P u g h , & W h it e , 2 0 0 7 ) . In th e m o d e l, questions are stated in th e P IC O fo rm a t. N e x t, th e research a n d n o n research evidence undergoes a p p ra is a l. N o n re s e a rc h evidence includ es n o t o n ly e x p e rt o p in io n , p a tie n t exp e rien c e d a ta , an d g u id e ­ lines, b u t also evidence g a th e re d fr o m o rg a n iz a tio n a l exp e rien c e such as q u a l­ ity im p ro v e m e n t re p o rts , p ro g ra m e v a lu a tio n s , a n d fin a n c ia l d a ta analysis. T h e fin a l step o f th e P E T process is tra n s la tio n , assessing th e evidence-based

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J CASE STUDY 10-1

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r. P. is a 52-year-old married, Hispanic male who is approximately 100 pounds over­ weight. 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 set­ ting, you have noticed that many of the patients you see in the clinic who are demographically similar to Mr. P. have poorer health outcomes as compared with some other patient populations.

Case Study Questions 1.

2.

What PICO(T) questions can you ask to generate evidence for the patient population represented in the case study? Based on a search of the literature, your exper­ tise, and what you know about the preferences of this patient population, what are some evidencebased nursing interventions that you might want to translate into clinical practice in this setting? ■

re co m m e n d a tio n s fo r tra n s fe ra b ility to th e p ractice setting. D u rin g this process, p ractices a re im p le m e n te d , e v a lu a te d , a n d c o m m u n ic a te d , le a d in g to a change in n u rs in g processes a n d o u tco m e s (p . 1 2 9 ).

C o nclu sio n C u rre n tly , th e greatest ch allen g e w e face in fu lly im p le m e n tin g evidence-based p ra c tic e in n u rs in g as a p ro fe s s io n is h o w to get th e evid en ce to th e p ra c tic in g n u rse . N u rs e s are v e ry busy ta k in g care o f p a tie n ts . F r o m th e p e rsp ec tive o f th e in d iv id u a l it c a n in d e e d be d a u n tin g , e s p e c ia lly w h e n m a n y p ra c tic in g nurses a re n o t k n o w le d g e a b le a b o u t e v id e n c e -b a s e d n u rs in g p ra c tic e . B u t d a u n tin g o r n o t, th e im p e tu s fo r e v id e n c e -b a s e d p ra c tic e w i l l c o n tin u e to g ro w . A s h e a lth c a re costs c o n tin u e to c lim b , consistent, d a ta -b a s e d answ ers to p a tie n t care p ro b le m s w ill be a n e x p e c ta tio n . P a tie n ts w ill e v e n tu a lly d e m a n d e vid e n ce -b a se d n u rs in g c are . P a tie n ts n o w h a ve access to m a n y c o m p u te riz e d d atabases a n d re p o rts , a n d th e y h a v e th e in c e n tiv e a n d th e tim e to re a d th e re p o rts . I f p a tie n ts a re a b le to d is c e rn best p ra c tic e s , th e y w ill e x p e c t th a t nurses c an as w e ll (S im p s o n , 2 0 0 4 ) .

Classroom A ctivity 1

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r e a te c lin ic a l q u e s tio n s in P I C O ( T ) f o r m a t f o r a p a t ie n t in a case s tu d y p r o v id e d b y th e in s t r u c to r o r a

p a t i e n t r e c e n t ly c a r e d f o r in th e c lin ic a l settin g ,

Classroom A ctivity 2

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o to th e c o m p u te r la b a n d access e v idence fr o m resources such as C I N A H L , th e N a t io n a l G u id e lin e C le a rin g h o u s e ,

o r C o c h ra n e L ib ra ry to p la n evidence-based care b a se d o n th e q u e s tio n s c re a te d in C la s s ro o m A c tiv ity 1.

Classroom A ctivity 3

P

a rtn e r w it h a lo c a l c lin ic a l fa c ility to w o r k jo in tly o n a P E T p ro je c t. C o lla b o r a te to

a n d p la n th e process o f tr a n s la tio n o f evidence in to p ra c tic e w it h in th e fa c ility o r o n a n u rs in g

id e n tify P IC O ( T ) q u e stio n s, fin d evidence,

u n it w it h in th e fa c ility ,

R e fe re n c e s Agency for Healthcare Research and Quality. (2002). Systems to rate the strength o f scientific evidence. File inventory, Evidence Report/Technology Assessment No. 47, AHRQ Publication No. 02-E016. Rockville, MD: Author. AGREE Collaboration. (2003). Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: The AGREE project. Quality and Safety in Health Care, 12, 18-23. AGREE Next Steps Consortium. (2009). Appraisal o f guidelines for research and evaluation. Ottawa, Ontario: AGREE Research Trust. Beyea, S. C., & Slattery, M. J. (2006). Evidence-based practice in nursing: A guide to successful implementation. Marblehead, MA: Healthcare Compliance Company. Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., ... Warren, J. (2007). Quality and safety education for nurses. Nursing O utlook, 55(3), 122-131. Di Cesenso, A., Guyatt, G., & Ciliska, D. (2005). Evidence-based nursing: A guide to clinical practice. St. Louis, MO: Mosby. Levin, R. F. (2006a). Evidence-based practice in nursing: What is it? In R. F. Levin & H. R. Feldman (Eds.), Teaching evidence-based practice in nursing: A guide for academic and clinical settings. New York, NY: Springer. Levin, R. F. (2006b). Teaching students to formulate clinical questions: Tell me your problems and then read my lips. In R. F. Levin & H. R. Feldman (Eds.), Teaching evidence-based practice in nursing: A guide for academic and clinical settings. New York, NY: Springer. Levin, R. F., & Feldman, H. R. (Eds.). (2006). Teaching evidence-based practice in nursing: A guide for academic and clinical settings. New York, NY: Springer. LoBiondo-Wood, G., Haber, J., & Krainovich-Miller, B. (2006). The research process: Integrating evidence-based practice. In G. LoBiondo-Wood & B. Haber (Eds.), Nursing research: M ethods and critical appraisal for evidence-based practice (6th ed.). St. Louis, MO: Mosby. Massachusetts Department of Higher Education. (2010). Nurse o f the future: Nursing core competencies. Retrieved from http://www.mass.edu/currentinit/documents/ NursingCoreCompetencies.pdf Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins. Newhouse, R. P., Dearholt, S. L., Poe, S. S., Pugh, L. C., & White, K. M. (2007). Johns Hopkins nursing evidence-based practice: Model and guidelines. Indianapolis, IN: Sigma Theta Tau International. Polit, D. F., & Beck, C. T. (2008). Nursing research: Generating and assessing evidence for nursing practice (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Pugh, L. C. (2012). Evidence-based practice: Context, concerns, and challenges. In S. L. Dearholt and D. Dang (Eds.), Johns Hopkins nursing evidence-based practice: Model and guidelines (2nd ed.). Indianapolis, IN: Sigma Theta Tau International. Sackett, D. L., Straus, S., Richardson, S., Rosenberg, W., & Haynes, R. B. (2000). Evidence-based medicine: H ow to practice and teach EBM (2nd ed.). London, England: Churchill Livingstone.

Simpson, R. L. (2004). Evidence-based nursing offers certainty in the uncertain world of healthcare. Nursing Management, 35(10), 10, 12. Spector, N. (2007). Evidence-based health care in nursing regulation. Chicago, IL: NCSBN. Titler, 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. Rockville, MD: Agency for Healthcare Research and Quality.

Ethical Issues in Professional Nursing Practice Karen Rich and Janie B. Butts

v_____ I_______ In th e previou s 1 0 0 years g re at te ch n o lo g ica l a n d m e d ic a l advances h ave h elp ed shape th e w o r ld o f bioethics, h e a lth care, a n d n u rs in g p ra c tic e . H o w e v e r, th ere has been a h u m a n p ric e fo r th e progress th a t has been m a d e . N e w a n d in tr ig u ­ in g m o ra l d ile m m a s h a v e su rfa ce d re la te d to p ro fe s s io n a l h e a lth c a re p ra c tic e , p a tie n t c are, a n d th e m e a n in g o f m o ra l s ta n d in g fo r in d iv id u a ls .

Learning Objectives A f t e r c o m p le tin g th is c h a p te r, th e s tu d e n t should be a b le to : 1. E x p la in im p o r ta n t e th ic a l iss u e s r e la te d to n u rs e s ' r e la tio n s h ip s w ith o th e rs , s u ch as p a tie n ts , fa m ilie s , and co lleag u es. 2 . Id e n tify an d d is c u s s k e y e th ic a l c o n c e p ts in vo lv ed in nu rse s' w o rk , such as b o u n d aries, d ig n ity , and a d vo cacy. 3 . Discuss th e c o n ce p t o f p a tie n t rig h ts in h e alth c are. 4 . C o m p are and c o n tra s t th e m eaning and d e ta ils of e n d -o f-life d o c u m e n ts -liv in g w ill, m ed ic al d ire c tiv e , and d u rab le p o w e r o f a tto rn e y . 5 . Id e n tify c o m p le x p ro b le m s in d e te rm in in g h e a lth c a re a llo c a tio n and e x p lo re s ta n d a rd s of d is trib u tiv e ju s tic e .

6 . D iscu ss th r e e m a jo r e th ic a l iss u e s t h a t a re in vo lv ed w ith org an tra n s p la n ta tio n . 7 . C o m p a re and c o n tra s t a c tiv e , passive, v o lu n ­ ta ry , and n o n v o lu n ta ry e u th a n as ia. 8 . D efin e key co n cep ts re la te d to e n d -o f-life care. 9 . Id e n tify a p p r o p r ia te d e c is io n -m a k in g s ta n ­ dards w hen p a tie n ts have lost decision -m aking c a p a c ity . 1 0. Id e n tify m o ra l d ile m m a s t h a t o c c u r d u rin g e n d -o f-life c a re and decision m aking.

R e la tio n s h ip s in P ro fe s s io n a l P ra c tic e

Key Terms and Concepts

A lth o u g h p ro fe s s io n a l h e a lth c a re p ra ctice s a re m a d e c re d ib le because o f fo r ­ m a l e x p e rt k n o w le d g e , re la tio n s h ip s a ris in g fr o m n a tu ra l h u m a n c o n d itio n s , such as illness, are a t th e fo u n d a tio n o f these p ra ctice s (S o k o lo w s k i, 1 9 9 1 ). I f nurses ta k e s e rio u s ly th e g u id a n c e o f th e A m e ric a n N u rs e s A s s o c ia tio n ’s ( A N A ) 2 0 0 1 C o d e o f E th ic s f o r N u r s e s w ith I n t e rp re tiv e S ta te m e n ts , p a tie n ts

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U n a v o id a b le t r u s t Boundaries Dignity Advocacy Moral right Informed consent 249

Key Terms and Concepts » Patient Self­ Determination Act » Advance directive » Living will » Medical directive » Durable power of attorney » Social justice » Active euthanasia » Passive euthanasia » Voluntary euthanasia » Nonvoluntary euthanasia » Rational suicide » Palliative care » Rule of double effect » Standard of substituted judgment » Pure autonomy standard » Best interest standard » Futile care » Terminal sedation (TS) » Physician-assisted suicide

a re to be th e c e n tra l focus o f n u rs in g a n d n u rs in g re la tio n s h ip s . H o w e v e r , th e q u a lity o f p a tie n t c are th a t nurses re n d e r o fte n depends o n th e existence o f h a rm o n io u s re la tio n s h ip s b e tw e e n nurses a n d p h y s ic ia n s , o th e r nurses, a n d o th e r h e a lth c a re w o rk e rs . N u rs e s w h o a re c o n c e rn e d a b o u t p ro v id in g c o m ­ p a ss io n ate care to p a tie n ts m u s t be c o n c e rn e d a b o u t th e ir re la tio n s h ip s w it h c o lleag u es as w e ll as w it h th e ir d ire c t re la tio n s h ip s w it h p a tie n ts . I f nurses v ie w life as a n e tw o r k o f in te rre la tio n s h ip s , a ll o f a n u rs e ’s re la tio n s h ip s can p o te n tia lly a ffe c t p a tie n ts ’ w e ll-b e in g . T h e re fo re , these re la tio n s h ip s h a ve a m o r a l n a tu re .

■ N urse-P hysician Relationships In 1 9 6 7 , S te in , a p h y s ic ia n , w r o te a n a rtic le c h a ra c te riz in g a ty p e o f r e la tio n ­ ship b e tw e e n p h y sic ia n s a n d nurses th a t he c a lle d “ th e d o c to r -n u r s e g a m e ” (S te in , W a tt s , & H o w e ll, 1 9 9 0 ) . T h e g a m e is based o n a h ie ra rc h ic a l re la ­ tio n s h ip , w it h d o c to rs b e in g in th e p o s itio n o f th e s u p e rio r. T h e h a llm a r k o f th e g a m e is th a t o p e n d is a g re e m e n t b e tw e e n th e d isc ip lin es is to be a v o id e d . A v o id a n c e o f c o n flic t is a ch ie v e d w h e n an e x p e rie n c e d n u rse , w h o is a b le to p ro v id e h e lp fu l suggestions to a d o c to r re g a r d in g p a tie n t c a re , c a u tio u s ly o ffers th e suggestions so th a t th e p h y s ic ia n does n o t d ire c tly perceive c o n s u lta ­ tiv e a d vic e as c o m in g fr o m a n u rse . In th e p a st, s tu d e n t nurses w e re e d u c a te d a b o u t th e rules o f “ th e g a m e ” w h ile a tte n d in g n u rs in g sch o o l. O v e r th e years, o th e r p e o p le h a ve g ive n c redence to th e h is to ric a l a c c u ra c y o f S te in ’s c h a ra c ­ te riz a tio n o f d o c to r -n u r s e re la tio n s h ip s (F ry & J o h n s to n e , 2 0 0 2 ; J a m e to n , 1 9 8 4 ; K e lly , 2 0 0 0 ) . S te in , a lo n g w it h tw o o th e r p h y s ic ia n s , w r o te a n a rtic le re v is itin g th e d o c to r -n u r s e g a m e in 1 9 9 0 , 2 3 years a fte r th e p h ras e w a s firs t c o in e d (S tein et a l., 1 9 9 0 ) . T h e y p ro p o s e d th a t nurses u n ila t e r a lly h a d d e c id e d to sto p p la y in g th e g a m e. S om e o f th e reasons fo r th is ch an g e a n d som e o f th e w a y s th e c h an g e w a s a c c o m p lis h e d in v o lv e d n u rse s ’ in c re a s e d use o f d ia lo g u e r a th e r th a n g a m e s m a n ­ sh ip , th e p ro fe s s io n ’s g o a l o f e q u a l p a rtn e rs h ip status w it h o th e r h e a lth c a re p ro fes s io n als, th e a lig n m e n t o f nurses w ith th e c iv il rig h ts a n d w o m e n ’s m o v e m e n ts , th e in crea se d p e r­ c en tag e o f nurses w h o are re c e iv in g h ig h e r e d u c a tio n , a n d th e jo in t d e m o n s tra tio n p ro je c ts o n c o lla b o ra tio n b e tw e e n nurses a n d p h y sic ia n s . In c o n ju n c tio n w it h th e d is m a n tlin g o f th e d o c to r-n u rs e gam e, som e nurses h a ve ta k e n an a d v e r­ s a ria l stance w it h p h y sic ia n s . T h e se nurses b elieve th a t th e y n e ed to c o n tin u e fig h tin g fo r fre e d o m fr o m p h y s ic ia n d o m i­ n a tio n to e sta b lish n u rs in g as a n a u to n o m o u s p ro fe s s io n . H o w e v e r , ra th e r th a n ta k in g a n a d v e rs a ria l stance th a t generates c o n flic t, th e n u rs in g p ro fe s s io n m ig h t be b e tte r served i f nurses ta k e a c o m m u n ita ria n a p p ro a c h w it h p h y s ic ia n s . I t is w it h in c o m m u n itie s th a t m o r a lit y in g e n e ra l

a n d b io e th ic s in p a rtic u la r re ce ive th e ir m e a n in g (E n g e lh a rd t, 1 9 9 6 ) . A c o m ­ m u n ity w o rk s to w a r d a c o m m o n g o o d a n d is h e ld to g e th e r b y m o r a l t r a d i­ tio n s . N u rs e s a n d p h y sic ia n s , as m e m b e rs o f th e h e a lth c a re c o m m u n ity , m u s t w o r k to g e th e r fo r th e h e a lth a n d w e ll-b e in g o f p a tie n ts w h e th e r th ose p a tien ts a re in d iv id u a ls , g ro u p s , o r c o m m u n itie s . W h e n o v e rt o r c o v e rt b a ttle s are w a g e d b e tw e e n nurses a n d p h y s ic ia n s , m o r a l p ro b le m s a ris e , a n d p a tie n ts c an be th e losers. S o m e ethicists h a v e c o n te n d e d th a t th e best a p p ro a c h fo r h e a lin g a c tu a lly in v o lv e s b rin g in g p a tie n ts in to th e c o m m u n ity o f h e a lth c a re p ro v id e rs (H e s te r, 2 0 0 1 ) . I f nurses a n d p h y s ic ia n s d o n o t see th em s elve s as m e m b e rs o f a c o m m o n c o m m u n ity , th e best in terests o f p a tie n ts m ig h t n o t be served.

■ N u rs e -P a tie n t-F a m ily Relationships Unavoidable Trust W h e n p a tie n ts e n te r th e h e a lth c a re system , th e y a re u s u a lly e n te rin g a fo re ig n a n d fo rb id d in g e n v iro n m e n t (C h a m b lis s , 1 9 9 6 ; Z a n e r , 1 9 9 1 ) . In tim a te c o n ­ v ers atio n s a n d a c tiv itie s , such as to u c h in g a n d p ro b in g , th a t n o r m a lly d o n o t o c c u r b e tw e e n s tran g ers, a re c o m m o n p la c e b e tw e e n p a tie n ts a n d h e a lth c a re p ro fe s s io n a ls . P a tie n ts are fre q u e n tly s trip p e d o f th e ir c lo th e s , s u b jec te d to sit a lo n e in c o ld a n d b a rre n ro o m s , a n d m a d e to w a it a n x io u s ly o n f r ig h t­ e n in g n e w s re g a rd in g th e c o n tin u a tio n o f th e ir v e ry b e in g . W h e n p a tie n ts a re in n eed o f h e lp fr o m nurses, th e y fre q u e n tly feel a sense o f v u ln e ra b ility a n d u n c e rta in ty . T h e te n s io n th a t p a tie n ts feel w h e n accessing h e a lth care is h e ig h te n e d b y th e n e ed fo r w h a t Z a n e r (1 9 9 1 ) calls u n a v o id a b le t r u s t . T h is c o n c e p t represents Z a n e r ’s c o n te n tio n th a t p a tie n ts , in m o s t cases, h a v e n o o p tio n b u t to tru s t nurses a n d o th e r h e a lth c a re p ro fes s io n als w h e n th e p a tie n t is a t th e p o in t o f n e e d in g c are. T h is u n a v o id a b le tru s t creates a n a s y m m e tric a l, o r u n e v e n , p o w e r s tru c ­ tu re in n u r s e -p a tie n t a n d fa m ily re la tio n s h ip s (Z a n e r , 1 9 9 1 ) . P ro fe s s io n a l n u rse s ’ respo nsiveness to th is tru s t m u s t in c lu d e p ro m is in g to be th e m o s t e xc ellen t nurses th a t th e y can be. A c c o rd in g to Z a n e r , h e a lth c a re pro fession als m u s t p ro m is e “ n o t o n ly to ta k e care o f, b u t to care fo r, the p a tie n t a n d fa m ily — to be c a n d id , sensitive, a tte n tiv e , a n d n e ve r to a b a n d o n th e m ” (p . 5 4 ). I t is p a ra d o x ic a l th a t tru s t Nurses must never take is n ecessary b e fo re h e a lth c a re is re n d e re d , b u t it c a n be for granted the fragility of e v a lu a te d o n ly in te rm s o f w h e th e r th e tru s t w a s w a rra n te d patients' trust. a fte r care is re n d e re d . N u rs e s m u s t n e ve r ta k e fo r g ra n te d th e fr a g ility o f p a tie n ts ’ tru s t.

Boundaries A discussion o f p ro fe s s io n a l b o u n d a rie s is sp ecifically c o ve red in p ro v is io n 2 .4 o f th e C o d e o f E th ic s f o r N u r s e s w ith In t e rp re tiv e S ta tem en ts ( A N A , 2 0 0 1 ) . In a d d itio n to th e issues o f tru s t discussed in th e p re v io u s section, bo u n d aries in

J

n u rs in g c an be th o u g h t o f in term s o f a p p ro p ria te p ro fe s s io n a l b e h a v io r th a t serves to m a in ta in tru s t b e tw e e n p a tie n ts a n d nurses a n d to m a in ta in nurses’ g o o d s ta n d in g w it h in th e ir p ro fe s s io n . A g a in , b y k e e p in g in m in d th a t th e p r im a r y c o n c e rn o f n urses’ care is “ p re v e n tin g illness, a lle v ia tin g s u ffe rin g , a n d p ro te c tin g , p ro m o tin g , a n d re s to rin g th e h e a lth o f p a tie n ts ,” nurses can fin d g u id a n c e in m a in ta in in g p ro fe s s io n a l b o u n d a rie s (p . 1 1 ). T h e n a tu re o f nurses’ w o r k w ith b o th p atien ts a n d colleagues has a v e ry p e rso n al e le m en t b u t m u s t n o t be confused w ith th e c o m m o n d e fin itio n o f frie n d s h ip . N u rs es are n o t d isc o u rag e d fr o m c a rin g fo r p a tie n ts , fa m ilie s , o r colleagu es. H o w e v e r , c a rin g fo r p a tie n ts a n d je o p a rd iz in g p ro fe s s io n a l b o u n d a rie s are tw o d is tin c t issues. C o n ce p ts th a t u n d e rlie n u r s e -p a tie n t b o u n d a rie s in c lu d e p o w e r , choice, a n d tru s t (M a e s , 2 0 0 3 ) . T h e a s y m m e try o f p o w e r in fa v o r o f th e nurse m u s t p r o m p t nurses to ask i f th e y a re in a p p r o p r ia te ly in flu e n c in g th e decision s o f p a tie n ts . P a tie n ts m u s t be p ro v id e d w it h c o m p le te in fo r m a tio n to m a k e choices, a n d nurses m u s t fa c ilita te in th e process o f p a tie n ts re c e iv in g th e in fo r m a tio n th a t th e y n e ed . P atien ts tru s t nurses to h a ve th e k n o w le d g e a n d s k ill necessary to p ro v id e th e m w it h c o m p e te n t care; nurses m u s t be fa ith fu l to th a t tru s t. P o te n tia l v io la tio n s o f n u r s e -p a tie n t b o u n d a rie s c an in v o lv e g ifts , in t i­ m a c y , lim its , n e g le c t, a b u s e , a n d re s tra in ts (M a e s , 2 0 0 3 ) . T h e g ifts th a t p a tie n ts give to nurses m u s t be c o n s id e re d in te rm s o f th e im p lic a tio n o f w h y th e g ift w a s g iv e n , its v a lu e , a n d w h e th e r th e g ift m ig h t p ro v id e th e ra p e u tic v a lu e fo r th e p a tie n t b u t n o t in flu e n c e th e lev el o f c are p ro v id e d b y th e nurse. G ifts g e n e ra lly le a d to b o u n d a ry v io la tio n s a n d n eed to be d is c o u ra g e d m o s t o f th e tim e . In a d d itio n to a n o b v io u s v io la tio n o f in tim a c y th ro u g h in a p ­ p ro p ria te s e x u a l re la tio n s h ip s , a v io la tio n o f in tim a c y m ig h t o c c u r i f a nurse in a p p r o p r ia te ly shares in fo r m a t io n w it h o th e r p e o p le in w a y s th a t v io la te p a tie n ts ’ p riv a c y . N u rs e s a n d p a tie n ts m u s t observe lim its th a t p re v e n t e ith e r p e rs o n fr o m b e c o m in g u n c o m fo rta b le in th e ir re la tio n s h ip . N u rs e s m u s t ta k e care to p ro v id e re as o n a b le care to a ll p a tie n ts a c c o rd in g to a p p ro p ria te e th ica l codes a n d state n u rse p ra c tic e acts so as n o t to be n e g le c tfu l in th e p ro v is io n o f n u rs in g care, a n d th e y m u s t d o e v e ry th in g possible to p re v e n t o r in te rv e n e to sto p p a tie n t abuse in w h a te v e r fo r m it occurs. F in a lly , p h y s ic a lly , c h e m i­ c a lly , a n d e n v iro n m e n ta lly re s tra in in g p a tie n ts c a n p ro v id e a m a jo r p itf a ll fo r nurses in te rm s o f b o u n d a ry v io la tio n s . N u rs e s m u s t k n o w th e p o licie s o f th e ir e m p lo y e r as w e ll as th e s tan d ard s set b y a c c re d itin g agencies to safe­ g u a rd p a tie n ts .

Dignity I n th e firs t p r o v is io n o f th e C o d e o f E t h ic s f o r N u r s e s w ith I n t e r p r e t i v e S ta te m e n ts , th e A N A (2 0 0 1 ) in c lu d e d th e s ta n d a rd th a t a n u rse m u s t h a ve “ respect fo r h u m a n d ig n ity ” (p . 7 ). H o w e v e r , S h o tto n a n d Seedhouse (1 9 9 8 ) p ro p o s e th a t th e te rm d ig n ity has been used in v ag u e w a y s . T h e y c h a ra c te riz e d ig n ity as b e in g re la te d to persons b e in g in a p o s itio n to use th e ir c a p a b ilitie s . In g e n e ra l te rm s , a p e rs o n has d ig n ity “ i f he o r she is in a s itu a tio n w h e re his

Relationships in Professional Practice

o r h e r c a p a b ilitie s c an be e ffe c tiv e ly a p p lie d ” (p . 2 4 9 ). F o r e x a m p le , nurses c a n e n h an ce d ig n ity w h e n c a rin g fo r elders b y assessing th e ir p rio ritie s a n d d e te rm in in g w h a t th e e ld er has been c ap a b le o f in th e p ast a n d w h a t th e perso n is c a p a b le o f in th e p re se n t. A la c k o f o r loss o f c a p a b ility is fr e q u e n tly a n issue w h e n c a rin g fo r p a tie n ts such as c h ild re n , e ld e rs , a n d p e o p le w h o are p h y s ic a lly a n d m e n ­ ta lly d is a b le d . H a v in g a b s e n t o r d im in is h e d c a p a b ilitie s is c o n s is te n t w it h w h a t M a c In t y r e (1 9 9 9 ) re fe rs to in his discu ssio n o f h u m a n v u ln e r a b ility . A c c o rd in g to M a c In t y r e , p e o p le g e n e ra lly pro gress fr o m a p o in t o f v u ln e r­ a b ility in in fa n c y to a ch ie vin g v a ry in g levels o f in d e p e n d e n t p ra c tic a l re as o n in g as th e y m a tu re . H o w e v e r , a ll p eo p le, in c lu d in g nurses, w o u ld do w e ll to re alize th a t a ll persons h a v e been o r w i l l be v u ln e ra b le a t som e p o in t in th e ir lives. T a k in g a “ th e re b u t fo r th e g ra ce o f G o d go I ” stan ce c a n p r o m p t nurses to d e v e lo p w h a t M a c In t y r e calls th e v irtu e s o f a c k n o w le d g e d d e p en d en c e. T h e s e v irtu e s in c lu d e ju s t g e n e ro s ity , m is e r ic o r d ia , a n d tru th fu ln e s s a n d are e xercised in c o m m u n itie s o f g iv in g a n d re c e iv in g . Just g e n e ro s ity is a fo r m o f g iv in g g e n e ro u s ly w it h o u t “ k e e p in g s co re ” o f w h o gives o r receives th e m o s t; m is e ric o rd ia is a L a tin w o r d th a t signifies g iv in g based o n u rg e n t need w ith o u t p re ju d ic e ; a n d tru th fu ln e s s in vo lv es n o t w ith h o ld in g in fo r m a tio n fr o m oth ers th a t is n e ed e d fo r th e ir o w n g o o d . N u rs e s w h o c u ltiv a te these th re e v irtu e s c an m o v e to w a r d p re s e rv in g p a tie n t d ig n ity a n d to w a r d th e c o m m o n g o o d o f th e c o m m u n ity .

P atien t Advocacy N u rs e s a c tin g as p a tie n t a d v o c a te s t r y to id e n t if y u n m e t p a tie n t needs a n d th e n f o llo w u p to a d d ress th e needs a p p r o p r ia te ly (J a m e to n , 1 9 8 4 ) . A d v o c a c y , as o p p o se d to a d v ic e , in v o lv e s th e n u rs e ’s m o v in g fr o m th e p a tie n t to th e h e a lth c a re system r a th e r th a n m o v in g fr o m th e n u rs e ’s v alu e s to th e p a tie n t. T h e c o n c e p t o f a d v o c a c y has been a p a rt o f th e In te rn a tio n a l C o u n c il o f N u r s in g ’s C o d e o f E t h ic s a n d th e A N A ’s co d e since th e 1 9 7 0 s (W in s lo w , 1 9 8 8 ) . In th e C o d e o f E t h ic s f o r N u r s e s w ith I n t e r p r e t i v e S t a t e m e n ts , th e A N A ( 2 0 0 1 ) c o n tin u e s to s u p p o rt p a tie n t a d v o c a c y in e la b o ra tin g o n th e “ p rim a c y o f th e p a tie n t’s in te re s t” (p . 9 ) a n d r e q u irin g nurses to w o r k c o l­ la b o r a t iv e ly w i t h o th e rs to a tta in th e g o a l o f a d d re s s in g th e h e a lth c a re needs o f p a tie n ts a n d th e p u b lic . N u rs e s a re c a lle d o n to e n su re t h a t a ll a p p r o p r ia te p a rtie s a re in v o lv e d in p a tie n t c are d ecisio n s, th a t p a tie n ts a re p ro v id e d w it h th e in fo r m a t io n n e e d e d to m a k e in fo r m e d d e cis io n s, a n d th a t c o lla b o r a tio n is used to in crea se th e a c c e s s ib ility a n d a v a ila b ilit y o f h e a lth care to a ll p a tie n ts w h o n e ed it. T h e In te r n a tio n a l C o u n c il o f B urses ( 2 0 0 6 ) , in th e C o d e o f E t h ic s f o r N u r s e s , a ffirm s th a t th e n u rse m u s t s h are “ w it h s o c ie ty th e re s p o n s ib ility fo r in itia tin g a n d s u p p o rtin g a c tio n to m e e t th e h e a lth a n d s o cia l needs o f th e p u b lic , in p a r tic u la r th o se o f v u ln e ra b le p o p u la tio n s ” (p . 2 ).

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KEY COMPETENCY 11-1 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Professionalism: Knowledge (K6) Understands role and responsibilities as patient advocate Attitudes/Behaviors (A6) Values role and responsibili­ ties as patient advocate Skills (S6) Serves as a patient advocate Source: Massachusetts Department of Higher Education (2010), p. 14.

CHAPTER 11 Ethical Issues in Professional Nursing Practice

■ N u rs e -N u rs e Relationships A s in th e case o f n u r s e -p h y s ic ia n re la tio n s h ip s , n u r s e -n u rs e re la tio n s h ip s c an be th o u g h t o f as re la tio n s h ip s w it h in a c o m m u n ity . N u rs e s in a n u rs in g c o m m u n ity m ig h t be w h a t E n g e lh a rd t (1 9 9 6 ) calls m o r a l frie n d s . A c c o rd in g to W ild e s (2 0 0 0 ) , m o r a l frie n d s e xist to g e th e r w it h in c o m m u n itie s a n d use s im ila r m o r a l la n g u a g e . T h e y “ s h are a m o r a l n a r r a tiv e a n d c o m m itm e n ts [a n d ] c o m m o n u n d e rs ta n d in g s o f th e fo u n d a tio n s o f m o r a lity , m o r a l re as o n , a n d ju s tific a tio n ” (p . 1 3 7 ). C o m m u n itie s a re s tro n g es t w h e n m o r a l frie n d s share “ c o m m o n m o r a l tr a d itio n s , p ra c tic e s , a n d [a] v is io n o f th e g o o d lif e ” (p . 1 3 7 ). In p u ttin g p a tie n ts firs t in n u rse s ’ p rio ritie s , nurses in a c o m m u n ity w o r k to g e th e r fo r a c o m m o n g o o d , usin g p ro fe s s io n a l tra d itio n s to g u id e th e c o m m u n a l n a rra tiv e o f n u rs in g . U n fo r tu n a te ly , nurses o fte n tr e a t o th e r nurses in h u r tfu l w a y s th ro u g h w h a t som e p e o p le h a v e c a lle d la te r a l o r h o r iz o n t a l v io le n c e (K e lly , 2 0 0 0 ; M c K e n n a , S m ith , P o o le , & C o v e rd a le , 2 0 0 3 ) . L a te ra l o r h o r iz o n ta l v io le n c e in v o lv e s in te rp e rs o n a l c o n flic t, h a ra s s m e n t, in tim id a t io n , h a rs h c ritic is m , s ab o tag e , a n d abuse a m o n g nurses. S om e p e o p le b e lie ve th a t th is o p p res sio n a m o n g nurses occurs because nurses feel oppressed b y o th e r d o m in a n t gro ups such as p h y sic ia n s o r in s titu tio n a l a d m in is tra to rs . K e lly (2 0 0 0 ) re p o rts th a t som e nurses h a v e c h a ra c te riz e d th e v io le n c e p e rp e tra te d a g a in s t nurses w h o e xc el a n d succeed as th e “ ta ll p o p p y s y n d r o m e .” N u rs e s w h o succeed a re o s tra c iz e d , th e re b y c re a tin g a c u ltu re a m o n g nurses th a t discourages success. L a te ra l v io le n c e in n u rs in g is v e ry c o u n te rp ro d u c tiv e fo r th e p ro fe s s io n . A m o re p ro d u c tiv e p a th fo r nurses m ig h t be to c u ltiv a te th e v irtu e o f s y m p a ­ th e tic jo y . S y m p a th e t ic jo y refers to e x p e rie n c in g h ap p in ess in re g a rd to th e g o o d th in g s e x p e rie n c e d b y o th e rs . T h e n u rs in g c o m m u n ity does n o t b e n e fit fr o m la te ra l v io le n c e , b u t nurses w h o c u ltiv a te th e v irtu e o f s y m p a th e tic jo y c an s tre n g th e n th e sense o f c o m m u n ity a m o n g nurses. N u rs e s m u s t s u p p o rt o th e r n urses’ success r a th e r th a n tr e a t colleagu es as “ ta ll p o p p ie s ” th a t m u s t be c u t d o w n . H o w e v e r , th e re a re occasions w h e n u n p le a s a n t a c tio n m u s t be ta k e n in re g a rd to n u rs in g c o lle ag u es . In a d d itio n to a d v o c a tin g d ire c tly fo r p a tie n ts ’ u n m e t n e ed s , n urses a re a d v o c a te s w h e n th e y ta k e a p p r o p r ia te a c tio n to p ro te c t p a tie n ts fr o m th e u n e th ic a l, in c o m p e te n t, o r im p a ir e d p ra c tic e o f o th e r nurses ( A N A , 2 0 0 1 ) . W h e n nurses a re a w a re o f these s itu a tio n s , th e y m u s t d e a l c o m p a s s io n a te ly w it h th e o ffe n d in g c o w o rk e rs w h ile e n su rin g th a t p a tien ts receive safe, q u a lity care. C oncerns m u s t be expressed to th e o ffe n d in g nurse w h e n p e rs o n a l safety o r p a tie n t safety is n o t je o p a rd iz e d in d o in g so a n d a p p ro p ria te g u id a n c e m u s t be o b ta in e d fr o m s u p e rv is o ry p e rs o n n e l a n d in s ti­ tu tio n a l p o lic ie s . A lth o u g h a c tio n m u s t be ta k e n to s a fe g u a rd p a tie n ts ’ c are, th e m a n n e r in w h ic h a nurse h a n d les s itu a tio n s in v o lv in g u n e th ic a l, in c o m ­ p e te n t, o r im p a ire d colleagu es m u s t n o t be a m a tte r o f gossip, condescension, o r u n p ro d u c tiv e d e ro g a to ry ta lk .

Moral Rights and Autonomy

M o ra l R ig h ts and A u to n o m y In a society th a t is p e rfe c tly ju s t, m o r a l rig h ts a n d leg a l rig h ts w o u ld o v e rla p ; h o w e v e r, th e tw o types o f rig h ts a re n o t th e sam e in o u r society (B ra n n ig a n & Boss, 2 0 0 1 ) . A m o ra l rig h t c an be d e fin e d as “ th e r ig h t to p e r fo r m c e rta in a c tiv itie s (a ) because th e y c o n fo r m to th e a cc ep ted s ta n d a rd s o r ideas o f a c o m m u n ity (o r o f a la w , o r o f G o d , o r o f conscience), o r (b ) because th e y w ill n o t h a rm , coerce, re s tra in , o r in frin g e o n th e interests o f o th ers , o r (c) because th e re a re g o o d r a tio n a l a rg u m e n ts in s u p p o rt o f th e v a lu e o f such a c tiv itie s ” (A n g e les , 1 9 9 2 , p . 2 6 4 ). G e n e ra lly , m o ra l rig h ts are sep a rated in to w e lfa re rig h ts a n d lib e rty rights (B ra n n ig a n & Boss, 2 0 0 1 ) . W e lfa re rig h ts a llo w persons to p u rsu e th e ir le g iti­ m a te interests o r those p e rso n al interests th a t d o n o t in te rfe re w it h th e interests o f o th e r p e rso n s ’ th a t a re s im ila r a n d e q u a l to o n e ’s o w n . “ W e lfa r e (p o s itiv e ) rig h ts e n ta il th e rig h t to receive basic goods such as e d u c a tio n , m e d ic a l c are, a n d p o lic e p ro te c tio n , as w e ll as a d u ty o n th e p a r t o f o th ers such as th e g o v ­ e rn m e n t to p ro v id e these social g o o d s ” (p . 3 3 ). A s o p p o s e d to w e lfa re rig h ts , lib e rty (n e g a tiv e ) rig h ts in v o lv e th e r ig h t to n o n in te rfe re n c e fr o m a n y p e rso n o r g o v e rn m e n ta l e n tity w h e n p u rs u in g o n e ’s le g itim a te in te re sts (B ra n n ig a n & Boss, 2 0 0 1 ) . “ L ib e r ty o r n e g a tiv e rig h ts in c lu d e a u to n o m y , p riv a c y , fre e d o m o f speech, a n d fre e d o m fr o m h a ras sm e n t, c o n fin e m e n t, u n w a n te d m e d ic a l tre a tm e n t, o r p a r tic ip a tio n in e x p e rim e n ts w it h o u t o u r in fo r m e d c o n s e n t” (p . 3 3 ). A lth o u g h th e W o r ld H e a lt h O r g a ­ n iz a tio n has p ro p o s e d th a t e v e ry p e rs o n has a fu n d a m e n ta l r ig h t to h e a lth w it h o u t p re ju d ic e , in th e U n ite d S tates, lib e r ty rig h ts a re e m p h a s ize d o v e r w e lfa re rig h ts , e x c e p t in cases o f elders a n d th e p o o r.

■ Inform ed Consent C o n s id e ra tio n s o f in fo r m e d c o n s e n t fa ll w it h in th e o v e rv ie w o f respect fo r a u to n o m y , o r s e lf-d ire c tio n (B e a u c h a m p & C h ild re s s , 2 0 0 9 ; V e a tc h , 2 0 0 3 ) . A lth o u g h nurses o fte n fa c ilita te in fo r m e d c o n se n t a n d h a v e a ro le in te rm s o f p a tie n t a d v o c a c y , th e a c tu a l re s p o n s ib ility fo r e n s u rin g in fo r m e d c o n ­ sent h is to ric a lly has b e lo n g e d to th e p h y s ic ia n . H o w e v e r , w it h th e in crea se d n u m b e rs o f a d v a n c e d p ra c tic e nurses a n d th e in crea se d c o m p le x ity o f n urses’ ro le s, in fo r m e d c o n se n t has b e co m e m o re o f a d ire c t e th ic a l issue fo r nurses. A lib e ra lly a p p lie d c o n c e p t o f in fo rm ed c o n s e n t in clu d es th e ru le th a t “ m e a n ­ in g fu l in fo r m a tio n m u s t be disclosed even i f th e c lin ic ia n does n o t b e lie ve th a t it [th e in fo r m a tio n ] w ill be b e n e fic ia l” (V e a tc h , 2 0 0 3 , p . 7 5 ). T h is d e fin itio n is in c o n tra s t to th e ru le a p p lie d u n d e r th e H ip p o c r a t ic O a th th a t a llo w e d fo r h e a lth c a re p ro fes s io n als to w ith h o ld in fo r m a tio n i f th e y b e lie v e d th a t it w o u ld h a r m o r u pset a p a tie n t. I t m u s t be n o te d th a t a p a tie n t’s sig n atu re o n a consent fo rm proves n e ith e r th a t a p a tie n t re a d th e fo rm n o r th a t th e p a tie n t u n derstands w h a t is w r itte n o n

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it (V e a tc h , 2 0 0 3 ) . I t w o u ld be im p o s s ib le to in fo r m each p a tie n t o f e v e ry th in g a b o u t a p ro c e d u re . In a n a tte m p t to d e al w it h th is re a lity , tw o s tan d ard s are o fte n a p p lie d . T h e firs t is th e reas o n a b le p erso n s ta n d a rd th a t states th e h e a lth ­ c are p ro fe s s io n a l w ill disclose in fo r m a tio n th a t a re a s o n a b le p e rs o n w o u ld w a n t to k n o w . T h e second is th e subjective s ta n d a rd th a t states th a t disclosure m u s t be based o n th e s u b jective interests o f a p a rtic u la r p a tie n t ra th e r th a n a h y p o th e tic a l re a s o n a b le p e rs o n . T h e id e a l s ta n d a rd , th e re fo re , adjusts w h a t a re as o n a b le p erso n w o u ld w a n t to k n o w w it h w h a t th e h e a lth c a re p ro fes s io n al k n o w s th a t a p a rtic u la r p a tie n t is o r m ig h t be in te re s te d in k n o w in g .

■ Patient S elf-D eterm ination Act T h e P a tie n t S e lf-D e te rm in a tio n A c t o f 1 9 9 0 , enacted in 1 9 9 1 , w as designed to fa c ilita te th e k n o w le d g e a n d use o f a d v a n c e d ire ctiv es (G u id o , 2 0 0 1 ) . U n d e r th e a ct, h e a lth c a re p ro v id e rs m u s t ask p a tie n ts i f th e y h a v e a d v a n c e d irectives a n d m u s t p ro v id e p a tie n ts w it h a d v a n c e d ire c tiv e in fo r m a tio n a c c o rd in g to p a tie n ts ’ w ish es. T h is a c t p ro v id e s nurses w it h a g o o d o p p o r tu n ity to ta k e an a c tiv e ro le in fa c ilita tin g th e m o r a l rig h ts o f p a tie n ts in re g a rd to e n d -o f-life decision s. In a d d itio n to re s p o n d in g to th e d ire c t q u estio n s th a t p a tie n ts ask a b o u t a d v a n c e d ire c tiv e s a n d e n d -o f-life o p tio n s , nurses w o u ld d o w e ll to “ lis te n ” fo r th e s u b tle cues th a t p a tie n ts give th a t sign al th e ir a n x ie tie s a n d u n c e rta in ty a b o u t e n d -o f-life c are . I t w o u ld be a p ra c tic e o f c o m p a s s io n fo r nurses to lis te n d e e p ly to p a tie n ts a n d to a c tiv e ly tr y to a lle v ia te p a tie n ts ’ s u f­ fe rin g a n d fears in re g a rd to e n d -o f-life d e cis io n m a k in g .

Advance Directives A n a d v a n c e d ire c tiv e is “ a w r it te n e x p re s s io n o f a p e rs o n ’s w is h es a b o u t m e d ic a l c a re , e s p e c ia lly c a re d u r in g a te r m in a l o r c ritic a l illn e s s ” (V e a tc h , 2 0 0 3 , p . 1 1 9 ). S a id a n o th e r w a y , in d iv id u a ls lose c o n tr o l o v e r th e ir lives w h e n th e y lose th e ir d e c is io n -m a k in g c a p a c ity , a n d a d va n ce directives becom e in s tru c tio n s a b o u t h e a lth care fo r th e fu tu re (D e v e tte re , 2 0 0 0 ) . A d v a n c e d ire c ­ tives m a y be s e lf-w ritte n in s tru c tio n s o r m a y be p re p a re d b y so m eo n e else as in s tru c te d b y th e p a tie n t. T h e re are th ree types o f ad va n ce directives: liv in g w ill, m e d ic a l care d ire c ­ tiv e , a n d d u ra b le p o w e r o f a tto rn e y (D e v e tte re , 2 0 0 0 ) . A living w ill is a fo rm a l le g a l d o c u m e n t th a t p ro v id e s w r itte n d ire c tio n s c o n c e rn in g m e d ic a l c are th a t is to be p ro v id e d in specific circ u m s ta n ce s (B e a u c h a m p & C h ild re s s , 2 0 0 9 ; D e v e tte re , 2 0 0 0 ) . T h e liv in g w ill g a in e d re c o g n itio n in th e 1 9 6 0 s , b u t th e K a re n A n n Q u in la n case in th e 1 9 7 0 s b ro u g h t p u b lic a tte n tio n to th e liv in g w i l l a n d s u b s e q u e n tly p r o m p te d le g a liz a tio n o f th e d o c u m e n t (D e v e tte re , 2 0 0 0 ) . A lth o u g h a t th e tim e , th e y w e re a g o o d b e g in n in g , to d a y liv in g w ills a re in a d e q u a te . L iv in g w ills o fte n co n sist o f v a g u e la n g u a g e , o n ly in s tru c ­ tio n s fo r u n w a n te d tre a tm e n ts , a n d a la c k o f leg a l p e n a ltie s fo r p e o p le w h o choose to ig n o re to fo llo w th e liv in g w ills . A ls o , liv in g w ills m ig h t be le g a lly q u e s tio n a b le in re g a rd to th e ir a u th e n tic ity .

A m ed ical d ire c tiv e is not a formal legal document but provides specific written instructions concerning the type of care and treatments that individuals want to receive if they become incapacitated (Devettere, 2000). One advantage to medical directives is that physicians can use them as a guide to know what the incapacitated patient wants in terms of specific healthcare treatments. Some attorneys believe that medical directives are only a minimal improvement over living wills. Their rationale is that they think that medical directives are only an elaborate informed consent. Also, other weaknesses of medical directives are that people cannot possibly anticipate every medical problem that might occur in their future, and people change over time and can change in regard to their future wishes. A d u rab le pow er of a tto r n e y , the legal document with the most strength, is a written directive in which a designated person is allowed to make either general or healthcare decisions for a patient (Devettere, 2000). Families and healthcare professionals can experience fear about making the wrong decisions regarding a patient who is incapacitated. Advance direc­ tives help to reduce emotional stress but at the same time can produce ethical dilemmas.

S o cial J u s tic e ■ Definition and Theories of Social Justice A Sicilian priest first used the term social justice in 1840, and then in 1848, the term was more popularized by Antonio Rosmini-Serbati (Novak, 2000). Since then, social ju s tic e has been defined as (Center for Economic & Social Justice, n.d.): A virtue that guides us in creating those organized human interac­ tions we call institutions. In turn, social institutions, when justly organized, provide us with access to what is good for the person, both individually and in our associations with others. Social justice also imposes on each of us a personal responsibility to work with others to design and continually perfect our institutions as tools for personal and social development. (p. 2) A large portion of the use of the term has been related more to competing powers of social systems and regulative principles on an impersonal basis, such as “high unemployment,” “inequality of incomes,” “lack of a living wage,” and “social injustice” (Novak, 20 0 0 , p. 1). The term also has been related to the question of what makes the common good for everyone (Brannigan & Boss, 2001). People who take a communitarian approach put common goods of the community over individual freedoms. In his social contract book, A T h eo ry o f Ju stice, John Rawls (1971) views fairness and equality under a “veil o f ign o ran ce.” This concept

KEY COMPETENCY 11-2 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Patient-Centered Care: Knowledge (K3) Integrates understanding of multiple dimensions of patientcentered care: patient/ family/community preferences, values Attitudes/Behaviors (A3c) Respects and encourages the patient's input into decisions about health care and services Skills (S3a) Communicates patient values, preferences, and expressed needs to other members of the health care team; (S3b) Seeks information from appro­ priate sources on behalf of patient when necessary Source: Massachusetts Department of Higher Education (2010), p. 9.

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m e a n s th a t i f p e o p le h a d a v e il to s h ie ld th e ir o w n o r o th e rs ’ e c o n o m ic , s o c ia l, a n d class s ta n d in g , e a c h p e rs o n w o u ld b e m o r e li k e ly to m a k e ju s tic e -b a s e d d e c is io n s f r o m a p o s itio n t h a t is fre e f r o m a ll b ias e s a n d w o u ld v ie w th e d is tr ib u tio n o f reso u rce s in im p a r t ia l w a y s . U n d e r th e v e il, p e o p le w o u ld v ie w s o c ia l c o n d itio n s n e u t r a lly b e c a u s e th e y w o u ld n o t k n o w w h a t th e ir o w n p o s itio n m ig h t be a t th e tim e th e v e il is lifte d . T h is “ n o t k n o w in g ” o r ig n o ra n c e o f p e rs o n s a b o u t th e ir o w n p o s itio n m e a n s th a t th e y c a n n o t g a in a n y ty p e o f a d v a n ta g e fo r th em s elve s b y th e ir choices. B a s e d o n th is “ ig n o r a n c e ” p r in c ip le , R a w ls s ta te d t h a t th is v ie w is ju s t (c ite d in B ra n n ig a n & Boss, 2 0 0 1 ) . R a w ls ( 1 9 7 1 ) a d v o c a te s tw o p rin c ip le s o f e q u a lity a n d ju s tic e : E v e ry o n e s h o u ld be g iv e n e q u a l lib e r t y n o m a t te r w h a t a d v e rs itie s e x is t fo r p e o p le , a n d d iffe re n c e s s h o u ld be r e c o g n iz e d a m o n g p e o p le b y m a k in g sure t h a t th e le a s t a d v a n ta g e d p e o p le a re g iv e n th e ir d e s e rt fo r im p ro v e m e n ts . N o z ic k (1 9 7 4 , c ite d in B ra n n ig a n & Boss, 2 0 0 1 ) presents th e id e a o f an e n title m e n t system in his b o o k A n a r c h y , S tate, a n d U to p ia , m e a n in g th a t if in d iv id u a ls c o u ld p a y fo r in s u ra n c e , o n ly th e n a re th e y e n title d to h e a lth c are. N o z ic k em phasizes th a t in o rd e r fo r a system to be ju st a n d fa ir, it m u s t re w a rd p e o p le w h o c o n trib u te to th e system (B ra n n ig a n & Boss, 2 0 0 1 ) . T h e n la te r, D a n ie ls e x p lo re s R a w ls ’s c o n c e p t o f ju stice fu rth e r b y b asin g his b o o k J u s t H e a lth C a r e (1 9 8 5 ; c ite d in B ra n n ig a n & Boss, 2 0 0 1 ) o n th e lib e rty p rin c ip le , as he espouses th a t e v e ry p e rs o n s h o u ld h a v e e q u a l o p p o r tu n it y . D a n ie ls em phasizes e q u a l h e a lth care a n d re as o n a b le access to h e a lth c a re services a n d re c o m m e n d s n a tio n a l h e a lth c a re re fo r m .

KEY COMPETENCY 11-3 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Professionalism: Attitudes/Behaviors (A8b) Values and upholds altruistic and humanistic principles Source: Massachusetts Department of Higher Education (2010), p. 15.

■ Allocation and Rationing of H ealthcare Resources T h e cost o f h e a lth care is s p ira lin g o u t o f c o n tro l w o r ld w id e , a n d th e re fo re , h e a lth c a re resources a n d d e c id in g h o w to a llo c a te th e m re m a in a t th e fo re ­ fr o n t o f p e o p les ’ concerns. T h e u n fo rtu n a te a n d tro u b le s o m e experiences w ith h e alth ca re re im b u rse m en ts are p la y e d o u t th ro u g h n a rra tiv e s o n the fr o n t page o f a lm o s t e very n e w s p a p e r. A c e n tra l q u e s tio n th a t h e a lth c a re p ro fes s io n als, econo m ists, a n d p o litic ia n s have asked them selves fo r years is w h a t m akes u p a just an d e q u ita b le he alth ca re system? T h e question continues to be u n an sw ered . T h e h e a lth c are o f p e o p le in th e U n ite d States is n o t th e best in th e w o r ld , y e t in 2 0 0 5 , U .S . h e a lth c a re e x p e n d itu re s w e re $ 2 t r illio n (K a is e r F a m ily F o u n d a tio n , 2 0 0 7 ) . T h e fe d e ra l g o v e rn m e n t’s second m a jo r g o a l in H e a lth y P e o p le 2 0 1 0 w a s to e lim in a te h e a lth d is p a ritie s . T h is re m a in s a m a jo r g o a l in th e H e a lt h y P eo p le 2 0 2 0 d o c u m e n t, y e t th e d is p a ritie s c o n tin u e to o c cu r w it h o u t m u c h , i f a n y , im p r o v e m e n t in th e h e a lth o f p e o p le in th e U n ite d States. I t is b e lie v e d th a t in e q u a litie s in h e a lth c are e xist because o f c o m p le x differences in so cio e co n o m ic status, ra c ia l a n d e th n ic b a c k g ro u n d s , e d u c a tio n levels, a n d h e a lth c a re access. These d iffere n c es u n d e rlie m a n y o f th e h e a lth

d is p a ritie s in th e U n ite d States. A s a re s u lt, h e a lth -p ro m o tin g b e h a v io rs are n o t as lik e ly to be p ra c tic e d . A s h e a lth c a re costs in crea se , resources b e co m e m o re lim ite d fo r p e o p le . D is tr ib u tiv e ju s tic e has b e c o m e a c r it ic a l issue in th e h e a lth c a re sys te m . G u id e lin e s in h o w scarce resources are d is trib u te d m u s t be c le a rly d e lin e a te d . S om e g u id in g q u e stio n s th a t m e m b e rs o f so ciety need to e x p lo re in te rm s o f d is trib u tiv e ju stice in c lu d e th e fo llo w in g : • • • •

D o e s e ve ry p e rs o n h a v e a r ig h t to h e a lth care? Is h e a lth c are a r ig h t o r a p riv ile g e th a t m u s t be earned? H o w s h o u ld resources be d is trib u te d so th a t e v e ry o n e receives a fa ir a n d e q u ita b le share fo r h e a lth care? S h o u ld h e a lth c a re r a tio n in g ever be c o n s id e re d as a n o p tio n in th e face o f scarce h e a lth c a re resources? I f so, h o w ?

T h e re m ig h t n e v e r be c le a r a n d concise answ ers to these c o m p le x q u e s ­ tio n s . B ra n n ig a n a n d Boss (2 0 0 1 ) o u tlin e c rite r ia th a t c o u ld be used w h e n r a tio n in g is c o n s id e re d . T h e c rite r ia in c lu d e s ta n d a rd s o f d is t r ib u t io n b y m a r k e t o r a c c o rd in g to p e o p le w h o c o u ld a ffo r d to p a y , s o cia l w o r th , m e d ­ ic a l needs, age, a firs t-c o m e , firs t-s e rv e d basis, a n d ra n d o m iz a tio n . F r o m th e 1 9 9 0 s to th e p re s e n t, system s o f m a n a g e d c are h a v e b een o p e ra tin g in th e U n ite d States as one s tra te g y to im p ro v e th e use o f services based o n needs a n d to m a x im iz e h e a lth a n d w e ll-b e in g w h ile re d u c in g o v e ra ll h e a lth c a re costs to in d iv id u a ls (S u g a rm a n , 2 0 0 0 ) . H o w e v e r , th e p u b lic has re s p o n d e d v e ry p o o r ly to m a n a g e d care. Som e p e o p le h a ve la b e le d m a n a g e d care as an e th ic a l disaster. B e fo re such c o m p la in ts a re m a d e , h o w e v e r, h e a lth c a re p ro fes s io n als an d nurses need to address th e sources o f th e p ro b le m s . S u g a rm a n (2 0 0 0 ) discusses th e e n o rm o u s tra v e s ty th a t o c c u rre d w it h th e M e d ic a id a n d M e d ic a r e system s fr o m 1 9 6 5 to 1 9 9 0 . B ig m o n e y w a s m a d e a v a ila b le b y th e U .S . fe d e ra l g o v e rn m e n t based o n th e a u to n o m o u s p ra c tic e o f p h y s ic ia n s — m e a n in g th a t p h y sic ia n s c o u ld re d ire c t la rg e a m o u n ts o f m o n e y fr o m ta x p a y e rs to th e c are o f sick p e o p le th ro u g h M e d ic a id a n d M e d ic a r e . S u g a rm a n te rm s th is p e rio d as “ th e g o o d o ld d a y s ,” w h e n p h y sic ia n s w e re n o t re q u ire d to ju s tify o r s h o w evidence fo r th e ir m e d ic a l care fo r sick p e o p le . Since 1 9 9 0 , h o w e v e r, tim es h a ve ch an g ed , a n d c ritic is m is p le n tifu l. S u g a rm a n c o n te n d s th a t n o m a tte r w h a t h e a lth c a re system is in p lac e , p h y sic ia n s an d th e p u b lic w o u ld be c ritic a l. E n g e lh a rd t (1 9 9 6 ), a b io e th ic is t, states th is a b o u t th e c u rre n t h e a lth c a re system : C o n c e p ts o f a d e q u a te care are n o t d is c o v e ra b le o u tsid e o f p a rtic u ­ la r vie w s o f th e g o o d life a n d o f p ro p e r m e d ic a l p ra c tic e . In n a tio n s e n co m p a s s in g d ive rs e m o r a l c o m m u n itie s , a n u n d e rs ta n d in g o f w h a t o n e w ill m e a n b y a n a d e q u a te lev el o r a d e c e n t m in im u m o f h e a lth care w ill n eed to be fa s h io n e d , i f it c an in d e e d be ag ree d to , th ro u g h o p e n discussion a n d b y fa ir n e g o tia tio n . (p . 4 0 0 )

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CHAPTER 11 Ethical Issues in Professional Nursing Practice

I CRITICAL THINKING QUESTION *

Think about the questions posed in this section in relation to the distribution of scarce healthcare resources under a “veil of igno­ rance,” and then think about the same ques­ tions considering your own circumstances. Do you come up with the same answers to the questions? *

KEY COMPETENCY 11-4 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Systems-Based Practice: Knowledge (K5a) Under­ stands that legal, political, regulatory, and economic factors influence the delivery of patient care; (K5b) Is aware that dif­ ferent models of health care financing and regulation can influence patient access to care Attitudes/Behaviors (A5a) Appreciates that legal, political, regulatory, and economic factors influence the delivery of patient care; (A5b) Values the need to remain informed of how legal, political, regulatory, and economic factors impact professional nursing practice Skills (S5a) Provides care based upon current legal, political, regulatory, and economic requirements Source: Massachusetts Department of Higher Education (2010), p. 20.

P ro m o tin g o p e n d ia lo g u e fo r exp ressin g m o ra l v ie w s in th e c o m m u n ity a n d in in s titu tio n s , n e g o tia tin g p o lic y c h an g e fo r b e tte r a llo c a tio n a n d a n im p ro v e d h e a lth c a re s ys te m , a n d m a in t a in in g a fir m c o m m itm e n t fo r b e tte r p a tie n t h e a lth o u tc o m e s a re ju s t a fe w w a y s th a t nurses c a n assist w it h s u p p o rtin g g o o d h e a lth fo r th e c o m m o n g o o d o f th e c o m m u n ity .

Ethics and Organ Transplantation

A d r a m a tic s o c ia l a llo c a t io n issue th a t in v o lv e s scarce resou rces is o rg a n tr a n s p la n ta tio n . In th e U n ite d States, p a tie n ts c a n “ o p t i n ” b y s ig n in g a d o n o r c a rd as p o te n tia l d o n o rs o f one o r m o re org an s in th e e ve n t o f th e ir d e a th (P e rrin & M c G h e e , 2 0 0 1 ) . I f p a tie n ts choose n o t to sign d o n o r c ard s , th e y a re free fr o m a n y o b lig a tio n to d o n a te o rg a n s . T h r e e e th i­ c a l issues a re in v o lv e d w it h o rg a n tr a n s p la n ta tio n : th e m o r a l a c c e p ta b ility o f tr a n s p la n tin g a n o rg a n fr o m o n e p e rs o n to a n o th e r, p ro c u re m e n t, a n d a llo c a tio n o f th e o rg an s (V e a tc h , 2 0 0 3 ) . F o r th e firs t e th ic a l issue, V e a tc h ( 2 0 0 3 ) poses th is q u e s tio n : “ Is p e r ­ fo rm in g tra n s p la n ts ‘p la y in g G o d ’ ?” (p . 1 3 6 ). T h is p h ras e has b e co m e q u ite c o m m o n in th e la s t fe w decades w it h tra n s p la n ts , genetics, a n d h u m a n r e p ro ­ d u c tio n te ch n o lo g ies b e in g so p o p u la r. M a n y p e o p le v ie w tra n s p la n ta tio n s as u n a c c e p ta b le based o n re lig io u s o r c u ltu ra l b eliefs, o r ju st basic b eliefs, such as th e a s s o c ia tio n th a t th e h u m a n h e a rt has w it h ro m a n c e a n d as th e “ seat o f th e s o u l” (V e a tc h , 2 0 0 3 , p . 1 3 7 ). T h e second e th ica l issue is p ro c u re m e n t o f organs. In som e c o u n trie s o th e r th a n th e U n ite d States, o rg an s c an be ro u tin e ly s alva g e d w it h o u t th e c o n se n t o f th e p a tie n t o r a n y o n e in th e fa m ily w it h th e basic b e lie f th a t o rg a n s , once th e p erso n is d e ad , becom e th e p ro p e rty o f th e state o r c o u n try (V e a tc h , 2 0 0 3 ) . In th e U n ite d States, it is b e lie v e d th a t d o n a tio n a n d in fo r m e d c o n s e n t are based o n th e rig h ts a n d a u to n o m y o f each p e rso n . T h e th ir d e th ica l issue is o rg a n a llo c a tio n , w h ic h is one o f th e m o s t d e b ated issues in h e a lth c are to d a y because o f th e s c a rc ity o f d o n o r o rg a n s . T h e re is a n a tio n a l w a itin g lis t esta b lish e d b y th e U n ite d N e t w o r k fo r O r g a n S h a rin g ( U N O S ) C o m m itte e (U .S . D e p a rtm e n t o f H e a lt h a n d H u m a n Services, 2 0 0 3 ) . A t least 9 8 ,1 5 1 p e o p le in th e U n ite d States are a w a itin g o rg an s fo r tra n s p la n t (O r g a n P ro c u re m e n t a n d T r a n s p la n ta tio n N e t w o r k , 2 0 0 7 ) . B ecause o f th e d e m a n d fo r o rg an s a n d th e p ro s p e c t o f m o n e y th a t c a n be m a d e , th e o rg a n b la c k m a r k e t is th riv in g . T h e U .S . o rg a n d o n o r system is o rg a n iz e d so th a t a llo c a tio n decision s a re c o o rd in a te d b y U N O S , a n d th e system is designed to be d riv e n b y th e p rin c ip le o f ju stice . U N O S o r th e o rg a n tra n s p la n t te a m s h o u ld n e v e r d e n y org an s based o n p e rc e iv e d s o cia l w o r th ; ra th e r, a llo c a tio n o f resources s h o u ld be d is trib u te d fa ir ly a n d e q u a lly based o n n e ed . F iv e m a jo r focus areas o f h e a lth d isp aritie s are k n o w n to a ffe c t ra c ia l a n d e th n ic g ro u p s in a ll ages: c a rd io v a s c u la r disease, d iab etes , can c er screening

Death and End-of-Life Care

a n d disease m a n a g e m e n t, a n d im m u n iz a tio n s (U .S . D e p a rtm e n t o f H e a lt h a n d H u m a n Services, 2 0 0 3 ) . P eo p le w h o s u ffe r th e m o s t fr o m h e a lth d is p a ritie s b e tw e e n p o p u la tio n s o fte n h a v e diseases th a t e v e n tu a lly re s u lt in a n e ed fo r o rg a n tra n s p la n ts . F o r in s ta n c e , a h e a lth c o n d itio n s re p o r t fr o m th e O ffic e o f M i n o r i t y H e a lt h (2 0 0 7 ) reveals th a t in 2 0 0 4 h ig h b lo o d p ressure o c c u rre d 1 .5 tim e s m o re in A fr ic a n A m e ric a n s th a n in n o n -H is p a n ic w h ite s a n d in 2 0 0 2 , A fr ic a n A m e ric a n m e n w e re 2 .1 tim e s as lik e ly to s ta rt tr e a tm e n t fo r en d -stag e re n a l disease re la te d to d iab etes as w e re n o n -H is p a n ic w h ite m e n . O n e p r im a r y ro le fo r nurses is to assist w it h a tte m p tin g to e lim in a te h e a lth disp arities. E d u c a tio n p ro g ra m s w ith s u bstantive c o n te n t th a t ta rg e t p a rtic u la r p o p u la tio n s p ro v id e a b e g in n in g ro le fo r nurses, w h o fu n c tio n o n a b ro a d c o m m u n ity lev el. O th e r roles fo r nurses in clu d e e n co u rag in g p atien ts a n d fa m ilie s to express th e ir feelings a n d a ttitu d e s a b o u t d o n a tio n s a n d tra n s p la n ta tio n s , especially in re g a rd to e th ic a l issues in v o lv in g d e a th a n d d y in g ; s u p p o rtin g , lis te n in g , a n d m a in ta in in g c o n fid e n tia lity w it h p a tie n ts a n d fa m ilie s ; assisting in m o n ito rin g p a tien ts fo r o rg a n needs; c o n tin u a lly b e in g a w a re o f in e q u a litie s a n d injustices in th e h e a lth c a re system , w h ic h c an a ffe c t th e care o f p a tie n ts ; a n d assisting in th e care o f s u rg ical o rg a n tra n s p la n t a n d d o n a tio n p a tie n ts a n d th e ir fa m ilie s .

D e a th and E n d -o f-L ife C are ■ Defining Death T h e last w o rd s o f th e g re a t c o m p o s e r F re d e ric C h o p in w e re , “ T h e e a rth is suf­ fo c a tin g .... S w e a r to m a k e th e m c u t m e o p e n , so th a t I w o n ’t be b u rie d a liv e ” (D e a th : T h e L a s t T a b o o , 2 0 0 3 ) . In th e 1 7 0 0 s a n d 1 8 0 0 s , especially in E u ro p e , th e re w a s w id e s p re a d fe a r o f p re m a tu re b u r ia l o r b e in g b u rie d a liv e because o f th e in a d e q u a te m e th o d s fo r d e te c tin g w h e n a p e rso n w a s d e ad a n d because o f a c tu a l a cc o u n ts o f p e o p le b e in g b u rie d a liv e (B o n d e s o n , 2 0 0 1 ) . In th ose d ays, w h e n a b o d y w a s e x h u m e d , c la w m a rk s s o m etim e s w e re fo u n d o n th e in s id e o f c o ffin lid s (M a p p e s & D e G r a z ia , 2 0 0 1 ) . B ecause o f th e w id e s p re a d fe a r, a v a rie ty o f special safe ty co ffin s w e re in v e n te d w it h d e ta ile d devices to h e lp th e d e ad , once th e y w e re b u rie d , to c o m m u n ic a te w it h o th ers a b o v e th e g ro u n d (D e a th : T h e L a s t T a b o o , 2 0 0 3 ) . T h e devices in c lu d e d such th in g s as a ro p e e x te n d in g to th e s u rface o f th e g ro u n d w it h a b e ll o n th e o th e r en d , a s p e a k in g tu b e to th e o u te r c o ffin , a s h o ve l, a n d fo o d a n d w a te r. In a d d itio n to a n e w la w th a t p re v e n te d p re m a tu re b u r ia l, fu n e ra l h o m e a tte n d a n ts even w e n t to th e e x te n t to h a v e th e ir e m p lo yees m o n ito r d e a d bodies fo r a n y signs o f life d u rin g th e “ w a i t ” tim e . F o r several c en tu ries , w h e n a p e rs o n b e ca m e u n co n s cio u s , p h y sic ia n s o r o th e r p e o p le w o u ld p a lp a te fo r a p u ls e, lis te n fo r b re a th sounds w it h th e ir ears, lo o k fo r c o n d e n s a tio n o n a n o b je c t w h e n it w a s h e ld close to th e b o d y ’s

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nose, a n d c h ec k fo r fix e d a n d d ila te d p u p ils (M a p p e s & D e G r a z ia , 2 0 0 1 ) . In 1 8 1 9 , fe a r w a s re d u c e d w h e n th e stethoscop e w a s in v e n te d because p h y s i­ cians c o u ld lis te n w it h g re a te r c e rta in ty fo r a h e a rtb e a t th ro u g h a m a g n ifie d lis te n in g device o n th e chest o f th e b o d y . In 1 9 0 3 , W ille m E in th o v e n , a D u tc h p h y sic ia n , discovered th e existence o f th e e le ctrica l p ro p erties o f th e h e a rt w ith his in v e n tio n o f th e e le c tro c a rd io g ra p h , w h ic h p ro v id e d sensitive in fo r m a tio n a b o u t w h e th e r th e e le ctrica l a c tiv ity o f th e h e a rt w as fu n c tio n in g . T h e a rtific ia l re s p ira to r o f th e 1 9 5 0 s b ro u g h t a b o u t m o re u n c e rta in ty o f d e a th as physicians k e p t p a tie n ts a liv e in th e absence o f a n a tu r a l h e a rtb e a t (D e a th : T h e L a s t T a b o o , 2 0 0 3 ) . B y th e 1 9 6 0 s , w h e n tra n s p la n ts w e re b e in g p e rfo rm e d , it w as b e c o m in g a p p a re n t th a t a d iag n o sis o f d e a th w o u ld n o t d e p e n d necessarily o n th e absence o f a h e a rtb e a t. R a th e r , th e d e fin itio n o f d e a th w o u ld n e ed to in c lu d e b ra in d e a th c rite r ia in th e fu tu re . T h e firs t a tte m p t to re d efin e d e a th w a s m a d e in th e U n ite d States b y the H a r v a r d M e d ic a l S ch o o l a d h o c c o m m itte e in 1 9 6 8 . T h e d e fin itio n w a s based o n th e c o m m itte e m e m b e rs ’ a tte m p t to id e n tify re lia b le c lin ic a l c rite r ia fo r re s p ira to r-d e p e n d e n t patien ts w h o h a d n o b ra in fu n c tio n (Y o u n g n e r & A rn o ld , 2 0 0 1 ) . T h e n , in 1 9 8 1 , th e P re s id e n t’s C o m m is s io n m em b ers san c tio n e d a d e fi­ n itio n o f d e a th , w h ic h in c lu d e d b ra in d e ath , a n d re c o m m e n d e d its a d o p tio n b y a ll states (M a p p e s & D e G ra z ia , 2 0 0 1 ) . T h e 1 9 8 1 d e fin itio n led to th e U n ifo r m D e te rm in a tio n o f D e a th A c t ( U D D A ) , in w h ic h d e a th is d e fin e d as fo llo w s : A n in d iv id u a l w h o has sustained e ith e r (1 ) irre v e rs ib le cessation o f c irc u la to ry a n d re s p ira to ry fu n c tio n s o r (2 ) irre v e rs ib le cessation o f a ll fu n c tio n s o f th e e n tire b r a in , in c lu d in g th e b ra in stem , is d e a d . A d e te rm in a tio n o f d e a th m u s t be m a d e in a c c o rd a n c e w it h accepted m e d ic a l stan d ard s. (P re s id e n t’s C o m m is s io n , 1 9 8 1 ; c ited in M a p p e s & D e G r a z ia , 2 0 0 1 , p . 3 1 8 ) S ince th is d e fin itio n w a s a d o p te d , c rite r ia fo r b r a in d e a th h a v e b e en in te ­ g ra te d in a lm o s t e ve ry state b u t h a ve been c o n tin u a lly d e b a te d . A p ro v o c a tiv e th o u g h t th a t V e a tc h (2 0 0 3 ) has c o n trib u te d to th e d e b ate o n th e d e fin itio n o f d e a th concerns th e loss o f fu ll m o ra l s tan d in g o f h u m a n beings. T h is s tatem e n t trig g ers th e q u e s tio n as to w h e n h u m a n s s h o u ld be tre a te d as fu ll m e m b e rs o f th e h u m a n c o m m u n ity . A lth o u g h a lm o s t e ve ry p e rs o n has re c o n c ile d th e th o u g h t th a t som e perso ns h a ve fu ll m o r a l s ta n d in g a n d o th ers d o n o t, th e re is c o n tin u e d c o n tro v e rs y a b o u t w h e n fu ll m o r a l s ta n d in g ceases to e xist a n d w h a t c h ara c te ris tic s q u a lify th e cessation o f fu ll m o r a l s ta n d in g . L o s in g fu ll m o r a l s ta n d in g is e q u iv a le n t to c ea sin g to e x is t. P re s e n tly , v a rio u s g ro u p s h a v e p ro p o s e d a n d d e b a te d th e fo llo w in g fo u r c o n ce p tio n s o f d e ath since th e e n ac tm e n t o f th e U D D A in 1 9 8 1 (M u n s o n , 2 0 0 4 , p p . 6 9 2 , 6 9 3 ): • • •

T r a d itio n a l: A p e rso n is d e a d w h e n he is n o lo n g e r b re a th in g a n d his h e a rt is n o t b e a tin g (c a r d io p u lm o n a ry ). W h o le -b r a in : D e a th is re g a rd e d as th e irre v e rs ib le cessation o f a ll b ra in fu n c tio n s . . . n o e le c tric a l a c tiv ity in th e b ra in , a n d even th e b ra in stem is n o t fu n c tio n in g (b ra in d e a th ).

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H ig h e r b ra in : D e a th is c o n s id e re d to in v o lv e th e p e rm a n e n t loss o f c o n ­ sciousness. S o m e o n e in a n irre v e rs ib le c o m a w o u ld be c o n s id e re d d e ad , even th o u g h th e b ra in stem c o n tin u e d to re g u la te b re a th in g a n d h e a rtb e a t (p e rs is te n t v e g e ta tiv e s tate). P e rs o n h o o d : D e a th occurs w h e n a n in d iv id u a l ceases to be a p e rs o n . T h is c a n m e a n loss o f fe a tu re s th a t a re ess en tia l to p e rs o n a l id e n tity o r fo r b e in g a p erso n .

W it h w h o le -b r a in d e a th , a p a tie n t p h y s ic a lly c a n s u rviv e fo r a n in d e te r­ m in a te p e rio d o f tim e w it h a m e c h a n ic a l v e n tila to r. W it h h ig h e r b ra in d e a th , a p a tie n t lives in a p e rsis te n t v e g e ta tiv e state in d e fin ite ly b u t w it h o u t th e need fo r m e c h a n ic a l v e n tila tio n . I t is because o f these s itu a tio n s th a t th e q u e s tio n exists re g a rd in g w h e n a p e rs o n s h o u ld be tre a te d as o n e w h o has fu ll m o ra l s ta n d in g w it h in th e h u m a n c o m m u n ity . S o ciety, p h y sic ia n s , a n d nurses h a ve h a d d iffic u lty in d e fin in g d e a th b y th e U D D A d e fin itio n , w h ic h in clu d es th e t r a d itio n a l a n d th e w h o le -b r a in c o n ce p ts . H o w e v e r , th e g re a te s t d iffic u lty has b e en w h e n th e y h a v e tr ie d to in c o rp o ra te th e co n cep ts o f h ig h e r b ra in d e a th a n d p e rs o n h o o d d e a th (M u n s o n , 2 0 0 4 ) . N o d e fin ite c rite r ia fo r e ith e r o f these c o n ce p ts — h ig h e r b ra in o r p e rs o n h o o d — h a v e been e sta b lish e d fo r d e fin in g d e a th . T h e d e b a te c o n tin u e s , a n d q u e s tio n s c o n tin u e a b o u t w h e n life begins, w h e n life ends, a n d w h a t it is th a t ceases to e xist w h e n so m eo n e is d e a d (B e n ja m in , 2 0 0 3 ; V e a tc h , 2 0 0 3 ) .

■ Euthanasia M o s t p e o p le d o n o t w a n t p ro lo n g e d a g o n y a n d s u ffe rin g b e fo re th e ir d e a th a n d w o u ld lik e to k e e p th e ir e m o tio n a l, fin a n c ia l, a n d s o cia l b u rd e n s to a m in im u m a n d th e ir d ig n ity in ta c t. H o w e v e r , d y in g th e “ g o o d d e a th ” is n o t a lw a y s p o s s ib le (M u n s o n , 2 0 0 4 ) . E u t h a n a s ia , m e a n in g “ g o o d d e a t h ” in G r e e k , has c o m e to m e a n “ easy d e a th ” a n d has d e v e lo p e d a s tro n g a p p e a l in re c e n t yea rs. A p a tie n t m ig h t p o n d e r o p tio n s o f e u th a n a s ia i f s u ffe rin g a n d p a in b e c o m e to o m u c h fo r th e p e rs o n to b e a r. T h e re a re tw o m a jo r types o f e u th a n a s ia : a c tiv e a n d p a ss ive . A c tiv e e u th a n a s ia occurs w h e n a p e rs o n takes a n a c tio n to end a life (in c lu d in g o n e ’s o w n life ). A c tiv e e u th a n a s ia c a n in c lu d e a le th a l dose o f Dying the “good death" m e d ic a tio n , such as in p h y s ic ia n -a s s is te d su ic id e. P a s s iv e always possible. e u th a n a s ia m ea n s th a t a p e rs o n a llo w s a n o th e r p e rs o n to d ie b y n o t a c tin g to stop d e a th o r p ro lo n g life . A n e x a m p le o f th is ty p e o f e u th a n a s ia in c lu d e s w it h h o ld in g tr e a tm e n t th a t is necessary to p re v e n t d e a th a t a p o in t in tim e . E u th a n a s ia also is re c o g n iz e d b y th e c a te g o rie s o f v o lu n ta r y a n d n o n ­ v o lu n ta r y (B ra n n ig a n & Boss, 2 0 0 1 ) . V o lu n ta ry e u th a n a s ia o c cu rs w h e n persons w it h a s o u n d m in d a u th o riz e a n o th e r p e rs o n to ta k e th e ir life o r to assist th e m in a c h ie v in g d e a th . A ls o , th is ty p e in c lu d e s th e ta k in g o f o n e ’s o w n life . N o n v o lu n ta ry e u th a n a s ia o c cu rs w h e n p e rs o n s a re n o t a b le to express th e ir d e cis io n a b o u t d e a th . A b le n d in g o f these types o f e u th a n a s ia

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CHAPTER 11 Ethical Issues in Professional Nursing Practice

c an o c c u r, such as v o lu n ta ry a c tiv e , n o n v o lu n ta ry a c tiv e , v o lu n ta ry passive, a n d n o n v o lu n ta ry passive. A v ig o ro u s d e b a te in th e U n ite d S tates c o n tin u e s a b o u t w h e th e r th e re is a re a l m o r a l d iffe re n c e b e tw e e n a c tiv e e u th a n a s ia , such as th e in te n tio n a l ta k in g o f so m e o n e ’s life , a n d passive e u th a n a s ia , such as w ith h o ld in g o r w it h ­ d ra w in g life -s u s ta in in g tre a tm e n ts (B ra n n ig a n & Boss, 2 0 0 1 ; Jonsen, V e a tc h , & W a lte rs , 1 9 9 8 ) . T h e a c tio n versus o m is s io n d is tin c tio n m a n y tim e s causes nurses a n d p h y sic ia n s to p o n d e r th is tro u b le s o m e q u e s tio n : “ Is th e re a m o ra l d iffe re n c e b e tw e e n a c tiv e ly k illin g a n d le ttin g d ie ? ”

■ Rational Suicide T h e th o u g h t o f m o r a lly a cc e p tin g th e a c t o f a p e rs o n ’s c o m m ittin g r a tio n a l suicide w e ig h s h e a v ily o n th e he arts o f m o s t p e o p le even to d a y . T h e v e ry c o n ­ n e c tio n o f th e te rm s ra tio n a l a n d s u ic id e seems a c o n tra d ic tio n (E n g e lh a rd t, 1 9 9 6 ; F in n e rty , 1 9 8 7 ) . H o w e v e r , su icid e is a n e n o rm o u s p u b lic h e a lth c ri­ sis. W o r ld w id e , th e re a re a n e s tim a te d 8 7 7 ,0 0 0 suicides each y e a r ( W o r ld H e a lt h O r g a n iz a tio n , 2 0 0 7 ) . In 2 0 0 4 , th e o c cu rren c e o f suicide in th e U n ite d States w a s m o re th a n 3 2 ,0 0 0 (C e n te rs fo r D isease C o n tr o l a n d P re v e n tio n , 2 0 0 7 ) . R a tio n a l s u ic id e is a s e lf-s la y in g a n d is c a te g o riz e d as v o lu n ta ry activ e e u th a n as ia. In th is c ate g o ry , th e perso n has m a d e a reaso n ed choice o f ra tio n a l s u icid e, w h ic h seems to m a k e sense to o th ers a t th e tim e . Siegel (1 9 8 6 ) states th a t th e p e rs o n c o n te m p la tin g r a tio n a l su icid e has a re a lis tic assessm ent o f life c irc u m s ta n ce s, is free fr o m severe e m o tio n a l distress, a n d has a m o tiv a ­ tio n th a t w o u ld seem u n d e rs ta n d a b le to m o s t u n in v o lv e d p e o p le w it h in th e p e rs o n ’s c o m m u n ity . E n d o rs in g a n y suicide seems so c o n tra d ic to ry to g o o d h e a lth c a re p ra c tic e because nurses a n d m e n ta l h e a lth p ro fe s s io n a ls h a v e b e en in te rv e n in g fo r years to p re v e n t s u ic id e. M a n y tim e s , n u rse s ’ responses a re g u id e d b y th e ir c u ltu r a l, re lig io u s , a n d p e rs o n a l b e lie fs . A u to n o m y a n d b en eficen ce n e e d to be c o n s id e re d w h e n nurses a re d e c id in g a b o u t in te rv e n tio n s to p ro v id e fo r p e rs o n s w h o a re p la n n in g r a t io n a l s u ic id e . A ls o , i f th e W W W J CRITICAL THINKING QU ESTIO N S* n u rse k n o w s o f th e p la n fo r r a tio n a l s u ic id e, w o u ld care Does a nurse have the right to try to stop be o b lig a to ry to w a r d th e p a tie n t? W h a t a c tio n s c o u ld th e a person from committing rational suicide n u rse ta k e a t th is p o in t? In te rv e n tio n s b e c o m e u n iq u e to (to act in the best interest of the patient)? each s itu a tio n a n d c an in c lu d e e v e ry th in g fr o m b e in g asked Is a nurse supposed to support the person’s to p ro v id e in fo r m a t io n re g a rd in g th e H e m lo c k S o c ie ty to autonomous decision to commit rational b e in g a s k e d a b o u t le th a l in je c tio n s . B ecause nurses a re suicide, even when that decision is morally m o re c lo s e ly in v o lv e d w it h e n d -o f-life d e c is io n m a k in g , and religiously incompatible with the nurse’s th e issue o f n u rs e s ’ re s p o n s ib ility w it h v o lu n ta r y a c tiv e perspective? * e u th a n a s ia is b e c o m in g a n in c re a s in g ly c o m m o n d ile m m a .

■ Palliative Care P a llia tiv e c a re is p ro v id in g c o m fo rt r a th e r th a n c u ra tiv e m easures fo r te r m i­ n a lly ill p a tie n ts . N u rs e s a re a c tiv e ly in v o lv e d in m e e tin g th e p a llia tiv e needs o f d y in g p a tie n ts . In th e la s t decade, th e p a llia tiv e care m o v e m e n t has b e co m e q u ite o rg a n iz e d th ro u g h o ffic ia l a ssociations a n d o rg a n iz a tio n s . T h e W o r ld H e a lt h O r g a n iz a tio n (2 0 0 3 ) defines p a llia tiv e c are as fo llo w s : A n a p p ro a c h th a t im p ro v e s th e q u a lity o f life o f p a tie n ts a n d th e ir fa m ilie s fa c in g th e p ro b le m associated w ith life -th re a te n in g illness, th ro u g h th e p re v e n tio n a n d re lie f o f s u ffe rin g b y m ea n s o f e a rly id e n tific a tio n a n d im p e c c a b le assessm ent a n d tr e a tm e n t o f p a in a n d o th e r p ro b le m s , p h y s ic a l, p s y c h o s o c ia l, a n d s p iritu a l. (p . 1) W h e n a p a tie n t chooses to receive th is ty p e o f c are, nurses n eed to u n d e rs ta n d th a t th e y d o n o t h a sten o r p ro lo n g d e a th fo r these p a tie n ts ; th e y p ro v id e re lie f o f p a in a n d s u ffe rin g a n d a tte m p t to a llo w th e p a tie n t to d ie w it h d ig n ity . P a tie n ts o r p a tie n ts ’ fa m ilie s m a y choose to fo rg o , w it h h o ld , o r w it h d r a w tre a tm e n t. S o m e p a tie n ts h a v e a d o -n o t-re s u s c ita te o rd e r, w h ic h is a w r itte n p h y s ic ia n ’s o rd e r th a t is p la c e d in th e p a tie n t’s c h a rt in a n a tte m p t to ensure th a t n o resu s citativ e m easures a re in itia te d w h e n a p a tie n t’s c a rd io p u lm o n a ry fu n c tio n s cease. U s u a lly th e re is one o f th re e reasons fo r th e d e cis io n to i n it i­ ate a d o -n o t-re s u s c ita te o rd e r: (1 ) T h e re is n o m e d ic a l b e n e fit th a t c an c o m e fr o m c a rd io p u lm o n a ry re s u s c ita tio n (C P R ), (2 ) th e p e rs o n h a d a v e ry p o o r q u a lity o f life b e fo re C P R , o r (3 ) th e p e rs o n ’s life a fte r C P R is a n tic ip a te d to be v e ry p o o r (M a p p e s & D e G r a z ia , 2 0 0 1 ) .

Rule of Double Effect T h e ru le o f d o u b le e ffe c t u s u a lly is d e fin e d n a r r o w ly in h e a lth c a re as th e use o f h ig h doses o f p a in m e d ic a tio n to lessen th e c h ro n ic a n d in tr a c ta b le p a in o f te r m in a lly ill p a tie n ts even i f d o in g so hastens d e a th (Q u ill, 2 0 0 1 ) . T h e firs t g ro u p to d e fin e th e ru le o f d o u b le e ffe c t w a s th e C a th o lic C h u rc h in m e d ie v a l tim e s . W h e n th e ru le is a p p lie d , nurses n e e d to be a w a re th a t th e h a r m fu l e ffe ct, o r th e h a s te n in g o f d e a th , c an be fo reseen b u t is n o t th e in te n d e d o u tc o m e o f th e ir a ctio n s . A c c o rd in g to Q u ill ( 2 0 0 1 ), c ritic a l aspects o f th e ru le are as fo llo w s : 1. T h e a ct m u s t be g o o d o r a t least m o r a lly n e u tra l. 2 . T h e a g e n t m u s t in te n d th e g o o d e ffe c t a n d n o t th e e v il e ffe c t (w h ic h c an be “ fo re s e e n ” b u t n o t in te n d e d ). 3 . T h e e v il e ffe c t m u s t n o t be th e m ean s to th e g o o d e ffe ct. 4 . T h e r e m u s t be a “ p r o p o r tio n a lly g ra v e re a s o n ” to ris k th e e v il e ffe c t (p . 1 6 7 ).

N u rs e s m ig h t h a v e c o n flic tin g m o r a l values c o n c e rn in g th e use o f h ig h doses o f p a in m e d ic a tio n s , such as m o rp h in e s u lfa te . In tim es w h e n nurses feel u n c o m fo rta b le , th e y n e ed to e x p lo re th e ir a ttitu d e s a n d o p in io n s w it h th e ir s u p e rv is o r a n d , w h e n a p p ro p r ia te , in c lin ic a l te a m m ee tin g s . In P ro v is io n 1 .3 o f th e C o d e o f E th ics f o r N u r s e s w ith In te rp re tiv e S ta tem en ts, th e A N A (2 0 0 1 ) s u p p o rts nurses in th e ir a tte m p ts to re lie v e p a tie n ts ’ p a in “ even w h e n those in te rv e n tio n s e n ta il risks o f h a s te n in g d e a th ” (p . 8 ).

■ Refusing or Forgoing T reatm en t W e ll-in fo r m e d p a tie n ts w it h d e c is io n -m a k in g c a p a c ity h a v e th e a u to n o m o u s rig h t to refuse o r fo rg o re c o m m e n d e d tre a tm e n ts (Jonsen, Siegler, & W in s la d e , 2 0 0 2 ) . W h e n a p e rs o n elects to fo rg o tre a tm e n t, m o s t o f th e tim e th e re is n o e th ic a l o r leg al b a c k la s h . T h e c o u rts u p h o ld th e rig h t o f c o m p e te n t p a tie n ts to refuse tr e a tm e n t (Jonsen et a l., 2 0 0 2 ; M a p p e s & D e G r a z ia , 2 0 0 1 ) . E v e n so, it is o f th e u tm o s t im p o rta n c e th a t h e a lth c a re pro fession als m a k e c e rta in th a t the p a tie n t’s d e cis io n is n o n c o e rc iv e a n d a u to n o m o u s a n d th a t th e d e cis io n has been m a d e based o n th e p a tie n t’s m e n ta lly c o m p e te n t d e c is io n -m a k in g c a p a c ity (M a p p e s & D e G ra z ia , 2 0 0 1 ) . A lth o u g h nurses a n d o th e r h e a lth c a re p ro fes s io n als m ig h t h a v e th e assurance o f th e p a tie n t’s a u to n o m o u s a n d c o m p e te n t d e cis io n m a k in g , s o m etim es th e p a tie n t’s d e c i­ sion is d iffic u lt to accept. R e fu s a l o f m e d ic a l tre a tm e n ts can o c c u r a t a n y tim e in life , w h e th e r a t th e en d o f life o r n o t, such as tim es w h e n p a tie n ts m ig h t refuse tr e a tm e n t based o n re lig io u s o r c u ltu ra l beliefs.

■ Deciding for Others W h e n p a tie n ts a re n o lo n g e r a b le to m a k e c o m p e te n t decision s, fa m ilie s can e x p e rie n c e p ro b le m s in tr y in g to d e te rm in e a p ro g res siv e r ig h t course o f ac­ tio n . T h e id e a l s itu a tio n is fo r p a tie n ts to be a u to n o m o u s d e cis io n m a k e rs , b u t w h e n a u to n o m y is n o lo n g e r possible, d ecision m a k in g falls to a s u rro g a te (B e a u c h a m p & C h ild re s s , 2 0 0 9 ) . T h e s u rro g a te , o r p r o x y , is e ith e r chosen b y th e p a tie n t, is c o u rt a p p o in te d , o r has o th e r a u th o r ity to m a k e decision s. T h e re a re th re e types o f s u rro g a te d e cis io n m a k e rs (B e a u c h a m p & C h il­ dress, 2 0 0 9 ; V e a tc h , 2 0 0 3 ) . T h e s ta n d a rd o f s u b s titu te d ju d g m e n t is used to g u id e m e d ic a l d e cis io n s th a t in v o lv e fo r m e r ly c o m p e te n t p a tie n ts w h o n o lo n g e r h a v e a n y d e c is io n -m a k in g c a p a c ity . T h is s ta n d a rd is based o n th e a s s u m p tio n th a t in c o m p e te n t p a tie n ts h a v e th e e x a c t rig h ts as c o m p e te n t p a tie n ts to m a k e ju d g m e n ts a b o u t th e ir h e a lth c a re (B u c h a n a n & B ro c k , 1 9 9 0 ). S u rro g ates m a k e m e d ic a l tre a tm e n t decisions based o n h o w th e s u rro ­ gates b e lie ve th a t th e p a tie n ts w o u ld h a ve d e cid e d w e re th e p a tie n ts s till c o m ­ p e te n t a n d able to express th e ir w ishes. In m a k in g decisions, th e surrogates use th e ir u n d e rs ta n d in g o f th e p a tie n ts ’ p re v io u s o v e rt o r im p lie d expressions o f

th e ir beliefs a n d values (V e a tc h , 2 0 0 3 ) . B e fo re lo s in g c o m p e te n c y , th e p a tie n t c o u ld h a ve e ith e r e x p lic itly in fo r m e d th e p r o x y o f tre a tm e n t w ishes b y o ra l o r w r itte n in s tru c tio n o r im p lic itly m a d e c le ar tre a tm e n t w ishes th ro u g h in fo r m a l c o n v e rs a tio n s w it h th e p ro x y . D ec is io n s based o n th e pure a u to n o m y s ta n d a rd are m a d e o n b e h a lf o f an in c o m p e te n t p e rs o n a n d a re based o n decisions th a t th e fo r m e r ly c o m p e te n t p e rs o n m a d e . T h is ty p e o f d e cis io n also is c a lle d th e p rin c ip le o f a u to n o m y e x te n d e d , m e a n in g th a t a p e rs o n ’s a u to n o m y c o n tin u e s to be h o n o re d even w h e n th e p e rs o n c a n n o t exercise a u to n o m y th ro u g h n o r m a l c h an n els. T h e b e st in te re s t s ta n d a rd is based o n th e g o a l o f th e s u rro g a te ’s d o in g w h a t is best fo r th e p a tie n t o r w h a t is in th e best in te re s t o f th e p a tie n t (V e a tc h , 2 0 0 3 ) . T h is s ta n d a rd is a p p lie d w h e n th e p a tie n t w h o th e p r o x y represents has n e v e r been c o m p e te n t, such as a c h ild .

■ W ithholding and W ithdrawing Treatm en t P e o p le in s o cie ty a n d h e a lth c a re p ro fe s s io n a ls h a v e a cc ep ted a n d e th ic a lly ju s tifie d w ith h o ld in g a n d w it h d r a w in g tre a tm e n ts th a t h a v e been d e em e d as fu tile o r e x tr a o r d in a ry . W h e n a tre a tm e n t has n o p h y s io lo g ic b e n e fit fo r a te r­ m in a lly ill p e rs o n , th e tre a tm e n t is co n sid e re d to be fu tile c a re (B e a u c h a m p & C h ild re s s , 2 0 0 9 ) . M e d ic a l tre a tm e n ts in c lu d e c a rd io p u lm o n a ry re s u s c ita tio n , m e d ic a tio n s , m e c h a n ic a l v e n tila tio n , a rtific ia l feed in g a n d flu id s , h e m o d ialy sis, c h e m o th e ra p y , a n d o th e r life -s u s ta in in g te c h n o lo g ie s . F u t ility issues n e ed to be discussed a m o n g nurses, p h y sic ia n s , fa m ily m e m b e rs , a n d p a tie n ts w h e n p o s sib le . A c o u rt-a p p o in te d o r fa m ily s u rro g a te d e c is io n m a k e r c a n be th e s p o ke sp ers o n fo r th e p a tie n t. N u rs e s n e ed to ensure th a t a d e c is io n -m a k in g process b e tw e e n th e h e a lth c a re te a m a n d th e d e cis io n m a k e rs fo r th e p a tie n t ta k e s p lac e so th a t e v e ry o n e has a ch an c e to express feelings a n d concerns (L a d d , P a s q u e re lla , & S m ith , 2 0 0 2 ) . T h r e e le g a l cases g e n e ra te d la n d m a r k decisions a b o u t w ith h o ld in g a n d w it h d r a w in g tre a tm e n ts . In 1 9 7 5 , K a re n A n n Q u in la n ’s case esta b lish e d th e rig h t to d isc o n tin u e m e c h a n ic a l v e n tila tio n (Jonsen et a l., 1 9 9 8 ; In r e Q u in la n , N e w Jersey). In 1 9 9 0 , th e U .S . S u p re m e C o u r t e s ta b lis h e d th ro u g h N a n c y C r u z a n ’s case th re e c o n d itio n s : th e p a tie n t has a rig h t to refuse m e d ic a l tr e a t­ m e n t; a rtific ia l fe e d in g c o n s titu te s m e d ic a l tr e a tm e n t; a n d i f th e p a tie n t is m e n ta lly in c o m p e te n t, th e n each state has to d o c u m e n t c le a r a n d c o n v in c in g evid e n ce th a t th e p a tie n t’s desires w e re fo r d is c o n tin u a n c e o f m e d ic a l tr e a t­ m e n t (Jonsen et a l., 1 9 9 8 ; I n r e C r u z a n , M is s o u r i). T h e t h ir d case is a m o re re c e n t o n e . I t is th e case o f T e r r i S c h ia v o , a y o u n g w o m a n in a p e rsis te n t v e g e ta tiv e s tate, w h o d ie d o n M a r c h 3 1 , 2 0 0 5 . T h e re w e re a to ta l o f 2 1 le g a l suits, b u t th e las t fe w cases in v o lv e d T e r r i ’s h u s b a n d M ic h a e l’s re q u e st to h a v e h e r fe e d in g tu b e d is c o n tin u e d , w h ic h also w o u ld end h e r a rtific ia l n u tr itio n a n d h y d ra tio n . T e r r i ’s p a re n ts fo u g h t th is re q u e s t. A c c o rd in g to F lo rid a la w , M ic h a e l S ch ia vo as a spouse a n d g u a rd ia n h a d a leg a l rig h t to serve as a s u rro g a te d e cis io n m a k e r fo r T e r r i S ch ia vo . In

c o n ju n c tio n w it h th is le g a l s ta n d a rd , s u b s titu te d ju d g m e n t w a s used as th e a p p ro p r ia te e th ic a l s ta n d a rd . Because T e r r i S ch ia vo h a d n o w r it te n a d v a n c e d ire c tiv e , h e r s u rro g a te w a s c h a rg e d w it h m a k in g a n u n b ia s e d s u b s titu te d ju d g m e n t a b o u t h e r c are. T h e ju d g m e n t s h o u ld be based o n an u n d e rs ta n d in g o f w h a t she w o u ld d e cid e f o r h e rs e lf a n d n o t th e v a lu e s o f th e s u rro g a te . M ic h a e l S ch ia vo a n d o th e r p e o p le te s tifie d th a t T e r r i h a d s tated th a t she d id n o t w a n t to liv e in a c o n d itio n in w h ic h she w o u ld be a b u rd e n to a n y o n e else. T h is evid e n ce served as th e basis fo r m a n y o f th e c o u r t’s d e n ials o f th e S c h in d le rs ’ requests to c o n tin u e T e r r i ’s a rtific ia l n u tr itio n a n d h y d ra tio n . I n th e C o d e o f E t h i c s f o r N u r s e s w it h I n t e r p r e t i v e S t a t e m e n t s , P ro v is io n 1 .3 , th e A N A (2 0 0 1 ) takes th e p o s itio n th a t nurses e th ic a lly s u p p o rt th e p ro v is io n o f co m p as sio n a te a n d d ig n ifie d e n d -o f-life care as lo n g as nurses d o n o t h a v e th e sole in te n tio n o f e n d in g a p e rs o n ’s life . A special s ta te m e n t c o n c e rn in g th e T e r r i S ch ia vo case w a s released to th e press b y th e A N A o n M a r c h 2 3 , 2 0 0 5 , th a t u p h e ld th e d e cis io n fo r th e r ig h t o f a p a tie n t o r s u r­ ro g a te to choose fo rg o in g a rtific ia l n u tr itio n a n d h y d ra tio n . N o m a tte r w h a t th e o u tc o m e o f d iffic u lt e n d -o f-life decision s, fa m ily m e m b e rs a n d p a tie n ts n eed to feel a sense o f c o n fid e n c e th a t nurses w ill m a in ta in m o r a l s e n s itiv ity a n d g o o d ju d g m e n t.

■ Term inal Sedation L e g a lly p e rm is s ib le y e t e th ic a lly c o n tro v e rs ia l, te rm in a l s e d a tio n (T S ) seems to be m o v in g to w a r d a s o cia l a n d an e th ic a l accep tan ce (Q u ill, 2 0 0 1 ) . Q u ill (2 0 0 1 ) defines te rm in a l s e d a tio n as fo llo w s : W h e n a s u ffe rin g p a tie n t is sedated to unconsciousness, u s u a lly th ro u g h th e o n g o in g a d m in is tra tio n o f b a rb itu ra te s o r b e n z o d ia z ­ epines. T h e p a tie n t th e n dies o f d e h y d ra tio n , s ta rv a tio n , o r som e o th e r in te rv e n in g c o m p lic a tio n , as a ll o th e r life -s u s ta in in g in te r ­ v e n tio n s are w ith h e ld . (p . 1 8 1 ) W h e n th e w o r d te r m in a l is used, th e re is a n u n d e rs ta n d in g a m o n g th e h e a lth ­ c are te a m m e m b e rs a n d fa m ily th a t th e o u tc o m e , a n d p o s s ib ly a d esired o u t­ c o m e, is d e ath (S u g a rm a n , 2 0 0 0 ) . T S has been used in s itu atio n s w h e n p atien ts n eed p a in r e lie f th a t re q u ire s b e in g sedated to th e p o in t o f unconsciousness. T h e A N A (2 0 0 1 ) does n o t address T S d ire c tly in th e C o d e o f E th ic s f o r N u r s e s w ith I n t e r p r e t iv e S ta te m e n ts b u t does state th a t nurses are to give c o m p a s ­ s io n ate c are a t th e e n d o f life . T h e re is an em p hasis in th e c ode th a t nurses a re n o t to h a v e th e sole in te n t o f e n d in g a p e rs o n ’s life .

■ Physician-Assisted Suicide M o r a l o u tra g e t o w a r d s o cia l a c c e p ta n c e re g a rd in g p h y s ic ia n -a s s is te d s u i­ cide has o c c u rre d in s o cie ty. P h y s ic ia n -a s s is te d s u ic id e is d e fin e d as “ th e act

o f p ro v id in g a le th a l dose o f m e d ic a tio n fo r th e p a tie n t to s e lf-a d m in is te r” (S u g a rm a n , 2 0 0 0 , p . 2 1 3 ). O re g o n a n d W a s h in g to n are th e o n ly states in th e U n ite d States th a t c u rre n tly a llo w p h y sic ia n -as sisted s u icid e. T h e le g a l basis in O r e g o n is th e D e a th w it h D ig n it y A c t, w h ic h w a s passed in 1 9 9 4 . W it h c e rta in re s tric tio n s , p a tie n ts w h o are n e a r d e a th c an o b ta in p re s c rip tio n s to e n d th e ir lives in a d ig n ifie d w a y . A lth o u g h th e A N A (2 0 0 1 ), in th e C o d e o f E th ic s f o r N u r s e s w ith I n t e r p r e ­ tiv e S ta te m e n ts , p la in ly states th a t nurses are n o t to a ct w it h th e sole in te n t o f e n d in g a p e rs o n ’s life , th e O re g o n N u rs e s A s s o c ia tio n issued special g uidelines fo r nurses th a t re la te to th e D e a th w it h D ig n it y A c t (L a d d et a l., 2 0 0 2 ) . T h e g u id e lin e s in c lu d e m a in ta in in g s u p p o rt, c o m fo r t, a n d c o n fid e n tia lity ; d is ­ cussing e n d -o f-life o p tio n s w it h th e p a tie n t a n d fa m ily ; a n d b e in g p re se n t fo r th e p a tie n t’s s e lf-a d m in is tra tio n o f m e d ic a tio n s a n d d u rin g th e d e a th . N u rs e s m a y n o t a d m in is te r th e m ed ic atio n s them selves; b re ac h c o n fid e n tia lity ; subject o th ers to a n y ty p e o f ju d g m e n ta l c o m m e n ts o r s tatem e n ts a b o u t th e p a tie n t; o r refuse c are to th e p a tie n t.

■ End-of-Life Decisions and Moral Conflicts N u rs e s firs t m u s t s o rt o u t th e ir o w n fe e lin g s a b o u t th e v a rio u s ty p e s o f e u th a n a s ia b e fo re a p p r o p r ia te g u id a n c e a n d d ir e c tio n c a n be o ffe r e d to p a tie n ts a n d fa m ilie s . In one Japanese s tu d y o f 1 6 0 nurses, K o n is h i, D a v is , a n d T o s h ia k i ( 2 0 0 2 ) s tu d ie d w it h d r a w a l o f a r tific ia l fo o d a n d flu id fr o m te r m in a lly ill p a tie n ts . T h e m a jo r it y o f th e nurses s u p p o rte d th is a c t o n ly u n d e r tw o c o n d itio n s : i f th e p a tie n t req u ested th e w ith d r a w a l o f a rtific ia l fo o d a n d flu id s , a n d i f th e a c t re lie v e d th e p a tie n t’s s u ffe rin g . N u rs e s a g re e d th a t c o m fo r t fo r th e p a tie n t w a s a g re a t c o n c e rn . O n e n u rse in th e s tu d y s tated th is : “ [A r tific ia l fo o d a n d flu id ] A F F o n ly p ro lo n g s th e p a tie n t’s s u ffe rin g . W h e n w it h d r a w n , th e p a tie n t s h o w e d pe ac e o n th e fa ce . I h a v e seen such p a tie n ts so m a n y tim e s ” (K o n is h i et a l., 2 0 0 2 ) . In th e sam e s tu d y , a n o th e r n u rse w h o w a s e x p e rie n c in g m o r a l c o n flic t w it h th e d e cis io n to w it h d r a w th e a rtific ia l fo o d a n d flu id s ta te d th is : “ W it h d r a w a l is k illin g a n d c ru e l. I feel g u ilty ” (K o n is h i et a l., 2 0 0 2 ) . O t h e r e n d -o f-life issues c a n g e n e ra te m o r a l c o n flic ts , as w e ll. G e o rg es a n d G r y p d o n c k (2 0 0 2 ) c o n d u c te d a lite r a tu re re v ie w o n th e to p ic o f e th ic a l issues in te rm s o f h o w nurses p e rce ive th e ir care to d y in g p a tie n ts . T h e y o u t­ lin e d som e o f th e m o r a l d ile m m a s th a t are p a rtic u la rly re la te d to nurses a n d e n d -o f-life c are . S om e o f th e m o ra l p ro b le m s o f nurses fo u n d in th e lite r a tu re w e re th e fo llo w in g : • • •

C o m m u n ic a tin g tr u th fu lly w it h p a tie n ts a b o u t d e a th because th e y w e re fe a rfu l o f d e s tro y in g a ll h o p e a m o n g th e p a tie n t a n d fa m ily M a n a g in g p a in s y m p to m s because o f fe a r o f h a s te n in g d e a th F e e lin g fo rc e d to c o lla b o ra te w it h o th e r h e a lth te a m m em b ers a b o u t m e d i­ c al tre a tm e n ts th a t in n urses’ o p in io n s a re fu tile o r to o b u rd e n s o m e

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CHAPTER 11 Ethical Issues in Professional Nursing Practice

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F e e lin g insecure a n d n o t a d e q u a te ly in fo r m e d a b o u t reasons fo r tre a tm e n t T r y in g to m a in ta in th e ir o w n m o r a l in te g r ity th ro u g h o u t re la tio n s h ip s w it h p a tie n ts , fa m ilie s , a n d c o w o rk e rs because o f fe e lin g th a t th e y are fo rc e d to b e tra y th e ir o w n m o ra l values

A lt h o u g h th e c o n s c ie n tio u s n u rs e has an o b lig a tio n to p r o v id e c o m ­ p a s s io n a te a n d p a llia tiv e c are , th e n u rse also has a r ig h t to w it h d r a w fr o m tre a tin g a n d c a rin g fo r a p a tie n t as lo n g as a n o th e r n u rse has assum ed care fo r th e d y in g p a tie n t. W h e n care is such th a t th e nurse perceives it as v io la tin g p e rs o n a l m o r a lit y a n d v alu e s, th e p ro fe s s io n a l n u rs e m u s t seek a lte rn a tiv e a p p ro a c h e s to a ch ieve p a tie n ts ’ goals.

C o nclu sio n N u rs e s ’ in v o lv e m e n t w it h b io e th ic a l issues becom es m o re c o m p lic a te d as tim e passes. N u rs e s m u s t le a rn to c u ltiv a te g o o d p ro fe s s io n a l re la tio n s h ip s w h ile also e n su rin g th a t th e stresses o f th e ir jo b d o n o t d is tra c t th e m fr o m d e liv e rin g d ire c t o r in d ire c t p a tie n t care th a t is e th ic a l a n d p a tie n t c e n te re d . P ra c tic in g n u rs in g e th ic a lly c a n n o t be based m e re ly o n in tu itiv e fu n c tio n in g . T o be a d v o ­ cates fo r p a tie n ts d u rin g d iffic u lt a n d sensitive tim e s, nurses m u s t u n d e rs ta n d k e y e th ic a l concepts a n d seek a c tiv e in v o lv e m e n t in b e in g v a lu a b le m e m b e rs o f h e a lth c a re te am s .

CASE STUDY ■ END-OF-LIFE CARE

G

ertrude, an 85-year-old woman, was diagnosed with end-stage renal disease, long-standing adult-onset diabetes, and aortic stenosis. Her renal disease now has led to a terminal condition. Still conscious, she told her youngest daughter that she wanted no life-sustaining measures done. On the next day, she lost consciousness. Then, her other two daughters arrived at the hospital from out of town. The three daughters argued about the treatment for their mother; the youngest wanted to honor the wishes of her mother and the other two wanted full medical treatment to be initiated. The physician and nurse dis­ cussed the treatment options and the futility issue with the family. To avoid further disagreement, the youngest daughter decided to go along with the decision of the other two sisters.

Case Study Questions 1. 2. 3.

4.

5.

Explain the reason that the physician and nurse discussed futile treatment with the daughters. Do you believe that the mother had a right to choose her course of treatment? Explain. Discuss the end-of-life options that the daughters could have chosen for their mother’s care had they chosen the “no treatment” option. Discuss the different types of surrogate decision making. Was there a surrogate decision maker in this family? Explain. What specific nursing support and care could you offer to this family and patient? ■

R e fe re n c e s American Nurses Association. (2001). Code o f ethics for nurses with interpretive statements. Washington, DC: Author. Angeles, P. A. (1992). The HarperCollins dictionary o f philosophy (2nd ed.). New York, NY: HarperCollins. Beauchamp, T. L., & Childress, J. F. (2009). Principles o f biomedical ethics (6th ed.). New York, NY: Oxford University Press. Benjamin, M. (2003). Pragmatism and the determination of death. In G. McGee (Ed.), Pragmatic bioethics (2nd ed.). London, England: Bradford Book—MIT Press. Bondeson, J. (2001). Buried alive: The terrifying history o f our most primal fear. New York, NY: W. W. Norton. Brannigan, M. C., & Boss, J. A. (2001). Healthcare ethics in a diverse society. Mountain View, CA: Mayfield. Buchanan, A. E., & Brock, D. W. (1990). Deciding for others: The ethics o f surrogate decision making. New York, NY: Cambridge University Press. Center for Economic Justice and Social Justice. (n.d.). Defining economic justice and social justice. Washington, DC: Author. Retrieved from http://cesj.org/thirdway/ economicjustice-defined.htm Centers for Disease Control and Prevention. (2007). Suicide: Facts at a glance. Retrieved from http://www.cdc.gov/ncipc/dvp/suicide/SuicideDataSheet.pdf Chambliss, D. E. (1996). Beyond caring: Hospitals, nurses, and the social organization o f ethics. Chicago: The University of Chicago Press. Daniels, N. (1985). Just health care. Cambridge, England: Cambridge University Press. Death: The last taboo. (2003). What is death? Australian Museum. Retrieved from http://australianmuseum.net.au/What-is-death. Devettere, R. J. (2000). Practical decision making in health care ethics: Cases and concepts (2nd ed.). Washington, DC: Georgetown University Press. Engelhardt, H. T. (1996). Rights to health care, social justice, and fairness in health care allocations: Frustrations in the face o f finitude: The foundations o f bioethics (2nd ed.). New York, NY: Oxford University Press. Finnerty, J. L. (1987). Ethics in rational suicide. Critical Care Nursing Quarterly, 10(2), 86-90. Fry, S., & Johnstone, M. J. (2002). Ethics in nursing practice: A guide to ethical decision making (2nd ed.). Oxford, England: Blackwell Science. Georges, J. J., & Grypdonck. M. (2002). Moral problems experienced by nurses when caring for terminally ill people: A literature review. Nursing Ethics, 9(2), 155-178. Guido, G. W. (2001). Legal and ethical issues in nursing (3rd ed.). Upper Saddle River, NJ: Prentice Hall. Hester, D. M. (2001). Community as healing: Pragmatist ethics in medical encounters. Lanham, MD: Rowman & Littlefield. International Council of Nurses. (2006). The International Council o f Nurses code o f ethics for nurses. Geneva: Author. Jameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs, NJ: Prentice Hall. Jonsen, A. R., Siegler, M., & Winslade, W. J. (2002). Clinical ethics (5th ed.). New York, NY: McGraw-Hill.

Jonsen, A. R., Veatch, R. M., & Walters, L. (1998). Source b o o k in bioethics. Washington, DC: Georgetown University Press. Kaiser Family Foundation. (2007). U.S. health care costs. Retrieved from http://www. kff.org/ Kelly, C. (2000). Nurses’ moral practice: Investing and discounting self. Indianapolis, IN: Sigma Theta Tau International. Konishi, E., Davis, A. J., & Toshiaki, A. (2002). The ethics of withdrawing artificial food and fluid from terminally ill patients: An end-of-life dilemma for Japanese nurses and families. Nursing Ethics, 9(1), 7-19. Ladd, R. E., Pasquerella, L., & Smith, S. (2002). Ethical issues in home health care. Springfield, IL: Charles C Thomas. MacIntyre, A. (1999). D ependent rational anim als. Chicago, IL: Open Court Publishing. Maes, S. (2003). How do you know when professional boundaries have been crossed? Oncology Nursing Society News, 18(8), 3-5. Mappes, T. A., & DeGrazia, D. (2001). Biomedical ethics (5th ed.). Boston, MA: McGraw-Hill. Massachusetts Department of Higher Education. (2010). Nurse o f the future: Nursing core competencies. Retrieved from http://www.mass.edu/currentinit/documents/ NursingCoreCompetencies.pdf McKenna, B. G., Smith, N. A., Poole, S. J., & Coverdale, J. H. (2003). Horizontal violence: Experiences of registered nurses in their first year of practice. Journal o f Advanced Nursing, 42(1), 90-96. Munson, R. (2004). Intervention and reflection: Basic issues in medical ethics (7th ed.). Victoria, Australia: Wadsworth-Thomson. Novak, M. (2000). Defining social justice. First Things First, 108, 11-13. Nozick, R. (1974). Anarchy, state and utopia. New York, NY: Basic Books. Office of Minority Health. (2007). Data statistics African American profiles: Health conditions. Retrieved from http://www.minorityhealth.hhs.gov/templates/browse. aspx?lvl=3&lvlid=23 Organ Procurement and Transplantation Network. (2007). Waiting list candidates. Retrieved from http://optn.transplant.hrsa.gov/ Perrin, K. O., & McGhee, J. (2001). Ethics and conflict. Thorofare, NJ: Slack. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. (1981). Defining d eath. Washington, DC: U.S. Government Printing Office. Quill, T. E. (2001). Caring for patients at the end o f life: Facing an uncertain future together. New York, NY: Oxford University Press. Rawls, J. (1971). A theory o f justice. Cambridge, MA: Harvard University Press. Shotton, L., & Seedhouse, D. (1998). Practical dignity in caring. Nursing Ethics, 5(3), 246-255. Siegel, K. (1986). Psychosocial aspects of rational suicide. American Journal o f Psychotherapy, 40(3), 405-418. Sokolowski, R. (1991). The fiduciary relationship and the nature of professions. In E. D. Pellegrino, R. M. Veatch, & J. P. Langan (Eds.), Ethics, trust, and the professions: Philosophical and cultural aspects (pp. 23-43). Washington, DC: Georgetown University Press.

Stein, L. I., Watts, D. T., & Howell, T. (1990). The doctor-nurse game revisited. Nursing Outlook, 38(6), 264-268. Sugarman, J. (2000). 20 common problems: Ethics in primary care. New York, NY: McGraw-Hill. U.S. Department of Health and Human Services. (2003). Organ donation and transplantation. Retrieved from http://www.hhs.gov/ Veatch, R. M. (2003). The basics o f bioethics (2nd ed.). Upper Saddle River, NJ: Prentice Hall. Wildes, K. W. (2000). Moral acquaintances: Methodology in bioethics. Notre Dame, IN: University of Notre Dame Press. Winslow, G. R. (1988). Ethical issues in professional life. New York, NY: Oxford University Press. World Health Organization. (2003). WHO definition of palliative care. Retrieved from http://www.who.int/cancer/palliative/definition/en/print.html World Health Organization. (2007). Mental health: The bare facts. Retrieved from http://www.who.int/mental_health/en Youngner, S. J., & Arnold, R. M. (2001). Philosophical debates about the definition of death: Who cares? Journal o f Medicine & Philosophy, 26(5), 527-537. Zaner, R. M. (1991). The phenomenon of trust and the patient-physician relationship. In E. D. Pellegrino, R. M. Veatch, & J. P. Langan (Eds.), Ethics, trust, and the professions: Philosophical and cultural aspects (pp. 45-67). Washington, DC: Georgetown University Press.

Law and the Professional Nurse Evadna Lyons and Kathleen Driscoll

T h e p ro fe s s io n s o f la w a n d n u rs in g a re b o th d e v o te d to h e lp in g p a tie n ts , c lie n ts , a n d s o cie ty. A h a rm o n io u s in te ra c tio n b e tw e e n th e areas o f la w a n d n u rs in g is necessary fo r a c h ie v in g e ffe c tiv e o u tco m e s fo r b o th th e n u rse a n d th e p a tie n t. N u rs e s m u s t u n d e rs ta n d h o w th e leg a l system w o rk s to be safe a n d e ffe c tiv e p ra c titio n e rs . T h e a d v a n c e d state o f m e d ic a l te c h n o lo g y creates n e w le g a l, e th ic a l, m o r a l, a n d fin a n c ia l p ro b le m s fo r th e c o n s u m e r a n d th e h e a lth c a re p ra c titio n e r. P a tie n ts a re m o re a w a re o f th e ir le g a l rig h ts ; hence, nurses m u s t m a k e a c o n c e rte d e ffo r t to p ra c tic e b y th e leg a l a n d p ro fe s s io n a l s tan d ard s set fo r th b y fe d e ra l a n d state en titie s. L a w a n d n u rs in g a re b o th pro fessio n s d e v o te d to h e lp in g p a tie n t/c lie n ts a n d society b y a d v o c a tin g fo r h e a lth c a re im p ro v e m e n ts a n d justice. L a w serves as a g u id in g fo rce fo r re la tio n s h ip s b e tw e e n perso n s, perso ns a n d g ro u p s, a n d g ro u p s a n d o th e r g ro u p s . N o te th e w o rd s g u i d i n g a n d f o r c e . F o r g u id a n c e to o c c u r, la w m u s t be d e v e lo p e d . F o r im p le m e n ta tio n to o c cu r, th e la w m u s t be e n fo rc e d .

Learning Objectives A fte r c o m p le tin g th is c h a p te r, th e s tu d e n t should be a b le to : 1. Discuss w h y an u n d e rs ta n d in g of th e legal p ro ­ fession is n e ce ss ary fo r th e nurse. 2 . D iscuss th e fu n c tio n s and s o u rc e s o f law as th e y re la te to h e a lth c a re and p ro fe s s io n a l nursing p ra c tic e . 3 . Discuss w h a t th e te rm s ta n d a rd o f c a r e m eans fo r th e nurse. 4 . Discuss th e e le m e n ts of m a lp ra c tic e and n egli­ gence and how th e y re la te to nursing p ra c tic e . 5 . D escribe th e tria l process in re g a rd to civil p ro ­ c ed u res including th e nurse's role as an e x p e rt w itness. 6 . E xa m in e th e fu n c tio n s of th e s ta te bo ard s of nursing in re la tio n s h ip to e d u c a tio n , p ra c tic e , and discipline.

7 . Discuss th e im p o rta n c e of th e N urse P ra c tic e A c t in re g a rd to s a fe and e ffe c tiv e n u rsin g p ra c tic e . 8 . A p p ly th e c o n c e p t o f p ro fe s s io n a l a c c o u n t­ a b ility to p ro fe s s io n a l and legal s ta n d a rd s in re la tio n s h ip to in fo rm e d c o n s e n t, c o n fid e n ti­ a lity , and p riv ac y. 9 . C ritiq u e th e legal a sp e cts of d e le g a tio n . 10. E xam ine s tra te g ie s fo r avoiding legal problem s. 11. D is c u s s h e a lth c a r e re fo r m r e la te d to th e P a tie n t P ro te c tio n and A ffo rd a b le C are A c t. 12. D escrib e th e nurse's m oral role in c o n fro n tin g bullying in th e w o rkp la ce .

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L a w e vo lves b y a c c o m m o d a tin g to chang es in s o c ie ty w h ile a d h e rin g to th e b asic p rin c ip le s set fo r th in a n a tio n ’s g u id in g d o c u m e n t, w h ic h in th e U n ite d States is th e C o n s titu tio n . P rin c ip le s set fo r th in th e C o n s titu tio n in c lu d e fre e d o m o f re lig io n a n d a ssem b ly, fre e d o m fr o m u n d u e in te rfe re n c e b y g o v e rn m e n t, a n d th e r ig h t to tr ia l b y ju r y in c rim in a l cases. T h r e e sources o f la w a re b u ilt o n th e fu n d a m e n ta l la w o f th e fe d e ra l C o n s titu tio n . T h e y a re s ta tu to ry la w , a d m in is tra tiv e la w o r re g u la to ry la w , a n d case la w . I t is im p o r ta n t to n o te th a t fe d e ra l la w is a d m in is te re d th e sam e in a ll states. H o w ­ ever, each state m ig h t v a ry o n h o w it in te rp re ts a n d im p le m e n ts la w s . H e n c e , in te rp re ta tio n o f leg a l issues fo r nurses v arie s fr o m state to s tate. N u r s in g a n d h e a lth c a re la w set fo r th n u rs in g a n d h e a lth p o lic y g o a ls. A n u rse p ra c tic e a ct has th e g o a l o f p ro te c tin g th e s afe ty o f th e p u b lic w h o receive n u rs in g care. E ac h state has statutes th a t g o v e rn th e p ra ctice o f n u rsin g , a n d a lth o u g h som e d iffere n c es e xist fr o m state to s tate, in g e n e ra l th e nurse p ra c tic e acts d e fin e w h o m u s t be licen sed , re q u ire m e n ts fo r lic e n s u re , duties o f th e licensed n u rse , a n d g ro u n d s o n w h ic h th e license m a y be re v o k e d o r ta k e n a w a y . T h is c h a p te r discusses th e th re e sources o f la w , n u rse p ra c tic e acts, d e le g a tio n stan d ard s o f c are , c iv il p ro ce d u re s, a n d p ro fe s s io n a l a n d leg al a c c o u n ta b ility in n u rs in g p ra c tic e .

T h e S o u rces of Law Key Terms and Concepts » Statutory law » Lobbyist » Administrative or regulatory law » Case law » Civil law » Tort » Expert witness » Negligence » Malpractice » Respondeat superior » Licensure » Alternative program » Informed consent » Privacy » Confidentiality » Delegation

■ S ta tu to ry Law In a d e m o c ra tic society such as th e U n ite d States, th e p e o p le elect re p re s e n ta ­ tives to g o v e rn in g bodies th a t co n sid e r p ro p o se d le g is la tio n . T h e states a n d the fe d e ra l g o v e rn m e n t h a v e a le g is la tiv e b o d y th a t is c o m p o s e d o f tw o houses. T h e fe d e ra l g o v e rn m e n t has th e H o u s e o f R e p re s e n ta tiv e s a n d th e S en ate. M o s t state legislatures h a ve s im ila r nam es fo r th e ir legislative bodies. T o g e th e r th e fe d e ra l le g is la tiv e b o d y is te rm e d C ongress. M o s t state leg is latu res also h a v e in c lu s iv e nam es fo r th e ir le g is la tiv e bodies; fo r e x a m p le , th e c o m b in a ­ tio n o f tw o state bo d ies m ig h t c a rry a d e s ig n a tio n such as G e n e ra l A s s e m b ly . S ta tu t o r y law consists o f e v e r-c h a n g in g rules a n d re g u la tio n s c re a te d b y th e U .S . C ongress, state leg is lato rs, lo c a l g o v e rn m e n ts , a n d c o n s titu tio n a l la w . T h e statutes are th e rig h ts , p riv ile g e s , o r im m u n itie s secured a n d p ro te c te d fo r each c itiz e n b y th e U .S . C o n s titu tio n (F re m g e n , 2 0 0 2 ) . T h e process o f c re a tin g le g is la tio n is c o m p le x . T h e process c a n b e g in w it h a le g is la to r re s p o n d in g to th e interests o f a g ro u p o f perso ns. A le g is la to r m ig h t also in itia te a c tio n o n a p ro b le m b y c o n v e n in g a g ro u p o f in te re s te d perso ns o r o th e r le g is la to rs to c o n s id e r le g is la tiv e o p tio n s fo r re s o lv in g th e p ro b le m . In te re s te d persons o r g ro u p s c an re p re s e n t specific c o n cern s. Since th e tu r n o f th e 2 1 s t c e n tu ry , n u rs in g o rg a n iz a tio n s such as th e A m e ric a n

N u rs e s A s s o c ia tio n ( A N A ) a n d th e A m e r ic a n A s s o c ia tio n o f C o lle g e s o f N u r s in g ( A A C N ) h a v e fo cused o n le g is la tio n a d d re ss in g p a tie n t s afe ty , such as specific s ta ffin g levels a n d c o n tro llin g m a n d a to ry o v e rtim e . Such o rg a n iz e d g ro u p s o fte n h ire lo b b y is ts r a th e r th a n re ly in g o n g ro u p m e m b e rs to p ro m o te th e ir interests to le g is la to rs . L o b b y is ts d e v e lo p e x p e rtis e o n p ro p o s e d le g is la tio n a n d le a rn to p re se n t th a t in fo r m a tio n to le g is la to rs c le a rly a n d c o n cis ely . C o n s c ie n tio u s leg is la ­ to rs a n d th e ir staffs lis te n to b o th sides b e fo re v o tin g o n a n issue. O n a v e ry im p o r t a n t issue, h o w e v e r , o rg a n iz a tio n s also e n c o u ra g e th e ir m e m b e rs to w r ite letters s u p p o rtin g th e o rg a n iz a tio n ’s p o s itio n o r to m a k e an a p p o in tm e n t to sp ea k w it h th e le g is la to r o r ta lk w it h th e le g is la to r’s s ta ff. G e n e ra lly , n o a c tio n is ta k e n o n b ills in tr o d u c e d to le g is la tiv e b o d ie s unless th ere is a c o n flu e n ce o f p ro b le m s , s o lu tio n s , a n d p o litic a l circum stances th a t c re a te a c lim a te fo r p a s s in g le g is la tio n (L o n g e s t, 2 0 0 2 ) . M a n y m o re bills are in tro d u c e d in to C ongress a n d th e state leg is latu res th a n a re passed. L e g is la tiv e a c tio n a lo n e is in s u ffic ie n t fo r a b ill to b e co m e la w . C o n g re s s io n a l bills re q u ire th e p re s id e n t’s s ig n a tu re , a n d state b ills re q u ire th e s ig n a tu re o f th e s ta te ’s g o v e rn o r to be e n ac te d in to la w . T h e p re s id e n t a n d state g o v ern o rs c an also choose to v e to le g is la tio n . T h is c h e c k o n le g is la tiv e p o w e r b y th e e x e c u tiv e b ra n c h o f g o v e rn m e n t is p a r t o f th e system o f balances a m o n g th e b ran ch es o f g o v e rn m e n t e n su red b y th e n a tio n ’s fo u n d e rs .

■ A dm inistrative Law (R egulations) O n c e a b ill becom es la w , th a t la w is su b ject to fu rth e r re fin e m e n t b y fe d e ra l o r s ta te a g en c ies , w h ic h a re p a r t o f th e e x e c u tiv e b ra n c h o f g o v e r n m e n t. E n a c te d s ta tu to ry la w states w h a t C o n g ress o r a state le g is la tu re w a n ts to a cc o m p lis h a n d w h a t activ ities sh o u ld o c cu r to a cc o m p lis h th e leg islative g o a l. F e d e ra l o r state agencies c a rry o u t th a t a c tiv ity b y d e v e lo p in g re g u la tio n s th a t fu r th e r d e fin e th e la w a n d e s ta b lis h th e p ro c e d u re s fo r a d m in is te rin g th e la w . F o r e x a m p le , a state n u rse p ra c tic e a ct m ig h t p ro v id e th a t a d v a n c e d p ra c tic e nurses d e v e lo p a fo r m u la r y o f m e d ic a tio n s th e y m a y p re s c rib e . T h e process fo r d e v e lo p in g th e fo r m u la r y w ill be d o n e th ro u g h th e ru le -m a k in g o r re g u la to ry process. T h e r e g u la t o r y p ro c e s s is it s e lf g o v e r n e d b y s ta t u t o r y l a w c a lle d a d m in is tr a tiv e p ro c e d u re acts a t b o th fe d e ra l a n d s tate le v e ls . T h e s e acts p ro v id e th a t b e fo re re g u la tio n s c an be a d o p te d a p u b lis h e d n o tic e o f th e p r o ­ po sed ru les a n d w h e re th e y a re a v a ila b le m u s t o c cu r. T h e p u b lis h e d n o tic e a n d a v a ila b ility o f th e p ro p o s e d ru le s p ro v id e c o n c e rn e d perso ns w it h th e o p p o rtu n ity to c o m m e n t o n a n d suggest changes to th e rules b e fo re fin a l a d o p ­ tio n . W h e n rules a re a d o p te d , th e y b e co m e a d m in is tra tiv e (o r re g u la to ry ) law w it h in a set p e rio d o f tim e . T h u s , th e process has th re e steps: (1 ) p ro p o s a l o f re g u la tio n s , (2 ) c o n s id e ra tio n o f p ro p o s e d re g u la tio n s , a n d (3 ) a d o p tio n o f re g u la tio n s w it h o r w it h o u t changes.

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S taffs o f e x e c u tiv e b ra n c h agencies d e v e lo p p ro p o s e d re g u la tio n s . In th e case o f fe d e ra l re g u la tio n s , n o tic e o f th e p ro p o s e d re g u la tio n s is p ro v id e d th r o u g h a p u b lic a tio n c a lle d th e F e d e r a l R e g is t e r . A n e x a m p le is M e d ic a r e re g u la tio n s th a t d e sc rib e c o n d itio n s fo r h e a lth c a re fa c ilitie s to re ce ive r e im ­ b u rs e m e n t. T h is is a serious c o n c e rn fo r h o s p ita ls because a h ig h p e rc e n ta g e o f h o s p ita l re v e n u e com es fr o m M e d ic a r e re im b u rs e m e n t. In f o r m a t io n o n fe d e ra l s ta tu to r y a n d a d m in is tr a tiv e l a w is a v a ila b le a t h t tp : //th o m a s .lo c . g o v . I n f o r m a t io n o n s ta te l a w c a n be fo u n d a t s tate w e b s ite s . T h e s e c a n be accessed b y e n te rin g te rm s such as S ta te o f O h i o o r S ta te o f C a lifo r n ia in a sea rch .

■ Case Law C as e la w is esta b lish e d fr o m c o u rt decision s, w h ic h c an e x p la in o r in te rp re t th e o th e r sources o f la w . F o r e x a m p le , a c o u rt case m ig h t e x p la in w h a t th e c o n s titu tio n , a s ta tu te , o r a re g u la tio n m ea n s . C as e la w o r c o m m o n la w also defin es le g a l rig h ts a n d o b lig a tio n s . F o r e x a m p le , a n u rs e ’ s o b lig a tio n to p ra c tic e as a re a s o n a b ly p ru d e n t nurse is a leg a l o b lig a tio n s te m m in g fr o m a c tu a l c o u rt decision s. C ase la w is based o n p re c e d e n t, m e a n in g a ru lin g in one case th a t is th e n sub seq u en tly a p p lie d to la te r s im ila r cases. W h e n case la w is a p p lie d , it m u s t be re v ie w e d b y th e c o u rt to d e te rm in e i f it is s till re le v a n t; hen ce, m a n y case la w s a re c h a n g e d a n d u p d a te d o v e r th e years. T h e p re v a il­ in g ru le r o v e r case la w is u ltim a te ly th e state s u p re m e c o u rt fo r state la w s a n d th e U .S . S u p re m e C o u r t fo r fe d e ra l s tatu te s. W h e n th e ju d ic ia l b ra n c h o f g o v e rn m e n t becom es in v o lv e d , it creates case la w . T h e ju d ic ia l b ra n c h o f g o v e rn m e n t is th e th ir d c o m p o n e n t o f th e b a la n c e o f p o w e r in g o v e rn m e n t a t b o th fe d e ra l a n d state levels.

C la s s ific a tio n and E n fo rc e m e n t of th e Law W h e n p e o p le c h o o s e n o t to f o llo w th e la w , c o u rts h a v e th e o b lig a tio n to en fo rc e th e la w . E n fo rc e rs o f th e la w also in c lu d e p o lic e a n d p ro se cu to rs . T h e ju stice d e p a rtm e n t a t th e fe d e ra l le v e l a n d th e a tto rn e y g e n e ra l’s offices a t th e state le v e l re p re s e n t fe d e ra l a n d state g o v e rn m e n t in te re sts. Judges a re also enfo rc e rs o f th e la w . In ju r y tria ls , th e y in s tru c t ju ro rs to a p p ly th e facts o f a case to th e la w ; in cases in w h ic h th e re is n o ju ry , tr ia l judges b o th e x a m in e th e facts a n d a p p ly th e la w . C ase law is b o th c iv il a n d c rim in a l. C ivil law invo lves re la tio n sh ip s b e tw ee n in d iv id u a ls o r b e tw e e n in d iv id u a ls a n d th e g o v e rn m e n t. C iv il la w s are d iv id e d in to s ix categories: to r t, c o n tra c t, p ro p e rty , in h e rita n c e , fa m ily , a n d c o rp o ra te la w . C r im in a l la w p ro te c ts th e p u b lic fr o m th e h a r m fu l acts o f o th ers .

■ Civil Law C iv il la w s th a t c o m m o n ly a ffe c t nurses in c lu d e to r t a n d c o n tra c t la w s . T o r t la w re fe rs to acts t h a t re s u lt in h a r m to a n o th e r . C o n tr a c t la w in c lu d e s e n fo rc e a b le agree m en ts b e tw e e n tw o o r m o re perso ns. A t o r t is a w r o n g fu l a c t th a t is c o m m itte d a g a in s t a n o th e r p e rs o n o r p ro p e rty th a t results in h a rm . T o sue fo r a t o r t , a p a tie n t m u s t h a ve s u ffe re d a m e n ta l o r p h y s ic a l in ju ry t h a t w a s cau s ed b y th e n u rs e . T o r ts c a n be in te n tio n a l o r a c c id e n ta l a n d th e p a tie n t m ig h t re c o v e r m o n e ta ry d a m ag e s. A c c o rd in g to F re m g e n (2 0 0 2 ), in te n tio n a l to rts c an in c lu d e assault, b a tte ry , false im p ris o n m e n t, d e fa m a tio n , fr a u d , a n d in v a s io n o f p riv a c y : •

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A s s a u lt: T h e th re a t o f b o d ily h a rm to a n o th e r. T h e re does n o t h a v e to be a c tu a l to u c h in g (b a tte ry ) fo r a n assault to ta k e p lac e . F o r e x a m p le , th re a t­ e n in g to h a rm a p a tie n t o r to p e rfo r m a p ro c e d u re w it h o u t th e in fo r m e d c o n se n t (p e rm is s io n ) o f th e p a tie n t. B a tte ry : A c tu a l b o d ily h a rm to a n o th e r p e rs o n w it h o u t p e rm is s io n . T h is is also re fe rre d to as u n la w fu l to u c h in g o r to u c h in g w it h o u t c o n se n t. F o r e x a m p le , p e rfo rm in g surgery o r a p ro c e d u re w ith o u t th e in fo rm e d consent (p e rm is s io n ) o f th e p a tie n t. False im p ris o n m e n t: A v io la tio n o f th e p e rs o n a l lib e rty o f a n o th e r p erso n th ro u g h u n la w fu l re s tra in t. F o r e x a m p le , refusing to a llo w a p a tie n t to leave a n o ffice , h o s p ita l, o r m e d ic a l fa c ility w h e n th e p e rso n requests to lea ve . D e fa m a tio n o f c h ara cter: D a m a g e caused to a p e rs o n ’s re p u ta tio n th ro u g h s p o k e n o r w r itte n w o r d . F o r e x a m p le , m a k in g a n e g a tiv e s ta te m e n t a b o u t a n o th e r n u rs e ’s a b ility . F ra u d : D e c e itfu l p ra c tic e , such as p ro m is in g a m ira c le c u re. In v a s io n o f p riv a c y : T h e u n a u th o riz e d p u b lic ity o f in fo r m a tio n a b o u t a p a tie n t. F o r e x a m p le , a llo w in g p e rs o n a l in fo r m a tio n , such as test results fo r H I V , to b e co m e p u b lic w it h o u t th e p a tie n t’s p e rm is s io n .

A n u n in te n tio n a l to r t u s u a lly occurs w h e n th e n u rse does n o t a c t w ith in th e re as o n a b le stan dards o f n u rs in g care. A re a s o n a b le s ta n d a rd o f c a re m eans th a t th e n u rse m u s t im p le m e n t th e ty p e o f care th a t a “ re a s o n a b ly p ru d e n t n u rse w o u ld use in a s im ila r c irc u m s ta n c e .” O fte n , u n in te n tio n a l to rts re s u lt fr o m n e g lig en c e. N e g lig e n c e is th e fa ilu re to p e rfo r m p ro fe s s io n a l d u tie s to a n a cc ep ted s ta n d a rd o f c are . N u rs e s s h o u ld focus o n p re v e n tin g n eglig ence r a th e r th a n tr y in g to d e fe n d it d u rin g a c iv il case.

The Trial Process for Civil Procedures N u rs e s a re m o s t o fte n in v o lv e d in c iv il cases re la te d to m a lp ra c tic e o r n e g li­ gence. T h e p a tie n t b rings th e case ag ain s t th e h e a lth c a re fa c ility o r nurse, w h o becom es th e d e fe n d a n t. I f th e d e fe n d a n t loses, th e p la in t if f receives m o n e ta ry dam ag es as c o m p e n s a tio n fo r th e in ju r y . F o r a c iv il case to be w o n , th e ju d g e o r ju r y m u s t fin d a p re p o n d e ra n c e o f evid en ce fo r th e w in n in g side.

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CHAPTER 12 Law and the Professional Nurse

Figure 12-1

Procedure for a civil tria l The complaining party, or attorney, prepares a complaint and files it with the proper court. The defendant is served a summons that formally notifies defendant of the plaintiff’s suit. The defen­ dant or defendant’s attorney prepares an answer and files it in the same court. Pretrial matters may be filed or heard. A settlement may be reached at any time. The case is heard in court by a judge or by a jury composed of 6 to12 jurors. Either party may wish to appeal the case to the court of appeals and perhaps eventually to the Supreme Court.

S ou rce: Adapted from A C itizen ’s G u id e to for the Courts, 1997.

jin gton C ourts. State Office o f Administrator

N u rs e s s h o u ld h a v e a basic u n d e rs ta n d in g o f th e p ro ce ed in g s in v o lv e d in a c iv il tr ia l because th is is th e ty p e o f tr ia l th a t in vo lv es th e n u rs in g p ro fes s io n . In a c iv il case, i f th e ju d g e o r ju r y fin d s in fa v o r o f th e p la in tiff, th e d e fe n d a n t w ill be o rd e re d to p a y th e p la in t iff a m o n e ta ry a w a rd . A p la in t iff o r d e fe n d a n t m a y a p p ea l th e decision to a h ig h e r c o u rt (H a v in g h u rs t, 1 9 9 8 ). See Figure 1 2 - 1 fo r an illu s tr a tio n o f a c iv il tr ia l p ro c e d u re .

Nurses as Expert Witnesses N u rs e s w it h a d v a n c e d degrees a n d c lin ic a l k n o w le d g e a re o fte n c a lle d as e x p e rt witnesses d u rin g c iv il tria ls . A n e x p e rt w itn e s s has c o m p le x k n o w le d g e b e y o n d th e g e n eral k n o w le d g e o f m o s t p e o p le in th e c o u rt o r o n th e ju ry . M o s t nurses w h o te s tify as e xp e rts are c a lle d to te s tify as to w h a t th e “ s ta n d a rd o f

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c a re ” fo r a p a tie n t is in a s im ila r c irc u m s ta n c e . E x p e r t w itnesses g e n e ra lly d o n o t te s tify a b o u t th e e x a c t facts o f th e case. In s te a d , th e y c la rify p o in ts o f k n o w le d g e u s in g c h a rts , m o d e ls , a n d d ia g ra m s .

■ Crim inal Law C r im in a l la w s p ro te c t society fr o m th e h a r m fu l acts o f o th e rs . C r im in a l acts a re classified as felo n ies o r m is d e m e a n o rs . A fe lo n y carrie s a p u n is h m e n t o f d e a th o r im p ris o n m e n t in a state o r fe d e ra l fa c ility . F e lo n ie s o fte n in v o lv e m u rd e r, ra p e , ro b b e ry , o r p ra c tic in g w ith o u t a license. M is d e m e a n o rs are less serious a n d in c lu d e th e ft, tra ffic v io la tio n s , a n d d is tu rb in g th e peace. A n u rs e ’s license m a y be re v o k e d b y th e state b o a rd i f he o r she is c o n v ic te d o f a c rim e . A n u rse sellin g o r s te a lin g drugs results in a c rim in a l case. In a c rim in a l case, society is th e p la in tiff, a n d th e n u rse becom es th e d e fe n d a n t. I f th e nurse d e fe n d a n t loses, th e n u rse w ill h a v e re s tric tio n s p lac e d o n his o r h e r lib e rty . R e s tric tio n s c a n in c lu d e a p ris o n te rm , p r o b a t io n , o r tr e a tm e n t in lie u o f c o n v ic tio n . In th e las t s itu a tio n , th e re s tric tio n is c o m p lia n c e w ith a d ru g tr e a t­ m e n t p ro g ra m th a t in clu d es ra n d o m d ru g te s tin g . F a ilu re to c o m p ly w it h th e tr e a tm e n t p ro g ra m c a n re s u lt in a c rim in a l p u n is h m e n t such as p ro b a tio n o r even in c a rc e ra tio n . C r im in a l cases h a v e a h ig h e r s ta n d a rd o f e vid e n ce . Juries m u s t fin d th e d e fe n d a n t g u ilty b e y o n d a re a s o n a b le d o u b t. T h e U .S . ju stice s ys te m is b a se d o n th e p re m is e th a t p e o p le a re in n o c e n t W W W 1 CRITICAL THINKING QUESTIONS* u n til p ro v e n g u ilty . Because th e p la in t iff is c la im in g th a t th e nurse v io la te d th e la w , th e b u rd e n o f p r o o f is p la c e d u p o n What measures are taken when a nurse th e p la in t if f to p ro v e th a t th e d e fe n d a n t is lia b le . is summoned to court for a legal action? Is B o ard s o f n u rs in g also a ct as en fo rc e rs o f th e la w w h e n a nurse more responsible than a doctor in th e y d is c ip lin e a n u rse fo r v io la tio n o f a p ro v is io n o f th e that situation if both were involved with the la w o r rules o f th e s ta te ’s nurse p ra c tic e a ct. B o ard s use th e patient’s care?* p re p o n d e ra n c e -o f-e v id e n c e s ta n d a rd .

M a lp ra c tic e and N eg lig en ce T h e p u b lic g e n e ra lly has a v e ry p o s itiv e v ie w o f nurses. N u rs e s a re e xp e cted to be o f g o o d m o r a l a n d e th ic a l c h a ra c te r because th e p u b lic has a g re a t d e al o f tru s t fo r nurses. F u r th e rm o re , th e p riv ile g e o f o b ta in in g a n u rs in g license is o fte n o v e rlo o k e d as a n o p p o r tu n ity , a n d th e r ig h t to p ra c tic e n u rs in g is fre q u e n tly p e rc e iv e d as a n “ in c id e n ta l e n title m e n t” a fte r c o m p le tin g a n u rs ­ in g e d u c a tio n (C le v e tte , E rb in -R o s e n m a n n , & K e lly , 2 0 0 7 ) . T h e n u r tu rin g aspect o f n u rs in g s u p p o rts a “ g o o d w i l l ” p ro file w it h little , i f a n y , in te n tio n o f w ro n g d o in g . H o w e v e r , w h e n nurses fa il to fo llo w th e s ta n d a rd s o f p ra c tic e , th is c a n re s u lt in c la im s o f m a lp ra c tic e o r neg lig en ce. N u rs e s are c itize n s w h o a re b o u n d b y p ro fe s s io n a l a c c o u n ta b ility a n d re s p o n s ib ility . A n eglig ence c la im is successful o n ly w h e n th e p la in t if f pro ves

KEY COMPETENCY 12-1 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Professionalism: Knowledge (K2) Describes legal and regulatory fac­ tors that apply to nursing practice Attitudes/Behaviors (A2a) Values professional stan­ dards of practice Skills (S2a) Uses recognized professional standards of practice Source: Massachusetts Department of Higher Education (2010), p. 13.

th e re q u ire d elem ents o f n e g lig en c e. T h e firs t e le m e n t is d u ty , w h ic h c an be d e fin e d as “ le g a l o b lig a tio n th a t is o w e d o r due to a n o th e r a n d th a t needs to be satisfied; a n o b lig a tio n fo r w h ic h s o m e b o d y else has a c o rre s p o n d in g r ig h t ” (G a r n e r , 2 0 0 9 ) . W h a t a re stan dards? T h e A N A defines s ta n d a rd s as “ a u th o r ita tiv e s tate ­ m en ts b y w h ic h th e n u rs in g p ro fe s s io n describes th e re sp o n sib ilities fo r w h ic h its p ra c titio n e rs are a c c o u n ta b le ” (A m e ric a n N u rs es A ss o cia tio n [ A N A ] , 2 0 0 4 , p . 1 ). A N A s ta n d a rd s o f p ra c tic e are b ro a d a n d are fo rm a tte d a c c o rd in g to th e steps o f th e n u rs in g process, w h ic h is th e c ritic a l th in k in g to o l o f n u rs in g . T h e steps in c lu d e assessm ent, d iag n o sis , o u tco m e s id e n tific a tio n , p la n n in g , im p le m e n ta tio n , a n d e v a lu a tio n . T h e A N A e lected to in c o rp o ra te m e a s u re ­ m e n t c rite ria fo r each step o f th e process, th us m a k in g th e m e a s u re m e n t c ri­ te ria p a r t o f th e s ta n d a rd . T h e co n sis te n t th em es o f th e m e a s u re m e n t c rite ria p e rm it d e te rm in in g w h e th e r th e s ta n d a rd s a re m e t. T h e y in c lu d e c u ltu ra lly a n d e th n ic a lly sensitive c are , m a in ta in in g a safe e n v iro n m e n t, e d u c a tio n o f p a tie n ts , c o n tin u ity o f care, c o o rd in a tio n o f care, m a n a g e m e n t o f in fo rm a tio n , e ffe c tiv e c o m m u n ic a tio n , a n d u s in g te c h n o lo g y . C a r r y o u t th e steps o f th e n u rs in g process, in c o rp o ra tin g th e a p p lic a tio n o f th e m e a s u re m e n t c rite ria , a n d th e s ta n d a rd o f care w ill be m e t. A leg al nurse c o n s u lta n t o r nurse e x p e rt s c ru tin izin g a h e a lth c a re re c o rd a t issue in a la w s u it c an use these stan d ard s to d e te rm in e w h e th e r th e re is reaso n to go fo r w a r d w it h a m a lp ra c tic e s u it. T h e n u rse w ill also a p p ly th e m o re s p ec ialize d a n d specific s tan d ard s d e v e lo p e d b y s p e c ia lty g ro u p s in n u rs in g . F o r e x a m p le , th e N e o n a ta l N u rs in g A s s o c ia tio n , th e A m e ric a n A s s o c ia tio n o f W o m e n ’s H e a lt h a n d O b s te tric a l a n d N e o n a ta l N u rs in g , a n d th e A m e ric a n A s s o c ia tio n o f C ritic a l C a re N u rs e s h ave th e ir o w n s tan d ard s. S ta n d a rd s com e fr o m o th e r sources as w e ll. A g o o d e x a m p le is th e B lo o d -B o rn e P a th o g e n S ta n d a rd p ro m u lg a te d b y th e O c c u p a tio n a l S afety a n d H e a lth A d m in is tra tio n . T h is s ta n d a rd is a n e x a m p le o f a s ta n d a rd fo r a ll h e a lth c a re p ro v id e rs , n o t ju s t nurses. S ta n d a rd s e vo lv e o v e r tim e as rese arch fin d in g s a re in c o rp o ra te d in to p ra c tic e . S ta n d a rd s o f p ra c tic e a re c ritic a l, b u t th e re are also s ta n d a rd s th a t are e x p e c ta tio n s o f a p ro fe s s io n a l. R e c o g n iz in g th ese e x p e c ta tio n s , th e A N A elected to a d d p ro fe s s io n a l p e rfo rm a n c e s tan dards to its 1 9 9 1 stan d ard s d o c u ­ m e n t. T h e se s ta n d a rd s address q u a lity o f p ra c tic e , e d u c a tio n , p ro fe s s io n a l p ra c tic e e v a lu a tio n , c o lle g ia lity , c o lla b o ra tio n , ethics, re se arch , re so u rce use, a n d le a d e rs h ip . Because s tan d ard s o f care e vo lv e, one o f th e A N A ’s p ro fe s ­ s io n al p e rfo rm a n c e stan dards speaks d ire c tly to th e nurse a tta in in g k n o w le d g e a n d c o m p e te n c y th a t reflects c u rre n t n u rs in g p ra c tic e ( A N A , 2 0 0 4 ) . P ra ctic e a n d p ro fe s s io n a l s tan dards c an also a p p e a r in state p ra ctice acts a n d rules. T h e le g a l n u rse c o n s u lta n t w ill e x p e c t th a t th e nurses d o c u m e n tin g in th e m e d ic a l re c o rd d e m o n s tra te c u rre n t k n o w le d g e a n d c o m p e te n c y based o n g e n e ra l an d s p ec ialize d s tan d ard s in th e ir a rea o f p ra c tic e .

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■ Evidence of Standards of Care Used in Court T h e ju d g e decides th e issue re g a rd in g th e e le m e n t o f d u ty in a n e g lig e n c e c la im . T h e fo llo w in g lis t in c lu d e d evid en ce o f s tan d ard s o f c are th a t are o fte n used in c o u rt: •

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S tatutes: C o m m o n la w ru les th a t m a n d a te c e rta in c o n d u c t. A n e x a m p le o f a s ta tu te as evid e n ce o f th e s ta n d a rd o f c are is c h ild abuse re p o rtin g re q u ire m e n ts . T h e se statutes c le a rly state w h a t a h e a lth c a re p ro v id e r m u s t d o w h e n c h ild abuse is suspected. A g e n c y re g u la tio n s : F e d e ra l a n d state a d m in is tra tiv e agencies p ro m u lg a te rules a n d re g u la tio n s th a t also c an a ffe c t th e s ta n d a rd o f c are. A c c re d ita tio n s tan d ard s: T h e J o in t C o m m is s io n s tan d ard s h a v e b e en re c ­ o g n iz e d in som e c o u rt cases as evid en ce fo r s ta n d a rd o f c are. F a c ility d o c u m en ts : T h e se m ig h t in c lu d e p o licie s, p ro ce d u re s, jo b d e sc rip ­ tio n s , a n d p ro fe s s io n a l n u rs in g g u id e lin e s . M a n u fa c t u r e r ’s in s tru c tio n s : In re g a rd to m e d ic a l e q u ip m e n t o r a m e d ic a ­ tio n in v o lv e d in an in ju r y , m a n u fa c tu re r in s tru c tio n s c a n be e x a m in e d as s tan d ard s o f c are. N u rs in g lite r a tu re : T h is in clu d es te x tb o o k s a n d jo u rn a l a rtic le s . E x p e rt te s tim o n y : E x p e r t w itnesses p ro v id e te s tim o n ia l evid en ce re le v a n t to d u ty a n d s ta n d a rd o f c are. I t is im p o r t a n t to re m e m b e r th a t nurses c a n n o t be h e ld as n e g lig e n t if, w h e n an in c id e n t h a p p e n s , th e y w e re p e rfo r m in g based o n s tan d ard s o f p ra c tic e . I t w o u ld be u p to th e ir e m p lo y e r to accept lia b ility o n th e ir b e h a lf. H o w e v e r , nurses a lw a y s n e ed to c a rry lia b ility in s u ra n c e in case th e y are c h a rg e d w it h n e g lig en ce o r m a lp ra c tic e .

M o s t nurses a re v e ry fa m ilia r w it h th e te rm s n e g lig e n c e a n d m a lp ra c tic e . W h a t is th e d iffere n c e b e tw e e n m a lp ra c tic e a n d negligence? N eg lig e n ce is d e fin e d as th e fa ilu re to a ct as a re a s o n a b ly p ru d e n t p e rs o n w o u ld h a v e a cte d in a specific s itu a tio n (F in k e lm a n , 2 0 0 6 ) . M a lp ra c tic e is th e fa ilu re o f a p ro fe s s io n a l to use such c a re as a re a s o n a b ly p r u d e n t m e m b e r o f th e p ro fe s s io n w o u ld use u n d e r s im ila r circum stances, w h ic h leads to h a rm . F o r e x a m p le , a n u rse a d m in is te rs th e p a tie n t’s d a ily dose o f L a n o x in w ith o u t c h e c k in g th e a p ic a l pulse a n d w ith o u t c h e c k in g th e d ig o x in lev el. T h e p a tie n t’s pulse d ro p s to 2 0 b eats p e r m in u te fo llo w e d b y a fu ll c a rd ia c a rre s t. U p o n in s p e c tio n o f th e p a tie n t’s d ig o x in level, th e nurse discovers th a t th e p a tie n t w a s e x p e rie n c in g d ig ita lis to x ic ity . A la y perso n m ig h t n o t k n o w to check the a p ic a l pulse a n d d ig o x in le v e l p r io r to L a n o x in a d m in is tra tio n ; b u t a p ro fe s s io n a l nurse k n o w s th a t fa ilu re to d o so p r io r to L a n o x in a d m in ­ is tra tio n is a b re a c h o f th e p ro fe s s io n a l s ta n d a rd o f care.

r Negligence is defined as the failure to act as a reasonably prudent person would have acted in a specific situation.

J

r Malpractice is the failure of a professional to use such care as a reasonably prudent member of the profession would use under similar circumstances, which leads to harm.

J

N u rs e s c a n be b o th n e g lig e n t a n d g u ilty o f m a lp r a c tic e . A c c o rd in g to F in k e lm a n ( 2 0 0 6 ) , to p ro v e n e g lig e n c e o r m a lp r a c tic e th e fo llo w in g fo u r elem ents m u s t be m e t: • • • •

T h e re w a s a d u ty o w e d to th e p a tie n t. T h e re w a s a b re a c h o f d u ty o r s ta n d a rd b y th e h e a lth c a re p ro fe s s io n a l. T h e re w a s h a r m caused b y th e b re a c h o f d u ty o r s ta n d a rd . T h e p e rs o n (p la in tiff) e x p e rie n c e d dam ag es o r in ju rie s .

S o m e e x a m p le s o f p o te n tia l risk s fo r nurses a re fa ilu r e to a d e q u a te ly assess, m o n ito r , a n d c o m m u n ic a te ; fa ilu re to a ct as a p a tie n t’s a d v o c a te (fo r e x a m p le , n o t p ro v id in g p ro p e r e d u c a tio n fo r a c lie n t w it h c o n g estive h e a rt fa ilu re ); o r fa ilu re to p ro te c t th e p a tie n t w h e n s u ic id a l o r a t ris k fo r fa lls . A ll nurses n e ed to c o n s id e r these risks w h e n c a rin g fo r p a tie n ts . A q u e s tio n th a t o fte n com es u p w it h nurses is w h o is u ltim a te ly re s p o n ­ sible fo r th e m a lp ra c tic e o r negligence: th e nurse o r th e e m p lo y in g in s titu tio n ? R e s p o n d e a t s u p e r io r is th e d o c trin e th a t in d ic a te s th e e m p lo y e r m ig h t also be re sp o n sib le i f th e nurse w a s fu n c tio n in g in th e e m p lo y e e ro le a t th e tim e o f th e in c id e n t (G ro s s m a n , 2 0 0 5 ) . T h is im p lie s th a t b o th th e h e a lth c a re o rg a n iz a tio n a n d th e nurse c a n be sued. T h e U .S . D e p a r tm e n t o f H e a lt h a n d H u m a n Services (2 0 0 3 ) c o n d u c te d a s tu d y to d e te rm in e th e types o f m a lp ra c tic e acts c o m m o n ly re p o rte d to th e N a t io n a l P ra c titio n e rs D a t a B a n k . T h e results o f th e s tu d y in d ic a te d a b o u t 1 o u t o f 5 0 m a lp ra c tic e re p o rts a re m a d e fo r nurses. T h e re p o rt is p u b lic ly a v a ila b le a t w w w .n p d b h ip d b .c o m . T h e n u rs in g s pecializations in c lu d e d in this stu d y w e re R N , nurse anesthetist, nurse m id w ife , nurse p ra c titio n e r, a d va n ce d p ra c tic e n u rse , a n d L V N / L P N (B o lin , 2 0 0 5 ) . T h e types o f m a lp ra c tic e codes re p o rte d a re lis te d in Table 12 -1 . C a n a nurse be b ro u g h t to c o u rt fo r negligence? Y e s . A fin d in g o f n e g li­ gence occurs w h e n th e nurse ow es a d u ty to a p a tie n t a n d breaches an o rd in a ry s ta n d a rd o f care k n o w n b y lay p e rso n s, a n d th e p a tie n t is h a rm e d . A n e x a m p le w o u ld be th e n u rse le a v in g th e side r a il d o w n o n th e bed o f a 2 -m o n th -o ld in fa n t. A n o r d in a r y p e rs o n w o u ld k n o w th a t le a v in g th e side r a il d o w n is u n s afe. F in d in g s o f e ith e r m a lp ra c tic e o r neglig ence re s u lt in th e n u rse b e in g lia b le to c o m p e n s a te th e h a rm e d p e rs o n . A m a lp ra c tic e la w s u it re q u ire s an e x p e rt w itn e s s , a n d a n eglig ence la w s u it does n o t. N u rs e s a re ra re ly in d iv id u a lly sued. M a lp r a c tic e in s u ra n c e o f th e fa c ility fo r w h ic h th e n u rse w o rk s w ill m o s t o fte n c o v e r d a m ag e s. N u rs e s , h o w e v e r, c an a n d sh o u ld p u rch ase m a lp ra c tic e in su ran ce to a v o id th e ris k o f lo sin g th e ir p e rs o n a l assets. T h e nurse m ig h t be in a s itu a tio n in w h ic h he o r she is v ie w e d as p ra c tic in g as a nurse a n d h a rm occurs. A n e x a m p le m ig h t be p o o r advice g iv e n to a frie n d in fa ilin g to re c o m m e n d fu rth e r assessm ent b y a h e a lth c a re p ro v id e r w h e n a c h ild is in ju re d in a fa ll. M a lp r a c tic e a n d neglig ence a re n o t in te n tio n a l actio n s o r in a c tio n s . T h e y a re careless a c tio n s o r in a c tio n s t h a t a re m o re lik e ly to o c c u r in stressfu l

Malpractice and Negligence

TAB LE 12-1 Diagnosis

285

M alpractice A c t or Om ission Codes

F a ilu re , w ro n g , im p ro p e r p e rfo rm a n c e , unnecessary, delay, la c k o f in fo rm e d consent Anesthesia F a ilu re to p ro p e rly assess, m o n i­ to r , test, a n d use e q u ip m e n t, im p ro p e r ch o ice, in tu b a tio n , p o s itio n in g , a n d fa ilu re to o b ta in in fo r m e d c o n se n t Surgery F a ilu re to p e rfo r m , im p ro p e r p o s itio n in g , fo re ig n b o d y , w r o n g b o d y p a rt, im p ro p e r p e rfo rm a n c e , unnecessary s u rg e ry, d e la y , im p ro p e r m a n a g e m e n t, a n d la c k o f in fo r m e d c o n se n t Medication W r o n g m e d , dosag e, im p ro p e r a d m in is tra tio n , im p ro p e r te c h n iq u e , a n d la c k o f in fo r m e d c onsent IV and Blood F a ilu re to m o n ito r , w r o n g s o lu tio n , w r o n g ty p e , im p ro p e r a d m in is tra tio n and m anagem ent

Obstetrics

Im p r o p e r d e liv e ry , d e la y in d e liv e ry , fa ilu re to p ro p e rly m a n a g e , d e la y , a b a n d o n m e n t Treatment W r o n g tre a tm e n t, im p ro p e r in s tru c ­ tio n , im p ro p e r p e rfo rm a n c e , fa ilu re to supervise, fa ilu re to re fe r o r seek c o n s u lt Monitoring F a ilu re to m o n ito r , fa ilu re to re s p o n d a n d re p o rt Equipment/Product Im p r o p e r m a in te n a n c e , im p ro p e r use, fa ilu re to in s tru c t p a tie n t, m a lfu n c tio n o r fa ilu re Miscellaneous B re a c h o f c o n fid e n tia lity , in ju ry to th ir d p a rtie s , im p ro p e r b e h a v io r, b re a c h o f in s titu tio n a l p o licies S ou rce: U.S. Department of Health and Human Services (2003).

circ u m s ta n ce s o r because th e n u rse has n o t m a in ta in e d k n o w le d g e a n d c o m ­ p e te n c y in a n a rea o f p ra c tic e . M o n tg o m e r y (2 0 0 7 ) e x a m in e s basic p rin c ip le s o f h u m a n e rro r a n d sleep p h y s io lo g y a n d eva lu ate s th e evid en ce fo r p o te n tia l effects o f fa tig u e d h e a lth c a re w o rk e rs a n d w o r k lo a d o n m e d ic a l e rro rs . T h e researchers c o n d u c te d th e s tu d y in a p e d ia tric in te n s iv e c are u n it, w h ic h is a h ig h ly c o m p le x e n v iro n m e n t in w h ic h fa tig u e a n d excessive w o r k lo a d m ig h t a llo w erro rs to o c cu r. T h e results in d ic a te d th a t n u rs in g fa tig u e a n d w o r k lo a d h a ve d o c u m e n te d effects o n in c re a s in g in te n s iv e c are u n it e rro rs , in fe c tio n s , a n d co st. S pecific e n v iro n m e n ta l fa c to rs such as d is tra c tio n s a n d c o m m u ­ n ic a tio n b a rrie rs w e re also ass o cia te d w it h g re a te r e rro rs . T h e researchers c o n c lu d e th a t fa tig u e , excessive w o r k lo a d , a n d th e p e d ia tric in te n s iv e care e n v iro n m e n t c o u ld a d ve rse ly a ffe c t th e p e rfo rm a n c e o f p h ysician s a n d nurses w o r k in g in th is ty p e o f setting. C a s tle d in e (2 0 0 6 ) re v ie w s a n u rs in g negligence case in w h ic h a re g is te re d n u rse w it h 6 m o n th s o f e x p e rie n c e p e rfo r m e d a b la d d e r ir r ig a tio n u s in g a c an o f c o la . T h e p a tie n t s u ffe re d m a jo r distress, a n d th e n u rse w a s re p o rte d to th e b o a rd o f n u rs in g fo r b re a c h o f th e co d e o f p ro fe s s io n a l c o n d u c t a n d n e g lig en c e. T h e nurse c la im e d th a t she th o u g h t th e c o la w o u ld b re a k d o w n th e “ d e b ris ” in th e b la d d e r. O b v io u s ly , th is n u rse d id n o t f o llo w p ro fe s s io n a l s ta n d a rd s o f p ra c tic e r e la tin g to b la d d e r i r r i ­ g a tio n . B ecause o f h e r in e x p e rie n c e a n d la c k o f k n o w le d g e , th e n u rse w a s o n ly re q u ire d to receive a d d itio n a l e d u c a tio n a n d s u p p o rt. N u rs e s m u s t be

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CHAPTER 12 Law and the Professional Nurse

a c c o u n ta b le fo r th e ir a c tio n s w h ile p r o v id in g p a tie n t c a re . T h e n u rse has a d u ty to p ra c tic e c o m p e te n tly a n d possess k n o w le d g e , s kills , a n d a b ilitie s re q u ire d fo r la w fu l, safe, a n d e ffe c tiv e p ra c tic e . M u r p h y (2 0 0 4 ) e x a m in e s a case ( L o g sd o n v. M iller ) in w h ic h th e p la in ­ t i f f d e v e lo p e d re fle x s y m p a th e tic d y s tro p h y in h e r le ft a rm a n d h a n d a fte r a 7 -h o u r re c o n s tru c tiv e ja w su rg e ry in 1 9 9 9 . T h e c irc u la tin g n u rse p o s itio n e d , s u p p o rte d , a n d p a d d e d th e p la in t iff. P o s to p e ra tiv e ly , th e p la in t iff w o k e w it h n u m b n ess a n d p a in in h e r le ft a rm . T h e p la in t if f s u ffe re d CRiTiCAL THiNKiNG QUESTION V p e rm a n e n t n e rv e d a m a g e a n d sued th e p h y s ic ia n a n d th e n u rse ’s e m p lo y e r h o s p ita l, a lle g in g neglig ence fo r fa ilu re to What does “reasonable and prudent” mean p ro p e rly p o s itio n th e p a tie n t. T h e c o u rt ru le d th a t th e nurse as it relates to standards of care?V w a s n o t lia b le because she h a d fo llo w e d th e a p p ro p r ia te s ta n d a rd o f c a re in p o s itio n in g th e p a tie n t. T h e s e cases in d ic a te th a t a ll nurses n eed to c o m p ly w it h th e g u id e lin e s a n d s tan d ard s o f n u rs in g p ra c tic e . P re v e n tio n requires le a rn in g h o w to m a n a g e stress a n d a d h e rin g to c u rre n t s tan d ard s o f c are . N u rs e s s h o u ld le a rn to lea ve th e ir p e rs o n a l life stresses a t th e d o o r o f th e ir w o rk p la c e . T h e y sh o u ld resist th e te m p ta tio n to s elf-m ed ic ate th e ir stresses w it h a lc o h o l o r o th e r d ru g s. W h e n th e y fin d th em selves d o in g so, th e y s h o u ld seek h e lp b e fo re th e ir p ro fe s s io n a l p ra c tic e is a ffe c te d . N u rs e s s h o u ld also seek to p ra c tic e in w o r k e n v iro n m e n ts th a t e n co u rag e e x a m in a tio n o f in cid e n ts th a t m ig h t h a ve caused o r d o cause h a rm to p a tie n ts . O fte n , systems in w h ic h th e n u rse w o rk s c an be c h a n g e d to m a k e th e e n v i­ ro n m e n t safer fo r nurses a n d p a tie n ts . T h e In s titu te o f M e d ic in e ( I O M ) re c ­ o m m e n d s c h a n g in g system s to lo w e r th e ris k o f p ra c tic e e rro rs in sev era l re p o rts . T h e s e in c lu d e T o E rr Is H um an: Building a Safer H ealth System , Crossing the Q uality C hasm : A N ew H ealth System fo r the 21st Century , an d WWW

I CRiTiCAL THiNKiNG QUESTiONV

You have been asked by a charge nurse on a medical surgical unit to discuss the importance of the legal system for nurses. What are the important aspects regarding law and nursing that you will include in your presentation?^

K eep in g Patients Safe: Transform ing the W o r k E nviron­ m ent o f N urses ( I O M , 2 0 0 0 , 2 0 0 1 , 2 0 0 4 ) . In a d d itio n th e I O M has released a re p o r t e n title d In form in g the Future: Critical Issues in H ealth th a t addresses q u a lity o f p a tie n t

care in th e U n ite d States ( I O M , 2 0 0 7 ) . C h a n g in g systems is n o t th e sole s o lu tio n . P a tte rn s o f s u b s ta n d a rd p ra c tic e s till re q u ire th e fa c ility to e ith e r h e lp th e n u rse im p ro v e p ra c tic e o r m a k e a c o m p la in t to th e state b o a rd o f n u rs in g so th a t d is c ip lin a ry a c tio n can re m o v e th e nurse fr o m being in a p o s itio n to h a r m p a tie n ts e ith e r th ro u g h re v o c a tio n , s u sp e n s io n , o r a m o n ito re d p ra c tic e im p ro v e m e n t p ro g ra m . A fre q u e n t q u e s tio n a b o u t leg a l issues fr o m p ra c tic in g nurses a t c o n fe r­ ences is “ S h o u ld I c a rry m y o w n m a lp r a c tic e in s u ra n c e e ve n th o u g h I a m c o v e re d u n d e r m y e m p lo y e r’s in s u ra n c e ? ” T h e a n s w e r is “ N e v e r leave h o m e w it h o u t i t ! ” N u rs e s s h o u ld c a rry th e ir o w n m a lp ra c tic e in s u ra n c e because th e re is a d iffe re n c e a n d s e p a ra tio n b e tw e e n th e n u rs e ’s lia b ility fo r a w r o n g ­ d o in g a n d his o r h e r e m p lo y e r ’s lia b ilit y . T h e n u rs e uses his o r h e r o w n

ju d g m e n t w it h in th e c o n te x t o f th e scope a n d s ta n d a rd s o f p ra c tic e ( A N A , 2 0 1 0 ) a n d th e business re la tio n s h ip w it h th e e m p lo y e r. T h e in s u re r o f th e e m p lo y e r h e a lth c a re in s titu tio n m ig h t h a v e re as o n to focus o n its e lf, ra th e r th a n fu lly d e fe n d in g th e n u rse . T h u s , th e n u rse needs to h a v e his o r h e r o w n in s u re r th a t w ill p a y fo r th e n u rs e ’s defense.

KEY COMPETENCY 12-2 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Professionalism:

N u rs in g L ic e n s u re ■ H istory of Licensure N u r s in g has e v o lv e d o n a tr a c k p a ra lle l w it h o th e r h e a lth c a re p ro fes s io n s. T h e e d u c a tio n o f nurses p a r tic u la r ly p a ra lle ls th e e d u c a tio n o f d o c to rs o f m e d ic in e . B o th d is c ip lin e s firs t e x p e rie n c e d a p p re n tic e s h ip e d u c a tio n f o l ­ lo w e d b y g ra d u a l e v o lu tio n to e d u c a tio n w ith in e d u c a tio n a l in s titu tio n s . E ve n to d a y , a c ritic a l piece o f th is e d u c a tio n re m a in s th e o p p o rtu n ity fo r c lin ic a l p ra c tic e in h e a lth c a re fa c ilitie s . In c re a s in g ly , h o w e v e r, u n d e rs ta n d in g o f h u ­ m a n p h y s io lo g y has been re fin e d to e x a m in a tio n a t th e c e llu la r a n d m o le c u la r levels. A d v a n c e s in d ia g n o s tic a n d tr e a tm e n t te c h n o lo g y h a v e also o c c u rre d . T h e se changes h a v e b re d th e n e ed fo r an in c re a s in g k n o w le d g e base a t b o th th e fo u n d a tio n a l a n d s p e c ia liz a tio n levels o f e d u c a tio n in b o th n u rs in g a n d m e d ic in e (K a lis c h & K a lis c h , 1 9 9 5 ). L ic e n s u re w a s n o t a lw a y s a re q u ire m e n t fo r n u rs in g p ra c tic e . I n fa c t, th e a c k n o w le d g e d fo u n d e r o f m o d e rn n u rs in g , F lo re n c e N ig h tin g a le , d id n o t b e lie v e nurses s h o u ld be re c o g n iz e d b y a g o v e rn m e n t b o d y (K a lis c h & K a lis c h , 1 9 9 5 ) . M e m b e r s o f th e field s o f m e d ic in e a n d n u rs in g e v e n tu a lly th o u g h t o th e rw is e . A n in c re a s in g k n o w le d g e base le d to in c re a s in g ris k fo r p a tie n ts . E v id e n c e o f a basic e d u c a tio n w it h re c o g n iz e d c o m p o n e n ts le d to nurses firs t b e in g re g is te re d a n d la t e r b e in g lic e n s e d . T h e te r m r e g i s t e r e d n u r s e is o f h is to ric a l v in ta g e a n d reflects th e p e rio d o f p e rm is s iv e lic e n s u re fo r nurses. P e rm is s iv e lic e n s u re m e a n t a n y o n e c o u ld p ra c tic e n u rs in g , b u t o n ly a p e rs o n w it h a re c o g n iz e d fo u n d a tio n o f n u rs in g e d u c a tio n c o u ld use th e title “ re g is te re d n u rs e .” D u r in g th is tim e , w h ic h in som e states s p an n ed 6 0 y e a rs , fr o m th e firs t to th e s ix th d ecad e o f th e 1 9 0 0 s , th e e d u c a tio n o f nurses p r im a r ily to o k p lac e in h o s p ita l schools o f n u rs in g . B ecause h o s p ita ls w e re n o t re c o g n ize d as in s titu tio n s o f h ig h e r le a rn in g , state lic e n s u re b o a rd s set th e s ta n d a rd s fo r n u rs in g e d u c a tio n . B o a rd s o f n u rs in g c o n tin u e to be in v o lv e d in p r o g r a m a c c re d ita tio n to d a y — d e sp ite th e a d v e n t o f a c c re d ita ­ tio n b o d ie s fo r n u rs in g e d u c a tio n . T h e a d v e n t o f p ra c tic a l n u rs in g e d u c a ­ tio n (k n o w n as v o c a tio n a l n u rs in g in som e states) w a s a n o th e r re a s o n fo r th e c h a n g e fr o m p e rm is s iv e to m a n d a t o r y lic e n s u re . P e rm is s iv e lic e n s u re p ro v id e s fo r tit le r e c o g n itio n . M a n d a t o r y lic e n s u re p ro v id e s fo r a scope o f p ra c tic e . T w o levels o f n u rs in g p ra c tic e n e ce ss ita ted d e fin in g a scope o f

Knowledge (K2) Describes legal and regulatory fac­ tors that apply to nursing practice Attitudes/Behaviors (A2b) Values and upholds legal and regulatory principles Skills (S2b) Implements plan of care within legal, ethical, and regulatory framework of nursing practice Source: Massachusetts Department of Higher Education (2010), p. 13.

p ra c tic e . T o d a y th e re a re also a d v a n c e d p ra c tic e nurses w h o h a v e specified scopes o f p ra c tic e u n d e r th e title s n u rse p ra c titio n e r , n u rse m id w ife , nurse a n e s th e tis t, a n d c lin ic a l s p ec ialist. N u rs in g licensure b o a rd s c o n tra s t w it h m e d ic a l b o a rd s in th a t th e y license o r c e rtify a t m u ltip le levels r a th e r th a n a sing le b a sic le v e l. I n m e d ic in e , a s tu d e n t o f m e d ic in e o b ta in s b o a r d c e rtific a tio n b y p a s s in g a p ro fe s s io n a l e x a m in a tio n th a t th e n a llo w s th e p h y s ic ia n to p ra c tic e in a s p e c ia lty a re a ; th e re is o n ly one lev el o f lice n su re. N u rs e lice n su re b o a rd s re q u ire th a t nurses w it h a m a s te r’s degree in a p a rtic u la r a rea pass a c e rtific a tio n e x a m g e n erated b y a re c o g n ize d n u rs in g p ro fe s s io n a l o rg a n iz a tio n p r io r to b e in g re c o g n ize d as a d v a n c e d p ra c tic e nurses. N u rs e s in itia lly licensed in one state c an a c q u ire licensure in a n o th e r state th r o u g h a pro cess c a lle d e n d o rs e m e n t. E n d o rs e m e n t re q u ire s v e rific a tio n th a t th e n u rs e ’s license has n o t b e en d is c ip lin e d in a n o th e r s tate. P re v io u s d is c ip lin e m ig h t o r m ig h t n o t p re c lu d e lic e n s u re b y e n d o rs e m e n t d e p e n d in g o n th e c irc u m s ta n c e s o f th e d is c ip lin e . T h e n u rse see kin g e n d o rs e m e n t also m u s t m e e t lic e n s u re re q u ire m e n ts in th e e n d o rs in g s ta te . C r im in a l b a c k ­ g ro u n d checks a n d c o n tin u in g e d u c a tio n re q u ire m e n ts a re tw o e x a m p le s o f such re q u ire m e n ts . In th e la te 1 9 9 0 s , th e N a t io n a l C o u n c il o f S tate B o ard s o f N u rs in g d e v e l­ o p e d th e N u rs e L ic e n s u re C o m p a c t. T h e c o m p a c t is a s ta tu to ry a g re e m e n t b e tw e e n a n d a m o n g states to p e r m it nurses w h o a re residents o f one state to h a v e th e p riv ile g e o f p ra c tic e in a n o th e r state w it h o u t a c q u irin g a license in th e second s tate. T h e n u rse does b e co m e su b ject to th e p ro v is io n s o f th e la w a n d ru les o f th e second s tate. In th is respect, c o m p a c t state nurses e n jo y th e sam e p riv ile g e s p ro v id e d b y a state d r iv e r ’s license. D riv e rs in one state c an tra v e l th ro u g h others subject to th e v e h ic u la r la w s o f o th e r states. If , h o w e v e r, th e d riv e r becom es a re s id e n t o f a n o th e r state, th e d riv e r m u s t o b ta in a license in th a t state. In th e case o f th e c o m p a c t, u n til a ll states a d o p t th e c o m p a c t, th e n u rse w ill h a v e to d e te rm in e w h e th e r th e state in w h ic h he o r she seeks to p ra c tic e re q u ire s lice n su re b y e n d o rs e m e n t o r is a m e m b e r o f th e c o m p a c t a lo n g w it h th e n u rs e ’s c u rre n t state o f lic e n s u re . A m a jo r a d v a n ta g e o f th e c o m p a c t is th e fa c ilita tio n o f p ra c tic e in b o rd e r areas o f states. T h e N a t io n a l C o u n c il o f S tate B o ard s o f N u rs in g (2 0 1 0 ) generates th e in it ia l lic e n s u re e x a m fo r b o th th e lic e n s e d p ra c tic a l n u rse a n d re g is te re d n u rs e . In i t i a l lic e n s u re m e a s u res c o m p e te n c e a t a m in im a l le v e l to e nsure safe p ra c tic e . C le a r ly , th e c h a n g in g n a tu re o f p ra c tic e d e m a n d s a c q u is itio n o f k n o w le d g e c o n s is te n t w it h c o n tin u in g c o m p e te n c e . T h e c o n te n t o f th e N C L E X - R N test p la n is o rg a n iz e d in to fo u r m a jo r c lie n t needs categories: safe a n d e ffe c tiv e care e n v iro n m e n t, h e a lth p r o m o tio n a n d m a in te n a n c e , p s y c h o ­ social in te g rity , a n d p h y s io lo g ic a l in te g rity . T h e c a te g o ry th a t relates to leg a l aspects o f n u rs in g is fo u n d p r im a r ily u n d e r th e c a te g o ry o f safe a n d e ffe ctive c are . T h e re la te d c o n te n t in clu d es th e fo llo w in g :

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A d v a n c e d ire c tiv e Advocacy C lie n t rig h ts C o lla b o r a tio n w it h in te rd is c ip lin a ry te a m C o n fid e n tia lity a n d in fo r m a tio n s ec u rity D e le g a tio n E th ic a l p ra c tic e In fo r m e d c o n se n t L e g a l rig h ts a n d re s p o n s ib ilitie s

A lth o u g h c o n tin u in g e d u c a tio n has n e ve r been c le a rly d e m o n s tra te d to be evidence o f c o n tin u in g c o m p eten c e in n u rs in g , m a n y states re q u ire c o n tin u in g e d u c a tio n fo r lice n su re re n e w a l. I t is a rg u e d th a t c o n sc ien tio u s nurses w o u ld u n d e rta k e c o n tin u in g e d u c a tio n v o lu n ta rily , a n d m a n d a to ry c o n tin u in g edu­ c a tio n adds o n ly re lu c ta n t nurses to p ro g ra m a tte n d a n c e w it h p e rh a p s little im p a c t o n th e re lu c ta n t nurses’ c o m p eten c e (H a ll, 1 9 9 6 ). C u rre n t co m p eten ce is also o f c o n c e rn fo r nurses re e n te rin g p ra c tic e . M a n d a t o r y re fre s h e r courses seem d e s ira b le b u t h a v e th e d ra w b a c k o f h ig h cost fo r persons w h o m ig h t be re e n te rin g p ra c tic e fo r e c o n o m ic reasons. Id e a lly , th e b u rd e n o f m a in ta in in g c o m p e te n c e rests w it h th e n u rse a n d th e n u rs e ’s w o rk p la c e . T h e w o rk p la c e s h o u ld p ro v id e a n d s u p p o rt o p p o rtu n itie s fo r g a in in g n e w k n o w le d g e a n d d e te rm in e its a p p lic a tio n in p ra c tic e .

■ The Function of Boards of Nursing Com position and Role of Boards T h e s ta tu to ry la w g o v e rn in g n u rs in g p ra c tic e in a ll states a n d te rrito rie s o f th e U n ite d States is k n o w n as th e N u rs e P ra c tic e A c t. B o ard s o f n u rs in g are th e state o r te r r ito r ia l agencies th a t a d m in is te r th e la w . M e m b e rs o f b o a rd s o f n u rs in g re p re s e n t v a rio u s types o f n u rs in g e x p e rtis e a n d v a rio u s g e o g ra p h ic areas w ith in th e state o r te rrito ry . A recent tre n d has been fo r bo ard s to in clu d e c o n s u m e r m e m b e rs to re p re s e n t th e p u b lic . B o a r d m e m b e rs a re g e n e ra lly a p p o in te d b y th e g o v e rn o r o f th e state o r te r r ito r y . T h e o v e rrid in g o b lig a tio n o f a ll b o a rd m e m b e rs is to p ro te c t th e safe ty o f th e p u b lic b y in itia lly a n d c o n tin u o u s ly licensing o n ly c o m p e te n t nurses. B o a rd m e m b e rs d ire c t th e a c tiv itie s o f th e agency th ro u g h p ro v id in g d ire c tio n to the e x e c u tiv e d ire c to r o f th e b o a rd , w h o in tu r n directs th e a c tiv itie s o f b o a rd s ta ff. B o a rd staffs c a n be as fe w as 2 o r as m a n y as 5 0 o r m o re , d e p e n d in g o n th e n u m b e r o f licensees in th e state o r te r r ito r y . B o ard s set s tan d ard s o f p ra c tic e a n d d e le g a tio n a n d o fte n s tan d ard s fo r n u rs in g e d u c a tio n th ro u g h th e r u le -m a k in g process. O t h e r b o a rd rules g o v e rn th e d is c ip lin a ry process a n d p ro g ra m s such as a lte rn a tiv e p ro g ra m s fo r d ru g a n d a lc o h o l abuse a n d p ra c tic e in te rv e n tio n im p ro v e m e n t.

B oards m ee t a t re g u la rly scheduled in te rv als d u rin g th e y e a r to act o n disci­ p lin a r y m a tte rs , a p p ro v e n u rs in g e d u c a tio n p ro g ra m s , a n d re v ie w a n d u p d a te th e nurse p ra c tic e a ct a n d re g u la tio n s g o v e rn in g p ra c tic e as n u rs in g p ra c tic e evolves. A tre n d a m o n g n u rs in g b o a rd s has been to assum e th e leg al o v ers ig h t o f o th e r types o f h e a lth c a re p ro v id e rs as w e ll. These in clu d e n u rs in g assistants, dialysis te ch n ician s, c o m m u n ity h e a lth w o rk e rs , a n d m e d ic a tio n te ch n ician s.

Discipline of Nurses I n le g a l te rm s , lice n su re is a p riv ile g e n o t a rig h t. N o t s u rp ris in g ly , a p riv ile g e c an be w it h d r a w n o r w ith h e ld fr o m a p e rs o n i f th e b e h a v io r o f th e p e rs o n does n o t m e r it th e p riv ile g e . T h u s , a b o a rd o f n u rs in g h o ld s le g a l a u th o r ity to d is c ip lin e a n u rse w h o h o ld s a license o r to a ct to w ith h o ld lice n su re fr o m a p e rs o n seeking in itia l lice n su re w it h in a state o r te r r ito r y . I n re ce n t years, b o a rd s o f n u rs in g h ave m o v e d to b a r fr o m in itia l licensure persons w h o h a v e b e en c o n v ic te d o f, w h o h a v e p le d g u ilty to , o r w h o h a d a ju d ic ia l fin d in g o f g u ilt fo r felonies in v o lv in g p o te n tia l o r a c tu a l p h y sic al h a rm to perso ns. E x a m p le s o f such felo n ies in c lu d e m u rd e r, ro b b e ry , k id n a p p in g , ra p e , s e x u a l b a tte r y , o r s e x u a l im p o s itio n . B ecause a la rg e p r o p o r tio n o f b o a rd d is c ip lin a ry a ctio n s is re la te d to a lc o h o l a n d substance abuse, b o a rd s a re c o n c e rn e d a b o u t p re v io u s h is to rie s o f d ru g abuse a n d d ru g tr e a tm e n t. U n c o n tr o lle d p s y c h ia tric illness is also o fte n a ss o cia te d w it h in c o m p e te n t p ra c tic e a n d s u b stan c e a b u se . P erson s w it h a h is to ry o f d r u g -re la te d a n d p s y c h ia tric h e a lth p ro b le m s seeking in itia l lice n su re in a state m a y be a llo w e d to p ra c tic e b u t a re re q u ire d to e n te r in to a n a g re e m e n t to be m o n ito re d fo r a p e rio d o f tim e u n d e r a set o f p re s c rib e d c o n d itio n s to ensure th a t th e y are safe p ra c titio n e rs . T h e m o n ito rin g w o u ld n o t c o n s titu te a d is c ip lin a ry a c tio n . H o w e v e r , i f m o n ito r in g c o n d itio n s a re v io la te d o r th e p e rs o n ’s p ra c tic e is unsafe, th e b o a rd can c o n sid e r th e fu ll ra n g e o f d is c ip lin a ry a ctio n s. A c c o rd in g to C le v e tte a n d colleagu es ( 2 0 0 7 ), c o m m o n d is c ip lin a ry c ateg o ries re v ie w e d b y b o a rd s o f n u rs in g in c lu d e th e fo llo w in g : •

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S u b s ta n d a rd n u rs in g p ra c tic e n o t in v o lv in g m e d ic a tio n s in c lu d in g v e rb a l a b u se , u s in g fo rc e to a d m in is te r m e d ic a tio n s , o r fa ilin g to re s p o n d to changes in p a tie n t c o n d itio n D e s tru c tio n o r a lte ra tio n o f p a tie n t re co rd s in c lu d in g fr a u d u le n t c h a rtin g a n d /o r s ig n atu res a n d /o r re p la c e m e n t o f re c o rd s w it h in te n t to m is le a d o r deceive P h y s ic a l p a tie n t abuse, such as w h e n a n u rse h its , s trik e s , o r p e rfo rm s s im ila r p h y s ic a l acts o f aggressio n in v o lv in g p h y s ic a l c o n ta c t F a ilu re to fo llo w p o lic y such as v io la tio n o f an e m p lo y e r’s p o lic y statem ents M e d ic a t io n “ e r r o r s ,” in c lu d in g in a c c u ra te d o c u m e n ta tio n , d is c a rd in g m eds a n d c h a rtin g th e m as g iv e n , w r o n g dosages, w r o n g ro u te , w r o n g tim e , a n d /o r in c o rre c t m e d ic a tio n te c h n iq u e

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C o n tr o lle d substance v io la tio n s o r c h e m ic a l d e p e n d e n c y in c lu d in g d iv e r­ sion o f drugs fr o m fa c ility o r p a tie n t fo r self-use o r sale, p re s c rip tio n fra u d , d o c to r-s h o p p in g to o b ta in p re s c rip tio n s , o r p ra c tic in g u n d e r th e in flu e n ce Im p a ir e d m e n ta l o r p h y s ic a l c o m p e te n c y . F o r e x a m p le , p ra c tic e is n e g a ­ tiv e ly a ffe c t b y m e n ta l o r p h y s ic a l in c a p a c ity In a p p ro p ria te m a n a g e m e n t decision such as w h e n a superviso r o r m a n a g e r m akes a d ecision c o n tra ry to acc ep tab le n u rs in g stan d ard s such as p e r m it­ tin g p ra c tic e w it h o u t a license P ra c tic e b e y o n d th e a u th o riz e d scope such as a d m in is te rin g m e d ic a tio n s w it h o u t a p h y s ic ia n ’s o rd e r S ex u a l m is c o n d u c t in c lu d in g n u rse a n d c lie n t c o m m u n ic a tio n o r c o n ta c t o f a s e x u a l n a tu re o r c o n v ic tio n s re la te d to s e x u a l m is c o n d u c t n o t w ith clients b u t re la te d to th e p ra c tic e o f n u rs in g P a tie n t o r e m p lo y e r a b a n d o n m e n t such as le a v in g o r n o t a rriv in g fo r a p a tie n t c are ass ig n m en t U n e th ic a l actions w it h a ra tio n a l re la tio n s h ip to n u rs in g p ra c tic e , in c lu d in g actio n s n o t d ire c tly re la te d to n u rs in g care such as fa ls ific a tio n o f licensure o r e m p lo y m e n t a p p lic a tio n s , d iv e rs io n o f th ir d -p a r ty p a y m e n ts , e m b e z z le ­ m e n t, o r d is trib u tio n o f a c o n tro lle d substance A c tio n s d e m o n s tra tin g p o o r ju d g m e n t, in c lu d in g ir r a tio n a l b e h a v io r n o t d e sc rib ed u n d e r th e o th e r categories

B o ard s o f n u rsin g h ave a n u m b e r o f d is c ip lin a ry choices: d e n yin g a license, im p o s in g a fin e , issu in g a r e p rim a n d , p la c in g re s tric tio n s o n a license, a n d su sp e n d in g o r re v o k in g a license. B o ard s m u s t fo llo w a d e s ig n a te d process b e fo re ta k in g a c tio n a g a in s t a license. F irs t, th e b o a rd m u s t re ce ive a c o m ­ p la in t. C o m p la in ts a re in v e s tig a te d b y b o a rd s ta ff. I f b o a rd s ta ff c o n c lu d e th a t th e evid en ce m e rits a c tio n a g a in s t th e n u rs e ’s license, a c o n se n t a g ree ­ m e n t m ig h t be o ffe re d . T h is p ro c e d u re is a d is c ip lin a ry a c tio n th a t bypasses th e h e a rin g process, a n d th e nurse agrees to c o n d itio n s p la c e d o n his o r h e r license. A n e x a m p le w o u ld be a p e rio d o f suspension w it h ra n d o m d ru g testing a n d tr e a tm e n t fo r d ru g abuse. C o m p lia n c e w it h th e a g re e m e n t w o u ld le a d to re tu r n in g to p ra c tic e w it h a p e rs o n in th e w o rk p la c e assigned to re p o rt o n th e n u rs e ’s p ra c tic e a t re g u la r in te rv a ls . T h e n u rse m ig h t also be e x p e c te d to p ro v id e evid en ce o f a tte n d a n c e a t a s u p p o rt g ro u p fo r persons w it h a d d ic ­ tio n s . C o n s e n t ag reem en ts m u s t be a p p ro v e d b y th e s ta te ’s b o a rd o f n u rs in g b e fo re b e in g im p le m e n te d . In th e absence o f a c o n s e n t a g re e m e n t, th e n u rs e receives a n o tic e o f o p p o r tu n ity fo r a h e a rin g . W h e n a tim e ly respo nse re q u e s tin g a h e a rin g is n o t re c e iv e d , th e b o a rd m e m b e rs d e cid e th e d is c ip lin a ry a c tio n a t a subse­ q u e n t b o a rd m e e tin g . H e a rin g s m ig h t be c o n d u c te d b y a b o a rd o r a h e a rin g e x a m in e r. In b o th in stan ce s, b o a rd m e m b e rs m u s t m a k e th e fin a l d e cis io n w it h respect to a c tio n a g a in s t a n u rs in g license.

KEY COMPETENCY 12-3 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Professionalism: Knowledge (K3) Understands the professional standards of practice, the evaluation of practice, and the responsi­ bility and accountability for the outcome of practice

R easo n s fo r d is c ip lin a ry a c tio n are d e sc rib ed in th e n u rse p ra c tic e a ct. S om e c o m m o n e x a m p le s in c lu d e c o n v ic tio n o f a m is d e m e a n o r in th e course o f p ra c tic e , c o n v ic tio n o f a n y fe lo n y , s e lf-a d m in is te rin g a p re s c rip tio n m e d ic a ­ tio n w it h o u t a p re s c rip tio n , im p a ir m e n t o f a b ility to p ra c tic e safe ly because o f h a b itu a l o r excessive use o f dru gs o r a lc o h o l, a n d a s s a u ltin g o r cau s in g h a rm to a p a tie n t. N u rs e s w o r k in g in lo n g -te rm care a n d h o m e h e a lth a re a t ris k fo r v io la tio n s o f th e p ra c tic e a c t such as th e ft a n d crossing p ro fe s s io n a l b o u n d a rie s , o fte n re s u ltin g in s ex u al offenses (D ris c o ll, 2 0 0 4 ) .

■ A ltern ative Program s for Nurses

In m a n y states, a n a lte r n a tiv e p ro g ra m fo r p erso n s w it h d ru g a n d a lc o h o l a d d ic tio n s exists. N u rs e s m u s t q u a lify fo r th e p ro g ra m . A c rite rio n is lik e ly to Attitudes/Behaviors (A3a) be th a t th e nurse tu rn s h e rs e lf in to th e b o a rd because th e nurse recog nizes the Recognizes personal capa­ bilities, knowledge base, and a d d ic tio n a n d n o p e rs o n o r fa c ility has m a d e a c o m p la in t to th e b o a rd . T h e se areas for development p ro g ra m s g re w as a d d ic tio n b ecam e v ie w e d as a disease re s u ltin g in calls fo r state b o a rd s a n d n u rse e m p lo y e rs to p ro v id e s u p p o rt fo r th e a d d ic te d nurse Skills (S3a) Demonstrates professional comportment (C a ro s e lli-K a rin ja & Z b o r a y , 1 9 8 6 ; D a n ie l, 1 9 8 4 ). Successful c o m p le tio n o f a m o n ito rin g p ro g ra m results in n o d is c ip lin a ry a c tio n b y a b o a rd . T h e n u rse ’s Source: Massachusetts Department of Higher Education (2010), p. 13. license re m a in s u n s c a th e d . D a t a fr o m these p ro g ra m s are e m e rg in g . H a a c k a n d Y o c o m (2 0 0 2 ) fo u n d s im ila r rates o f re la p s e in a 6 -m o n th p e rio d a fte r a d m is s io n to b o th a lte rn a tiv e a n d d is c ip lin a ry p ro g ra m s , a lth o u g h d is c ip lin ­ a ry a c tio n w a s m o re lik e ly w it h c rim in a l c o n v ic tio n s , a n d th ose persons w e re less lik e ly to be e m p lo y e d o r h o ld an a c tiv e license. A lth o u g h n o t g e n e ra lize a b le , th e s tu d y does p ro v id e s u p p o rt fo r th e re h a b ilita tiv e W W W J CRITICAL THINKING QUESTION* a p p ro a c h p ro v id e d b y th e a lte rn a tiv e p ro g ra m . What are the differences between nursing In te rv e n tio n p ro g ra m s as a n a lte rn a tiv e to d is c ip lin e disciplinary action by a board of nursing a re n o t lim ite d to substance ab u se. P ra c tic e in te rv e n tio n and legal ramifications set forth by state and im p ro v e m e n t p ro g ra m s are also e m e rg in g as an a lte rn a tiv e federal laws?* to d is c ip lin e .

P ro fe s s io n a l A c c o u n ta b ility : In fo rm e d C o n s e n t, P riv a c y and C o n fid e n tia lity , and D e le g a tio n ■ Inform ed Consent In fo rm ed c o n se n t “ m an d a te s to th e p h y s ic ia n o r in d e p e n d e n t h e a lth c a re p ra c ­ titio n e r th e s ep a rate leg a l d u ty to disclose n e ed e d m a te r ia l facts in te rm s th a t p a tien ts c an re a s o n a b ly u n d e rs ta n d so th a t th e y can m a k e an in fo rm e d c h o ic e ” (G u id o , 2 0 0 1 , p . 1 2 9 ). T h e p ra c titio n e r is re q u ire d to in fo r m th e p a tie n t w h o

w ill p e rfo r m th e p ro c e d u re o r tr e a tm e n t, discuss a v a ila b le a lte rn a tiv e s to th e re c o m m e n d e d tre a tm e n t, a n d id e n tify possible c o m p lic a tio n s o f th e p ro c e d u re in te rm s th a t th e p a tie n t c an u n d e rs ta n d . T h e A m e ric a n M e d ic a l A s s o c ia tio n (2 0 0 7 ) states th a t in fo r m e d c o n se n t is m o re th a n s im p ly g e ttin g a p a tie n t to sign a w r it te n c o n se n t fo rm . I t is a process o f c o m m u n ic a tio n b e tw e e n a p a tie n t a n d p h y s ic ia n th a t results in th e p a tie n t’s a u th o r iz a tio n o r a g re e m e n t to u n d e rg o a specific m e d ic a l in te rv e n tio n . In th e c o m m u n ic a tio n s process, th e p h y sic ia n p ro v id in g o r p e rfo r m in g th e tr e a tm e n t a n d /o r p ro c e d u re (n o t a d e l­ eg ated re p re s e n ta tiv e ) s h o u ld disclose a n d discuss w it h th e p a tie n t th e fo llo w in g in fo r m a tio n : • • • • • •

T h e p a tie n t’s d iag n o sis , i f k n o w n T h e n a tu re a n d p u rp o s e o f a p ro p o s e d tr e a tm e n t o r p ro c e d u re T h e risks a n d benefits o f a p ro p o s e d tr e a tm e n t o r p ro c e d u re A lte rn a tiv e s (regardless o f th e ir cost o r th e e x te n t to w h ic h th e tr e a tm e n t o p tio n s a re c o v e re d b y h e a lth in s u ra n c e ) T h e risks a n d benefits o f th e a lte rn a tiv e tr e a tm e n t o r p ro c e d u re T h e ris k s a n d b e n e fits o f n o t re c e iv in g o r u n d e rg o in g a tr e a tm e n t o r p ro c e d u re

T h is c o m m u n ic a tio n process is b o th a n e th ic a l o b lig a tio n a n d a le g a l re q u ire m e n t sp elled o u t in statutes a n d case la w in a ll 5 0 states. In fo r m e d c o n se n t cases are a ty p e o f m a lp ra c tic e suit. A n in fo r m e d c o n ­ sent case c an be b ro u g h t b y a p a tie n t w h e n a ris k o f a p ro c e d u re occurs th a t s h o u ld h a ve been d iv u lg e d b u t w a s n o t o r w h e n a lte rn a tiv e s to th e p ro c e d u re w e re n o t p ro v id e d th a t th e p a tie n t w o u ld h a v e chosen h a d he o r she k n o w n th e p a rtic u la r ris k . In fo r m e d c o n se n t cases arise w it h in va s iv e p ro ce d u re s a n d c o m p lic a te d tre a tm e n t reg im en s such as those fo r c an cer. C e n tra l to in fo rm e d c o n se n t is e n s u rin g th a t th e p a tie n t is c a p a b le o f c o m p re h e n d in g th e in fo r m a ­ tio n ; o th e rw is e , th e c o n se n t is in v a lid . In fo r m a tio n c o m p o n e n ts o f in fo r m e d c o n se n t in c lu d e e x p la n a tio n b y th e p h y s ic ia n o f th e n a tu re o f th e p ro c e d u re , its ris k s , its b e n e fits , a n d a lte r n a ­ tives to th e p ro c e d u re , in c lu d in g th e risk s a n d b e n efits o f th e a lte rn a tiv e s . T h e in fo r m a t io n to be p ro v id e d is g e n e ra lly d e s c rib e d as w h a t is m a te r ia l to th e p a tie n t’s d e c is io n to go fo r w a r d w it h th e p ro c e d u re , d e c lin e th e p ro c e ­ d u re , o r select a n a lte rn a tiv e to th e p ro p o s e d p ro c e d u re . M a t e r i a l risk s are e x p e c te d serious risk s such as d e a th , h e m o rrh a g e , in fe c tio n , o r a n y o th e r ris k th a t w o u ld s e rio u s ly c o m p ro m is e th e fu n c tio n in g o f a p e rs o n , such as a s tro k e o r p a ra ly s is . F a ilu r e to m e e t th ese s ta n d a rd s o f d is c lo s u re p u ts th e p h y s ic ia n a t ris k fo r a m a lp r a c tic e s u it re s u ltin g fr o m fa ilu r e to p ro v id e in fo r m e d c o n s e n t i f th e u n d is c lo s e d ris k occurs a n d th e p a tie n t is h a rm e d (N ic k e ll v. G o n z a le z , 1 9 8 5 ) . In a le a d in g case th a t h e lp e d e s ta b lis h th is ty p e o f m a lp r a c tic e s u it, th e p h y s ic ia n d id n o t in fo r m th e p a tie n t o f th e ris k o f

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CHAPTER 12 Law and the Professional Nurse

p a ra ly s is w it h b a c k s u rg e ry ( C a n t e r b u r y v. S p e n c e , 1 9 7 2 ) . I n a n O h io case, a p a t ie n t ’ s in c a p a b ilit y to e xp ress h im s e lf b e ca u se o f te m p o r a r y a p h a s ia le d to th e s ig n in g o f a c o n s e n t f o r m f o r a p ro c e d u re th a t in his in d iv id u a l case p u t h im a t h ig h ris k fo r a s tro k e , a n d a s tro k e o c c u rre d (G r e y n o ld s v. K u r m a n , 1 9 9 3 ) . In a C a lifo r n ia case (T r u m a n v. T h o m a s , 1 9 8 0 ) , a p h y s i­ c ia n w a s sued fo r fa ilin g to w a r n th e p a tie n t o f th e risk s o f n o t c o n s e n tin g to a d ia g n o s tic test. T h e s ta n d a rd s used fo r d e te rm in in g w h e th e r c o n se n t in fo r m a tio n is s u f­ fic ie n t v a ry fr o m state to s tate. T h e firs t is th e m e d ic a l s ta n d a rd — w h a t are re g a rd e d as m a te r ia l risks in th e m e d ic a l c o m m u n ity . T h e second is w h a t a re a s o n a b le p a tie n t w o u ld n eed to k n o w . T h e th ir d is w h a t a p a rtic u la r p a tie n t needs to k n o w . T h e firs t errs in fa v o r o f th e m e d ic a l c o m m u n ity . T h e second is c o n s id e re d o b je c tiv e because it p ro v id e s a s ta n d a rd fa v o rin g th e p a tie n t c o m m u n ity . T h e th ir d is c le a rly su b jec tive a n d e ss en tia lly leaves p h ysician s in th e d a rk as to w h a t in fo r m a tio n to give p a tie n ts . Is th e re a ro le fo r nurses w h e n in fo r m e d c o n se n t is re q u ire d ? T h e re is an a d v o c a c y ro le . W h e n a n u rse o b ta in s a s ig n a tu re o n a h o s p ita l o r a m b u la to ry fa c ility c o n s e n t fo rm , th a t in te ra c tio n p ro v id e s a n o p p o r tu n ity to a s c e rta in w h e th e r th e p a tie n t has qu estio n s a b o u t a p ro c e d u re . W h e n a c o n v e rs a tio n reveals th a t th e p a tie n t has m is c o n c e p tio n s a b o u t th e p ro c e d u re o r its risks a n d b e n efits, th e n u rse s h o u ld c o n ta c t th e p h y s ic ia n so th a t a d d itio n a l c o m ­ m u n ic a tio n re g a rd in g th e p ro c e d u re c an o c cu r. T h e a d v o c a c y ro le o f th e nurse in this s itu a tio n is n o t a le g a lly d e fin e d ro le . I t fa lls in the CRiTiCAL THiNKiNG QUESTIONS V re a lm o f p ro fe s s io n a l p e rfo rm a n c e stan d ard s a n d a code o f ethics re s p o n s ib ility to c o lla b o ra te w it h o th e r h e a lth c a re Are there differences in the responsibility p ro v id e rs a n d th e p a tie n t to ensure a p p ro p r ia te c are . T h e related to informed consent for the nurse and leg a l ro le o f th e nurse in this s itu a tio n is a c tin g as a w itness physician? If so, what are the differences?^ to th e p a tie n t’s s ig n a tu re .

■ Privacy and C onfidentiality P riv a c y is th e r ig h t o f a p e rs o n to be fre e fr o m u n w a n te d in tr u s io n in to th e p e rs o n ’s p e rs o n a l a ffa irs . T o re ce ive a p p ro p r ia te h e a lth c a re , h o w e v e r, a p e rs o n o fte n m u s t disclose v e ry p e rs o n a l in fo r m a tio n . S ex u a l a c tiv ity a n d a c k n o w le d g m e n t o f a lc o h o l o r d ru g a b u se a re e x a m p le s o f such p e rs o n a l in fo r m a tio n . B ecause o f th e s tig m a a tta c h e d to m e n ta l illness, p a tie n ts m ig h t also be re lu c ta n t to disclose a fa m ily o r p e rs o n a l h is to ry o f m e n ta l illness. T o f u lf ill th e ir s o c ia l c o n tr a c t to p ro v id e n u rs in g c a re , nurses m u s t o fte n g a th e r such sensitive in fo r m a tio n fr o m p a tie n ts . T h u s , th e n u rse , a lo n g w it h o th e r care g ive rs , has th e o b lig a tio n to k ee p h e a lth c a re in fo r m a tio n c o n fid e n ­ tia l. P riv a c y is th e r ig h t o f th e p a tie n t. C o n fid e n tia lity is th e o b lig a tio n o f a ll h e a lth c a re p ro v id e rs .

T h e C o d e o f E th ics fo r N u rs e s w ith In terp reta tiv e S ta tem en ts addresses p ri­ vacy a n d c o n fid e n tia lity u n d e r p ro v is io n 3 , “ T h e nurse p ro m o te s, advocates fo r, a n d strives to p ro te c t th e h e a lth , safety, a n d rights o f th e p a tie n t” ( A N A , 2 0 0 1 ). R u les o f b o a rd s o f n u rs in g can also spell o u t th e n u rse ’s d u ty o f c o n fid e n tia lity . In 2 0 0 0 , fin a l fe d e ra l ru les p ro te c tin g p a tie n t p riv a c y w e re issued. T h e ru les a ffe c t h e a lth p la n s , h e a lth c a re c le arin g h o u s es , a n d h e a lth c a re p ro v id e rs w h o engage in e le c tro n ic tra n s a c tio n s . T h e ru les w e re a response to concerns th a t p a tie n t p riv a c y w o u ld be c o m p ro m is e d w it h o u t le g a l s tan d ard s fo r th e scope o f in fo r m a t io n th a t c o u ld be s h a re d . T h e ru le s re q u ire d a ll o f these g ro u p s (c a lle d e n titie s ) to be in c o m p lia n c e w it h th e ru les b y A p r il 1 4 , 2 0 0 3 , w it h th e e x c e p tio n o f s m a ll h e a lth p la n s . T h e s m a ll h e a lth p la n c o m p lia n c e d a te w a s A p r il 1 4 , 2 0 0 4 . T h e ru les w e re p ro m u lg a te d b y th e D e p a r tm e n t o f H e a lt h a n d H u m a n Services u n d e r p ro v is io n s o f th e H e a lt h In s u ra n c e P o r ta ­ b ility a n d A c c o u n ta b ility A c t ( H IP A A ) o f 1 9 9 6 . T h e ru les assure p a tie n ts th a t o n ly necessary in fo r m a tio n w ill be sh ared w it h g ro u p s such as in su rers a n d th ir d -p a r ty in te rm e d ia rie s w h o a d m in is te r in s u ra n c e p lan s b y e n g ag in g in fu n c tio n s such as cla im s pro cessin g a n d m e m ­ b e rs h ip tra c k in g . T h e ru les also ensure access to p a tie n t re co rd s b y p a tie n ts th em s elve s, a lth o u g h a re a s o n a b le p e rio d o f tim e m ig h t be n e e d e d to c o p y th o se re c o rd s , a n d th e p a tie n t m ig h t be c h a rg e d fo r th e cost o f c o p y in g a n d s en d in g re c o rd s . T h e ru les p r o h ib it p a tie n t in fo r m a t io n fr o m b e in g sh are d fo r m a r k e tin g p u rp o s e s w it h o u t th e p a t ie n t ’s c o n s e n t. T h e ru le s r e q u ire e m p lo y e e tr a in in g o n th e p ro v is io n s o f th e ru les fo r e m p lo yees o f a ll h e a lth ­ c are e m p lo y e rs . H IP A A p ro te c tio n o f p a tie n t p riv a c y hig h lig h ts the tra d itio n a l v alu e placed o n p a tie n t p riv a c y b y th e h e a lth c a re pro fes s io n s. N u rs e s s h o u ld re m e m b e r th a t c o n v e rs a tio n s in h e a lth c a re fa c ilitie s a b o u t p a tie n ts s h o u ld o c c u r o n ly a m o n g h e a lth c a re p ro v id e rs . E le v a to rs a n d c afeterias a re n o t a p p ro p ria te sites fo r such discussions. P ictu re s o f p a tie n ts a n d specific h e a lth c a re in fo r m a tio n s h o u ld be shared w it h fa m ily m em b ers o n ly w it h th e express p e rm is s io n o f th e p a tie n t. G e n e ra lly , m e d ic a l reco rd s c a n n o t be sent to a n y o n e w it h o u t w r itte n c o n se n t e x c e p t w h e n th e re c o rd is s u b p o e n ae d . E a c h n u rse needs to be a w a re o f a n d fo llo w th e p o licie s a n d p ro ce d u re s re la te d to o ra l, w r itte n , o r e le c tro n ic p a tie n t-id e n tifia b le d a ta set u p b y th e h e a lth c a re o rg a n iz a tio n re g a rd in g issues w h e re th e n u rse p ra ctice s; h o w e v e r, som e k e y areas are a ffe c te d b y these n e w p riv a c y re g u la tio n s : • • •

P a tie n ts m u s t be in fo r m e d o f th e ir p riv a c y rig h ts . P a tie n ts m u s t be in fo r m e d as to w h o w ill see th e ir reco rd s a n d fo r w h a t p u rp o s e . P a tie n ts h a v e th e r ig h t to in s p e c t a n d o b ta in a c o p y o f th e ir m e d ic a l re c o rd s . (T h e re a re som e e xc e p tio n s to th is th a t each o rg a n iz a tio n s h o u ld m a k e c le a r to s ta ff.)

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CHAPTER 12 Law and the Professional Nurse

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V a l i d a u th o r iz a tio n to release h e a lth in fo r m a t io n m u s t c o n ta in c e rta in in f o r m a t io n , such as a c o p y o f th e s ig n e d a u th o r iz a tio n g iv e n to th e p a tie n t, in u n d e rs ta n d a b le la n g u a g e , a n d h o w th e p a tie n t m a y re v o k e a u th o r iz a tio n . A lt h o u g h in f o r m a t io n m ig h t be used fo r re s e a rc h p u rp o s e s to assess o u tb re a k o f a disease, a ll in d iv id u a l id e n tifia b le d a ta m u s t be re m o v e d . P erson al d a ta m a y n o t be used fo r m a rk e tin g (fo r e x a m p le , p h a rm a cies m a y n o t share this in fo r m a tio n w ith others fo r this p u rp o se ) (F in k e lm a n , 2 0 0 6 ).

Delegation

T o d a y , nurses face m a n y w o r k - r e la te d issues, such as th e n u rs in g s h o rta g e , th e in c re a s in g n e ed fo r services, a n d c o n s ta n t chang es w it h in th e e n v iro n ­ m e n t a n d g o v e r n m e n t. “ In a n e ffo r t to re d u c e la b o r costs b y d e c re a s in g re g is te re d n u rse p o s itio n s , h o s p ita ls h a v e in c re a s in g ly tu rn e d to a n e w k in d o f h e a lth c a re w o r k e r , u n lic e n s e d assistive p e rs o n n e l ( U A P ) ” (K le in m a n & S a c c o m a n o , 2 0 0 6 , p . 1 6 4 ). T h e use o f U A P h elp s fill th e c h a s m cau sed b y th e n u rs in g s h o rta g e a n d h elp s d ecrease th e c o st o f p a tie n t c a re . H o w e v e r , in th e p a s t, “ n u rse s w e re e d u c a te d in p ra c tic e s e ttin g s w h e r e th e m o d e l o f c a re w a s p r im a r y n u r s in g o r a s im ila r m o d e l in w h ic h th e re g is te re d nurses w e re re s p o n s ib le fo r m o s t o f th e d ire c t c a re needs o f th e p a tie n ts ” (K le in m a n & S a c c o m a n o , 2 0 0 6 , p . 1 6 6 ). T h e r e fo r e , m a n y nurses a re n o t fa m ilia r w it h h o w to d e le g a te tasks to U A P because th e y w e re n o t ta u g h t these s k ills . T h u s , le g a l d e le g a tio n has b e c o m e a n in c re a s in g c h a lle n g e fo r re g is te re d nurses ( R N s ) . A s licensed p ro fe s s io n a ls , R N s a re re sp o n sib le to the c o m m u n ity fo r p ro ­ v id in g safe, c o m p e te n t, a n d effective care fo r p a tien ts in a v a rie ty o f h e a lth c a re settings. In each s ettin g , R N s w o r k beside o th e r licensed p ro fe s s io n a ls a n d assign a n d d elegate tasks to these o th e r licensed p ro fes s io n als to give e ffic ie n t c are to p a tie n ts . A d d itio n a lly , R N s re m a in a c c o u n ta b le o r a n s w e ra b le fo r p a tie n t o u tc o m e s a n d a re re s p o n s ib le fo r s u p e rv is in g d e le g a te d ta sk s . T h e A N A a n d th e N a t io n a l C o u n c il o f S tate B o ard s o f N u rs in g ( N C S B N ) define d e le g a tio n as “ th e process fo r a n u rse to d ire c t a n o th e r p e rs o n to p e rfo r m n u rs in g tasks a n d a c tiv itie s ” ( A N A & N C S B N , 2 0 0 6 , p . 1 ). D e le g a tio n can be d ire c t (i.e ., v e rb a l in s tru c tio n s ) o r in d ire c t (i.e ., tasks v e rifie d b y h o s p ita l p o lic y ) in th e h e a lth c a re settin g (T ra p p e n , W eiss , & W h it e ­ h e a d , 2 0 0 4 ) . T h e R N o r n u rse m a n a g e r judges w h ic h s ta ff m e m b e r is c o m p e te n t to p e r fo r m a n assig ned d u ty ; h o w ­ e ver, p e rm itte d tasks m ig h t d e p e n d o n th e o rg a n iz a tio n o r in s titu tio n . In term s o f a c c o u n ta b ility , nurses m u s t ta k e re s p o n s i­ b ility fo r th e ir a c tio n s a n d th e a ctio n s o f o th e rs in v o lv e d in th e d e le g a tio n pro cess. W h e n a lle g a tio n s o f u n e th ic a l,

ille g a l, a n d in a p p ro p r ia te c o n d u c t o c c u r, nurses “ m u s t a n s w e r to p a tie n ts , n u rs in g e m p lo y e rs , th e b o a rd o f n u rs in g , a n d th e c iv il a n d c r im in a l c o u rt system w h e n th e q u a lity o f p a tie n t c a re p ro v id e d is c o m p ro m is e d ” ( A N A , 2 0 0 5 , p . 4 ). T h e re fo re , it is im p o r t a n t fo r R N s a n d n u rse m a n a g e rs to be k n o w le d g e a b le o f th e d e le g a tio n g u id e lin e s w it h in each s ta te ’s n u rse p ra c tic e a ct, jo b d e s c rip tio n s , a n d th e scope o f p ra c tic e o f a ll p e rs o n n e l. D e le g a tio n is p a rt o f th e lan g u a g e o f m a n a g e m e n t. W o r k m ig h t be w ith in th e jo b d e s c rip tio n o f a h e a lth c a re w o r k e r , b u t th is does n o t a u to m a tic a lly m a k e d e le g a tio n o f a p a rtic u la r ta s k a p p ro p ria te . T h e nurse m a k in g a n assign­ m e n t is a c tin g as a m a n a g e r o f c are . T h e nurse m u s t c a re fu lly select th e p e rso n to w h o m a ta sk is assigned because u ltim a te ly th e nurse as m a n a g e r is a c c o u n t­ a b le fo r w h e th e r th e ta s k is a c c o m p lis h e d a n d w h e th e r th e d esired o u tc o m e is a ch ie ve d . C o m p le te in d e p en d en c e in c a rin g fo r a c o m p le x c ritic a l care p a tie n t w o u ld n o t be an a p p ro p ria te assig n m en t fo r a n e w ly licensed re g istered nurse. L ice n s ed p ra c tic a l nurses c a n n o t s h o u ld e r c o m p le te re s p o n s ib ility fo r a c tin g o n assessm ent o f a n e w ly a d m itte d p a tie n t. U n lic e n s e d assistive p erso n n el m a y ta k e b lo o d pressures, b u t th e y s h o u ld d o so w it h c le a r p a ra m e te rs estab lish ed fo r c o m m u n ic a tin g d e v ia n c e fr o m th o se p a ra m e te rs . C e r ta in a c tiv itie s c a n n o t be d e le g a te d . A n a d v a n c e d p ra c tic e n u rse m a y d e le g a te th e d r a w in g o f b lo o d to a n u rs in g a s s is ta n t b u t c a n n o t d e le g a te th e d e c is io n fo r th e typ es o f la b tests to be p e rfo r m e d ( A N A , 2 0 0 4 ) . O n ly th e a d v a n c e d p ra c tic e n u rs e c a n m a k e th e ju d g m e n t as to w h a t tests are n e ce ss ary. F u r th e r m o r e , th e a d v a n c e d p ra c tic e n u rse c o u ld n o t d e le g a te th e b lo o d d r a w to a n u rs in g a s s is ta n t i f th e n u rs in g a s s is ta n t h a d n o t le a rn e d th e p r o p e r te c h n iq u e fo r d r a w in g b lo o d a n d h a d n o t re c e iv e d s u ffic ie n t s u p e rv is io n in c a rry in g o u t th e p ro c e d u re to d e te rm in e th e n u rs in g assis­ t a n t ’s c o m p e te n c e . U n lic e n s e d assistive p e rs o n n e l c a n n o t dele g a te a ta s k d e le g a te d to th e m b y a nurse because th a t w o u ld be e n g ag in g in th e p ra c tic e o f n u rs in g w ith o u t a license. S im ila rly , a n u rse c a n n o t dele g a te a ta s k i f th e n u rse does n o t k n o w h o w to d o th e ta s k . T h a t w o u ld be d e le g a tin g b e y o n d th e n u rs e ’s scope o f p ra c tic e . T h e nurse d e le g a tin g a n y ta s k m u s t p ro v id e s u p e rv is io n to th e un licen sed p erso n . T h is m ean s d e te rm in in g th e c o m p eten c e o f th e p e rso n to c a rry o u t th e ta s k p ro p e rly . I f th e unlicensed perso n does n o t p ro p e rly c a rry o u t th e ta sk , the u n lice n s ed p e rs o n s h o u ld n o t a g a in be d e le g a te d th e ta sk u n til fu rth e r e d u c a ­ tio n ensures th a t th e p e rso n has re a c h e d a lev el o f c o m p e te n c e . D e m o n s tra te d c o m p e te n c e does n o t e lim in a te th e s u p e rv is o ry ro le . T h e fiv e rig h ts o f d e le g a tio n as o u tlin e d b y th e N a t io n a l C o u n c il o f S tate B o a rd s o f N u rs in g in 2 0 0 6 a re as fo llo w s : • •

T h e r ig h t ta sk : O n e th a t is d e le g a b le fo r a specific p a tie n t. T h e r ig h t c irc u m s ta n c e s : A n a p p r o p r ia t e p a t ie n t s e ttin g , a v a ila b le resou rces, a n d c o n s id e ra tio n o f o th e r re le v a n t fa c to rs .

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T h e r ig h t p e rso n : T h e r ig h t p e rs o n is d e le g a tin g th e r ig h t ta s k to th e rig h t p e rs o n to be p e rfo rm e d o n th e r ig h t p erso n . T h e r ig h t d ire c tio n a n d c o m m u n ic a tio n : A c le a r, concise d e s c rip tio n o f th e ta s k , in c lu d in g o b je ctiv es , lim its , a n d e x p e c ta tio n s . T h e r ig h t s u p e rv is io n a n d e v a lu a tio n : A p p r o p r ia te m o n ito rin g , in te rv e n ­ tio n , a n d as n e ed e d , fe e d b a c k .

K e e p in g th is rig h ts m a n tr a in m in d h e lp s th e n u rs e to d e le g a te c a re a c c o rd in g to th e leg a l s ta n d a rd o f a c tin g as a re a s o n a b le p ru d e n t nurse w o u ld d o in s im ila r circu m stan ces. H o w e v e r , a u th o r ity to d elegate varies, so licensed nurses m u s t ch ec k th e ju ris d ic tio n ’s statutes a n d re g u la tio n s . R N s m ig h t need to d e le g a te to th e L P N th e a u th o r ity to d e le g a te to th e U A P .

Barriers to Delegation N u rs e s face m a n y challeng es w h e n tr y in g to dele g a te to o th e rs . C o n tr ib u tin g fa cto rs le a d in g to d e le g a tio n b a rrie rs “ ra n g e fr o m n o t h a v in g h a d e d u c a tio n a l o p p o rtu n itie s to le a rn h o w to w o r k w it h o th e rs e ffe c tiv e ly to n o t k n o w in g th e s k ill le v e l a n d a b ilitie s o f n u r s in g a ss is tiv e p e rs o n n e l to s im p lify th e w o r k p ace a n d tu r n o v e r o f p a tie n ts ” ( A N A & N C S B N , 2 0 0 6 , p . 4 ) . A ls o , th e scope o f th e n u rs in g p ra c tic e is c h a n g in g a n d th e tasks p e rfo r m e d b y U A P a re in c re a s in g in c o m p le x ity . T h is c a n m a k e m a n y nurses a p p re h e n s iv e in d e le g a tin g ta sk s b e ca u se o f a fe a r o f e n d a n g e rin g th e ir o w n lic e n s u re . P lu s, because o f th e n u rs in g s h o rta g e , m a n y in e x p e rie n c e d nurses a re b e in g p la c e d a t th e h e lm . T h u s , m a n y n urses a re n o t k n o w le d g e a b le o f h o w to c o m m u n ic a te e ffe c tiv e ly a n d h o w to use th e in s titu tio n ’s resources e ffic ie n tly . U lt im a te ly , b a rrie rs th a t le a d to in e ffe c tiv e d e le g a tio n p la c e a s tra in o n th e q u a lity o f p a tie n t c are . I n 2 0 0 5 , K a lis c h c o n d u c te d a q u a lit a t iv e s tu d y to e x a m in e th e c a re m issed o n m e d ic a l-s u rg ic a l u n its . B y in te rv ie w in g 1 0 7 R N s , 15 L P N s , a n d 5 1 n u rs in g assistants (N A s ) fr o m tw o h o s p ita ls in th e U n ite d States, K a lis c h ( 2 0 0 6 ) fo u n d th a t th e fo llo w in g a c tiv itie s w e re fr e q u e n tly m issed: “ a m b u ­ la t io n , tu r n in g , fe e d in g s , p a tie n t te a c h in g , d is c h a rg e p la n n in g , e m o tio n a l s u p p o r t, h y g ie n e , in ta k e a n d o u t p u t d o c u m e n ta tio n , a n d s u r v e illa n c e ” (p . 3 0 7 ) . S ev e ral fa c to rs c o n trib u te d to w h y h o s p ita l em p lo ye es m issed these im p o r t a n t m ea s u res ; in e ffe c tiv e d e le g a tio n w a s c ite d as o n e o f th e m a jo r fa c to rs . K a lis c h ( 2 0 0 6 ) d is c o v e re d th a t m a n y N A s w e re n o t p re s e n t d u rin g ro u tin e n u rs in g re p o rts , a n d n e ith e r d id th e nurses re p o r t to th e N A s . “ E v e n w h e n N A s re c e iv e d re p o r t, th e re w a s a la c k o f c o lla b o ra tiv e p la n n in g fo r p a tie n t c a re ” (K a lis c h , 2 0 0 6 , p . 3 1 0 ) . T h e r e fo r e , la c k o f c o m m u n ic a tio n m ig h t h a v e b e en a p ro b le m . A ls o , m a n y nurses h a d d iffic u lty re ta in in g a c c o u n ta b ility . “ M a n y nurses c o n s id e re d th e w o r k d e le g a te d to N A s as n o lo n g e r th e R N ’s re s p o n s ib ility ”

(K a lis c h , 2 0 0 6 , p . 3 1 0 ) . T h is is a m a jo r m is c o n c e p tio n because th e n u rse re m a in s a c c o u n ta b le fo r th e care g iv e n to th e p a tie n t. A n o th e r p ro b le m w as th a t m a n y s ta ff m e m b e rs d id n o t feel th a t it w a s th e ir jo b to p e rfo r m a p a r ­ tic u la r ta s k . “ N u rs e s s ta te d th a t c e rta in tasks such as v it a l signs w e re th e N A ’s re s p o n s ib ility , a n d i f th e N A d id n o t c o m p le te these tasks, it w a s th e ‘fa u lt’ o f th e N A , n o t th e R N ” (K a lis c h , 2 0 0 6 , p . 3 1 0 ). S tate n u rse p ra c tic e acts d e fin e th e scope o f p ra c tic e a n d w h a t nurses c an d e le g a te . A ls o , h o s p ita ls a n d in s titu tio n s h a v e p o lic ie s a n d p ro c e d u re s th a t h e lp d e fin e w h ic h tasks c an be d e le g a te d . K a lis c h ( 2 0 0 6 ) also cites th a t m a n y nurses h a d d iffic u lty w it h c o n flic t m a n a g e m e n t. “ M a n y nurses re p o rte d lim ite d a u th o r ity a n d in flu e n c e o v e r th e N A s a n d e xp ressed re lu c ta n c e to c o n fr o n t N A s w h o d id n o t ‘d o th e ir jo b ’ ” (K a lis c h , 2 0 0 6 , p . 3 1 0 ) . In several cases, s ta ff m e m b e rs tr ie d to a v o id c o n fro n ta tio n a n d h a d d iffic u lty en g ag in g in c o n flic t m a n a g e m e n t to strive fo r a s o lu tio n . “ I f delegates a re re s is ta n t, th e d e le g a to r m a y s im p ly choose to do th e ta s k h im o r h e rs e lf to a v o id c o n fro n ta tio n s ; in s te a d , th e s itu a tio n s h o u ld be re e v a lu a te d fr o m th e U A P ’ s p o in t o f v ie w ” (Q u a llic h , 2 0 0 5 , p . 1 2 2 ). I n som e cases, U A P m ig h t la c k th e c o n fid e n c e o r k n o w le d g e to p e r fo r m a ta s k ; h o w e v e r, i f U A P re fu s e to p e rfo r m a ta s k as a w a y to d e fy a u th o r ity , g u id e lin e s fo r d e le g a tio n s h o u ld be c le a rly re in s titu te d . A ls o , i f a n u rse lacks c o n fid e n c e a n d does n o t tru s t th e a b ilitie s o f o th e r s ta ff m e m b e rs , d e le g a tio n is u n lik e ly to o c c u r. “ S im ila rly , d e le g a tio n w i l l be unsuccessful i f th e o n ly tasks th a t a re d e le g a te d a re th o se th a t a re tim e -c o n s u m in g o r u n p le a s a n t; th is a p p ro a c h risks e x h a u s tin g s ta ff th a t a re o th e rw is e c a p a b le ” (Q u a llic h , 2 0 0 5 , p . 1 2 2 ). R eg a rd les s o f th e in s titu tio n , d e le g a tio n has a s tric t c h a in o f c o m m a n d a m o n g e m p lo ye es . N u rs e s som etim es m ig h t e x p e rie n c e feelings o f g u ilt a b o u t th o se to w h o m th e y d e le g a te ta sk s . T h e R N also m ig h t w o r r y a b o u t b e in g la b e le d as la z y w h e n d e le g a tin g a ta s k to o th e r e m p lo y e e s . “ B u t w o r k in g in a n o rg a n iz a tio n a l h ie ra rc h y s h o u ld n o t re s u lt in th e d e le g a to r ta k in g o n d is p ro p o r tio n a te a m o u n ts o f re s p o n s ib ility in o rd e r to re sp e ct th e feelings o f o th e r d e le g a te e s ” (Q u a llic h , 2 0 0 5 , p . 1 2 2 ). S om e nurses m ig h t also feel th a t th e y s h o u ld s h o w lo y a lty to o th e r nurses a n d s h o u ld d e le g a te to s tu d e n t a n d g ra d u a te nurses o n ly . H o w e v e r , th is lo y a lty o r d is c r im in a tio n is n o t c o s t-e ffic ie n t a n d o n ly acts as a n o th e r d e le g a tio n b a r r ie r . P lu s, i f a n u rse refuses to d e le g a te a ta s k as in s tru c te d b y th e e m p lo y e r, th e n u rse c a n face d is c ip lin a ry a ctio n s b y th e e m p lo y e r (H a s la u e r & Jones, 2 0 0 3 ) . I f a nurse has concerns re g a rd in g th e im p le m e n ta tio n o f a ta s k o r a c tiv ity , it is im p o r ta n t to d o c u m e n t c o n ce rn s fo r p a tie n t s afe ty a n d to in fo r m th e e m p lo y e r. A fte r th e s ta ff b e c o m e c o m fo rta b le w it h th e ir s k ill a t d e le g a tio n , th e n e x t c h a lle n g e is m a k in g sure th e y h a v e th e s kills necessary to assess th e c o m p e te n c e o f th e ir U A P fo r in d iv id u a l tasks.

KEY COMPETENCY 12-4 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Leadership: Knowledge (K6) Understands the principles of account­ ability and delegation Attitudes/Behaviors (A6a) Recognized the value of delegation; (A6b) Accepts accountability for nursing care given by self and del­ egated to others Skills (S6b) Assigns, directs, and supervises ancillary per­ sonnel and support staff in carrying out particular roles/ functions aimed at achieving patient care goals Source: Massachusetts Department of Higher Education (2010), p. 18.

Delegation Decision-Making Tree In 1 9 9 7 , th e N C S B N d e v e lo p e d a d e le g a tio n d e c is io n -m a k in g tree th a t id e n ­ tifies s everal steps nurses c an ta k e to h e lp th e m m a k e d e le g a tio n decision s. In 2 0 0 6 , th e A N A a n d th e N C S B N p u b lis h e d a jo in t p a p e r o n th e to p ic o f d e le g a tio n th a t in clu d es th e A N A p rin c ip le s o f d e le g a tio n a n d th e N C S B N d e c is io n -m a k in g tree . T h e d e c is io n -m a k in g tree is a useful to o l o r “ g rid th a t m a y be used b y s ta ff e d u c a tio n specialists to p ro v id e o rie n ta tio n a n d e d u c a tio n to s ta ff nurses a n d U A P ” (K le in m a n & S ac c o m an o , 2 0 0 6 , p . 1 6 8 ). T h e d e ci­ s io n -m a k in g tree is a v a ila b le o n lin e a t w w w .n c s b n .o rg /J o in t_ s ta te m e n t.p d f.

H e a lth c a re R e fo rm T h e U .S . C o n g ress passed th e P a tie n t P ro te c tio n a n d A ffo r d a b le C a re A c t o n M a r c h 2 1 , 2 0 1 0 , a s w e e p in g h e a lth c a re r e fo r m la w t h a t w i l l e x p a n d h e a lth c a re c o ve rag e to 3 2 m illio n A m e ric a n s . A G a llu p p o ll o n b e h a lf o f th e R o b e r t W o o d Jo h n s o n F o u n d a tio n o f 1 ,5 0 0 p a rtic ip a n ts re c ru ite d fr o m a c a ­ d e m ia , in s u ra n c e c o m p a n ie s , a n d h e a lth c a re o rg a n iz a tio n s fo u n d th a t nurses h a d th e lea st in flu e n c e o n th e design o f th is h e a lth c a re r e fo r m . N u rs e s a re in a p o s itio n to focus o n p re v e n tio n a n d m a n a g e m e n t o f c h ro n ic disease as w e ll as to p ro m o te h e a lth y a g in g a n d w e lln es s. I t is im p o r ta n t fo r nurses to c o n ­ tin u e to stay a b re a s t o f n e w h e a lth c a re la w s a n d to re m a in p o litic a lly a c tiv e . T h e firs t n a tio n w id e e ffo r t to im p ro v e h e a lth c a re access fo r lo w -in c o m e a n d e ld e rly A m e ric a n s w a s in th e 1 9 6 0 s w it h th e c r e a tio n o f M e d ic a r e , M e d ic a id , a n d C o m m u n ity H e a lt h C e n te rs . D e s p ite these im p ro v e m e n ts , 5 0 years la te r, ra c ia l, e th n ic , a n d s o c io e c o n o m ic d is p a ritie s re m a in b o th in h e a lth c are as w e ll as h e a lth status. T h e A ffo r d a b le C a re A c t addresses ra c ia l a n d e th n ic h e a lth care a n d h e a lth status d isp aritie s in several im p o r ta n t w a y s . T h e a ct p ro v id e s access to in s u ra n c e fo r a ll A m e ric a n s th ro u g h t a x c red its a n d p re m iu m assistance, w h ic h s h o u ld s ig n ific a n tly im p ro v e access to h e a lth c are . T h is n e w h e a lth c a re le g is la tio n is 2 ,4 0 0 pages lo n g a n d has 1 0 m a jo r sections (g o v tra c k .u s , 2 0 1 0 ) . Because o f th e c o m p le x ity o f th e le g is la tio n , fe w p e o p le even w it h in th e h e a lth c a re in d u s try are fu lly a w a re o f a ll th e in tr ic a ­ cies in v o lv e d . A s th is la w is e n ac te d , d ra s tic changes w ill be m a d e to th e w a y h e a lth care is fin a n c e d a n d d e liv e re d in th e U n ite d States.

E th ic a l, L eg al, and M o ral C o u rag e to C o n fro n t B u llyin g in th e W o rk p la c e W o rk p la c e v e rb a l a n d p h y sic al abuse has m a n y sources; h o w e v e r, it is m o s t stressful w h e n a c o w o rk e r is th e p re d a to r (C e n te r fo r A m e ric a n N u rs e s , 2 0 0 7 ).

Preventing Legal Problems

T h e nurse w h o bullies others is o fte n using p o w e r as a w a y to c o n tro l a n o th e r perso n. N u rs es h ave an e th ica l a n d legal re s p o n s ib ility to s u p p o rt a colleagu e w h o is being bullied: T h e ethical o b lig a tio n is o u tlin e d b y A N A (2 0 0 1 ) as fo llow s: T h e p rin c ip le o f respect fo r persons exte n d s to a ll in d iv id u a ls w ith w h o m th e nurse in te ra cts. T h e nurse m a in ta in s co m p as sio n a te a n d c a rin g re la tio n sh ip s w ith colleagues a n d others w ith a c o m m itm e n t to th e fa ir tr e a tm e n t o f in d iv id u a ls . . . th e s ta n d a rd o f c o n d u c t p re c lu d e s a n y fo r m o f h a ra s s m e n t o r th re a te n in g b e h a v io r, o r d is re g a rd fo r th e e ffe c t o f o n e ’s b e h a v io r o n o th e rs . (p . 9 ) N u rs e s s h o u ld s u p p o rt each o th e r a n d m a in ta in th e d ig n ity a n d in te g rity o f o th e r nurses. A c tin g le g a lly a n d m o ra lly re q u ires k n o w le d g e o f p ro fes s io n al e th ic a l o b lig a tio n s a n d th e c o u ra g e to c o n fro n t th e p ro b le m ass ertiv e ly .

P re v e n tin g Legal P ro b le m s P re v e n tin g leg a l p ro b le m s in te n tio n a lly ru n s as a th e m e th ro u g h th is c h a p te r. In s u m m a ry , p re v e n tio n re q u ire s c o n sis te n tly fo llo w in g th e n u rs in g process— th e d e c is io n -m a k in g process o f n u rs in g in a ll n u rs in g care s itu a tio n s . Because nurses a ct as m an ag e rs o f care, fo llo w in g m a n a g e m e n t p rin c ip le s also reduces th e ris k o f le g a l p ro b le m s . T h is is e s p e cia lly tru e w it h d e le g a tio n o f c are , an a c tiv ity th a t p re d ic ta b ly w ill increase as c are system s a d ju s t to th e n u rs in g s h o rta g e . C o m m u n ic a tio n w it h p a tie n ts , fa m ilie s , n u rs in g s ta ff, a n d o th e r h e a lth ­ care p ro v id e rs also reduces th e ris k o f le g a l p ro b le m s . A o n c e -a -y e a r c o m m it­ m e n t to re v ie w in g th e state nurse p ra c tic e a ct a n d rules as w e ll as p ro fe s s io n a l s tan d ard s o f c are a n d code o f ethics w ill e n h an ce th e n u rs e ’s a p p re c ia tio n o f leg a l a c c o u n ta b ility in c are . B e y o n d these g e n e ra l a c tiv itie s th e n u rse s h o u ld t a ilo r ris k p re v e n tio n to b e in g a w a re o f th e la w a n d ru le s th a t a ffe c t th e n u rs e ’s p a rtic u la r p ra c tic e s itu a tio n . H o s p ita l a n d lo n g -te rm care settings are a ffe c te d b y d iffe re n t la w a n d ru le s. N u rs e s h o ld in g a d m in is tra tiv e p o s itio n s s h o u ld k n o w th e la w s a n d ru les a ffe c tin g th e ir a re a o f p ra c tic e . I n tu rn , th e y s h o u ld e d u c a te n u rs in g s ta ff in th e ir re s p o n s ib ilitie s to c a rry o u t th e la w in th e ir p ra c tic e settin g . T h e p ra c tic e o f n u rs in g is n e v e r s ta tic . P ra c tic e is a c o n tin u o u s q u e st in v o lv in g a d a p ta tio n to th e c u rre n t h e a lth c a re e n v iro n m e n t w it h a c o m m it­ m e n t to m a k in g t h a t e n v ir o n m e n t as safe as p o s s ib le fo r th e p a tie n ts fo r w h o m nurses care.

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CHAPTER 12 Law and the Professional Nurse

C o nclu sio n N u rs e s a re g e n e ra lly la w -a b id in g c itize n s w h o h a v e a p o s itiv e re la tio n s h ip a n d re s p e c t fo r th e ir p ro fe s s io n . H o w e v e r , n u rse s m u s t d e v e lo p a c le a r u n d e rs ta n d in g o f th e leg a l system , sources o f la w , nurse p ra c tic e acts, d e le g a ­ tio n , s tan d ard s o f c are , h e a lth c a re r e fo r m , a n d strategies fo r a v o id in g leg al p ro b le m s . N u rs e s s h o u ld m a k e e ve ry e ffo r t to p ro v id e h ig h -q u a lity c are fo r p a tie n ts th a t n o t o n ly helps th e m re c o v e r th e ir h e a lth b u t also a vo id s la w s u its . N u rs e s h a v e a le g a l a n d e th ic a l d u ty to be k n o w le d g e a b le a b o u t th e ir scope o f p ra c tic e a n d leg a l issues.

CASE STUDY 12-1

s 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 ad­ equate care for all of 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 vital signs for Mr. Martin and you request that the second nursing

A

assistant assess Ms. Smith’s level of pain because you have recently administered pain medication. Case Study Questions 1.

2.

Is the delegation of the assignment to the first nursing assistant in the case study appropriate? Why or why not? Is the delegation of the assignment to the second nursing assistant in the case study appropriate? Why or why not? ■

Classroom A ctivity 1 m o c k tr ia l is a fu n w a y to e x p lo re som e o f th e c o n ce p ts in th is c h a p te r. A ss ig n ro le s to s tu d e n ts a n d use a g ra d u a tio n g o w n fo r th e ju d g e to increase th e re a lis m . M a k e

A

u p y o u r o w n case o r use one a lre a d y p re p a re d such as th e e x c e lle n t m o c k t r ia l p re s e n te d in N u r s e E d u c a t o r b y H a id in y a k (2 0 0 6 ).

R e fe re n c e s American Medical Association. (2007). Informed consent. Chicago, IL: Author. American Nurses Association. (2001). Code o f ethics for nurses with interpretive statements. Washington, DC: Author. American Nurses Association. (2004). Nursing: Scope and standards o f practice. Washington, DC: Author. American Nurses Association. (2005). Principles for delegation [Brochure]. Retrieved from http://www.healthsystem.virginia.edu/internet/e-learning/ principlesdelegation.pdf American Nurses Association. (2010). Nursing: Scope and standards o f practice. Silver Spring, MD: Author. American Nurses Association & National Council of State Boards of Nursing. (2006). Joint statement on delegation. Retrieved from http://www.ncsbn.org/ Joint_statement.pdf Bolin, J. N. (2005). When nurses are reported to the national practitioner’s data bank. Journal o f Nursing Law, 10(3), 141-148. Canterbury v. Spence, 464 F.2d 772 (D.C. Cir. 1972). Caroselli-Karinja, M. F., & Zboray, S. D. (1986). The impaired nurse. Journal o f Psychosocial Nursing and Mental Health Services, 24(6), 14-19. Castledine, G. (2006). Nurse whose inexperience and negligence in bladder washout put her patient at risk. British Journal o f Nursing, 15(3), 141-143. Center for American Nurses. (2007). Lateral violence and bullying in the workplace. Retrieved from http://www.mc.vanderbilt.edu/root/pdfs/nursing/center_lateral_ violence_and_bullying_position_statement_from_center_for_american_nurses.pdf Clevette, A., Erbin-Rosenmann, M., & Kelly, C. (2007). Nursing licensure: An examination of the relationship between criminal convictions and disciplinary actions. Journal o f Nursing Law, 11(1), 5-8. Daniel, I. Q. (1984). Impaired professionals: Responsibilities and roles. Nursing Economics, 2, 190-193. Driscoll, K. (2004). Current issues: Crossing professional boundaries: Ethical, legal, and case perspectives. Rehabilitation Nursing, 29(3), 78-79. Finkelman, A. W. (2006). Leadership and management in nursing. Upper Saddle River, NJ: Pearson Prentice Hall. Fremgen, B. F. (2002). Medical law and ethics. University of Notre Dame. Upper Saddle River, NJ: Prentice Hall. Garner, B. A. (2009). Black’s law dictionary (9th ed.). St. Paul, MN: West Group. Govtrack.us. (2010). H.R. (111th) 3590: Patient protection and affordable care act. Retrieved from http://www.govtrack.us/congress/bills/111/hr3590 Greynolds v. Kurman, 91 Ohio App.3d 389 (1993). Grossman, S. C. (2005). The new leadership challenge. Philadelphia, PA: F. A. Davis. Guido, G. (2001). Legal and ethical issues in nursing (3rd ed.). Upper Saddle River, NJ: Prentice Hall. Haack, M. R., & Yocom, C. J. (2002). State policies and nurses with substance abuse disorders. Journal o f Nursing Scholarship, 34, 89-94. Haidinyak, G. (2006). Try a mock trial. Nurse Educator, 31(3), 119-123. Hall, J. K. (1996). Nursing ethics and law. Philadelphia, PA: Saunders.

Haslauer, S., & Jones, D. (2003, Winter). Delegation: Concept, art, skill, process. Arkansas State Board o f Nursing Update, 22-24. Havinghurst, C. (1998). Health care law and policy: Readings, notes and questions. Westbury, NY: Foundation Press. Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment o f nurses. Washington, DC: National Academy Press. Institute of Medicine. (2007). Informing the future: Critical issues in health. Washington, DC: National Academies Press. Kalisch, B. J. (2006). Missed nursing care: A qualitative study. Journal o f Nursing Care Quality, 21(4), 306-313. Kalisch, P. A., & Kalisch, B. J. (1995). The advance o f American nursing (3rd ed.). Philadelphia, PA: Lippincott. Kleinman, C. S., & Saccomano, S. J. (2006). Registered nurses and unlicensed assistive personnel: An uneasy alliance. Journal o f Continuing Education in Nursing, 37(4), 162-170. Longest, B. B. (2002). Health policymaking in the United States (3rd ed.). Chicago, IL: Health Administration Press. Massachusetts Department of Higher Education. (2010). Nurse o f the future: Nursing core competencies. Retrieved from http://www.mass.edu/currentinit/documents/ NursingCoreCompetencies.pdf Montgomery, V. L. (2007). Effect of fatigue, workload, and environment on patient safety in the pediatric intensive care unit. Pediatric Critical Care Medicine, 8(Suppl. 2), S11-6. Murphy, E. K. (2004). Implications for perioperative nurses. American Operating Room Nurse, 80(2), 314-317. National Council of State Boards of Nursing. (2010). NCLEX-RN test plan. Chicago, IL: Author. Nickell v. Gonzalez, 17 Ohio St.3d 136, 477 N.E.2d 1145 (1985). Quallich, S. A. (2005). A bond of trust: Delegation. Urologic Nursing, 25(2), 120-123. State Office of Administration for the Courts. (1997). A citizen’s guide to Washington courts. The procedure for a civil trial. Washington, DC: Author. Trappen, R. M., Weiss, S. A., & Whitehead, D. K. (2004). Essentials o f nursing leadership and management (3rd ed., pp. 91-103). Philadelphia, PA: F. A. Davis. Truman v. Thomas, 27 Cal. 3d 285, 611. P2d (1980). U.S. Department of Health and Human Services. (2003). Survey o f the national practitioner’s data bank. Washington, DC: Author.

The Role of the Professional Nurse in Patient Education Kathleen Masters

v_____________________ P a tie n t e d u c a tio n has fo r m a lly b e en a p a r t o f n u rs in g c a re since th e tim e o f F lo re n c e N ig h tin g a le ( 1 8 6 0 /1 9 6 9 ) . D u r in g th e 1 9 0 0 s , p a tie n t e d u c a tio n in c re a s in g ly b e ca m e id e n tifie d as a ro le o f th e p ro fe s s io n a l nurse; h o w e v e r, it w a s n o t u n til 1 9 7 3 th a t th e A m e ric a n N u rs e s A s s o c ia tio n ( A N A , 1 9 7 3 ) d e fin e d p a tie n t e d u c a tio n as a c o m p o n e n t o f th e p ra c tic e o f th e re g is ­ te re d n u rs e . B e g in n in g in 1 9 7 6 , th e J o in t C o m m is s io n o n A c c re d ita tio n o f H e a lth c a r e O r g a n iz a tio n s (T h e J o in t C o m m is s io n , 1 9 9 5 ) in c lu d e d p a tie n t a n d fa m ily e d u c a tio n as a fu n c tio n c r itic a l to p a tie n t c a re . T h e A m e ric a n A s s o c ia tio n o f C olleges o f N u rs in g ( A A C N , 1 9 9 8 , 2 0 0 8 ) also re c o g n ize d th a t th e im p le m e n ta tio n o f th e p ro fe s s io n a l n u rs in g ro le re q u ire s th a t nurses are p re p a re d to te a c h p a tie n ts e ffe c tiv e ly . T o d a y , p a tie n t e d u c a tio n is b o th an e x p e c ta tio n a n d le g a l o b lig a tio n o f th e p ro fe s s io n a l n u rse .

Learning Objectives A f t e r c o m p le tin g th is c h a p te r, th e s tu d e n t should be a b le to : 1. D iffe re n tia te b e tw e e n p a tie n t e d u c a tio n and p a tie n t te a c h in g . 2 . Discuss th e purposes of p a tie n t e d u ca tio n . 3 . D escribe th e pro cess of p a tie n t e d u ca tio n . 4 . Id e n tify th re e dom ains o f lea rn in g . 5 . Discuss tw o th e o re tic a l fra m e w o rk s re la te d to th e lea rn in g process.

6 . D e m o n s tra te use of a re a d a b ility fo rm u la to assess re ad in g g ra d e level. 7 . D iscuss s tra te g ie s to a c c o m m o d a te fo r a g e re la te d b a rrie rs to lea rn in g in o ld e r ad u lts. 8 . D iscuss th e d e v e lo p m e n t of c u ltu ra lly a p p ro ­ p ria te p a tie n t ed u ca tio n .

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Key Terms and Concepts » » » » » » » » » »

P atient teaching Patient education Learning domains Andragogy Health Belief Model (HBM) Social learning theory Self-efficacy Readiness to learn Health literacy Age-related changes

P a tie n t E d u catio n : W h a t Is It? “ P a tie n t e d u c a tio n is a n y set o f p la n n e d , e d u c a tio n a l a c tiv itie s d e sig n e d to im p r o v e p a tie n ts ’ h e a lth b e h a v io rs , h e a lth s ta tu s , o r b o t h ” (L o r ig , 2 0 0 1 , p . x i i i ) . T h e r e is n o th in g in th is d e fin itio n a b o u t im p r o v in g k n o w le d g e , a lth o u g h a c h a n g e in k n o w le d g e m ig h t be nece ss ary to re a c h th e g o a l o f c h a n g in g h e a lth status o r h e a lth b e h a v io rs . In c o n tra s t, a c tiv itie s a im e d a t im p r o v in g k n o w le d g e a re k n o w n as p a tie n t te a c h in g (L o r ig , 2 0 0 1 , p . x iv ). T h e p o in t is th a t th e p u rp o s e o f p a tie n t e d u c a tio n in v o lv e s m o re th a n a c h an g e in k n o w le d g e . T h e p u rp o se s o f p a tie n t e d u c a tio n a re to m a in ta in h e a lth , to im p ro v e h e a lth , o r to s lo w d e te rio ra tio n o f h e a lth . T h e s e pu rp o ses are m e t th ro u g h changes in h e a lth -re la te d b e h av io rs a n d a ttitu d es (L o rig , 2 0 0 1 ) . These changes are n o t easily ach ieved . E ffe c tiv e p a tie n t e d u c a tio n requires th e n u rse to h a v e th e a b ility to c o m m u n ic a te e ffe c tiv e ly w it h p a tie n ts to assess th e in d iv id u a l needs, a ttitu d e s , a n d p referen ces o f th e p a tie n t th a t c an a ffe c t h e a lth b e h a v io rs b e fo re a n y changes c a n be e x p e c te d (F a lv o , 2 0 0 4 , 2 0 1 1 ) . In a d d itio n to c o m m u n ic a tio n a n d assessm ent s kills , i f th e n u rs e is to be e ffe c tiv e as a p a tie n t e d u c a to r, th e n u rs e m u s t also h a v e s u ffic ie n t k n o w le d g e o f th e in f o r ­ m a tio n th a t needs to be ta u g h t. I f th e k n o w le d g e base o f th e n u rse is in s u ffic ie n t, th e n u rse risk s p r o v id in g in a d ­ e q u a te o r in a c c u ra te in fo r m a t io n to th e p a tie n t (F a lv o , 2 0 0 4 , 2 0 1 1 ). F in a lly , to be a n e ffe c tiv e p a tie n t e d u c a to r, it is im p o r ta n t th a t th e nurse h a v e a n u n d e rs ta n d in g o f h o w to c o n d u c t p a tie n t e d u c a tio n . T h e re m a in d e r o f th is c h a p te r p ro v id e s a fo u n d a tio n fo r th e c o n d u c t o f p a tie n t e d u c a tio n .

T h e o rie s and P rin c ip le s of L e arn in g M a n y e d u c a tio n a l th e o rie s a n d p rin c ip le s c an be used to g u id e th e p a tie n t e d u c a tio n process. S om e th a t a re m o s t c o m m o n ly used in th e h e a lth c a re set­ tin g a re p re se n ted h ere.

■ Domains of Learning F irs t, w e s h o u ld e x a m in e th e n a tu re o f le a rn in g in re la tio n s h ip to lea rn in g d o m a in s . Id e n tific a tio n o f th e le a r n in g d o m a in re flec ts th e ty p e o f le a r n ­ in g d e sire d as a re s u lt o f th e p a tie n t e d u c a tio n process. L e a rn in g occurs in th re e d o m a in s : th e c o g n itiv e , th e p s y c h o m o to r, a n d th e a ffe c tiv e (B lo o m , 1 9 5 6 ) . E a c h d o m a in has levels, a n d each le v e l b u ild s o n th e p re v io u s one in

a h ie ra rc h ic a l fa s h io n . In th e c o g n itiv e a n d p s y c h o m o to r d o m a in s , levels are a rra n g e d in th e o rd e r o f in c re a s in g c o m p le x ity . In th e a ffe c tiv e d o m a in , levels are o rg a n iz e d a c c o rd in g to th e degree o f in te rn a liz a tio n o f a v a lu e o r a ttitu d e . C o g n itiv e le a rn in g encom passes th e in te lle c tu a l s kills o f re m e m b e rin g , u n d e rs ta n d in g , a p p ly in g , a n a ly z in g , e v a lu a tin g , a n d c re a tin g . P s y c h o m o to r le a rn in g refers to le a rn in g o f m o to r skills a n d p e rfo rm a n c e o f b e h a v io rs o r skills th a t re q u ire c o o rd in a tio n . A ffe c tiv e le a rn in g re q u ire s a c h an g e in fe el­ ings, a ttitu d e s , o r beliefs (A n d e rs o n & K r o th w o h i, 2 0 0 1 ) . U n d e r s ta n d in g w h ic h d o m a in is th e ta rg e t o f le a rn in g h elp s g u id e th e p la n n in g , im p le m e n ta tio n , a n d e v a lu a tio n o f le a rn in g . F o r e x a m p le , i f based o n assessm ent y o u k n o w th a t a p a tie n t is k n o w le d g e a b le a b o u t in s u lin a d m in ­ is tra tio n a n d is c o m m itte d to a d m in is te rin g th e in je c tio n b u t has n o t y e t been able to m a n ip u la te th e syringe c o rre c tly to a d m in is te r th e in je c tio n , y o u k n o w th a t y o u r ta rg e t d o m a in fo r le a rn in g is th e p s y c h o m o to r d o m a in , a n d th e focus o f y o u r o b je ctiv es , p la n n in g , le a rn in g a c tiv itie s , a n d e v a lu a tio n w ill be o n th e p e rfo rm a n c e o f th e id e n tifie d b e h a v io rs .

■ A ndragogy A n d ra g o g y , in itia lly d e fin e d as “ th e a rt a n d science o f h e lp in g a d u lts le a r n ” (K n o w le s , 1 9 7 0 ) , has ta k e n o n a b ro a d e r m e a n in g o v e r th e p a st 3 5 years a n d is c u rre n tly used to re fe r to le a rn e r-fo c u s e d e d u c a tio n fo r p e o p le o f a ll ages (C o n n e r, 2 0 0 4 ) . T h e a n d ra g o g ic m o d e l asserts th a t fo u r issues be c o n sid e re d a n d addressed in le a rn in g . T h e s e in c lu d e th e fo llo w in g (K n o w le s , S w a n s o n , & H o lt o n , 1 9 9 8 , 2 0 1 1 ): • • • •

L e ttin g le a rn e rs k n o w w h y s o m e th in g is im p o r ta n t to le a rn S h o w in g le a rn e rs h o w to d ire c t th em selves th ro u g h in fo r m a tio n R e la tin g th e to p ic to th e le a rn e rs ’ experiences R e a liz in g th a t p e o p le w ill n o t le a rn u n til th e y are re a d y a n d m o tiv a te d

A d u lts le a rn best w h e n th e re is im m e d ia te o p p o r tu n ity fo r a p p lic a tio n . A d u lts in p a rtic u la r are m o tiv a te d to le a rn w h e n th e y re co g n ize a gap b e tw e e n w h a t th e y k n o w a n d w h a t th e y w a n t to k n o w o r w h a t th e y n e e d to k n o w (K n o w le s , 1 9 7 0 ). T h e re fo re , a d u lt le a rn e rs are ra re ly in te re s te d in le a rn in g d e ta ile d a n a to m y a n d p h y s io lo g y re la te d to th e ir c h ro n ic disease, b u t th e y a re m o tiv a te d to le a rn h o w to c are fo r th em selves a fte r d isc h a rg e fr o m th e h o s p ita l. E ffe c tiv e p a tie n t e d u c a tio n w ill be based o n p rin c ip le s th a t c a p ita liz e o n these c h ara c te ris tic s o f th e a d u lt le a rn e r.

■ Health Belief Model T h e H e a lth B e lie f M odel (H B M ) is o n e o f th e m o s t w id e ly used fr a m e w o rk s in re se arch a n d p ro g ra m s re la te d to h e a lth p r o m o tio n a n d p a tie n t e d u c a tio n . T h is m o d e l w a s o r ig in a lly d e v e lo p e d to p re d ic t th e lik e lih o o d o f a p e rs o n

KEY COMPETENCY 13-1 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Communication (Teaching/ Learning): Knowledge (K5d) Is aware of the three domains of learning: cognitive, affec­ tive, and psychomotor Attitudes/Behaviors (A5c) Values the need for teaching in all three domains of learning Source: Massachusetts Department of Higher Education (2010), p. 29.

fo llo w in g a re c o m m e n d e d a c tio n a n d to u n d e rs ta n d th e p e rs o n ’s m o tiv a tio n a n d d e c is io n m a k in g re g a rd in g s ee kin g h e a lth services (H o c h b a u m , 1 9 5 8 ). A c c o rd in g to th e H B M , th e lik e lih o o d o f a p e rs o n a c tin g in respo nse to a h e a lth th re a t depen ds o n s ix fa c to rs : • • • • • •

T h e p e rs o n ’s p e rc e p tio n o f th e s ev erity o f th e illness T h e p e rs o n ’s p e rc e p tio n o f s u s c e p tib ility to illness a n d its consequences T h e v a lu e o f th e tr e a tm e n t b en efits (i.e ., d o th e co st a n d side effects o f tr e a tm e n t o u tw e ig h th e consequences o f th e disease?) B a rrie rs to tr e a tm e n t (i.e ., expense, c o m p le x ity o f tre a tm e n t) C osts o f tr e a tm e n t in p h y s ic a l a n d e m o tio n a l te rm s C ues th a t s tim u la te ta k in g a c tio n to w a r d tre a tm e n t o f illness (i.e ., m ass m e d ia c a m p a ig n s , p a m p h le ts , a d vic e fr o m fa m ily o r frie n d s , a n d p o s tc a rd re m in d e rs fr o m h e a lth c a re p ro v id e rs )

T h e H B M c an p ro v id e a fr a m e w o r k fo r assessing areas w h e re p a tie n ts h a v e gaps in k n o w le d g e , such as s e v e rity o f illness o r s u s c e p tib ility to illness, a n d th e n address th ose areas to in crea se th e p o te n tia l fo r c o m p lia n c e w it h th e tre a tm e n t re g im e n . T h r o u g h use o f th e H B M , y o u c an W W W J CRITICAL THINKING Q U ESTIO N * e a s ily c a te g o riz e a n d c o v e r th e e ss en tia l c o m p o n e n ts o f Think about your own life. Do you act to pre­ y o u r e d u c a tio n a l m essage, th us p ro v id in g th e p a tie n t w it h vent a disease or accident when you perceive a basic u n d e rs ta n d in g o f th e s e v e rity o f th e illness, th e ris k that you are not susceptible to the disease or a n d consequences o f th e illness, th e v a lu e o f tre a tm e n t, th e at risk for the accident? V b a rrie rs to tre a tm e n t, a n d th e costs o f tre a tm e n t.

■ Social Learning Theory A c c o rd in g to B a n d u ra ’s social learning th e o ry , i f a perso n believes th a t he o r she is c ap ab le o f p e rfo rm in g a b e h a v io r (s e lf-e ffic a c y ) a n d also believes th a t the b e h a v io r w ill lea d to a d esirable o u tc o m e , th e perso n w ill be m o re lik e ly to p e r­ fo rm th e b e h a v io r (B a n d u ra , 1 9 9 7 ). In c o n tra s t, i f a person does n o t believe th a t he o r she is cap a b le o f p e rfo rm in g a b e h a v io r, he o r she w ill h ave n o in ce n tiv e to d o so, even i f th e p erso n is a c tu a lly c a p a b le . P erceptions o f self-efficacy are p a rtic u la rly im p o rta n t in re la tio n s h ip to a p a tie n t’s le a rn in g c o m p le x a ctivities o r lo n g -te rm changes in b e h a v io r (P ro h a s k a & L o rig , 2 0 0 1 , p . 1 6 3 ). T h e r e a re fo u r m e th o d s fo r d e v e lo p in g o r e n h a n c in g e ffic ac y e x p e c ta ­ tio n s i f assessm ent reveals a n e ed fo r such e n h a n c e m e n t. T h e se m e th o d s a re as fo llo w s : • • • •

P e rfo rm a n c e a c c o m p lis h m e n ts V ic a rio u s e x p e rie n c e o r m o d e lin g V e r b a l p e rsu as io n In te r p r e ta tio n o f p h y s io lo g ic state

P e rfo rm a n c e a c c o m p lis h m e n t is th e m o s t d ire c t a n d in flu e n tia l w a y to e n h an ce s elf-effica cy . In th is m e th o d , th e p a tie n t firs t p e rfo rm s tasks th a t he

o r she c a n e as ily p e r fo r m . B y su cceed in g w it h these firs t ta sk s , th e p a tie n t develo p s a sense o f c o m p e te n c e a n d e n h a n c e m e n t o f s e lf-e ffic a c y b e fo re p r o ­ c ee d in g to m o re d iffic u lt ta sk s . A lo n g these sam e lin es , it is also im p o r ta n t to set s h o rt-te rm goals th a t are m e a s u ra b le so th a t p a tie n ts c an see th e ir suc­ cess a n d th e im p a c t o f th e ch an g e in th e ir b e h a v io r. A p a tie n t w h o c a n see th e benefits o f a b e h a v io r ch an g e w it h in a re a s o n a b le tim e is m o re lik e ly to c o n tin u e p ra c tic in g th e b e h a v io r. T h e second m e th o d fo r en h an cin g self-efficacy is th ro u g h m o d e lin g , w h e re th e p a tie n ts o b serve o th e rs w h o a p p e a r to be s im ila r a n d w h o are success­ fu lly p e rfo rm in g b e h a v io rs . M o d e lin g c an also be ach ie ve d th ro u g h th e use o f illu s tra tio n s in p a m p h le ts o r in p ro g ra m m in g m a te ria ls b y usin g illu s tra tio n s a n d m o d e ls th a t a re o f v a rio u s c u ltu re s , b o d y shapes, a n d ages (P ro h a s k a & L o r ig , 2 0 0 1 ) . V e r b a l p e rs u a s io n c a n also be a n e ffe c tiv e m e th o d o f e n h a n c in g s e lf­ efficacy e x p e ctatio n s. T h e c o n te n t o f th e m essage needs to in c lu d e basic fa c tu a l in fo r m a tio n th a t em p h asizes th e im p o rta n c e o f p e rfo r m in g th e b e h a v io r. I t is u s u a lly b e tte r to ask fo r in c re m e n ta l changes o r ask th e p a tie n t to do ju s t s lig h tly m o re th a n he o r she is c u rre n tly d o in g (P ro h a s k a & L o r ig , 2 0 0 1 ) . E n c o u ra g e m e n t a n d s u p p o rt n o t o n ly fr o m th e n u rse b u t also fr o m fa m ily a n d frie n d s h e lp th e p a tie n t to be successful. M o s t illnesses p re s e n t w it h s y m p to m s , a n d m o s t n e w b e h a v io rs cause s o m e p h y s io lo g ic c h a n g e s . A d d r e s s in g th e m e a n in g o f s y m p to m s a n d p h y s io lo g ic states c a n in flu e n c e s e lf-e ffic a c y . F o r e x a m p le , a p a tie n t w h o is tr y in g to q u it s m o k in g c a n e x p e c t w it h d r a w a l s y m p to m s . I f th e p a tie n t u n d e rs ta n d s th e re a s o n s fo r th e s y m p to m s a n d th e lim it a t io n in th e d u r a ­ t io n o f th e s y m p to m s , th e p a t ie n t m ig h t d e c id e t h a t h e o r she h a s th e a b ilit y to m a k e th e c h a n g e . W it h o u t t h a t k n o w le d g e , th e p a tie n t m ig h t g iv e u p b e c a u s e h e o r she e x p e rie n c e s p h y s io lo g ic c h a n g e s t h a t a re n o t u n d e rs to o d .

KEY COMPETENCY 13-2 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Communication (Teaching/ Learning): Knowledge (K5c) Under­ stands the principles of teaching and learning Attitudes/Behaviors (A5b) Accepts the role and respon­ sibility for providing health education to patients and families Skills (S5c) Assists patients and families in accessing and interpreting health informa­ tion and identifying healthy lifestyle behaviors Source: Massachusetts Department of Higher Education (2010), p. 29.

T h e P a tie n t E d u c a tio n P ro cess A c c o rd in g to R e d m a n (2 0 0 1 , 2 0 0 6 ) , th e process o f p a tie n t e d u c a tio n c an be v ie w e d as p a ra lle l to th e n u rs in g process. E a c h o f these processes begins w ith assessm ent, n e g o tia tio n o f goals a n d o b je ctiv es , p la n n in g , in te rv e n tio n , an d fin a lly e v a lu a tio n (R a n k in , 2 0 0 5 ; R a n k in & Stallings, 2 0 0 1 ).

■ Assessm ent T h e g o a l o f th e n u rse in th e process o f p a tie n t e d u c a tio n is to assist th e p a tie n t in o b ta in in g th e k n o w le d g e , s kills, o r a ttitu d e th a t w ill h e lp th e p a tie n t d e v e lo p b e h a v io rs to m e e t needs a n d m a x im iz e th e p o te n tia l fo r p o s itiv e h e a lth

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The process of patient education can be viewed as parallel to the nursing process.

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o u tco m e s (F a lv o , 2 0 0 4 , 2 0 1 1 ) . B ecause n o p a tie n t o r s itu a tio n is e x a c tly th e sam e, a n assessm ent is re q u ire d . M a n y a v a ila b le g u id e s a re h e lp fu l in assessing th e le a r n in g needs o f p a tie n ts (R e d m a n , 2 0 0 3 ) . S om e nurses c o n s tru c t th e ir o w n assessm ent to o ls to m e e t specific needs. O b s e rv a tio n , in te rv ie w s , o p e n -e n d e d q u estio n s, focus g ro u p s , a n d th e p a tie n t’s m e d ic a l re c o rd are a d d itio n a l w a y s to g a th e r in f o r ­ m a tio n fo r th e assessm ent o f le a rn in g needs. R a n k in a n d S ta llin g s (2 0 0 1 , p . 2 0 0 ) suggest som e specific qu estio n s th a t m u s t be addressed in th e assessm ent o f le a rn in g needs. T h e se q u estio n s a re as fo llo w s : • • • • • • • •

W h a t in fo r m a tio n does th e p a tie n t need? W h a t a ttitu d e s s h o u ld be e xp lo re d ? W h a t s k ills does th e p a tie n t n e e d to b e a b le to p e r f o r m h e a lth c a r e behaviors? W h a t fa c to rs in th e p a tie n t’s e n v iro n m e n t m a y be b a rrie rs to th e p e r fo r ­ m a n c e o f d esired behaviors? Is th e p a tie n t lik e ly to r e tu r n hom e? C a n th e fa m ily o r c a re g iv e r h a n d le th e care th a t w ill be re q u ire d ? Is th e h o m e s itu a tio n a d eq u ate o r a p p ro p ria te fo r th e ty p e o f care required? W h a t k in d s o f assistance w ill be re q u ire d ?

■ Learning Styles T o p ro v id e th e m o s t e ffe c tiv e p a tie n t te a c h in g th e n u rs e m u s t a ls o assess p a tie n t le a rn in g style. A lth o u g h m o s t p e o p le le a rn best w h e n m u ltip le te c h ­ n iq u e s are used in p a tie n t te a c h in g , assessm ent o f th e p a tie n t’s le a rn in g style is a fu n d a m e n ta l step p r io r to b e g in n in g a n y le a rn in g a c tiv ity . L e a rn in g styles a re m e th o d s o f in te ra c tin g w it h , ta k in g in , a n d pro cessin g in fo r m a tio n th a t a llo w in d iv id u a ls to le a rn . L e a rn in g styles a re g e n e ra lly c a te g o riz e d as v is u a l, a u d ito ry , o r ta c tile /k in e s th e tic . T h e p a tie n t w h o is a v is u a l le a rn e r p re fe rs w r it te n in s tru c tio n s r a th e r th a n v e rb a l in s tru c tio n s b u t p re fe rs p h o to g ra p h s a n d illu s tra tio n s to w r itte n in s tru c tio n s . T h e nurse te a c h in g th e p a tie n t w h o is a v is u a l le a rn e r s h o u ld use a v a rie ty o f in te re s tin g v is u a l le a rn in g m a te ria ls , in c lu d in g o rg a n iz e d v is u a l p re s e n ta tio n s , p h o to g ra p h s , o r c o m p u te riz e d m a te ria ls (R u s s e ll, 2 0 0 6 ) . T h e p a tie n t w h o is a n a u d ito ry le a rn e r re m em b e rs v e rb a l in stru c tio n s w e ll a n d learns th ro u g h discussion. T h e nurse te a c h in g a p a tie n t w h o is an a u d ito ry le a rn e r w ill w a n t to be sure th e p a tie n t is p o s itio n e d to be able to h e a r a n d w ill w a n t to re p h ra s e w h a t is said several d iffe re n t w a y s to be sure th e in te n d e d m essage is c o m m u n ic a te d . T h e n u rse m ig h t also w a n t to use m u ltim e d ia th a t in c o rp o ra te s o u n d in p a tie n t te a c h in g (R u s se ll, 2 0 0 6 ) . T h e p a tie n t w h o lea rn s best th ro u g h g e ttin g p h y s ic a lly in v o lv e d is th e ta c tile o r k in e s th e tic le a rn e r. T h e k in e s th e tic le a rn e r lea rn s th ro u g h d o in g o r

e x p e rie n c in g p h y s ic a lly . T h e k in e s th e tic le a n e r has d iffic u lty s ta y in g in one p lac e fo r v e ry lo n g a n d enjoys h a n d s -o n a c tiv itie s . T h e nurse te a c h in g th e k in ­ esthetic le a rn e r sh o u ld p ro v id e a ctivities d u rin g th e session a n d sh o u ld p ro v id e sam ples o r supplies fo r p ra c tic in g o r d e m o n s tra tin g skills (R u s s e ll, 2 0 0 6 ) .

■ Readiness A n im p o r ta n t v a ria b le in th e p a tie n t e d u c a tio n process is re ad in e ss to le a rn . A fte r a n e ed to le a rn has been id e n tifie d , a p a tie n t’s readiness o r evid en ce o f m o tiv a tio n to receive in fo r m a tio n at th a t p a rtic u la r tim e m u s t also be assessed (F a lv o , 2 0 0 4 , 2 0 1 1 ; T h e J o in t C o m m is s io n , 1 9 9 9 , 2 0 0 3 ; R e d m a n , 2 0 0 1 ) . A v a rie ty o f fa c to rs such as p a in , a n x ie ty , a n d e m o tio n a l re a c tio n s c an a ffe c t a p a tie n t’s readiness to le a rn . M o d e r a te to severe a n x ie ty has been s h o w n to in te rfe re w it h a p a tie n t’s a b ility to c o n c e n tra te a n d u n d e rs ta n d n e w in fo r m a ­ tio n (S tep h en s o n , 2 0 0 7 ) . I f a p a tie n t is d is tra c te d b y p h y s ic a l o r e m o tio n a l p a in , a tte m p ts a t p a tie n t te a c h in g w ill n o t be successful. T h e b e tte r choice is to w a it u n til th e p a in has subsided o r to address th e a n x ie ty th a t th e p a tie n t is e x p e rie n c in g , a n d th e n w h e n th e p a tie n t is re a d y , p ro c e e d w it h p a tie n t e d u c a tio n a c tiv itie s (R e d m a n , 2 0 0 1 , 2 0 0 6 ; S te p h e n so n , 2 0 0 7 ) .

■ Health Literacy H e a lth lite r a c y is d e fin e d as th e a b ility to re a d , u n d e rs ta n d , a n d a c t o n h e a lth in fo r m a tio n . T o d a y th e re is m o re access to h e a lth c a re in fo r m a tio n th a n at a n y tim e in h is to ry . T h e lo w h e a lth lite ra c y p ro b le m is n o t an issue o f access to in fo r m a tio n , b u t ra th e r, it is a crisis o f u n d e rs ta n d in g m e d ic a l in fo r m a tio n (D o a k & D o a k , 2 0 0 2 ) . I t is a crisis. R e s e a rc h studies h a ve d e m o n s tra te d th a t p a tie n ts w it h lo w h e a lth lite ra c y skills m a k e m o re e rro rs w it h th e ir m e d ic a ­ tio n s a n d tre a tm e n ts (B a k e r et a l., 1 9 9 6 ; W illia m s , B a k e r, H o n ig , L e e , & N o w la n , 1 9 9 8 ) . T h e y o fte n fa il to seek p re v e n tiv e c are a n d a re also a t h ig h e r ris k fo r h o s p ita liz a tio n , w h ic h results in h ig h e r a n n u a l h e a lth c a re costs (B a k e r, P a r k e r, W illia m s , & C la r k , 1 9 9 8 ; W e is s , 1 9 9 9 ). C u r r e n tly in th e U n ite d States, one in fiv e a d u lts a n d n e a rly tw o o f five o ld e r a d u lts a n d m in o ritie s re a d a t th e 5 th -g ra d e lev el o r b e lo w . T h e a ve rag e A m e ric a n reads a t th e 8 th - to 9 th -g ra d e lev el. M o s t m a te ria ls used fo r p a tie n t e d u c a tio n a re w r it te n a b o v e 1 0 th -g ra d e re a d in g le v e l (D o a k & D o a k , 2 0 0 2 ; D o a k , D o a k , & R o o t, 1 9 9 6 ). W e k n o w th a t w h e n th e re a d in g level o f p rin te d m a te ria ls is b e y o n d th e s k ill o f th e le a rn e r, c o m p re h e n s io n is decreased, re c a ll is s k e tc h y a n d in a c c u ra te , a n d m o tiv a t io n to le a rn is d e creased (R e d m a n , 2 0 0 1 , 2 0 0 6 ). W h e n in fo r m a tio n is c o m p le x o r tim e is lim ite d , nurses fr e q u e n tly re ly o n p rin te d m a te ria ls b y in s tru c tin g p a tie n ts to re a d o r re v ie w th e in fo r m a tio n a t h o m e . These m a te ria ls are h e lp fu l w h e n th e y p ro v id e p a tie n ts w h o h ave a d e q u a te re a d in g s kills w it h a re so u rce to re m in d th e m o f th e in s tru c tio n s

KEY COMPETENCY 13-3 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Communication (Teaching/ Learning): Knowledge (K5a) Under­ stands the influences of different learning styles on the education of patients and families Attitudes/Behaviors (A5a) Values different means of communication used by patients and families Source: Massachusetts Department of Higher Education (2010), p. 29.

KEY COMPETENCY 13-4 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Communication (Teaching/ Learning): Knowledge (K5e) Under­ stands the concept of health literacy Skills (S5a) Assesses factors that influence the patient's and family's ability to learn, including readiness to learn, preferences for learning style, and levels of health literacy Source: Massachusetts Department of Higher Education (2010), p. 29.

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g iv e n b y th e n u rse , b u t fo r th o se p a tie n ts w it h lo w h e a lth lite ra c y s kills , th e p rin te d m a te ria ls m ig h t be o f n o use. P a tie n ts w it h lo w h e a lth lite ra c y skills a re g e n e ra lly to o e m b a rra s s e d to re v e a l to th e nurse th a t th e y c a n n o t re a d o r c a n n o t re a d w e ll e n o u g h to u n d e rs ta n d th e w r itte n in s tru c tio n s . I t is th e re fo re im p o r ta n t th a t th e nurse ta k e th e in itia tiv e in th e assessm ent o f lite ra c y skills o f p a tie n ts i f w r it te n m a te ria ls a re g o in g to be used in th e p a tie n t e d u c a tio n process. D ir e c t q u e s tio n in g o f p a tie n ts a b o u t re a d in g a b ility is u s u a lly n o t effec­ tiv e . T h u s , h o w c an y o u d e te rm in e th e re a d in g a b ility o f th e p a tie n t? O n e o p tio n is to use one o f several in s tru m e n ts th a t h a v e been d e v e lo p e d to assess p a tie n t lite ra c y q u ic k ly . S o m e o f th e lite ra c y assessm ent in s tru m e n ts m o s t c o m m o n ly used in h e a lth c a re settings in c lu d e th e R a p id E s tim a te o f A d u lt L ite ra c y in M e d ic in e (D a v is et a l., 1 9 9 3 ) a n d th e W id e R a n g e A c h ie v e m e n t T e s t (J as ta k & W ilk in s o n , 1 9 9 3 ). O n e o f th e best w a y s to assess lite ra c y is s im p ly th ro u g h c a re fu l o b s e rv a ­ tio n o f y o u r p a tie n t. C lu es th a t m ig h t be o b s erve d in a p a tie n t w it h lo w h e a lth lite r a c y s kills in c lu d e fo rm s th a t a re fille d o u t in c o m p le te ly o r in c o rre c tly , w r it t e n m a te r ia ls th a t a re h a n d e d to a p e rs o n a c c o m p a n y in g th e p a tie n t, a lo o fn e ss o r w it h d r a w a l d u r in g p ro v id e r e x p la n a tio n s , s u rv e illa n c e o f th e b e h a v io r o f o th ers in th e sam e s itu a tio n to c o p y th e ir a c tio n s , a n d a re q u e st fo r h e lp fr o m s ta ff o r o th e r p a tie n ts . V e r b a l responses such as “ I w ill re a d th is a t h o m e ” o r “ I c a n ’t re a d th is n o w because I fo rg o t m y glasses” a re also c o m m o n (B a s ta b le , 2 0 0 6 ; D o a k & D o a k , 2 0 0 2 ) .

CRITICAL THINKING Q UESTIO NS*

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? V

■ Assessing the R eadability of Patient Education M aterials

M a n y h e a lt h - r e la t e d te a c h in g m a t e r ia ls a re w r it t e n o n a le v e l t h a t is a b o v e th e a v e ra g e p a t ie n t ’s lite r a c y le v e l a n d c o n ta in to o m u c h m e d ic a l ja r g o n ( N a t io n a l C e n te r fo r E d u c a tio n S ta tis tic s , 2 0 0 7 ) . W r i t t e n m a t e r i­ als c a n s till be u s e fu l s u p p le m e n ts fo r p a tie n ts w it h lo w h e a lth lite r a c y s k ills i f th e w r it te n m a te r ia ls selected a re a p p r o p r ia te to th e re a d in g le v e l o f th e p a tie n t. W r i t t e n m a te r ia ls f o r p a tie n ts w i t h l o w h e a lth lite r a c y s k ills s h o u ld be w r it t e n a t o r b e lo w fifth -g r a d e re a d in g le v e l (D o a k & D o a k , 2 0 0 2 ). S e v e ra l r e a d a b ilit y fo rm u la s a re a v a ila b le to d e te rm in e th e g ra d e le v e l o f m a te r ia ls (F le s c h , 1 9 4 8 ; F r y , 1 9 6 8 ; M c L a u g h l in , 1 9 6 9 ) . O n e o f th e e asiest fo rm u la s to use is th e S M O G fo r m u la , w h ic h p re d ic ts th e re a d in g g ra d e le v e l o f m a te r ia ls w it h in 1 .5 g ra d e s 6 8 % o f th e tim e ( M c L a u g h lin , 1 9 6 9 ) . T h e p ro c e d u re fo r u s in g th e S M O G r e a d a b ilit y fo r m u la is o u tlin e d in B o x 1 3 - 1 , a n d a n e x a m p le o f th e use o f th e f o r m u la is p r o v id e d in Box 1 3 -2 .

The Patient Education Process

BOX 13-1 SMOG READABILITY FORMULA 1. C h o o s e 1 0 co n se cu tive sentences n e a r th e b e g in n in g , 1 0 c o n secu tive sentences fr o m th e m id d le , a n d 1 0 c o n se cu tive sentences fr o m th e end o f th e m a te r ia l. 2 . In these 3 0 sentences, c o u n t the n u m b e r o f w o rd s c o n ta in in g th ree o r m o re syllables, in clu d in g repetitions. C o n sid er h y p h e n ated w o rd s as one w o rd . P ro p e r nouns are also cou n ted . N u m e ra ls and abbreviations should be c o unted as th ey w o u ld i f the w o rd s w e re w ritte n o u t. W h e n a c o lo n divides w o rd s , each p o rtio n o f the sentence is considered a separate sentence. 3 . E s tim a te th e square ro o t o f th e n u m b e r o f p o ly s y lla b ic w o rd s c o u n te d . 4 . A d d th re e to th e s q u are r o o t. T h is gives th e S M O G g ra d in g , w h ic h is th e re a d in g g ra d e lev el th a t a p e rs o n m u s t h a v e a c h ie v e d to fu lly u n d e rs ta n d th e m a te r ia l. 5 . T h e q u ic k e s t w a y to assess re a d in g g ra d e lev el is to use th e S M O G c o n v e rs io n ta b le . S im p ly c o m p a re th e to ta l n u m b e r o f w o rd s c o n ta in in g th re e o r m o re syllables in th e 3 0 sentences w it h th e S M O G C o n v e rs io n T a b le . H o w e v e r , n o t a ll w r itte n p a tie n t e d u c a tio n m a te ria ls c o n ta in 3 0 sentences. T o assess m a te ria ls w it h fe w e r th a n 3 0 sentences: 1. C o u n t a ll o f th e p o ly s y lla b ic w o rd s . 2 . C o u n t th e n u m b e r o f sentences. 3 . F in d th e a ve rag e n u m b e r o f p o ly s y lla b ic w o rd s p e r sentence. 4 . M u l t i p l y th a t a ve rag e b y th e n u m b e r o f sentences s h o rt o f 3 0 . 5 . A d d th a t fig u re to th e to ta l n u m b e r o f p o ly s y lla b ic w o rd s . 6. F in d th e square ro o t o f th e n u m b e r y o u o b ta in e d in step 5 a n d a d d the co n stan t o f th ree. T h is p ro ce d u re also gives y o u th e S M O G g ra d in g .

SMOG Conversion Table W o rd C o u n t 0 -2 3 -6 7 -1 2 1 3 -2 0 2 1 -3 0 3 1 -4 2 4 3 -5 6 5 7 -7 2 7 3 -9 0 9 1 -1 1 0 1 1 1 -1 3 2 1 3 3 -1 5 6 1 5 7 -1 8 2 1 8 3 -2 1 0 2 1 1 -2 4 0

G ra d e L evel 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

S ou rce: D ata are from Office of Cancer Communications, National Cancer Institute (1989).

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CHAPTER 13 The Role of the Professional Nurse in Patient Education

BOX 13-2 USING THE SMOG READABILITY FORMULA (FOR MATERiALS WiTH FEWER T h a n 3 0 sENTENCEs)

Check Your Weight and Heart Disease IQ T h e fo llo w in g s ta te m e n ts a re e ith e r tr u e o r fa lse . T h e s ta te m e n ts test y o u r k n o w le d g e o f o v e rw e ig h t a n d h e a rt disease. T h e c o rre c t answ ers c an be fo u n d o n th e b a c k o f th is sheet. 1. B e in g o v e rw e ig h t puts y o u a t ris k fo r h e a rt disease. 2 . I f y o u are o v e rw e ig h t, lo s in g w e ig h t helps lo w e r y o u r h ig h b lo o d c h o le s te ro l a n d h ig h b lo o d pressure. 3 . Q u it tin g s m o k in g is h e a lth y , b u t it c o m m o n ly leads to excessive w e ig h t g a in , w h ic h increases y o u r ris k fo r h e a rt disease. 4 . A n o v e rw e ig h t p e rs o n w it h h ig h b lo o d pressure s h o u ld p a y m o re a tte n tio n to a lo w -s o d iu m d ie t th a n to w e ig h t re d u c tio n . 5 . A re d u c e d in ta k e o f s o d iu m o r s alt does n o t a lw a y s lo w e r h ig h b lo o d pressure to n o r m a l. 6 . T h e best w a y to lose w e ig h t is to e a t fe w e r calo ries a n d to exercise. 7 . S k ip p in g m ea ls is a g o o d w a y to c u t d o w n o n calo ries . 8 . F o o d s th a t a re h ig h in c o m p le x c a rb o h y d ra te s (s ta rc h a n d fib e r) are g o o d choices w h e n y o u are tr y in g to lose w e ig h t. 9 . T h e single m o s t im p o r ta n t ch an g e m o s t p e o p le c an m a k e to lose w e ig h t is to a v o id sugar. 1 0 . P o ly u n s a tu ra te d fa t has th e sam e n u m b e r o f calo ries as s a tu ra te d fa t. 1 1 . O v e rw e ig h t c h ild re n are v e ry lik e ly to b e co m e o v e rw e ig h t a d u lts . S ou rce: U.S. Department of Health and Human Services (1993).

L o w h e a lth lite ra c y c an be a b a rrie r to e ffe c tiv e p a tie n t e d u c a tio n , b u t th e p a tie n t w it h lo w h e a lth lite ra c y skills is c a p a b le o f le a rn in g i f th e nurse is w illin g to in ve s t th e e x tra tim e th a t is re q u ire d . I t is im p o r ta n t fo r th e nurse to ta k e e x tra care to p re se n t in fo r m a tio n in te rm s th a t th e p a tie n t is fa m ilia r w ith ra th e r th a n using m e d ic a l ja rg o n , to use a lte rn a te fo rm a ts such as p ic to g ra p h s w h e n p o s sib le , to re state in fo r m a tio n usin g s im p le w o rd s , a n d to v e rify th e p a tie n t’s u n d e rs ta n d in g b y h a v in g h im o r h e r c o n v e y th e in fo r m a tio n in his o r h e r o w n w o rd s . T h e d iv id e n d s fo r th e e x tra e ffo r t in c lu d e th e p a tie n t w h o is a b le to m a n a g e his o r h e r o w n illn e s s , m a k e in fo r m e d h e a lth d e cisio n s, a n d m a k e h e a lth -re la te d b e h a v io r changes as a re s u lt o f a p a tie n t e d u c a tio n process th a t has a c c o m m o d a te d fo r his o r h e r w eaknesses.

■ Planning T h e p a tie n t a n d th e n u rse share th e p la n n in g process fo r p a tie n t e d u c a tio n , b u t it is th e re s p o n s ib ility o f th e n u rse to g u id e th e process. T h e nurse guides th e process th ro u g h th e use o f goals a n d objectives. L e a rn in g goals are d e riv e d

fr o m th e le a rn in g assessm ent, a n d n u rs in g d iag nosis a n d o b jectives are d e v e l­ o p e d based o n goals in c o lla b o ra tio n w it h th e p a tie n t. T h e use o f goals a n d objectives helps th e nurse to focus o n w h a t is im p o rta n t fo r th e p a tie n t to le a rn a n d k ee p p a tie n t e d u c a tio n fo cused o n o u tco m e s (R a n k in & S ta llin g s, 2 0 0 1 ) . P a tie n t e d u c a tio n is d ire c te d to w a r d b e h a v io ra l c h an g e. T h e re fo re , th e o b jectives fo r p a tie n t e d u c a tio n are s tated as b e h a v io ra l o b je ctiv es . T h e re are th re e c o m p o n e n ts o f b e h a v io ra l o b je ctiv es th a t in c lu d e p e rfo rm a n c e , c o n d i­ tio n s , a n d c rite r ia (M a g e r , 1 9 9 7 ) . P e rfo rm a n c e refe rs to th e a c tiv ity th a t th e p a tie n t w ill engage in a n d answ ers th is q u e s tio n : “ W h a t c an th e le a rn e r d o ? ” T h e c o n d itio n refe rs to s p ecial c irc u m s ta n c e s o f th e p a tie n t’s p e rfo rm a n c e a n d answ ers th is q u e s tio n : “ U n d e r w h a t c o n d itio n s w ill th e le a rn e r p e rfo r m th e b e h a v io r? ” T h e c rite ria o r e v a lu a tio n c o m p o n e n t re fers to h o w lo n g o r h o w w e ll th e b e h a v io r m u s t be p e rfo rm e d to be a c c e p ta b le a n d answ ers this q u e s tio n : “ W h a t is th e p e rfo rm a n c e s ta n d a rd ? ” (R a n k in & S ta llin g s , 2 0 0 1 ) . T h e le a rn in g o b je ctiv es s h o u ld be specific, m e a s u ra b le , a n d a tta in a b le ( R a n k in , 2 0 0 5 ; R a n k in & S ta llin g s , 2 0 0 1 ) . L e a r n in g o b je c tiv e s a re also w r itte n in a m a n n e r th a t is le a rn in g d o m a in specific. R e c o g n iz in g th e ta rg e te d d o m a in o f le a rn in g as c o g n itiv e , p s y c h o m o to r, o r a ffe c tiv e h elp s g u id e th e process o f w r itin g b e h a v io ra l le a rn in g objectives a n d thus guides th e selection o f le a rn in g a c tiv itie s .

■ Im plem entation T h e n e x t stage o f th e process in v o lv e s th e a c tu a l in te rv e n tio n . W h e th e r th e te a c h in g w ill o c cu r in a g ro u p o r w ith a n in d iv id u a l p a tie n t, le a rn in g activ ities n e ed to be co n sis te n t w it h le a rn in g o b je ctiv es . U s in g v a rio u s le a rn in g a c tiv itie s c an m a k e le a rn in g m o re fu n a n d m o re e ffe c tiv e . S om e c o m m o n le a rn in g a c tiv itie s in c lu d e lec tu res , d e m o n s tra tio n s , p ra c tic e , g a m e s , s im u la tio n s , ro le p la y in g , d isc u s sio n s , a n d s e lf-d ire c te d le a rn in g th ro u g h c o m p u te r-a s s is te d in s tru c tio n o r s e lf-d ire c te d w o rk b o o k s . P a tie n t e d u c a tio n m a te ria ls a re fr e q u e n tly used in th e im p le m e n ta tio n stage o f th e p a tie n t e d u c a tio n pro cess. P a tie n t e d u c a tio n m a te ria ls c a n be designed to be used a lo n e o r to s u p p le m e n t o th e r types o f p a tie n t e d u c a tio n a c tiv itie s b u t s h o u ld be p re v ie w e d b e fo re use a n d used o n ly i f co n sis te n t w ith le a rn in g o b je ctiv es . T h e re are m a n y types o f p a tie n t e d u c a tio n m a te ria ls c u r­ re n tly o n th e m a r k e t, o r y o u m ig h t o p t to p ro d u c e y o u r o w n m a te ria ls . P a tie n t e d u c a tio n m a te r ia ls g e n e r a lly in c lu d e a u d io v is u a l m a te r ia ls , c o m p u te r p ro g ra m s , In te rn e t resou rces, p o sters, flip c h a rts , c h a rts , g ra p h s , c arto o n s , slides, o v e rh e a d transparencies, p h o to g ra p h s , d ra w in g s , p a tie n t e d u ­ c a tio n n e w s le tte rs , o r w r itte n p a tie n t m a te ria ls such as h a n d o u ts , b ro c h u re s , o r p a m p h le ts . These m a te ria ls , even i f designed to be used a lo n e , sh o u ld n o t be used w ith o u t som e v e rb a l in s tru c tio n as to w h y th e p a tie n t is b e in g in s tru c te d to v ie w th e v id e o ta p e o r re a d th e b ro c h u re (F a lv o , 2 0 0 4 , 2 0 1 1 ) . A d d itio n a lly , th e n u rse s h o u ld k e e p th e d o o r o f c o m m u n ic a tio n o p e n b y in v itin g questions th a t th e p a tie n t m ig h t h a v e as a re s u lt o f e x p o s u re to th e te a c h in g m a te ria ls .

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CHAPTER 13 The Role of the Professional Nurse in Patient Education

Y o u m u st evalu ate a v a rie ty o f factors as y o u lo o k a t the appropriateness o f p a tien t education m aterials. T h re e im p o rta n t criteria fo r judging p a tien t education m ateria ls in clu d e the fo llo w in g (D o a k , D o a k , G o rd o n , & L o rig , 2 0 0 1 , p. 1 8 4 ): • • •

T h e m a te r ia l c o n ta in s th e in fo r m a tio n th a t th e p a tie n t w a n ts . T h e m a te r ia l c o n ta in s th e in fo r m a tio n th a t th e p a tie n t needs. T h e p a tie n t u n d e rs ta n d s a n d uses th e m a te r ia l as p re se n ted .

I t is an e xp e ctatio n o f th e J o in t C o m m is sio n th a t th e rig h t ed u ca tio n a l m a te ­ rials are used in p a tie n t a n d fa m ily ed u ca tio n a n d th a t th e m ateria ls are accurate, age specific, easily accessible, a n d a p p ro p ria te to p a tie n t needs (T h e J o in t C o m ­ m ission, 1 9 9 9 , 2 0 0 3 ). T o address a ll o f these c rite ria , the nurse needs to c o n d u c t a needs assessment b e fo re p re p a rin g o r choosing p a tie n t e d u c a tio n m a te ria ls .

C o n s id e ra tio n s : P a tie n t E d u c a tio n w ith O ld er A d u lts

r

W h e n c a rin g fo r o ld e r a d u lts , o n e o f th e p r im a r y c o n s id e ra tio n s re la te d to th e p a tie n t e d u c a tio n process is a c c o m m o d a tio n fo r a g e -re la te d b a rrie rs to le a rn in g . T h e a g e -re la te d b a rrie rs p a rtic u la rly im p o r ta n t in th e p a tie n t e d u ca ­ tio n process in c lu d e a g e -re la te d c h an g es in c o g n itio n , v is io n , a n d h e a rin g . R e s e a rc h has d e m o n s tra te d th a t te a c h in g is n o t as e ffe c tiv e i f it does n o t a c c o m m o d a te fo r a g e -re la te d c o g n itiv e a n d sensory changes \ (D o n lo n , 1 9 9 3 ; M a s te rs , 2 0 0 1 ; W e in r ic h , W e in r ic h , B o y d , A tw o o d , & C e rv e n k a , 1 9 9 4 ) . G e ro g o g y in p a tie n t e d u c a ­ When caring for older tio n has been d e fin e d as th e tra n s fe rrin g o f essential in f o r ­ adults, one of the primary m a tio n th a t has been d esig n ed , m o d ifie d , a n d a d a p te d to considerations related to the a c c o m m o d a te fo r th e p h y s io lo g ic a n d p s y c h o lo g ic changes patient education process in e ld e rly persons b y ta k in g in to a c c o u n t th e p e rs o n ’s d is­ is accommodation for ease pro cess, a g e -re la te d c h an g es , e d u c a tio n a l le v e l, a n d age-related barriers m o tiv a tio n (P e arso n , 2 0 1 2 ) . to learning. A g e -re la te d changes in c o g n itiv e fu n c tio n occur s lo w ly a n d are th o u g h t to b e g in a t a p p ro x im a te ly 6 0 years o f age in h e a lth y a dults ( M ille r , 2 0 0 4 ) . A g e -re la te d v is u a l changes a re th e m o s t p re v a le n t p h y s ic a l im p a irm e n ts a ffe c tin g o ld e r a d u lts . H e a rin g im p a irm e n t ra n ks as one o f th e fo u r m o s t p re v a le n t c h ro n ic co n d itio n s affectin g th e o ld e r p o p u la tio n , o c c u rrin g in o n e -th ird o f th e U .S . p o p u la tio n b e tw e e n the ages o f 6 5 a n d 7 4 years a n d in 4 7 % o f th e p o p u la tio n 7 5 years o f age a n d o ld e r (N a tio n a l In s titu te s o f H e a lth , 2 0 1 2 ) . E a c h o f these a g e -re la te d changes can h ave a p ro fo u n d effect o n the te ac h in g a n d le a rn in g process. Specific a ge-related changes in c o g n itio n , v is io n , a n d h e a rin g are liste d in B o x 1 3 -3 . Specific strategies c an be used d u rin g th e p a tie n t e d u c a tio n process to h elp o v e rc o m e th e a g e -re la te d le a rn in g b a rrie rs in c o g n itio n , v is io n , a n d h e a rin g . S om e o f these strategies a re in c lu d e d in B o x 1 3 -4 .

Considerations: Patient Education with Older Adults

BOX 13-3 AGE-RELATED BARRIERS TO LEARNING C a te g o r y o f A g e -R e la te d

C o g n it iv e a n d S e n s o r y C h a n g e s

C hange C o g n itiv e

• • •

V is u a l

• • • •

• H e a r in g

C h an g es in e n c o d in g a n d s to rag e o f in fo r m a tio n C h an g es in th e re trie v a l o f in fo r m a tio n D ecreases in th e speed o f pro cessin g in fo r m a t io n * S m a lle r a m o u n t o f lig h t reaches th e re tin a R e d u c e d a b ility to focus o n close objects S c a tte rin g o f lig h t re s u ltin g in g la re C h an g es in c o lo r p e rc e p tio n results in d iffic u lty d is tin g u is h in g c o lo rs such as d a rk g re en , b lu e , a n d v io le t D e c rea se in d e p th p e rc e p tio n a n d p e rip h ­ e ra l v is io n t

R e d u c e d a b ility to h e a r sounds as lo u d ly • D e c rea se in h e a rin g a c u ity • D e c rea se in a b ility to h e a r h ig h -p itc h e d sounds • D e c rea se in th e a b ility to filte r b a c k ­ g ro u n d n o is e t

S ou rces: *M erriam & Caffarella (19 9 9 , 2 0 0 7 ); t M iller (2004).

BOX 13-4 STRATEGIES TO ACCOMMODATE FOR AGE-RELATED BARRIERS TO LEARNING C a te g o r y o f A g e -R e la te d

S tr a te g ie s to A c c o m m o d a te fo r

C hange

C o g n it iv e a n d S e n s o r y C h a n g e s

C o g n itiv e

• • • • • •

S lo w th e p ace o f th e p re s e n ta tio n . G iv e s m a lle r a m o u n ts o f in fo r m a tio n a t a tim e . R e p e a t in fo r m a tio n fre q u e n tly . R e in fo rc e v e rb a l te a c h in g w it h a u d io v i­ suals, w r itte n m a te ria ls , a n d p ra c tic e . R e d u c e d is tra c tio n s . A llo w m o re tim e fo r s elf-e x p re s s io n o f le a rn e r. (c o n t in u e s )

317

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CHAPTER 13 The Role of the Professional Nurse in Patient Education

BOX 13-4 STRATEGIES TO ACCOMMODATE FOR AGE-RELATED BARRIERS TO LEARNING (continued)

Category of Age-Related Strategies to Accommodate for Change Cognitive and Sensory Changes •

U s e a n a l o g ie s a n d e x a m p l e s f r o m e v e r y d a y e x p e r i e n c e t o i ll u s t r a t e a b s t r a c t in fo r m a tio n .

•

In c r e a s e th e m e a n in g fu ln e s s o f c o n te n t to

•

T e a c h m n e m o n ic d e v ic e s a n d im a g in g

•

U s e p r i n t e d m a t e r ia l s a n d v is u a l a id s t h a t

th e le a rn e r. te c h n iq u e s . a r e a g e s p e c if ic * V is u a l

•

M a k e s u r e p a t i e n t ’s g la s s e s a r e c l e a n a n d

•

U s e p r i n t e d m a t e r ia l s w i t h 1 4 - t o

•

U s e b o ld ty p e o n p r in te d m a te r ia ls , a n d

•

A v o id t h e u s e o f d a r k c o lo r s w ith d a r k

in p l a c e . 1 6 - p o in t fo n t a n d s e r if le tte r s . d o n o t m ix fo n ts . b a c k g r o u n d s f o r t e a c h in g m a t e r ia l s , b u t i n ­ s te a d u s e la r g e , d is tin c t c o n f ig u r a t io n s w ith h ig h c o n t r a s t t o h e lp w ith d is c r im in a tio n . •

A v o id b lu e , g r e e n , a n d v i o l e t t o d if f e r e n ­

•

U s e lin e d r a w in g s w i t h h i g h c o n t r a s t .

•

U s e s o f t w h i t e lig h t t o d e c r e a s e g l a r e .

•

L i g h t s h o u ld s h in e f r o m b e h i n d t h e

•

U s e c o l o r a n d t o u c h t o h e lp d if f e r e n t i a t e

•

P o s i t i o n m a t e r ia l s d ir e c t l y i n f r o n t o f t h e

tia te ty p e , illu s tr a tio n s , o r g r a p h ic s .

le a rn e r. d e p th . l e a r n e r .! H e a rin g

•

S p e a k d is t i n c t l y .

•

D o n o t s h o u t.

•

S p e a k i n a n o r m a l v o ic e , o r s p e a k in a lo w e r p itc h .

•

D e c r e a s e e x tr a n e o u s n o is e .

•

F a c e t h e p e r s o n d ir e c t l y w h ile s p e a k i n g

•

R e i n f o r c e v e r b a l t e a c h i n g w i t h v is u a l

a t a d is t a n c e o f 3 t o 6 f e e t .

aids o r e a s y -to -re a d m a te ria ls . ! Sou rces: *W einrich, Boyd, & Nussbaum (1989); tO ldaker (1992) and W einrich, Boyd, & Nussbaum (1989).

Evaluation

C u ltu ra l C o n s id e ra tio n s D e v e lo p in g an e d u c a tio n a l p ro g ra m th a t is c u ltu ra lly a p p ro p ria te is n o t m u c h d iffe re n t fr o m c re a tin g a n y o th e r p a tie n t e d u c a tio n p ro g ra m . Y o u b e g in w ith a needs assessment; th en , y o u w rite objectives a n d design the p ro g ra m . T h e d iffe r­ ence is th a t y o u m u st be c u ltu ra lly sensitive a n d in c o rp o ra te c u ltu ra l in fo rm a tio n th a t y o u h ave le a rn e d a b o u t the ta rg e t g ro u p in to the p a tie n t e d u c a tio n process (B astab le, 2 0 0 6 ; G o n z a le z & L o rig , 2 0 0 1 ; L e n g e tti, O r d e lt, & P yle, 2 0 0 7 ). H o w im p o r t a n t is it th a t y o u in c o rp o ra te c u ltu r a l in fo r m a t io n in th e p a tie n t e d u c a tio n process? C u ltu r a l a w aren ess a n d s e n s itiv ity o f nurses can in flu e n c e th e a b ility o f p a tie n ts to receive a n d a p p ly in fo r m a tio n re g a rd in g th e ir h e a lth care (C a m p in h a -B a c o le , Y a h le , & L a n g e n k a m p , 1 9 9 6 ). T h e w a y th a t in fo r m a tio n is c o m m u n ic a te d c a n in flu e n c e a p a tie n t’s p e rc e p tio n o f th e h e a lth c a re system a n d a ffe c t ad h eren c e to p re s c rib e d tre a tm e n ts . I n a re ce n t study, p a tien ts w h o received care fr o m nurses w it h c u ltu ra l s e n s itivity tr a in in g n o t o n ly s h o w e d im p ro v e m e n t in use o f social resources b u t also im p ro v e m e n t in o v e ra ll fu n c tio n a l c a p a c ity (M a ju m d a r , B ro w n e , R o b e rts , & C a rp io , 2 0 0 4 ) . In a d d itio n to th e d iffe re n c e th a t it c an m a k e in re la tio n s h ip to p a tie n t o u tc o m e s , J o in t C o m m is s io n s ta n d a rd s re q u ire n o t o n ly th a t th e p a tie n t’s le a rn in g needs, a b ilitie s , a n d readiness to le a rn are assessed b u t also th a t the p a tie n t’s p re fe re n c e s a re assessed. T h is assessm ent m u s t c o n s id e r c u ltu ra l a n d re lig io u s p ra ctice s, as w e ll as e m o tio n a l a n d la n g u a g e b a rrie rs (T h e J o in t C o m m is s io n , 1 9 9 9 , 2 0 0 3 ) . H o w d o y o u in c o rp o ra te c u ltu ra l in fo r m a tio n in to th e p a tie n t e d u c a tio n process? G o n z a le z a n d L o r ig (2 0 0 1 , p . 1 7 2 ) suggest th e fo llo w in g : • • •

C h a n g e th e in fo r m a tio n in to m o re specific o r m o re re le v a n t te rm in o lo g y . C re a te d e s c rip tio n s o r e x p la n a tio n s th a t fit w it h d iffe re n t p e o p le ’s u n d e r­ s ta n d in g o f k e y concepts. In c o rp o ra te a g ro u p ’s c u ltu ra l beliefs a n d practices in to th e p ro g ra m c o n ­ te n t a n d process.

In a d d itio n , a n y v is u a l aids th a t are used s h o u ld re fle c t th e ta rg e t g ro u p o r p o p u la tio n . T h e use o f c u ltu ra lly re le v a n t an alo g ies c an also h e lp p e o p le to u n d e rs ta n d c o m p le x , a b s tra c t, o r fo re ig n concepts (G o n z a le z & L o r ig , 2 0 0 1 ) .

E v a lu a tio n E v a lu a tio n d e te rm in e s w o r th b y ju d g in g s o m e th in g a g a in s t a s ta n d a rd . T h e s ta n d a rd used in the p a tie n t e d u c a tio n process is th e le a rn in g o b je c tiv e . T h u s , th e te rm e v a lu a tio n as used h e re im p lie s m e a s u rin g th e o u tc o m e s re s u ltin g fr o m s y s te m a tic a lly p la n n e d a c tiv itie s im p le m e n te d as a p a r t o f a p a tie n t e d u ­ c a tio n p ro g ra m o r p a tie n t e d u c a tio n process a g a in s t th e le a rn in g objectives to d e te rm in e w h e th e r le a rn in g o c c u rre d .

319

KEY COMPETENCY 13-5 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Communication (Teaching/ Learning): Skills (S5g) Evaluates patient and family learning Source: Massachusetts Department of Higher Education (2010), p. 29.

In itia t io n o f th e p a tie n t e d u c a tio n e v a lu a tio n process is th e re s p o n s ib ility o f th e n u rse , a n d a c c o rd in g to R a n k in a n d S talling s (2 0 0 1 , p . 3 2 6 ), th e e v a lu ­ a tio n process s h o u ld in c lu d e th e fo llo w in g : • • • • •

M e a s u rin g th e e x te n t to w h ic h th e p a tie n t has m e t th e le a rn in g o b jectives Id e n tify in g w h e n th e re is a n e ed to c la rify , c o rre c t, o r re v ie w in fo r m a tio n N o t in g le a rn in g o b jectives th a t a re u n c le a r P o in tin g o u t s h o rtc o m in g s in p a tie n t te a c h in g in te rv e n tio n s Id e n tify in g b a rrie rs th a t p re v e n te d le a rn in g

N u rs e s c o m m o n ly use s e v e ra l m e th o d s to e v a lu a te p a tie n t le a rn in g . T h e s e m e th o d s in c lu d e d ire c t o b s e rv a tio n , th e te a c h -b a c k m e th o d o r a sk in g p a tie n ts to e x p la in s o m e th in g in th e ir o w n w o rd s , s itu a tio n a l fe e d b a c k to d e te rm in e if th e p a tie n t selects a p p ro p ria te b e h a v io r, records o f h e a lth -re la te d b e h a v io rs th a t p a tie n ts re p o rt, p a tie n t in te rv ie w s a n d q u e s tio n n a ire s , a n d c ritic a l in c id e n ts such as re a d m is s io n , e m e rg e n c y ro o m visits, a n d m o r ta lity ( M c N e ill, 2 0 1 2 ) .

D o c u m e n ta tio n of P a tie n t E d u c a tio n I t is e s s e n tia l t h a t th e p ro c e s s o f p a t ie n t e d u c a tio n b e d o c u m e n te d . D o c u m e n ta tio n fu n c tio n s to p ro m o te c o m m u n ic a tio n a m o n g m e m b e rs o f th e h e a lth c a re te a m , to p ro v id e a leg a l re c o rd , to s u p p o rt q u a lity assurance e ffo rts , to p ro m o te c o n tin u ity o f care, to p ro m o te re im b u rs e m e n t, a n d to m ee t J o in t C o m m is s io n s ta n d a rd s . D o c u m e n ta tio n o f p a tie n t e d u c a tio n s h o u ld be concise, o rg a n iz e d , a n d fo c u s e d o n p a tie n t o u tc o m e s . D o c u m e n ta tio n system s v a ry b y s e ttin g , b u t th e fo llo w in g elem en ts o f th e p a tie n t e d u c a tio n process s h o u ld be in c lu d e d in d o c u m e n ta tio n (R a n k in & S ta llin g s , 2 0 0 1 , p . 3 3 6 ): • • • • •

In it ia l assessments a n d reassessm ents N u r s in g diag noses, p a tie n t needs, a n d p rio ritie s In te rv e n tio n s p la n n e d a n d in te rv e n tio n s p ro v id e d P a tie n t’s response a n d o u tco m e s o f care P a tie n t a n d fa m ily a b ility to m a n a g e needs a fte r discharge

C o nclu sio n T h is c h a p te r p ro vid e s an in tro d u c tio n to som e o f th e m a jo r concepts re la te d to th e process o f p a tie n t e d u c a tio n . T h e re is n o re cip e fo r p a tie n t e d u c a tio n th a t w ill fit e v e ry o n e , b u t i f y o u m ix th e basic p rin c ip le s discussed in th is c h a p te r w it h som e p ra c tic e , y o u w ill be o n y o u r w a y to p ro v id in g y o u r p a tie n ts w it h e ffe c tiv e e d u c a tio n .

Conclusion

321

CASE STUDY 13-1 ■

M

r. Martin, an 82-year-old African American patient, is ready for discharge from the medi­ cal unit after a 3-day hospitalization resulting from exacerbation of heart failure. Prior to discharge from the hospital, the student nurse reviews the medi­ cation orders and provides Mr. Martin with standard patient education materials related to control of heart failure symptoms.

Case Study Questions 1.

2.

3.

What else could the student nurse in the case study do to enhance the effectiveness of the patient edu­ cation process for Mr. Martin? Do you have any suggestions for the student nurse related to accommodating for age-related changes of this patient? Do you have any suggestions for the student nurse related to cultural considerations as she educates this patient? ■

Classroom A ctivity 1 r o v id e s tu d e n ts w i t h a c o p y o f p r in t e d p a tie n t e d u c a tio n m a t e r ia ls . T h e s e c a n b e o b t a in e d f r o m a l o c a l h e a lt h ­ c a re o r g a n i z a t io n o r f r o m o n lin e s o u rc e s s u c h as th e A m e r ic a n H e a r t A s s o c ia t io n . A s k s tu d e n ts to e v a lu a te th e m a t e r ia ls f o r r e a d a b i l i t y u s in g th e S M O G f o r m u l a in

P

B o x 1 3 - 1 . N e x t ask s tu d e n ts to e v a lu a te th e m a t e r ia ls f o r use w i t h o ld e r a d u lts u s in g th e in f o r m a t io n p re s e n te d in B o x 1 3 -3 a n d B o x 1 3 -4 . F in a lly , h a v e s tu d e n ts e v a lu a te th e m a te r ia ls fo r use w it h a p o p u la tio n o f a d iffe r ­ e n t c u ltu re . A s k s tu d e n ts to s h are fin d in g s d u r­ in g in fo r m a l p re s e n ta tio n s to classm ates,

Classroom A ctivity 2 iv id e th e class in to s m a ll g ro u p s a n d ask stu d en ts to c rea te a p a tie n t e d u c a ­ tio n b ro c h u re th a t c o n fo rm s to re c o m ­ m e n d e d re a d in g le v e ls , c o n s id e rs a g e -re la te d le a rn in g b a rrie rs , a n d a c c o m m o d a te s c u ltu ra l d iffere n c es . T h e g ro u p m a y choose a fic titio u s case scenario o r a n a c tu a l scenario fr o m a recent c lin ic a l e xp e rien c e.

D

F o r th is a c t i v i t y , s e v e ra l s tu d e n ts w i l l n e e d to b r in g la p to p s to c la ss , th e class w i l l n e e d to h a v e access to a c o m p u te r la b , o r th e s tu d e n ts w i l l n e e d c o lo r e d p e n c ils a n d p a p e r . A lt e r n a t e l y , th is a c t iv it y c o u ld b e a s s ig n e d to s tu d e n ts to c o m p le te o u ts id e o f c lass to b e s h a re d w i t h th e class o r s u b m itte d f o r a

g r a d e .!®

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Fry, E. (1968). A readability formula that saves time. Journal o f Reading, 11, 513-577. Gonzalez, V. M., & Lorig, K. (2001). Working cross-culturally. In K. Lorig (Ed.), Patient education: A practical approach (3rd ed., pp. 163-182). Thousand Oaks, CA: Sage. Hochbaum, G. M. (1958). Public participation in m edical screening programs: A socio-psychological study. Public Health Service Publication No. 572. Washington, DC: U.S. Government Printing Office. Jastak, S., & Wilkinson, G. S. (1993). Wide range achievement test: Review 3 . Wilmington, DE: Jastak Associates. The Joint Commission. (1995). Comprehensive accreditation manual for hospitals (Vols. 1 and 2). Oakbrook Terrace, IL: Author. The Joint Commission. (1999). Hospital accreditation standards. Oakbrook Terrace, IL: Author. The Joint Commission. (2003). Join t Commission guide to patient and family education. Oakbrook Terrace, IL: Author. Knowles, M. (1970). The modern practice o f adult education: Andragogy versus pedagogy. New York, NY: Association Press. Knowles, M., Swanson, R., & Holton, E. (1998). The adult learner: The definitive classic in adult education and human resource development. Houston, TX: Gulf. Knowles, M., Swanson, R., & Holton, E. (2011). The adult learner: The definitive classic in adult education and human resource development (7th ed.). New York, NY: Elsevier. Lengetti, E., Ordelt, K., & Pyle, N. (2007, November). Patient teaching competency for staff. Patient Education Management, 123-124. Lorig, K. (2001). Patient education: A practical approach (3rd ed.). Thousand Oaks, CA: Sage. Mager, R. (1997). Preparing instructional objectives (3rd ed.). Atlanta, GA: Center for Effective Performance. Majumdar, B., Browne, G., Roberts, J., & Carpio, B. (2004). Effects of cultural sensitivity training on health care provider attitudes and patient outcomes. Journal o f Nursing Scholarship, 36(2), 161-166. Massachusetts Department of Higher Education. (2010). Nurse o f the future: Nursing core competencies. Retrieved from http://www.mass.edu/currentinit/documents/ NursingCoreCompetencies.pdf Masters, K. (2001). The effect o f education that is modified to accommodate for agerelated barriers to learning in older adult hom e health patients with congestive heart failure. Unpublished doctoral dissertation. Louisiana State University Health Sciences Center. McLaughlin, G. H. (1969). SMOG grading—a new readability formula. Journal o f Reading, 12, 639-646. McNeill, B. E. (2012, January-March). You “teach” but does your patient really learn?: Basic principles to promote safer outcomes. Tar Heel Nurse, 9-16. Merriam, S. B., & Caffarella, R. S. (1999). Learning in adulthood: A comprehensive guide. San Francisco, CA: Jossey-Bass. Merriam, S. B., & Caffarella, R. S. (2007). Learning in adulthood: A comprehensive guide. San Francisco, CA: Jossey-Bass. Miller, C. A. (2004). Nursing for wellness in older adults: Theory and practice (4th ed.). Philadelphia, PA: Lippincott.

National Center for Education Statistics. (2007). Literacy in everyday life: Results from the 2003 National Assessment of Adult Literacy. Retrieved from http://nces. ed.gov/pubsearch/pubsinfo.asp?pubid=2007480 National Institutes of Health. (2012). NIHSeniorHealth: Hearing loss. Retrieved from http://nihseniorhealth.gov/hearingloss/hearinglossdefined/01.html Nightingale, F. (1969). Notes on nursing: What it is and what it is not. New York, NY: Dover. (Original work published 1860) Office of Cancer Communications, National Cancer Institute. (1989). Making health communications w ork. Rockville, MD: Author. Oldaker, S. M. (1992). Live and learn: Patient education for the elderly orthopaedic client. Orthopaedic Nursing, 11(3), 51-56. Pearson, M. (2012, June-August). Gerogogy in patient education—revisited. Oklahoma Nurse, 12-17. Prohaska, T. R., & Lorig, K. (2001). What do we know about what works: The role of theory in patient education. In K. Lorig (Ed.), Patient education: A practical approach (3rd ed., pp. 163-182). Thousand Oaks, CA: Sage. Rankin, S. H. (2005). Patient education in health and illness. Philadelphia, PA: Lippincott. Rankin, S. H., & Stallings, K. D. (2001). Patient education: Principles and practice (4th ed.). Philadelphia, PA: Lippincott. Redman, B. K. (2001). The practice o f patient education (9th ed.). St. Louis, MO: Mosby. Redman, B. K. (2003). Measurement tools in patient education (2nd ed.). New York, NY: Springer. Redman, B. K. (2006). The practice o f patient education: A case study approach (10th ed.). St. Louis, MO: Mosby. Russell, S. S. (2006). An overview of adult-learning processes. Urologic Nursing, 26(5), 349-352, 370. Stephenson, P. L. (2007). Before teaching begins: Managing patient anxiety prior to providing education. Clinical Journal o f Oncology Nursing, 10(2), 241-246. U.S. Department of Health and Human Services. (1993). Check your weight and heart disease I.Q . Publication No. 93-3034. Washington, DC: U.S. Government Printing Office. Weinrich, S. P., Boyd, M., & Nussbaum, J. (1989). Continuing education: Adapting strategies to teach the elderly. Journal o f Gerontological Nursing, 15(11), 17-21. 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), 494-500. Weiss, B. D. (1999). Twenty common problems in primary care. New York, NY: 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, 1008-1015.

Informatics and Technology in Professional Nursing Practice Cathy K. Hughes

v_______________________ H e a lth c a r e d e liv e ry la rg e ly d e p en d s o n in fo r m a t io n fo r e ffe c tiv e d e c is io n m a k in g . E v e ry n u rs in g a c tio n relies o n k n o w le d g e based o n in fo rm a tio n . T h e nursing process begins w ith o b ta in in g an d c o m m u n ic a tin g in fo rm a tio n in the in itia l a n d o n g o in g assessment. N u rs in g in fo rm atic s ( N I ) is the m a n ­ ag em en t o f d a ta , in fo r m a tio n , k n o w le d g e , a n d w is d o m rel­ evant to nursing (A m eric an N urses A ssociation [A N A ] , 2 0 0 8 ). A s w e enter the era o f the electronic h e a lth re co rd (E H R ), N I has becom e an indispensable elem ent in the practice o f nursing. A ll nurses u tilize in fo rm a tic s skills in th e ir practice.

N u rs in g In fo rm a tic s D efined N ursing in fo rm a tic s (N I) is to g eth er a fie ld o f study a n d an area o f s p ecializatio n . In th e m id -1 9 0 0 s , N I w a s firs t id e n tifie d as th e use o f in fo r m a tio n te c h n o lo g y

Learning Objectives A f t e r c o m p le tin g th is c h a p te r, th e s tu d e n t should be a b le to : 1. D efine nursing in fo rm a tic s (N I). 2 . Discuss in flu e n ce s and d ire c tio n o f th e fu tu re of NI p ra c tic e . 3 . Discuss levels of nurse in fo rm a tic s c o m p e te n ­ cies fo r professional nursing p ra ctice . 4 . Discuss p rin cip les to e v a lu a te in fo rm a tio n on th e In te rn e t and w e b s ites . 5 . D e s c rib e th e use o f e le c tro n ic d a ta b a s e s to o b tain in fo rm a tio n . 6 . D e s c rib e fa c to rs to c o n s id e r w h en accessing and e va lu atin g h e alth in fo rm a tio n online.

7 . Discuss and apply th e p rivacy regulations of th e H ea lth Insurance P o rta b ility and A cco u n tab ility A c t (H IP A A ) to NI. 8 . E x p la in s e c u r it y a n d p r iv a c y is s u e s fo r e le c tro n ic h e a lth records. 9 . Discuss social m ed ia, te le h e a lth , and handheld d e vices w ith a p p lic atio n s to nursing and N I. 1 0. Envision fu tu re tren d s in h e alth ca re technology.

325

Key Terms and Concepts » Nursing informatics (N I) » HIPAA » Search engines » Databases » EBSCO Publishing » CINAHL » ERIC » Health Source » MEDLINE » PsycINFO » Electronic health record » Email » Listservs » Asynchronous » Social media » Telehealth » PDAs

KEY COMPETENCY 14-1 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Informatics and Technology: Knowledge (K7) Describes the rationale for involving the interdisciplinary team in the design, selection, imple­ mentation, and evaluation of applications and systems in health care Attitudes/Behaviors (A7) Values nurses' involvement in design, selection, imple­ mentation, and evaluation of information technologies to support patient care Skills (S7a) Provides input to the design, selection, and application of information technologies to support patient care Source: Massachusetts Department of Higher Education (2010), p. 24.

in n u rsin g p ractice (H a n n a h , 1 9 8 5 ). In 1 9 9 2 , th e A m e ric a n N u rs es A ss o cia tio n ( A N A ) re c o g n iz e d N I as a n u rs in g s p e c ia lty . T h e o rig in a l A N A S c o p e a n d S ta n d a rd s o f N u r s i n g I n fo rm a tic s P ra c tic e p u b lis h e d in 2 0 0 1 w a s revised in 2 0 0 8 a n d defines N I as a s p e c ia lty th a t in te g ra te s n u rs in g science, c o m p u te r science, a n d in fo r m a tio n science to m a n a g e a n d c o m m u n ic a te d a ta , in fo r m a ­ tio n , a n d k n o w le d g e in n u rs in g p ra c tic e . N u r s in g in fo r m a tic s fa c ilita te s th e in te g ra tio n o f d a ta , in fo r m a tio n , k n o w le d g e , a n d w is d o m to s u p p o rt p a tie n ts , nurses, a n d o th e r p ro v id e rs in th e ir d e cis io n m a k in g in a ll roles a n d settings. T h is s u p p o rt is a c c o m ­ p lis h e d th ro u g h th e use o f in fo r m a t io n s tru c tu re s , in fo r m a t io n processes, a n d in fo r m a tio n te c h n o lo g y . ( A N A , 2 0 0 8 , p . 9 2 ) In fo r m a tic s c o n trib u te s to th e d is c ip lin e o f n u rs in g b y c o n n e c tin g th e a rt o f n u rs in g to th e science o f n u rs in g (S a b a , 2 0 0 1 ) . T h e s p e c ia lty o f N I is fo cused o n d e v e lo p in g a n d im p le m e n tin g s o lu tio n s fo r th e m a n a g e m e n t a n d c o m m u n ic a tio n o f h e a lth in fo r m a tio n p e rtin e n t to p ro v id in g b e tte r q u a lity p a tie n t/c lie n t c are (Z y k o w s k i, 2 0 0 3 ) . T h e d e fin itio n o f N I c o n tin u e s to e vo lv e as te c h n o lo g y is in c o rp o ra te d in to h e a lth c are . T h e u p d a te d A N A S c o p e a n d S ta n d a rd s (2 0 0 8 ) fo r n u rs in g in fo r m a tic s in c lu d e s “ re d ire c tin g th e discu ssio n o n ro le s fr o m jo b title s to fu n c tio n s th a t m a y be in te g ra te d in to v a rio u s N I roles a n d s u b s p e c ia liza tio n s ” (p . 2 ). T h e roles o r fu n c tio n s o f a n in fo rm a tic s nurse c an in c lu d e p ro je c t m a n ­ ager, c o n s u lta n t, e d u c a to r, researcher, b u d g e t m a n a g e r, o r d istan ce le a rn in g d e ve lo p er. In s tru c tio n o r m a n a g e m e n t o f te le n u rs in g , te le h e a lth e d u c a tio n , e le c tro n ic h e a lth , th e c o m p u te riz e d p a tie n t re c o rd , a n d a p p lic a tio n o f n e w o r e v o lv in g te c h n o lo g y are also in te g ra l ro le s. T h e in fo rm a tic s nurse c o n trib u te s to s e le c tio n , te s tin g , a n d im p le m e n ta tio n o f h e a lth c a re system s as w e ll as m a in te n a n c e a n d e v a lu a tio n o f th e system s. N I pro vides th e s u p p o rt fo r in fo r m a tio n m a n a g e m e n t fo r a ll o f th e n u rsin g sp ecialties. T h e A m e ric a n N u rs e s A s s o c ia tio n a t w w w .n u r s in g w o r ld .o r g has a w e b p a g e fo cused o n H e a lt h In fo r m a tio n T e c h n o lo g y (H e a lth I T ) In itia tiv e s w it h c u rre n t p a rtic ip a tio n in lis te d in itia tiv e s a n d H e a lt h I T resources. T h e A m e ric a n N u rs in g In fo rm a tic s A s s o c ia tio n w e b s ite (w w w .a n ia .o r g ) a n d th e A llia n c e fo r N u r s in g In fo r m a tic s w e b s ite (w w w .a llia n c e n i.o r g ) b o th o ffe r in fo r m a tio n re la te d to n u rs in g in th e d ig ita l w o r ld , in c lu d in g m e m b e rs h ip , c o n feren ces, a n d o n lin e resources.

N u rsin g In fo rm a tic s : D ire c tio n fo r th e F u tu re C a n p a tie n t c a re be im p r o v e d w i t h in f o r m a t io n te c h n o lo g y ( I T ) ? M a n y fo rce s a re a p a r t o f r e fo r m o f n u rs in g e d u c a tio n a n d n u rs in g p ra c tic e th a t in c lu d e th e in t e g r a t io n o f n u r s in g in fo r m a t ic s a n d h e a lth i n f o r m a t io n

technology for improved outcomes in healthcare delivery. Some of these are as follows: • • •

• •

• • • •

American Association of Colleges of Nursing BSN Essentials, www.aacn. nche.edu American Nurses Association (ANA) S c o p e a n d S t a n d a rd s , www.nursingworld.org Carnegie Foundation Report E d u c a t i n g N u r s e s : A C a ll f o r R a d ic a l T r a n s fo r m a tio n , www.carnegiefoundation.org/elibrary/educating-nurseshighlights Institute of Medicine (IOM) reports Joint Commission, Robert W ood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine, www.jointcommission. org/assets/1/18/RWJ_Future_of_Nursing.pdf National League for Nursing (NLN) Position Statements, www.nln.org Quality and Safety Education for Nurses (QSEN), www.qsen.org Robert W ood Johnson Foundation Future of Nursing Campaign for Action IO M recommendations, thefutureofnursing.org/recommendations Technology Informatics Guiding Education Reform (TIGER) Initiative, www.tigersummit.com

■ Am erican Association of Colleges of Nursing Some of the informatics and technology-related outcomes suggested by the AACN for baccalaureate nursing graduates are the following: • Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice. • Apply safeguards and decision-making support tools embedded in patient care technologies and inform ation systems to support a safe practice environment for both patients and healthcare workers. • Understand the issues of Clinical Information Systems (CIS) to document interventions related to achieving nurse-sensitive outcomes. • Use standardized terminology in a care environment that reflects nursing’s unique contribution to patient outcomes. • Uphold ethical standards related to data security, regulatory requirements, confidentiality, and clients’ right to privacy. • Recognize that redesign of workflow and care processes should precede implementation of care technology to facilitate nursing practice (American Association of Colleges of Nursing [AACN], 2008, pp. 1 8 -1 9 ).

■ N ational League for Nursing The National League for Nursing (NLN, 2008) position paper supports the “reform of nursing education to promote quality education that prepares a

w o rk fo rc e c a p a b le o f p ra c tic in g in a h e a lth c are e n v iro n m e n t w h e re te c h n o l­ o g y c o n tin u e s to in c re a s e in a m o u n t a n d s o p h is tic a tio n ” (p . 2 ). W it h th e ch arg e to “ p re p a re th e n e x t g e n e ra tio n o f nurses w it h th e necessary in fo r m a t­ ics c o m p eten c ies to p ro v id e safe a n d q u a lity c a re ” (p . 2 ), th e N L N re c o m ­ m en d s actio n s fo r fa c u lty , a d m in is tra to r, m e m b e rs , a n d th e N L N .

■ Q uality and S afety Education for Nurses S p o n s o re d b y th e R o b e r t W o o d J o h n s o n F o u n d a tio n , Q u a lit y a n d S a fe ty E d u c a tio n fo r N u rs e s ( Q S E N ) has th e o v e r a ll g o a l o f “ p r e p a r in g fu tu r e nurses w h o w ill h a v e th e k n o w le d g e , s kills a n d a ttitu d e s (K S A s ) necessary to c o n tin u o u s ly im p r o v e th e q u a lit y a n d s a fe ty o f th e h e a lth c a re system s w it h in w h ic h th e y w o r k ” (Q u a lit y a n d S afety E d u c a tio n fo r N u rs e s [Q S E N ], 2 0 1 2 ) . T h is in itia tiv e is d ire c te d to d e v e lo p c o m p e te n c ie s o f fu tu re n u rs in g g ra d u a te s in s ix k e y areas in c lu d in g p a tie n t-c e n te re d c a re , e v id e n c e -b a s e d p ra c tic e , q u a lit y im p r o v e m e n t, te a m w o r k a n d c o lla b o r a tio n , s a fe ty , a n d in fo r m a tic s . Phases I a n d I I h a v e b e en c o m p le te d b y a d is tin g u is h e d te a m . In Phases I a n d I I , th e c o m p e te n c ie s w e re d e fin e d a n d p ilo te d in s ix n u rs in g schools to d e v e lo p strategies fo r im p le m e n ta tio n . S om e o f th e g o als o f Phase I I I in 2 0 0 9 - 2 0 1 2 a re in n o v a tiv e d e v e lo p m e n t o f m e th o d s fo r assessm ent o f s tu d e n t le a rn in g o f K S A s o f th e s ix I O M / Q S E N c o m p e te n c ie s a n d fa c u lty e x p e rtis e d e v e lo p m e n t in th e Q S E N c o m p e te n c ie s . F iv e o f th ese c o m p e ­ ten cies a re fr o m th e I O M c o m p e te n c ie s ( I O M , 2 0 1 1 ) . T h e a p p lic a tio n o f in fo r m a tic s in n u rs in g p ra c tic e w ill be a v it a l c o m p o n e n t in th e m a s te ry o f th e d e fin e d K S A s .

■ Technology Inform atics Guiding Education Reform Initiative W it h k e y aspects o f N I th e fo cu s , h u n d re d s o f p ra c tic in g nurses a n d n u rs ­ in g students v o lu n te e re d th e ir tim e to w o r k in n in e c o lla b o ra tiv e te am s o n aspects o f th e T e c h n o lo g y In fo r m a tic s G u id in g E d u c a tio n R e fo r m ( T IG E R ) In itia tiv e . F o r ty n u rs in g p ro fe s s io n a l o rg a n iz a tio n s also w e re a p a r t o f th e in p u t process. “ T h e team s id e n tifie d resources, references, gaps, a n d areas th a t n eed fu rth e r d e v e lo p m e n t, a n d p ro v id e re c o m m e n d a tio n s fo r th e in d u s try to acc elerate th e a d o p tio n o f I T fo r n u rs in g ” (T e c h n o lo g y In fo r m a tic s G u id in g E d u c a tio n R e fo rm , 2 0 0 8 , p . 2 ). A w a re n e s s ra is in g w it h n u rs in g s ta k e h o ld e rs fo cused o n th re e k e y areas: • • •

D e v e lo p a U .S . n u rs in g w o r k f o r c e c a p a b le o f u s in g e le c tro n ic h e a lth reco rd s to im p ro v e th e d e liv e ry o f h e a lth c are . E n g a g e m o r e n u rs e s in th e d e v e lo p m e n t o f a n a t io n a l h e a lth c a r e in fo r m a tio n te c h n o lo g y ( N H I T ) in fra s tru c tu re . A c c e le ra te a d o p tio n o f s m a rt, s ta n d a rd s -b a s e d , in te ro p e ra b le te c h n o lo g y th a t w ill m a k e h e a lth c a re d e liv e ry safer, m o re e ffic ie n t, tim e ly , accessible,

Informatics Competencies

a n d p a tie n t-c e n te re d (T e c h n o lo g y In fo rm a tic s G u id in g E d u c a tio n R e fo rm , 2 0 0 8 , pp. 3 -5 ). S o m e o f th e re c o m m e n d a tio n s fo r n u rs in g p ra c tic e in c lu d e th e d e v e lo p ­ m e n t o f th e m in im u m set o f n u rs in g in fo rm a tic s co m p eten c ies a n d stan d ard s w it h tu to ria ls fo r nurses. A p r io r it y is to address th e e d u c a tio n a l needs o f th e e x is tin g w o r k fo r c e a n d d e v e lo p e d u c a tio n p ro g ra m s w it h le a rn e rs w it h d iffe r e n t lev els o f c o m p u te r use c o m fo r t. T h e u ltim a te fo cu s in v o lv e s th e d e v e lo p m e n t o f in n o v a tiv e w a y s to use te c h n o lo g y to im p ro v e h e a lth c a re d e liv e ry . O n e e x a m p le is d e v e lo p m e n t o f v ir tu a l le a rn in g p la tfo rm s fo r nurses to e x p lo re te c h n o lo g ie s . See w w w .tig e r s u m m it.c o m fo r m o re in fo r m a tio n . W it h th e fe d e ra l m a n d a te fo r th e a d o p tio n o f a ll e le c tro n ic h e a lth re co rd s b y 2 0 1 4 (W h ite H o u s e A rc h iv e s , 2 0 0 4 ) , th e o v e ra ll goals o f th e T I G E R In itia tiv e a re tim e ly a n d im p o rta n t.

In fo rm a tic s C o m p e te n c ie s A ll nurses n e ed c o m p eten c ies in in fo rm a tic s . D e fin e d levels o f c o m p eten c ies v a r y fr o m b e g in n in g n u rs e , e x p e rie n c e d n u rs e , in fo r m a tic s s p e c ia lis t, to in fo rm a tic s in n o v a to r (H e b d a & C z a r, 2 0 0 9 ; M c G o n ig le & M a s t r ia n , 2 0 0 9 ; S taggers, G a s se rt, & C u r r a n , 2 0 0 1 ) . T h e b e g in n in g n u rse e n te rin g p ra c tic e is e xp e cted to h a v e c o m p u te r lite ra c y a n d basic in fo r m a tio n m a n a g e m e n t skills. C o m p u te r lite ra c y s kills in c lu d e skills in use o f w o r d pro cessin g , h e a lth c a re d a ta b a s e a n d s p re a d s h e e t a p p lic a tio n s , p re s e n ta tio n s o ftw a re , a n d e m a il. In fo r m a tio n lite ra c y skills en ab le a nurse to lo c a te , access, a n d e v a lu ate c lin ic a l d a ta . Access in clu d es th e a b ility to p e rfo r m b ib lio g ra p h ic re trie v a ls usin g th e In te r n e t a n d lib ra ry -b a s e d resources ( M c N e i l et a l., 2 0 0 3 ) . Im p o r ta n t te c h n o lo g y skills o f th e e n try -le v e l nurse in c lu d e k n o w in g h o w to use n u rs in g -s p e c ific s o ftw a re such as c o m p u te riz e d d o c u m e n ta tio n ; use o f p a tie n t care tech nologies such as m o n ito rs , p u m p s , a n d m e d ic a tio n dispensing; a n d in fo r m a tio n m a n a g e m e n t fo r p a tie n t s afe ty ( A A C N , 2 0 0 8 , p p . 1 9 - 2 0 ) . T h e c o n s tru c ts o f im p le m e n tin g a n d m a in ta in in g h e a lth p o lic ie s fo cus o n p riv a c y , s ec u rity , a n d c o n fid e n tia lity o f c lie n t in fo r m a tio n such as m a n d a te d b y th e H e a lt h In fo r m a tio n P riv a c y a n d P o r ta b ility A c t ( H IP A A ) a n d in flu e n c e o f a ll facets o f N I . E x p e rie n c e d nurses s h o u ld be s k ille d in in fo r m a t io n m a n a g e m e n t a n d c o m p u te r te c h n o lo g y to su stain th e ir specific a re a o f p ra c tic e . T h e s e skills in c lu d e m a k in g ju d g m e n ts based o n tren d s o f d a ta in a d d itio n to c o lla b o ra tio n w it h in fo rm a tic s nurses ( I N ) in th e d e v e lo p m e n t o f n u rs in g system s. A n in fo rm a tic s n u rse s p ec ialist (IN S ) has a d v a n c e d in fo rm a tic s p re p a ­ r a tio n a t th e g ra d u a te le v e l a n d assists th e p ra c tic in g n u rse in m e e tin g his o r h e r needs fo r in fo r m a tio n ( A N A , 2 0 0 8 ) . T h e in fo rm a tic s in n o v a to r also has a d v a n c e d in fo r m a tic s p r e p a r a tio n a n d possesses s k ills fo r c o n d u c tin g

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CHAPTER 14 Informatics and Technology in Professional Nursing Practice

in fo rm a tic s research a lo n g w it h th e o ry d e v e lo p m e n t (T h e d e , 2 0 0 3 ) . C e rtific a ­ tio n fo r N I b ecam e a v a ila b le in 1 9 9 5 th ro u g h th e A m e ric a n N u rs e s C re d e n tia lin g C e n te r (2 0 0 7 ). In fo r m a tio n o n e lig ib ility a n d test c o n te n t is a v a ila b le a t w w w .n u rs e c re d e n tia lin g .o rg /C e rtific a tio n /N u rs e S p e c ia ltie s /In fo rm a tic s .a s p x .

In te rn e t R eso u rce s N o t since th e in v e n tio n o f th e p rin tin g press has th e speed w it h w h ic h n e w in fo r m a tio n c a n be o b ta in e d c h a n g e d so m u c h as w it h th e d e v e lo p m e n t o f th e W e b . Search to o ls a n d s e a rc h engines assist users in fin d in g specific topics o n th e W e b b y c o m p ilin g a d a ta b a s e o f In te rn e t sites. P o p u la r search engines a re A lt a V is ta , In fo S e e k , W e b C r a w le r , Y a h o o , N o r th e r n lig h t , a n d H o t b o t . A ll h a v e d iffe re n t search fe atu re s a n d p ro d u c e s o m e w h a t W W W I CRITICAL THINKING QUESTION V d iffe r in g re s u lts . In a d d itio n to search e n g in es , th e re a re How can you locate online sources for more m etas ea rc h engines. A m etas ea rc h engine co n d u cts a search information on a new treatment or medica­ o f a v a r ie ty o f search engines. M e ta c r a w le r (w w w .m e ta tion for a health condition you discussed in a c r a w le r .c o m ), G o o g le (w w w .g o o g le .c o m ), a n d D o g p ile nursing class or clinical this week?V (w w w .d o g p ile .c o m ) a re e x a m p le s o f m e ta s e a rc h engines. E a c h search e ngine q u eries d iffe re n t databases usin g d iffe r ­ e n t search te ch n iq u es (Bliss & D e Y o u n g , 2 0 0 2 ) a n d uses a ra n g e o f engines fo r re trie v a l o f in fo r m a tio n . A lth o u g h a p o p u la r w e b source, W ik ip e d ia .c o m is n o t c o n s id e re d a n a c c e p ta b le source fo r n u rs in g re fe ren ce .

W e b s ite E v a lu a tio n T h e W e b has g r o w n r a p id ly since its b e g in n in g , a n d in fo r m a t io n c a n be p u b lis h e d e as ily a n d in e x p e n s iv e ly . A n In te r n e t site c an be c re a te d b y a n y ­ o n e w it h th e a b ilit y to c re a te a w e b p a g e . M a n y sites a re fo r c o m m e rc ia l p u rp o s e s , a n d o th e rs s im p ly p u b lis h th e o p in io n s o f th e W W W I CRITICAL THINKING QUESTION V w e b s ite o w n e r . W e b s ite s a re u n d e r n o g u id e lin e s o r s ta n ­ d a rd s . A d d itio n a lly , n o o ffic ia l o rg a n iz a tio n is resp o n sib le What is your role as a nurse in the evaluation fo r site e v a lu a tio n . A s a re su lt, a vast a m o u n t o f in fo r m a tio n of information on the Internet? V is a v a ila b le o n th e W e b , b u t n o t a ll in fo r m a tio n is re lia b le . A p p ly in g th ese g u id e lin e s c a n assist y o u in e v a lu a tin g a re so u rce o n th e W e b (T h e d e , 2 0 0 3 ; T h e d e & S e w e ll, 2 0 1 0 ) a n d a c q u irin g re lia b le in fo r m a tio n fr o m th e W e b : • •

A c c u ra c y : Is th e in f o r m a t io n a c c u ra te , r e lia b le , a n d fre e fr o m e rro r? S p e llin g a n d p u n c tu a tio n e rro rs c an in d ic a te a n u n tru s tw o rth y site. A u th o r it y o r source: L o o k fo r th e c re d e n tia ls o f th e a u th o r o r th e re p u ta ­ tio n o f th e h o s tin g o rg a n iz a tio n . A g o o d in d ic a tio n o f a u th o r ity is p eer re v ie w .

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O b je c tiv ity : W h a t are th e goals a n d o b jectives o f th e site? W h a t biases are present? Is th e site tr y in g to p re s e n t a specific o r n e u tra l p o in t o f view ? C u r r e n c y o r tim e lin e s s : L o o k fo r p u b lic a t io n a n d u p d a te d d a te s to d e te rm in e i f th e i n f o r m a t io n is c u r r e n t. D e a d lin k s c a n in d ic a te o ld in fo r m a tio n . C o v e ra g e o r q u a lity : Is th e s u b ject m a tte r p re se n ted o n th e site o f a p p ro ­ p ria te q u a lity fo r th e in te n d e d audience? In te n d e d p u rp o s e : D o e s th e site h a v e choices fo r users such as th e p u b ­ lic , h e a lth c a re p ro v id e rs , stu d en ts, o r e d u c a to rs (H e b d a & C z a r, 2 0 0 9 ; T h e d e , 2 0 0 3 )? U s a b ility : Is th e site d e sig n e d fo r easy n a v ig a tio n ? A r e th e re excessive g ra p h ic s th a t re q u ire lo n g d o w n lo a d tim es? A re a ll lin k s c u rre n t a n d do th e y lo a d easily?

S o m e w e b s ites th a t fe a tu re w e b in a rs a n d o n lin e p ro g ra m s h a v e closed c a p tio n in g (C C ) a n d copies o f th e scripts a v a ila b le o n d e m a n d fo r these p r o ­ g ra m s . L a n g u a g e o p tio n s are a v a ila b le o n som e w ebsites fo r p r in t a n d a u d ib le p ro g ra m s . I f th e w e b s ite is a h e a lth resou rce, p riv a c y c o n sid eratio n s w ith easily u n d e rs ta n d a b le statem en ts a n d m e e tin g o f accep ted p riv a c y s tan d ard s s h o u ld also be e v a lu a te d (T h e d e & S ew ell, 2 0 1 0 ) . N u rs e s can consider assisting clients b y e d u c a tin g th e m o n h o w to e v a lu a te w e b -b a s e d in fo r m a tio n . In a d d itio n , site users c an g a in in s ig h t in to d o m a in o w n e rs h ip to v e rify th e d o m a in re g is tra tio n . Is th e a u th o rs h ip o r s ponsor id e n tifie d ? O n e d o m a in re g is tra tio n v e rific a tio n source is e a s y w h o is .c o m .

E le c tro n ic D a ta b a s e s A n in c re a s in g n u m b e r o f d a ta b a s e s a re a v a ila b le o n th e In te rn e t a n d c an be accessed th ro u g h lo c a l lib ra rie s o r b y s u b s c rip tio n fr o m a v e n d o r such as E B S C O P u b lis h in g , w h ic h p ro v id e s access to o n lin e d atabases a n d e -jo u rn a ls . M o s t o f th e d atabases a llo w k e y w o r d searches a n d a re c a p a b le o f lim ite d o r a d v a n c e d s ea rch in g as w e ll as lim ite d to fu ll te x t. S om e o f th e m o s t b e n e fic ia l d atabases to n u rs in g in c lu d e th e fo llo w in g : •

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C IN A H L (C u m u la tiv e In d e x o f N u r s in g a n d A llie d H e a lt h L ite r a tu r e ) is th e a u t h o r it a t iv e re s o u rc e f o r n u r s in g a n d a llie d h e a lt h p r o fe s ­ s io n a ls , s tu d e n ts , e d u c a to rs , a n d re s e a rc h e rs . T h is d a ta b a s e p ro v id e s in d e x in g a n d a b s tra c tin g fo r m o re th a n 1 ,7 0 0 c u rre n t n u rs in g a n d a llie d h e a lth jo u rn a ls a n d p u b lic a tio n s d a tin g b a c k to 1 9 8 2 , to ta lin g m o re th a n 8 8 0 ,0 0 0 re c o rd s . C o c h ra n e L ib r a r y is a n o n lin e c o lle c tio n o f s ix databases w it h “ in d e p e n ­ d e n t h ig h -q u a lity evidence fo r h e a lth c a re decision m a k in g ” (T h e C o c h ra n e C o lla b o ra tio n , 2 0 1 2 ) . T h is is a v a ila b le a t a ca d em ic in s titu tio n s a n d is also fu n d e d fo r free access in m a n y c o u n trie s a n d re g io n s o f th e w o r ld .

KEY COMPETENCY 14-2 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Informatics and Technology: Skills (S2b) Evaluates information and its sources critically and incorporates selected information into his or her own professional knowledge base; (S5f) Assesses the accuracy of health information on the internet Source: Massachusetts Department of Higher Education (2010), p. 22.

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KEY COMPETENCY 14-3

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Examples of Applicable Nurse of the Future: Nursing Core Competencies

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Informatics and Technology: Knowledge (K9) Describes general applications avail­ able for research

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Attitudes/Behaviors (A9) Values technology as a tool for generating knowledge Skills (S9a) Conducts on-line literature searches Source: Massachusetts Department of Higher Education (2010), p. 25.

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E R IC , th e E d u c a t io n a l R e s o u rc e In f o r m a t io n C e n te r , is a n a t io n a l in fo r m a tio n system s u p p o rte d b y th e U .S . D e p a r tm e n t o f E d u c a tio n , th e N a t io n a l L ib ra ry o f E d u c a tio n , a n d th e O ffic e o f E d u c a tio n a l R esearch an d Im p ro v e m e n t. I t p ro v id e s access to in fo r m a tio n fr o m jo u rn a ls in c lu d e d in th e C u rre n t In d e x o f J o u rn a ls in E d u c a tio n a n d R esources in E d u c a tio n In d e x . E R IC p ro v id e s fu ll te x t o f m o re th a n 2 ,2 0 0 digests a lo n g w it h re fe ren ce s fo r a d d itio n a l in fo r m a t io n a n d c ita tio n s a n d a b s tra c ts fr o m m o re th a n 1 ,0 0 0 e d u c a tio n a l a n d e d u c a tio n -re la te d jo u rn a ls . G o o g le S c h o la r (g o o g le s c h o la r.c o m ), la u n c h e d in 2 0 0 4 , c o n ta in s som e fu ll-t e x t p e e r-re v ie w e d jo u rn a ls , a b strac ts , lin k s to s u b s c rip tio n jo u rn a ls , a n d a rticle s fo r p u rc h a s e as w e ll as te c h n ic a l re p o rts , theses, a n d b o o k s . H e a lth S o u rc e , th e N u rs in g /A c a d e m ic E d itio n , p ro v id e s m o re th a n 5 5 0 s c h o la rly fu ll-t e x t jo u rn a ls , in c lu d in g m o re th a n 4 5 0 p e e r-re v ie w e d jo u r ­ nals fo c u s in g o n m a n y m e d ic a l d isc ip lin es , in c lu d in g n u rs in g a n d a llie d h e a lth . M E D L IN E , c re a te d b y th e N a t io n a l L ib r a r y o f M e d ic in e , is th e la rg e s t b io m e d ic a l lite r a tu re d a ta b a s e th a t p ro v id e s a u th o r ita tiv e m e d ic a l in f o r ­ m a tio n o n m e d ic in e , n u rs in g , d e n tis try , v e te rin a ry m e d ic in e , th e h e a lth ­ c a re s ys te m , a n d p re c lin ic a l sciences. I n M E D L I N E , users c a n search a b s tra c ts fr o m m o re th a n 4 ,6 0 0 c u rre n t b io m e d ic a l jo u rn a ls . In c lu d e d a re c ita tio n s fr o m In d e x M e d ic u s , In te r n a tio n a l N u rs in g In d e x , In d e x to D e n ta l L ite r a tu r e , P R E M E D L I N E , A ID S L I N E , B IO E T H IC S L I N E , a n d H e a lt h S T A R . P s y c IN F O c o n ta in s n e a rly 2 m illio n c ita tio n s a n d s u m m a rie s o f jo u rn a l a rtic le s , b o o k c h a p te rs , b o o k s , d is s e rta tio n s , a n d te c h n ic a l re p o rts , a ll in th e fie ld o f p s y c h o lo g y . I t also in clu d es in fo r m a tio n a b o u t th e p s y c h o lo g i­ c al aspects o f re la te d d is c ip lin e s such as m e d ic in e , p s y c h ia try , n u rs in g , sociology, e d u c a tio n , p h a rm a c o lo g y , p h y sio lo g y , linguistics, a n th ro p o lo g y , business, a n d la w .

W e b access to g o v e rn m e n t o rg a n iz a tio n s a n d n o n p r o fit o rg a n iz a tio n s is also a v a ila b le . T h e U .S . N a t io n a l L ib r a r y o f M e d ic in e (w w w .n lm .n ih .g o v / h in fo .h tm l) o ffers a w e a lth o f h e a lth in fo r m a tio n w ebsites. P u b M e d a n d M e d lin e P lu s p e rm it searches o f m u ltip le re trie v a l system s a n d p ro v id e e x c e lle n t in fo r m a tio n . T h e e v a lu a tio n g u id e lin e s discussed e a rlie r s h o u ld be a p p lie d to a ll In te rn e t sites b e fo re usin g th e in fo r m a tio n in p a tie n t te a c h in g (T h e d e , 2 0 0 3 ; T h e d e & S e w e ll, 2 0 1 0 ) .

H e a lth In fo rm a tio n O nline T h e n u m b e r o f p e o p le accessing h e a lth in fo r m a tio n o n lin e c o n tin u e s to g ro w . T h is increase in n u m b e rs d e m o n stra te s th e c ritic a l im p o rta n c e th a t h e a lth c a re w ebsites p ro v id e re lia b le a n d c re d ib le in fo r m a tio n . N u rs e s a re resp o n sib le fo r

assisting th e p u b lic in e v a lu a tin g h e a lth in fo r m a tio n a v a ila b le o n th e W e b . A d d itio n a lly , nurses a re in th e id e a l p o s itio n to p ro v id e h e a lth p r o m o tio n e d u c a tio n to th e ir p a tie n ts a n d to th e p u b lic a t la rg e . W h e th e r nurses are d e v e lo p in g o n lin e m a te ria ls o r usin g e x is tin g o n lin e in fo r m a tio n , it is im p o r ta n t fo r th e m to u n d e rs ta n d w h a t m ak e s th e in fo r m a ­ tio n accessible to a ll p e o p le (T h e d e , 2 0 0 3 ) a n d to be a b le to m a k e in fo r m e d re c o m m e n d a tio n s a b o u t w eb sites to in d iv id u a ls w it h d is a b ilitie s (C a rm o n a , 2 0 0 5 ; S m e ltze r, S im m e rm a n , F ra in , D e S ilte s , & D u ff in , 2 0 0 3 ) . C o n te n ts o f sites s h o u ld be p re s e n te d in a w a y th a t p e o p le w it h d is a b ilitie s a n d w it h lo w -e n d te c h n o lo g y a re a b le to n a v ig a te a n d use. W e b s ite s d is p la y in g th e “ B o b b y A p p r o v e d ” ic o n (w w w .a c c e s s ib le .o rg /b o b b y -a p p ro v e d .h tm l) h a v e been screened fo r a cc es sib ility b y in d iv id u a ls w it h d is a b ilitie s , a n d th e ic o n is a n in d ic a tio n o f th e s ite ’s a p p ro p ria te n e s s fo r p a tie n t use. V u ln e ra b le p o p u la tio n s a n d u n d e rs e rv e d p o p u la tio n s , W W W | CRITICAL THINKING QUESTION V w h ic h in c lu d e p erso n s w it h lo w e r s o c io e c o n o m ic statu s, Discuss issues of the digital divide. Explore w it h lo w e r re a d in g levels, in r u r a l areas, o r w it h d is a b ili­ resources in your city and county for the ties, h a ve issues w it h access to care a n d access to in fo r m a ­ general public to have free Internet access tio n a b o u t h e a lth c are . F o r perso ns in these p o p u la tio n s , and assistance. What other technologyth e te rm d ig ita l d iv id e has ty p ic a lly been used to describe type resources are available for underserved decreased access to in fo r m a tio n te c h n o lo g ie s , p a rtic u la rly populations?^ th e v ia th e In te rn e t (C h a n g et a l., 2 0 0 4 , p . 4 4 9 ). A s th e In te rn e t c o n tin u e s to g a in in p o p u la r ity , m o re p e o p le are using th e W e b fo r fin d in g h e a lth in fo r m a tio n . W e b -k n o w le d g e a b le nurses n e ed to assist p a tie n ts a n d th e ir fa m ilie s in e v a lu a tin g th e q u a lity o f W e b resources. T h e H e a lt h o n th e N e t F o u n d a tio n ( H O N ) , fo u n d e d in 1 9 9 5 , is a n o n p ro fit o rg a n iz a tio n d e d ic a te d to assisting p e o p le in o b ta in in g re lia b le h e a lth in fo r m a tio n o n th e W e b . T h e H O N C o d e o f C o n d u c t ( H O N c o d e ) is a v a ila b le a t w w w .h o n .c h /H O N c o d e /C o n d u c t.h tm l (H e a lth o n th e N e t F o u n ­ d a tio n , 2 0 0 9 ) . T o o b ta in c e rtific a tio n , a w e b s ite a p p lie s fo r re g is tra tio n . T h e site is e v a lu a te d a n d , i f a p p ro v e d , q u a lifie s to d is p la y th e H O N c o d e seal. T h e site is r a n d o m ly c h e c k e d fo r c o m p lia n c e . F r o m th e H O N w e b s ite , th e H O N to o lb a r c an be d o w n lo a d e d a n d a d d e d to y o u r W e b b ro w s e r. T h e seal is illu m in a te d w h e n a c e rtifie d site is accessed. A n o th e r o rg a n iz a tio n th a t c an be used as a re so u rce is th e H a r d in M D ( H a r d in M e t a D ir e c to ry ) a t w w w .lib .u io w a .e d u /h a r d in /m d . T h e site is m a in ­ ta in e d b y H a r d in L ib r a r y fo r th e H e a lt h Sciences a t th e U n iv e rs ity o f Io w a a n d lists several d ire c to rs fo r h e a lth a n d m e d ic in e . M e d lin e P lu s (a v a ila b le a t w w w .n lm .n ih .g o v /m e d lin e p lu s ) is a c o n s u m e r-o rie n te d site th a t c o m b in e s in fo r m a t io n fr o m th e N a t io n a l L ib r a r y o f M e d ic in e ( N L M ) , th e N a t io n a l In s titu te s o f H e a lt h ( N I H ) , a n d o th e r g o v e rn m e n t agencies a n d h e a lth -re la te d o rg a n iz a tio n s . T h e site is m a in ta in e d b y th e N a t io n a l L ib r a r y o f M e d ic in e . S e v e ra l sites w it h th e O ffic e o f th e N a t io n a l C o o r d in a to r fo r H e a lt h I n f o r m a t io n T e c h n o lo g y ( O N C , 2 0 1 1 a ) o f H I T such as H e a lt h IT .g o v a t w w w .h e a lth it.g o v /p a tie n ts -fa m ilie s /ty p e s -e -h e a lth -to o ls h a v e in fo r m a t io n

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CHAPTER 14 Informatics and Technology in Professional Nursing Practice

o n e -h e a lth to o ls fo r th e p u b lic to re v ie w a n d use. Sites such as H e a lt h 2 .0 D e v e lo p e r C h a lle n g e (2 0 1 2 ) a t w w w .h e a lth 2 c o n .c o m /d e v c h a lle n g e h o ld in n o ­ v a tio n c o m p e titio n s a n d c o m m u n ity a c tio n p ro g ra m s to address s o lu tio n s fo r k e y challeng es in h e a lth in fo r m a tio n te c h n o lo g y .

C o n fid e n tia lity , S e c u rity , and P riv a c y of H e a lth c a re In fo rm a tio n P ro te c tin g a n in d iv id u a l’s p e rs o n a l a n d p riv a te in fo r m a tio n fr o m o th ers has h is to ric a lly been a s ig n ific a n t issue fo r n u rs in g . H e a lth c a re in fo r m a tio n is a c o lle c tio n o f d a ta re la tin g to a c u te ly p e rs o n a l aspects o f a n in d iv id u a l’s life . Im p ro p e r disclosure can cause d e va statin g consequences. M a n y p e o p le depen d o n th e u n d e rs ta n d in g t h a t in fo r m a t io n p ro v id e d to a h e a lth c a re p ro v id e r w ill n o t be disclosed. I t is p ossible fo r p a tie n ts n o t to disclose c e rta in types o f in fo r m a tio n essential to th e ir c are i f th e y b e lie ve th e in fo r m a tio n w o u ld n o t c o n tin u e to be c o n fid e n tia l. T h e in tr o d u c tio n o f e le c tro n ic d o c u m e n ta ­ tio n a n d c o m m u n ic a tio n has in crea se d th e d iffic u lty o f m a in ta in in g p riv a c y . Im p ro v e d access to h e a lth c a re in fo r m a tio n c an a n d does increase effic ie n c y a n d im p ro v e p a tie n t care, b u t a c c o m p a n y in g th e benefits are g re ater difficulties in m a in ta in in g p riv a c y a n d c o n fid e n tia lity . P re se rvin g s ec u rity o f th e in fo r m a ­ tio n system becom es c ritic a l because u n a u th o riz e d access to th e c o m p u te riz e d h e a lth c a re in fo r m a tio n system c o m p ro m is e s th e p riv a c y a n d c o n fid e n tia lity o f p e rs o n a l re co rd s. P ro te c tio n a g a in s t u n a u th o riz e d access c an be a ch ie v e d b y im p le m e n tin g a lo g in process th a t verifies th a t th e user has p e rm is s io n to use th e system . T h e m a jo r ity o f systems re ly o n a user I D a n d p a s s w o rd fo r v e rific a tio n . P assw ords m u s t be c h an g ed fre q u e n tly to p ro te c t a g ain s t b re ac h o f sec u rity . Users sh o u ld n e v e r d iv u lg e o r share p a s s w o rd s . H e a lth c a re agencies h a v e w r it te n p o licies re g a rd in g th e p e n a ltie s o f m isu se o f th e s ystem . C o n se q u e n c es a re u s u a lly severe a n d c an re s u lt in te rm in a tio n o f th e e m p lo y e e (T h e d e , 2 0 0 3 ) .

■ H ealth Insurance P ortability and A ccountability Act In 1 9 9 6 , C ongress passed th e H e a lt h In s u ra n c e P o rta b ility a n d A c c o u n ta b ility A c t ( H IP A A ) to im p ro v e th e e ffic ie n c y a n d effectiveness o f th e h e a lth c a re sys­ te m b y e n c o u ra g in g th e d e v e lo p m e n t o f a h e a lth in fo r m a tio n system . S everal areas are addressed b y th e a ct, in c lu d in g s im p lify in g h e a lth c a re c la im s , d e v e l­ o p in g stan d ard s fo r d a ta tran s m iss io n , a n d im p le m e n tin g p riv a c y re g u la tio n s . T h e p riv a c y re g u la tio n s p ro te c t clien ts b y lim itin g th e w a y s th a t h e a lth p lan s, p h a rm a c ie s , h o s p ita ls , a n d o th e r e n titie s c a n use c lie n ts ’ p e rs o n a l m e d ic a l in fo r m a tio n . T h e re g u la tio n s p ro te c t m e d ic a l re co rd s a n d o th e r in d iv id u a lly

Electronic Health Records

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id e n tifia b le h e a lth in fo r m a tio n , w h e th e r it is c o m m u n ic a te d W W W I CRITICAL THINKING QUESTION * o ra lly , o n p a p e r, o r e le c tro n ic a lly . What is your role as a nurse in protecting A c c o m p a n y in g th e p riv a c y re g u latio n s are specific secu­ patient healthcare information?* r ity rules th a t p ro te c t h e a lth in fo r m a tio n in e le c tro n ic fo rm . T o be in co m p lia n c e, agencies m u s t ensure th e c o n fid e n tia lity a n d in te g r ity o f a ll e le c tro n ic h e a lth in fo r m a t io n th a t is c re a te d , re c e iv e d , tra n s m itte d , o r stored; p ro te c t ag ain s t th re a ts to security; p ro te c t a g a in s t d is ­ KEY COMPETENCY 14-4 closures o f in fo r m a t io n ; a n d e nsure c o m p lia n c e o f its e m p lo y e e s (G a r n e r , Examples of Applicable 2 0 0 3 ) . H IP A A , w h e n fu lly im p le m e n te d , w ill c o n trib u te to a “ fu lly in te g ra te d Nurse of the Future: Nursing h e a lth c a re system ” (T h e d e , 2 0 0 3 , p . 3 2 7 ). Core Competencies

Informatics and Technology:

E le c tro n ic H e a lth R eco rds In 2 0 0 4 , P re s id e n t G e o rg e B ush, as p a r t o f th e N a t io n a l H e a lt h In fo r m a tio n In fr a s tru c tu r e , e sta b lish e d a te c h n o lo g y a g en d a a u th o r iz in g th e d e v e lo p m e n t o f a n e le c tro n ic h e a lth re c o rd fo r a ll A m e ric a n s b y 2 0 1 4 (H e a lth c a r e I T , 2 0 0 4 ) . In fo r m a t io n o n th is a g en d a c an be fo u n d a t th e U .S . D e p a r tm e n t o f H e a lt h a n d H u m a n Services w e b s ite: g e o rg e w b u s h -w h ite h o u s e .a rc h iv e s .g o v / n e w s /r e le a s e s /2 0 0 4 /0 5 /p r in t/2 0 0 4 0 5 2 7 -2 .h tm l. E le c tro n ic in fo r m a tio n systems c o n trib u te to m o re e ffe c tiv e c o m m u n ic a ­ tio n a n d c o lle c tio n o f p a tie n t in fo r m a tio n , re s u ltin g in m o re e ffe c tiv e p a tie n t c a re (T h e d e , 2 0 0 3 ) . T h e e le c tro n ic in fo r m a t io n s ys te m c a n m a x im iz e th e tim e nurses spend o n d ire c t p a tie n t c are , im p ro v e th e a c c u ra c y o f d o c u m e n ta ­ tio n , decrease m e d ic a tio n e rro rs , a n d p ro m o te p a tie n t safe ty . W h y a u to m a te n u rs in g a n d h e a lth c a re d o c u m e n ta tio n ? U p -t o -d a te , a c c u ra te in fo r m a t io n o f each step o f th e n u rs in g pro cess is th e p o w e r b e h in d safe, h ig h -q u a lity p a tie n t-c e n te re d c are. “ T h e g o a l o f n u rs in g in fo r m a tic s ( N I ) is to im p ro v e th e h e a lth o f p o p u ­ la tio n s , c o m m u n itie s , fa m ilie s , a n d in d iv id u a ls b y o p tim iz in g in fo r m a t io n m a n a g e m e n t a n d c o m m u n ic a tio n ” ( A N A , 2 0 0 1 , p . 1 7 ). In fo r m a t io n m a n ­ a g e m e n t is in te g r a l to p r o v id in g h ig h - q u a lity h e a lth c a re c o s t-e ffe c tiv e ly . T o p ro v id e th is le v e l o f c a re , i t is im p o r t a n t to h a v e a c c u ra te c lin ic a l in f o r ­ m a tio n . T h e h e a lth in fo r m a t io n system o r e le c tro n ic h e a lth re c o rd ( E H R ) re p re se n ts m u ltip le system s th a t in te rfa c e to s h are d a ta a n d a re n e tw o rk e d to s u p p o rt in fo r m a tio n m a n a g e m e n t a n d c o m m u n ic a tio n w it h in a h e a lth c a re o r g a n iz a tio n . E H R s h a v e n u m e ro u s a d v a n ta g e s c o m p a r e d w i t h t r a d it io n a l p a p e r re co rd s. T h e y c an store la rg e a m o u n ts o f d a ta th a t are accessible fr o m re m o te sites b y m a n y p e o p le a t th e sam e tim e . In fo r m a t io n c a n be accessed m o re easily a n d q u ic k ly , a llo w in g m o re tim e fo r p a tie n t c are . T h e E H R c an p ro v id e c lin ic a l ale rts a n d re m in d e rs , id e n tify a b n o rm a l p a ra m e te rs o f la b o ra to ry a n d assessm ent d a ta , a n d p r o m p t c lin ic ia n s o n im p o r t a n t tasks a n d p ro to c o ls (H e b d a & C z a r, 2 0 0 9 ; Y o u n g , 2 0 0 0 ) .

Knowledge (K6) Describes patients' rights as they per­ tain to computerized infor­ mation management Attitudes/Behaviors (A6) Values the privacy and confidentiality of protected health information in elec­ tronic health records Skills (S6ba) Discusses the principles of data integrity, professional ethics, and legal requirements; (S6c) Describes ways to protect data Source: Massachusetts Department of Higher Education (2010), p. 24.

T h e d e (2 0 0 3 ) id e n tifie s th e fo llo w in g types o f in fo r m a tio n system s used w it h in h e a lth c a re o rg a n iz a tio n s : •

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A d m is s io n , d is c h a rg e , a n d tr a n s fe r: T h is s y s te m c o lle c ts a n d tra c k s p a tie n t in fo r m a tio n , such as d em o g ra p h ics , h o s p ita l n u m b e r, re la tiv es , an d p r im a r y p h y s ic ia n . A ll p a tie n t c o n ta cts a re c o n n e c te d to th e in fo r m a tio n in th is system . F in a n c ia l system s: T h is system is re sp o n sib le fo r th e fiscal o p e ra tio n s o f an o rg a n iz a tio n . O r d e r e n try : F r o m a c o m p u te r screen, a c lin ic ia n places a n o rd e r fo r a specific s ervice. T h e system is c a p a b le o f sch e d u lin g , re p o rtin g , a n d b ill­ in g . T h e system m ig h t h a v e th e p o te n tia l o f p ro g ra m m e d p a tie n t safety fu n c tio n s th a t id e n tify a n d r e p o rt p o te n tia l e rro rs . A n c illa r y systems: A n c illa r y a p p lic a tio n s p e r m it s h a rin g o f in fo r m a tio n a m o n g m u ltip le system s a n d s p e c ia lty areas such as th ose o f ra d io lo g y , la b o ra to ry , p h y s ic a l th e ra p y , a n d p h a rm a c y . C lin ic a l d o c u m e n ta tio n : T h is system e n ab les th e E H R , o r c h a rt, to be accessed a t a n y tim e . S c h e d u lin g a p p lic a tio n s a re used fo r s ta ff, p a tie n ts , supplies, a n d p ro c e ­ d u res . A c u ity a p p lic a tio n s a tte m p t to p re d ic t th e resources necessary fo r p a tie n t c a re . T h e y a re in te g ra te d w it h o th e r system s such as s ta ffin g to c re a te a d e q u a te s ta ffin g . S p e c ia lty systems a re fo u n d in s p ec ialize d u n its w it h in th e h e a lth c a re set­ tin g . E x a m p le s in c lu d e m o n ito r in g e q u ip m e n t in in te n s iv e care u n its th a t a u to m a tic a lly m easure a n d re c o rd p h y sio lo g ic d a ta , generate tren d s, sound a la rm s fo r a b n o rm a litie s , a n d in te ra c t w it h o th e r in fo r m a t io n system s w it h in th e p a tie n t e n v iro n m e n t. C o m m u n ic a tio n system s such as e m a il a n d In te rn e t a cc es sib ility fa c ilita te c o m m u n ic a tio n a m o n g v a rio u s d isc ip lin es w it h in th e o rg a n iz a tio n . C r itic a l p a th w a y s , g e n e ra te d b y in fo r m a t io n system s, id e n tify specific p a tie n t o u tco m e s a n d m a k e d o c u m e n ta tio n b y d iffe re n t d isc ip lin es p o s ­ sible. T h is p ro m o te s c o s t-e ffe c tiv e c are th ro u g h e ffe c tiv e c o m m u n ic a tio n .

T h e d e (2 0 1 2 ) re p o rts a “ c a rd in a l ru le in in fo rm a tic s is one e n try o f a piece o f d a ta , m a n y uses” (p . 2 ). A s d a ta a re e n te red in to th e system , th e a p p lic a tio n c an p ro m p t th e c lin ic ia n fo r a d d itio n a l in fo r m a tio n th a t m ig h t be m issed. T h e sam e d a ta c an be used in a v a rie ty o f re p o rts , le a d in g to decreased re d u n d a n c y o f c h a rtin g . D a t a such as pulse ra te o r b lo o d pressure c an be c o lle c te d d ire c tly fr o m m o n ito rs a tta c h e d to th e c lie n t a n d fe d in to th e system (H u n t e r , 2 0 0 2 ) . C lin ic a l d o c u m e n ta tio n system s h a v e th e a d v a n ta g e o f c o lle c tin g d a ta to use in p la n n in g a n d research . S e n s m e ie r ( 2 0 0 8 ) o ffe rs w a y s to im p r o v e n u rs in g p ra c tic e w it h te c h ­ n o lo g y , in c lu d in g s e e k in g n u rs in g in p u t r e la te d to w o r k f lo w , in v e s tin g in I T tr a in in g , p r o m o tin g I T e x c e lle n c e , a n d w o r k in g fo r a stag ed a p p ro a c h

to a d o p tin g a p a p erle ss E H R . T h e d e (2 0 0 8 ) suggests th a t n u rs in g p ro fe s ­ sion als m u s t engage in discussion to decid e h o w d o c u m e n ta tio n d a ta w ill be u tiliz e d . T h e p ro fe s s io n m u s t c o n s id e r w h ic h d a ta a re to be in c lu d e d in th e E H R a n d th e a c c e p ta b le te rm in o lo g y used w h e n re c o rd in g th e d a ta . N u rs in g in fo rm a tic s p ro v id e s th e to o ls a n d skills to assist h e a lth c are to m o v e a h e a d in th e e v e r-c h a n g in g w o r ld .

C o m m u n ic a tio n O nline ■ Email E m ail (e le c tro n ic m a il) c a n be sent to a n y o n e in th e w o r ld w h o has an e m a il address. T h is a llo w s m a n y h e a lth c a re p ro v id e rs to be a b le to c o m m u n ic a te w it h p a tie n ts . I n m o m e n ts , m essages c an be sent across tim e z o n e s , a llo w ­ in g in s ta n t c o m m u n ic a tio n . F o r sev era l re a s o n s , a tte n tio n m u s t be p a id to th e c o n te n t o f m essages sent b y e m a il. S o m e o n e o th e r th a n th e in te n d e d re c ip ie n t c an access a m essage w h ile it is tra n s m itte d o v e r th e In te rn e t. A ls o , m essages c o n ta in in g sensitive in fo r m a tio n c an a c c id e n ta lly o r p u rp o s e fu lly be fo rw a rd e d . P ro te c te d h e a lth in fo r m a tio n ( P H I) is c o v e re d u n d e r H IP A A . P riv a c y o f e m a il is a leg a l a n d e th ic a l issue (T h e d e , 2 0 0 3 ) . A lth o u g h e m a il can be a w a y o f fa c ilita tin g d ire c t c o m m u n ic a tio n b e tw e e n c o n su m e rs o f h e a lth c are a n d h e a lth c a re p ro v id e rs , p re c a u tio n s m u s t be ta k e n to ensure th a t o n ly th e in te n d e d re c ip ie n t receives h e a lth -re la te d e m a il m essages. T o send a n d receive e m a il, a p e rso n m u s t h a ve a n in d iv id u a l address th a t consists o f tw o m a in p a rts s ep a rated b y an a t (@ ) sign. T h e firs t p a r t is c a lle d a lo g in n a m e o r a user I D . T h e p a r t a fte r th e @ is th e n a m e o f th e c o m p u te r used to access th e In te rn e t. T h e characters a fte r th e last d o t in a n e m a il address in d ic a te th e d o m a in o r m a in s u b d ivis io n o f th e In te rn e t to w h ic h th e c o m p u te r belo n g s. A ddresses m u s t be a c c u ra te fo r th e m essage to be sent. A p p ro p r ia te ­ ness o f address m u s t be co n sid e re d w h e n selecting y o u r lo g in n a m e . P ro fe s ­ sionals s h o u ld n o t use suggestive o r in se n s itive w o rd in g fo r th e ir lo g in n am es. E m a il is a s p ecial fo r m o f c o m m u n ic a tio n a n d c arrie s its o w n fo r m o f e tiq u e tte . P ag an a (2 0 0 7 ) suggests nurses fo llo w these g u id elin es w h e n sending a business o r p ro fe s s io n a l m essage: • • • • •

D o n ’t use a ll u p p ercase le tte rs . T y p in g in a ll caps is d e e m e d s h o u tin g . In c lu d e a specific su b ject lin e . Sign y o u r messages w it h te x t th a t in clu d es y o u r e m a il address a n d c o n ta c t in fo r m a tio n . U se th e “ r e p ly to a ll ” fu n c tio n a p p r o p r ia te ly because n o t e v e ry o n e is in te re s te d in re c e iv in g y o u r c o m m e n ts . A v o id fo r w a r d in g c h a in le tte rs , a n d de le te a ll u n n ecessary in fo r m a tio n fr o m fo r w a r d e d m essages.

KEY COMPETENCY 14-5 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Informatics and Technology: Knowledge (K5) Describes the computerized systems presently utilized to facili­ tate patient care Attitudes/Behaviors (A5) Values the importance of technology on patient care Skills (S5a) Applies tech­ nology and information man­ agement tools to support safe processes of care and evaluate impact on patient outcomes; (S5b) Accesses, enters, retrieves data used locally for patient care Source: Massachusetts Department of Higher Education (2010), p. 23.

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D o n o t send c o n fid e n tia l in fo r m a t io n , a n d c h ec k fo r c o rre c t re c ip ie n ts b e fo re sen d in g . U se th e s p ell-c h ec k a n d g ra m m a r fu n c tio n s . D o n o t use e m a il fo r th a n k -y o u c o rre s p o n d e n c e .

■ Listserv Groups and Mailing Lists M a ilin g lists a n d lis ts e rv s are fo rm s o f g ro u p e m a il th a t p ro v id e an o p p o r­ tu n ity fo r p e o p le w it h s im ila r interests to share in fo r m a tio n . S u b s c rib in g to a lis t is u s u a lly free . O n c e s u b sc rib e d , y o u c a n send a n d receive m essages to a n d fr o m th e lis t. T h e c o m m u n ic a tio n is a s y n c h ro n o u s , m e a n in g it does n o t o c cu r in re a l tim e . S o m e o n e posts a q u e s tio n o r c o m m e n t to th e lis t, a n d o th e r m e m b e rs re p ly in tim e . L is t g ro u p s a re u s u a lly la y p e rs o n o rie n te d o r p ro fe s ­ s io n a l o rie n te d . T h e re are n u m e ro u s g ro u p s d e v o te d to th e to p ic o f n u rs in g . T o fin d a lis t, ask frie n d s a n d colleagu es o r v is it L -S o ft, a sea rch a b le d a ta b as e th a t c an be accessed a t w w w .ls o ft.c o m /c a ta lis t.h tm l. M o s t listservs p ro v id e specific in s tru c tio n s o n s u b sc rib in g . E v e ry listserv has tw o addresses. O n e address is used to jo in , a n d th e s eco n d is used to send m essages th a t c an b e re a d b y th e g ro u p . L is ts e rv g ro u p s c an be o p e n to a n y o n e , o r y o u m ig h t h a ve to h a v e p e rm is s io n to jo in . I t is im p o r t a n t to re m e m b e r th a t m essages sent to th e lists e rv a re re a d b y e v e ry o n e s u b s c rib e d to th a t lis ts e rv . P o s tin g a p e rs o n a l m essage to an in d iv id u a l o n a lists e rv is g e n e ra lly n o t c o n s id e re d a p p ro p r ia te . D o n o t send a tta c h m e n ts to th e lis t. T h e lis t m ig h t h a v e h u n d re d s o f m e m b e rs , a n d som e w ill n o t h a v e c o m p u te rs th a t s u p p o rt s o p h is tic a te d g ra p h ic s o r la rg e files. A d d itio n a lly , viruses c an be tra n s m itte d in a tta c h m e n ts . T h e a b ility fo r m u ltip le p e o p le to send a n d receive m essages in m u ltip le places is h a v in g a d ire c t im p a c t o n h e a lth c are . F o r e x a m p le , th ro u g h th e use o f e m a il, nurses c a n e as ily a n d e ffic ie n tly fa c ilita te a v ir tu a l s u p p o rt g ro u p fo r fa m ilie s a n d p a tie n ts w it h c h ro n ic c o n d itio n s o r lim ita tio n s in accessing h e a lth care. T h e lists c o n n e ct th e p a rtic ip a n ts to in d iv id u a ls w it h s im ila r h e a lth concerns so th a t th e y c an share experiences, receive a d vic e o n d iffic u ltie s , a n d a lle v ia te th e fe e lin g o f is o la tio n (M e n d e ls o n , 2 0 0 3 ) .

■ Social Media S o c ia l m ed ia a re “ In te rn e t-b a s e d a p p lic a tio n s th a t e n a b le p e o p le to c o m ­ m u n ic a te a n d share resources a n d in fo r m a t io n ” (L in d s a y , 2 0 1 1 ) . E x a m p le s o f s o cia l m e d ia are Y o u T u b e , F a c e b o o k , L in k e d In , a n d T w it t e r , as w e ll as blogs, w ik is , a n d c h a t ro o m s . T h e m a n y choices o f h o w users c a n “ s h a re ” in fo r m a tio n can be fo u n d o n th e A m e ric a n N u rs e s A s s o c ia tio n w e b s ite (w w w . n u r s in g w o rld .c o m ). T h e d ro p -d o w n m e n u o n th e S hare b u tto n lists th e v a r i­ ous o p tio n s a v a ila b le fo r users.

G r o w in g p a r tic ip a tio n in s o c ia l n e tw o r k in g sites poses c h a lle n g e s fo r n u rs in g . A lth o u g h s o c ia l n e tw o r k in g aids w it h p e rs o n a l a n d p ro fe s s io n a l k n o w le d g e exch an g e a n d p ro m p ts in te ra c tio n w it h o th ers, it com es w it h risks. P e rs o n a l a n d p a tie n t p riv a c y issues (i.e ., H IP A A re q u ire m e n ts ) c a n be ra is e d . S om e n e tw o r k in g discussions m ig h t be v ie w e d as “ fa c t” a n d n o t v a lid a te d . A N A has a d o p te d th e P rin c ip le s fo r S o c ia l N e t w o r k in g , w h ic h in c lu d e th e fo llo w in g : • • • • • •

N u rs e s m u s t n o t tr a n s m it o r p lac e o n lin e in d iv id u a lly id e n tifia b le p a tie n t in fo r m a tio n . N u rs e s m u s t o b s e rv e e th ic a lly p re s c rib e d p ro fe s s io n a l p a tie n t-n u r s e b o u n d a rie s . N u rs e s s h o u ld u n d e rs ta n d th a t p a tie n ts , c o lle ag u es , in s titu tio n s , a n d e m ­ p lo y e rs m ig h t v ie w p o s tin g s . N u rs e s s h o u ld ta k e a d v a n ta g e o f p riv a c y settings a n d seek to s e p a ra te p e rs o n a l a n d p ro fe s s io n a l in fo r m a tio n o n lin e . N u rs e s s h o u ld b rin g c o n te n t th a t c o u ld h a r m a p a tie n t’s p riv a c y , rig h ts , o r w e lfa re to th e a tte n tio n o f a p p ro p r ia te a u th o ritie s . N u rs e s s h o u ld p a rtic ip a te in d e v e lo p in g in s titu tio n a l p o licie s g o v e rn in g o n lin e c o n ta c t ( A N A , 2 0 1 1 a , 2 0 1 1 b ) .

T h e N a t io n a l C o u n c il o f S tate B o ard s o f N u rs in g has also a d o p te d g u id e ­ lines re la te d to th e re sp o n sib le use o f so cia l m e d ia a n d has e n d o rs ed th e p r in ­ ciples a d o p te d b y A N A . T h e g u id e lin e s fr o m th e N C S B N (N a tio n a l C o u n c il o f S tate B o ard s o f N u rs in g [N C S B N ], 2 0 1 1 ) a re a v a ila b le a t w w w .n c s b n .o rg / S o c ia l_ M e d ia .p d f a n d address issues o f c o n fid e n tia lity a n d p riv a c y , c o m m o n m yth s a n d m isu n d ers ta n d in g s re la te d to social m e d ia , possible consequences in th e use o f social m e d ia in c lu d in g consequences w it h b o a rd o f n u rs in g im p lic a ­ tio n s , a n d h o w to a v o id p ro b le m s . T h e g u id elin es also in c lu d e seven scenarios re la te d to social m e d ia use b y nurses w it h b o a rd o f n u rs in g im p lic a tio n s . A c c o rd in g to th e N C S B N (2 0 1 1 ) w h ite p a p e r, d e p e n d in g o n th e ju ris ­ d ic tio n , th e b o a rd o f n u rs in g m ig h t in v e s tig a te re p o rts o f in a p p ro p r ia te d is ­ closures re la te d to th e use o f s o cia l m e d ia o n th e g ro u n d s o f th e fo llo w in g : u n p ro fe s s io n a l c o n d u c t, u n e th ic a l c o n d u c t, m o ra l tu rp itu d e , m is m a n a g e m e n t o f p a tie n t re co rd s, re v e a lin g a p riv ile g e d c o m m u n ic a tio n , a n d b re a c h o f c o n fi­ d e n tia lity . I f a lle g a tio n s are fo u n d to be tru e , th e nurse c o u ld face d is c ip lin a ry a c tio n b y th e b o a rd o f n u rs in g th a t c a n in c lu d e a re p rim a n d , s a n c tio n , assess­ m e n t o f a fin e , o r th e te m p o ra ry o r p e rm a n e n t loss o f lice n su re. In a d d itio n , im p ro p e r use o f s o cia l m e d ia m ig h t v io la te state a n d fe d e ra l la w s , re s u ltin g in c iv il o r c rim in a l p e n a ltie s th a t c a rry w it h th e m fines o r ja il tim e . S o c ia l n e tw o r k in g c a n h a v e b o th p o s itiv e a n d n e g a tiv e c onsequences. N e g a tiv e consequences c an a ffe c t n o t o n ly n u rse s ’ p e rs o n a l re p u ta tio n s b u t also th e ir p ro fe s s io n a l s ta n d in g . N u rs es s h o u ld c o n sid e r th a t c u rre n t o r fu tu re e m p lo y e rs m ig h t v ie w th e ir p e rs o n a l social m e d ia pages.

KEY COMPETENCY 14-6 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Informatics and Technology: Skills (S6b) Maintains pri­ vacy and confidentiality of patient information Source: Massachusetts Department of Higher Education (2010), p. 24.

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CHAPTER 14 Informatics and Technology in Professional Nursing Practice

O n th e o th e r h a n d , social m e d ia c an be used in disasters as a m ea n s o f d is s e m in a tin g in fo r m a t io n a n d as a n e m e rg e n c y m a n a g e m e n t to o l. S o c ia l m e d ia c an be a source o f in fo r m a tio n in a crisis s itu a tio n as w e ll as p a r t o f a p la n to m o b iliz e re sp o n d ers. I n disaster p re p a ra tio n , social m e d ia sites c an be used to p u b lic iz e tr a in in g events a n d dates (L in d s a y , 2 0 1 1 ) . W W W 1 CRITICAL THINKING QU ESTIO N S* F u tu r e c h a lle n g e s o f s o c ia l m e d ia in c lu d e th e use o f th e te c h n o lo g y fo r th e d e liv e ry o f a c c u ra te a n d p e rtin e n t W h a t needs o f populations in yo u r region or in fo r m a t io n b y e x p e rts a n d h e a lth c a re p ro v id e rs a n d b y state could be addressed by telehealth? W h a t peers a n d th e la y p u b lic . H e a lth c a re p ro v id e r’s uses o f social ideas can you envision to assist in the access m e d ia te c h n o lo g y m a y in c lu d e p u b lic e d u c a tio n re la te d to to and delivery o f healthcare services where sources o f in fo r m a tio n a n d m o n ito rin g th e im p a c t o f social you live or w o rk ? V m e d ia o n h e a lth o u tco m e s.

T e le h e a lth T e le h e a lth is d e fin e d as “ u s in g e le c tro n ic c o m m u n ic a tio n fo r tr a n s m ittin g h e a lth c a re in fo r m a t io n such as h e a lth p r o m o tio n , disease p re v e n tio n , p r o ­ fe ss io n a l o r la y e d u c a tio n , d iag n o sis , o r a c tu a l tre a tm e n ts to p e o p le lo c a te d a t d iffe re n t g e o g ra p h ic a l lo c a tio n s ” (T h e d e , 2 0 0 3 , p . 1 2 9 ). H a r d w a r e a n d s o ftw a re such as p e rs o n a l d ig ita l assistants, pagers, c e llu la r p h o n e s , la p to p c o m p u te rs , a n d m o b ile h a rd w a re p e rip h e ra ls a re b e in g used b y c lin ic ia n s in in c re a s in g n u m b e rs . H e a lth c a re p ro v id e rs c a n m o n ito r a n d send messages to p a tie n ts in th e ir h o m e s re g a rd in g changes in h e a lth statu s. In fo r m a t io n a n d im ages c a n be c o m m u n ic a te d d ig ita lly fo r c o n s u lta tio n w it h o th e r h e a lth c a re p ro v id e rs . T h is fo r m o f h e a lth c a re p ro m is es to p ro v id e m a n y s o lu tio n s fo r p a tie n t c are in th e fu tu re (N e w b o ld , 2 0 0 3 ) . A lm o s t a d ecad e ag o , N e ls o n ( 2 0 0 3 ) p ro p o s e d th e fo llo w in g ideas fo r th e fu tu re o f h e a lth care: T h e tr a d itio n a l o ffice v is it w ill be re p la c e d w it h th e v ir tu a l a p p o in tm e n t th ro u g h th e use o f v id e o p h o n e s a n d m o n ito rin g e q u ip ­ m e n t. S h o p p in g m a lls w ill h a ve a m b u la to ry s u rg ery centers a n d h e a lth b o o th s p ro v id in g access to h e a lth c a re p ro v id e rs . T re a tm e n t in fo r m a tio n o b ta in e d b y e m a il w ill be c o m m o n p ra c tic e fo r p a tie n ts a n d care g ive rs . O n lin e c o m m u n i­ ties a n d s u p p o rt g ro u p s w ill assist p a tie n ts in s elf-ca re a n d disease m a n a g e ­ m e n t. P a tie n ts w ill be a b le to d o w n lo a d p e rs o n a l p h y s io lo g ic d a ta fr o m a n y site. W e a r a b le te c h n o lo g y w ill m o n ito r , d e te ct, a n d send d a ta w ire le s s ly to h e a lth c a re fa c ilitie s . I t w ill be possible to p re d ic t disease as a re s u lt o f te c h ­ n o lo g y in s ta lle d in th e h o m e o r w o r n o n th e p e rs o n . T h in k o f h o w m a n y o f these p re d ic tio n s to d a y a re a p a r t o f th e e v e ry d a y h e a lth c a re e n v iro n m e n t: •

H o m e h e a lth , h o s p ice , a n d p r im a r y c are N P s in th e h o m e settin g use ta b ­ lets o r n o te b o o k c o m p u te rs to d o c u m e n t a n d c o m m u n ic a te in fo r m a tio n to m a in o r b ra n c h o ffices. S u p p lie s c a n be o rd e re d o n lin e im m e d ia te ly fo llo w in g th e v is it.

Handheld Devices

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C o m p u te rs o n W h e e ls (C O W s ) are used in c lin ic a l settings fo r p o in t-o fuse d o c u m e n ta tio n . W e b c a m s in co m p u te rs are used fo r tw o -w a y c o m m u n ic a tio n w it h p atien ts in h o m e settings. F o r p a y h o m e a le rt services are a v a ila b le to a id w it h safe ty in th e h o m e settin g . P ractitioners in re m o te areas can connect to large h o s p ita l em ergency d e p a rt­ m e n t s ta ff o r re fe rra l c o n te n t experts fo r co n su ltatio n s a n d second o p in io n s . F r o m a m o to r v e h ic le c ras h site, th e e m e rg e n c y m e d ic a l system (E M S ) respo nse fie ld te a m c an tr a n s m it in fo r m a tio n a n d d o c u m e n ta tio n to th e e m e rg e n c y d e p a rtm e n t fo r c are d ire c tio n a n d in p re p a ra tio n fo r a rriv a l. M o b ile disaster response u n its d isp atch e d a t th e site o f a disaster c an b rin g c o m p u te r-b a s e d re g is tra tio n a n d tr a c k in g system s a n d a n in fo r m a t io n re fe ren ce d a ta b a s e . T h is d isa s ter response system c a n in c lu d e a tw o -w a y lin k u p w it h c o n s u lta tio n a p p lic a tio n s to discuss specific p a tie n t needs w ith o th e r H C P s a t a n o th e r site. P a tie n ts w it h h o m e use o f c o n tin u o u s p o s itiv e a ir w a y p ressure (C P A P ) m a c h in e s c an b rin g in th e u n it’s m e m o ry file to th e H C P fo r r e v ie w o f effectiveness o f th e in te rv e n tio n o f sleep a p n e a episodes since th e las t v is it. T h e m o n ito r in g o f m a te r n a l p re te rm c o n tra c tio n s has a d v a n c e d in th e h o m e settin g . T h e use o f in te ra c tiv e c o n fe re n c in g b y in te rd is c ip lin a ry h e a lth p ro fes s io n al te am s is e x p a n d in g . P a tie n ts c an m a in ta in a n d c a rry a p e rs o n a l c o p y o f th e ir p e rs o n a l h e a lth re co rd s (P H R s ) o n a fla sh d riv e .

P a tie n t p riv a c y is p ro te c te d b y H IP A A re g u la tio n s , a n d v a ria n ce s in state re g u la tio n s also e x is t. C o n s id e ra tio n s fo r th e fu tu re in c lu d e d isc u s sio n o f H IP A A p riv a c y p ro te c tio n i f th e p a tie n t’s p r im a r y c are lo c a tio n a n d th e te le ­ h e a lth p ra c titio n e r a re in d iffe re n t states.

H an d h eld D evices P e rs o n a l d ig ita l assistants ( P D A s ) a re h a n d h e ld devices th a t h a v e w ire le s s c o n n e c tiv ity a n d c a n s y n c h ro n iz e d a ta a n d in fo r m a t io n b e tw e e n th e P D A a n d a c o m p u te r. U se o f th e P D A is b e c o m in g w id e ly p o p u la r in h e a lth care a n d n u rs in g . T h e devices c a n be used as a d ig ita l re fe re n c e fo r o b ta in in g d ru g in fo r m a tio n , dosage c a lc u la tio n s , a n d d ia g n o s tic test resu lts, as w e ll as d e c i­ sion p ro to c o ls fo r a d m in is tra tio n . T h e y are useful to o ls fo r d a ta c o lle c tio n a n d m a n a g e m e n t o f p a tie n t o u tco m e s. P D A s c an be in te rfa c e d w it h th e e le c tro n ic m e d ic a l re c o rd to o b ta in a n d u p d a te v ita l p a tie n t in fo r m a t io n . Im m e d ia te access to th e In te r n e t a llo w s th e h e a lth c a re p r o v id e r to o b ta in v a lu a b le in fo r m a tio n th ro u g h n a tio n a l a n d in te rn a tio n a l resources.

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CHAPTER 14 Informatics and Technology in Professional Nursing Practice

H IP A A re g u la tio n s m u s t be s tric tly fo llo w e d w h e n usin g P D A s a n d o th e r w ireless te c h n o lo g y (T h o m p s o n , 2 0 0 5 ) . T h e use o f P D A s in th e c lin ic a l setting m u s t be c o m p lia n t w it h H IP A A ru les a n d re g u la tio n s . F a c u lty a n d n u rs in g s tudents m u s t be a d v is e d a n d ta u g h t a b o u t s e c u rity a n d sto ra g e o f p a tie n t in fo r m a tio n (M a s tr ia n , M c G o n ig le , M a h a n , & B ix le r, 2 0 1 1 ) . H y b r id devices h a v e a c o m b in a tio n o f c a p a b ilitie s , such as a cell p h o n e th a t is also a n In te rn e t-e n a b le d P D A w it h a n M P 3 p la y e r a n d c a m e ra th a t includ es te x t m essaging c a p a b ilitie s , m ap s a n d d ire ctio n s assistance, a n d in te r­ activ e v o ice assistance. A v a ila b le o p tio n s can v a ry w it h d iffe re n t service plan s, c o ve rag e areas, a n d m e m o ry size. U p o n e m p lo y m e n t a n d w h e n th e re a re a n y c o rp o ra te p o lic y changes, nurses m u s t re v ie w th e h e a lth c a re fa c ility p o licies o n th e use o f h a n d h e ld devices w h ile a t w o r k .

P re s e n t and F u tu re T re n d s B e g in n in g in 2 0 1 2 , a n in itia tiv e o f th e C e n te rs fo r M e d ic a r e & M e d ic a id Services (C M S ) , th e H o s p ita l V a lu e -B a s e d P u rc h a sin g (V B P ) P ro g ra m , a ffe cted p e rfo rm a n c e a n d q u a lity o f care in d e te rm in in g h o w m u c h th e h o s p ita l is p a id fo r services. M a n y specific m easures o f p a tie n t care b y nurses www^] CRITICAL THINKING Q U ESTIO N S* w ill n e e d to be re p o rte d . S om e process m easu res in c lu d e discharge in s tru c tio n s , seru m glucose levels fo r p o s to p e ra ­ W h a t is y o u r nursing role in e arly detec­ tiv e c a rd ia c p a tie n ts , a n d several o th e r specific m easures fo r tio n , reportin g, and surveillance o f em erg­ th e p a tie n t u n d e rg o in g su rg e ry. S om e m easures o f p a tie n t ing threats in y our geographical area? W h a t sources are available and h o w current are exp e rien c es o f c are h a v e b e n c h m a rk s fo r c o m m u n ic a tio n they?V w it h nurses, c o m m u n ic a tio n a b o u t m ed ic in es , re sp o n siv e ­ ness o f th e h o s p ita l s taff, a n d discharge in fo r m a tio n (C M S , 2 0 1 2 ). E d u c a tio n , surveillance, re p o rtin g , an d c o m m u n ic a tio n o f V B P m easures fo r th e n u rs in g a n d h o s p ita l s ta ff w ill be a p r io r ity ro le fo r in fo rm a tic s nurses. T h e O ffic e o f th e N a t io n a l C o o r d in a to r fo r H e a lt h In fo r m a t io n T e c h ­ n o lo g y ( O N C ) a t w w w .H e a lth IT .g o v is a source o f in fo r m a tio n fo r h e a lth c a re p ro v id e rs , p a tie n ts a n d fa m ilie s , as w e ll as p o lic y researchers ( M u r p h y , 2 0 1 1 ; O N C , 2 0 1 1 a ) . T h e M e d ic a r e a n d M e d ic a id E H R In c e n tiv e P ro g ra m s h a ve th e focus o f th e “ m e a n in g fu l use” o f c e rtifie d E H R te c h n o lo g y in a c h ie v in g h e a lth g o a ls. F in a n c ia l in ce n tiv es a re a tta c h e d to these goals. T h e re a re five p a tie n t-d riv e n d o m a in s: to “ im p ro v e q u a lity , safety, efficiency; engage p atien ts & fa m ilie s; im p ro v e care c o o rd in a tio n ; im p ro v e p u b lic a n d p o p u la tio n h e alth ; ensure p riv a c y a n d s e c u rity fo r p e rs o n a l h e a lth in fo r m a t io n ” ( O N C , 2 0 1 1 b ) . F ifte e n c o re o b je ctiv es a re d e sc rib ed a n d lin k e d to th e d o m a in s . R esources a b o u t q u estio n s to e x p lo re a n d m easures a re lin k e d fo r each o b je c tiv e . T h e use o f H I T p re s e n tly a n d in th e fu tu re w i l l be v it a l in e v o lv in g h e a lth c a re p ro g ra m s a n d d e liv e ry system s. I t is essential to h a v e a q u a lifie d w o rk fo rc e to m e e t th e d e m a n d s o f these p ro g ra m s .

Conclusion

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C le a r ly , c o m p u te riz e d te c h n o lo g y w ill shape th e fu tu re o f h e a lth care. R e c o g n iz in g this fa ct, th e fo rm e r H e a lth y P eo ple 2 0 1 0 objectives (U .S . D e p a r t­ m e n t o f H e a lt h a n d H u m a n Services [ D H H S ] , 2 0 0 0 ) c a ll fo r in c re a s in g th e n u m b e r o f h o u s e h o ld s w it h access to th e In te r n e t. H e a lt h c o m m u n ic a tio n a n d h e a lth in fo r m a tio n te c h n o lo g y is n o te d as o b je ctiv es o f H e a lt h y P eo p le 2 0 2 0 w it h th e g o a l to im p ro v e h e a lth c a re q u a lity a n d s a fe ty (U .S . D H H S , 2 0 1 2 ) . M a n y h e a lth c a re o rg a n iz a tio n s a n d p u b lic service agencies use th e In te r n e t as th e m a in a v e n u e fo r in fo r m a t io n d e liv e ry . T h u s , h a v in g access to th e In te r n e t w ill be essential to a c q u irin g h e a lth in fo r m a tio n a n d services. C h an g es in d e liv e ry o f p a tie n t care are c o m m o n in c lin ic a l fa c ilitie s in m a n y areas o f th e c o u n try . N u rs e s a n d h e a lth c a re p ro v id e rs h a v e b e c o m e accus­ to m e d to c o m p u te riz e d o rd e r e n try fo r m e d ic a l d ire ctiv es a n d p o in t-o f-c a re te c h n o lo g y fo r p a tie n t c are , a u to m a te d m e d ic a tio n d isp en s in g , p h y s io lo g ic m o n ito r in g system s, a n d “ s m a rt” in fu s io n p u m p d e liv e ry system s (S a b a & M c C o r m ic k , 2 0 0 6 ) . A d v a n c e s in te c h n o lo g y m ig h t m a k e vaccines fo r can c er a n d m e d ic a tio n s to p re v e n t v a s c u la r disease a v a ila b le s o m e d a y . N e w o rg an s a n d b o d y p a rts th a t c o rre c t o r im p ro v e fu n c tio n m ig h t be c o m m o n ly accessible. I t is c o n c e iv ­ a b le th a t bloodless su rg e ry w ill be p e rfo r m e d a n d dru gs w it h o u t side effects w ill be d e v e lo p e d . C o m p u te r p ro g ra m s a n d c lin ic a l s im u la to rs w ill be used u n iv e rs a lly fo r p ra c tic e in h e a lth e d u c a tio n . R o b o tic s w ill p e rfo r m n u rs in g s u p p o rt services fo r p a tie n t care th ro u g h p ro v id in g m e d ic a ­ tio n a d m in is tra tio n a n d p h y s io lo g ic m o n ito rin g . W W W .) CRITICAL THINKING QUESTIONS* In fo r m a tic s te c h n o lo g ie s w ill h a v e roles in p ro te c tio n E xp lo re online sources and discuss: W h a t a n d response fo r b io te rro ris m a n d n a tio n a l s e c u rity . T h e se services utilizin g robotics are available in a c a p a b ilitie s w ill in c lu d e e m ergency response system s, h e a lth 1-hour radius from your home? W hich popu­ a le rt n e tw o rk s , a u to m a te d access to g o v e rn m e n ta l s u p p o rt lations can benefit fro m these services? H o w n e tw o r k s , a n d e n lis tm e n t o f w o r k f o r c e s o lu tio n s . I n f o r ­ m any persons by age groups potentially could m a tic s nurses w ill be c a lle d u p o n to e sta b lish , im p le m e n t, need these services in the next 10 years?V a n d e v a lu a te these in itia tiv e s . In th e fu tu re , w o r k m u s t be d o n e to re fin e a n d im p le ­ m e n t s ta n d a rd iz e d n u rs in g te rm in o lo g ie s (S N T s ) th a t b e tte r express n u rs in g c are. A s S N T s becom e u n iq u e to n u rs in g , som e benefits in clu d e b e tte r c o m m u ­ n ic a tio n , im p ro v e d p a tie n t c are, a n d u n ifo rm style fo r n u rs in g d a ta c o lle c tio n to a id in e v a lu a tio n o f n u rs in g c are o u tco m e s (T h e d e & S c h w ira n , 2 0 1 1 ) .

C o nclu sio n N u r s in g in fo r m a tic s p ro v id e s th e s o lu tio n to m a n y o f th e c h a lle n g e s th a t h e a lth c a re is fa c in g — fr o m e a s in g th e s tra in o f th e n u r s in g s h o rta g e to im p ro v in g p a tie n t safe ty . “ B e tw e e n th e h e a lth care w e h a v e a n d th e c are w e c o u ld h a v e lies n o t ju s t a g a p , b u t a c h a s m ” w a s re p o rte d in th e I O M (2 0 0 1 )

la n d m a r k re p o rt. N u rs e s m u s t e m b ra c e te c h n o lo g y a n d in te g ra te it in to th e ir n u rs in g p ra c tic e . T e c h n o lo g y w ill n o t go a w a y . I t w ill c o n tin u e to tra n s fo rm h e a lth c a re d e liv e ry system s. Because o f te c h n o lo g y , in d iv id u a ls a n d g ro u p s c o m m u n ic a te in n e w w a y s , th e m e th o d s w it h w h ic h w e te a c h a n d le a rn h a v e c h a n g e d , a n d th e w a y h e a lth care is d e liv e re d a n d a c q u ire d has ch an g ed . N u rs in g m u s t c o n tin u e to ta k e a le a d e rs h ip ro le in th e in c o rp o ra tio n o f te c h n o lo g y in h e a lth c a re . N u rs in g in fo rm a tic s w ill p ro v id e th e to o ls a n d skills to assist h e a lth care to m o v e a h e a d in th e e v e rc h a n g in g w o r ld . T h e b a c c a la u re a te -p re p a re d n u rse s h o u ld c o n tin u e to s trive to e x p lo re a n d p ra c tic e th e co n stru c ts o f N I c o m p e te n c ie s to im p ro v e p o p u la tio n h e a lth o u tco m e s a n d h e a lth c a re q u a lity .

Classroom A ctivity 1 E

x p lo r e k e y w o rd s a n u rs e w o u ld use to lo c a te m o re in f o r m a t io n a b o u t aspects o f a h e a lth issue to p ic o r a p o p u la tio n

o f in te re s t o f y o u r c h o ice . R e p o r t w h a t single o r c o m b in a tio n o f k e y w o rd s y ie ld e d th e best results fo r y o u r to p ic o r p o p u la tio n .

Classroom A ctivity 2

E

x p lo r e p o s s ib le W e b s o u rces to lo c a te s u p p o rt g ro u p s a v a ila b le fo r in d iv id u a ls n e e d in g services in y o u r a re a , c o u n ty o r

Classroom A ctivity 3

L

o c a te t w o c o n s u m e r-fo c u s e d lis ts e rv s th a t y o u c an suggest as resources fo r th e h e a lth c a re c onsu m er.

p a ris h re g io n , a n d s tate. E E ?

References

Classroom A ctivity 4

O

n th e In te r n e t lo c a te a s u p p o rt g ro u p fo r a specific n e ed th a t is a v a ila b le fo r in d iv id u a ls in y o u r a rea o r state.

Classroom A ctivity 5 ie w th e N C S B N Social M e d ia G u id elin es v id e o th a t is a v a ila b le a t w w w .n c s b n . o r g /2 9 3 0 .h t m

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Thede, L. Q. (2003). Informatics and nursing: Opportunities and challenges (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Thede, L.Q., & Sewell, J. P. (2010). Informatics and nursing competencies and applications. Philadelphia, PA: Wolters Kluwer Lippincott Williams & Wilkins. Thompson, B. W. (2005). HIPAA guideline for using PDAs. Nursing, 99(35), 24. U.S. Department of Health and Human Services. (2000, November). Healthy People 2010, With understanding and improving health and objectives for improving health (2nd ed., 2 vols.). Washington, DC: U.S. Government Printing Office. U.S. Department of Health and Human Services. (2012). Healthy People 2020. Retrieved from http://healthypeople.gov/2020/topicsobjectives2020/overview. aspx?topicid=18 White House Archives. (2004). Fact sheet: Transforming health care for all Americans. Retrieved from http://georgewbush-whitehouse.archives.gov/news/ releases/2004/05/20040527-2.html Young, K. M. (2000). Informatics for healthcare professionals. Philadelphia, PA: F. A. Davis. Zykowski, M. E. (2003). Nursing informatics: The key to unlocking contemporary nursing practice. AACN Clinical Issues, 14(3), 271-281.

Future Directions in Professional Nursing Practice Katherine Elizabeth Nugent

v_________________________ T h e h a rd e s t th in g is n o t to get p e o p le to accep t n e w ideas; it is to get th e m to fo rg e t o ld ones. — J o h n M a y n a r d K eyes A discussion o f fu tu re d ire ctio n s in n u rs in g p ra c tic e m u s t be c o n sid e re d w ith in th e c o n te x t o f th e im m e n s e changes th a t h a ve o c c u rre d in h e a lth c are . I n th e p a s t d e c a d e , h e a lth c are has e x p e rie n c e d d ra m a tic chang es in te c h n o lo g y , re im b u rs e m e n t o f services, in c re a s e d a g in g p o p u la tio n n e e d in g c h ro n ic ill­ ness m a n a g e m e n t, in crea se d d e m a n d fo r access to c are a n d in c re a s e d c o n ­ s u m e r aw areness d e m a n d in g h ig h -q u a lity , c o s t-e ffe c tiv e c are . T h e se changes, a lth o u g h p ro v id in g th e U .S . h e a lth c a re system w it h th e o p p o r tu n ity to tra n s ­ fo r m its e lf a n d d e liv e ry o f c are , a re p la c in g a tre m e n d o u s s tra in o n th e tr a d i­ tio n a l h ie ra rc h ic a l, o rg a n iz a tio n a l stru c tu res o f h e a lth c a re agencies th a t are s tru g g lin g to a d a p t to th e n e w business m o d e l in h e a lth c a re . S uccessfully tra n s itio n in g w ill re q u ire th e tr a n s fo r m a tio n o f o rg a n iz a tio n a l system s a n d e n titie s p ro v id in g h e a lth care a n d e s p e cia lly th e p ro fe s s io n o f n u rs in g , w h ic h has th e la rg e s t n u m b e r o f h e a lth c a re p ro v id e rs . P e te r D r u c k e r s ta te d th a t th e best w a y to p re d ic t th e fu tu re is to c rea te it. Since th e p u b lic a tio n o f th e firs t e d itio n o f th is b o o k , several im p o r ta n t tren d s h a ve e m e rg e d th a t a ffe c t th e fu tu re d ire c tio n s o f h e a lth care a n d p ro fe s s io n a l

Key Terms and Concepts » Nursing shortage » Nursing faculty shortage » Cultural competence » Clinical nurse leader (CNL) » Doctor of Nursing Practice (DNP) » Gap between educa­ tion and practice

Learning Objectives A f t e r c o m p le tin g th is c h a p te r, th e s tu d e n t should be a b le to : 1. Id e n tify p re s e n t tre n d s a s s o c ia te d w ith th e profession of nursing th a t a ffe c t th e tra n s itio n of professional nursing p ra c tic e fo r th e fu tu re . 2 . A rtic u la te th e vision fo r th e fu tu re of nursing practice.

3 . R e fle c t on th e a p p ro p ria te respo nse of nursing le a d e rs h ip c o n c e rn in g iss u e s a ffe c tin g th e fu tu re o f nursing p ra c tic e .

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n u rs in g p ra c tic e . S e v e ra l o rg a n iz a tio n s such as th e In s titu te o f M e d ic in e , R o b e r t W o o d J o h n s o n F o u n d a tio n , a n d th e T r i C o u n c il fo r N u rs in g (w h ic h in c lu d e s th e A m e r ic a n A s s o c ia tio n o f C o lle g e s o f N u r s in g , th e A m e ric a n N u rs e s A s s o c ia tio n , th e A m e ric a n O r g a n iz a tio n o f N u rs e E x e c u tiv e s ), a n d th e N a t io n a l L e a g u e fo r N u rs in g h a v e p ro m o te d ch an g e in n u rs in g th ro u g h p u b lic a tio n s a n d p o s itio n s tatem e n ts re fle c tin g issues a ssociated w it h n u rs ­ in g p ra c tic e , e d u c a tio n , a n d re se arch . T h e A g e n c y fo r H e a lth c a re R es ea rch a n d Q u a lit y ( A H R Q ) , w h ic h has a m is s io n to im p ro v e th e q u a lity , s afe ty , e ffic ie n c y , a n d effectiveness o f h e a lth care fo r a ll A m e ric a n s , has p o s itio n e d q u a lity h e a lth c are as a p r io r ity . In 2 0 0 8 , th e R o b e r t W o o d J o h n s o n F o u n d a tio n (R W J F ) a n d th e In s ti­ tu te o f M e d ic in e ( I O M ) fo rm e d a p a rtn e rs h ip to assess a n d re s p o n d to th e n e ed e d tr a n s fo r m a tio n in h e a lth c are . T h e p re m is e o f th e ir p a rtn e rs h ip w a s th a t tr a n s fo r m a tio n in h e a lth c a re c o u ld n o t o c c u r w it h o u t th e le a d e rs h ip a n d tr a n s fo r m a tio n o f th e n u rs in g p ro fe s s io n . T h e re fo re , th e y c o n d u c te d a 2 -y e a r s tu d y o n tr a n s fo r m a tio n n e e d e d in th e n u rs in g p ro fe s s io n to re a liz e th e v is io n o f a n e w h e a lth c a re system th a t p ro v id e d access to q u a lity , e ffic ie n t p a tie n t c are . T h e p ro d u c t o f th is s tu d y w a s th e p u b lic a tio n o f T h e F u t u r e o f N u r s in g : L e a d i n g C h a n g e , A d v a n c in g H e a lth ( I O M , 2 0 1 1 ) , w h ic h c o n ta in s k e y re c o m m e n d a tio n s discussed la te r in th is c h a p te r. In 2 0 1 0 , C ongress passed a n d P re s id e n t O b a m a signed in to la w c o m p re ­ h en sive h e a lth c a re le g is la tio n . T h e P a tie n t P ro te c tio n a n d A ffo r d a b le C a re A c t (P u b lic L a w 1 1 1 -1 4 8 ) a n d th e H e a lt h C a re a n d E d u c a tio n A ffo r d a b ility R e c o n c ilia tio n A c t (P u b lic L a w 1 1 1 - 1 5 2 ) p ro p o s e th e b ro a d e s t changes to th e h e a lth c a re system since th e c o n c e p tio n o f th e M e d ic a r e a n d M e d ic a id p ro g ra m s . I t is im p o r ta n t to n o te th a t in th e m id s t o f these s ig n ific a n t changes, th e p ro fe s s io n o f n u rs in g is fa c in g som e d a u n tin g challeng es th a t w ill a ffe c t its resp o n se to tr a n s fo r m a tio n , such as a n u rs in g s h o rta g e , w o rk p la c e issues, th e e d u c a tio n -p ra c tic e g a p , u n c le a r p ra c tic e ro le s , a n d changes in p o p u la ­ tio n d e m o g ra p h ic s . A lth o u g h it is tru e th a t each o f these issues is n o t a n e w c h a lle n g e to n u rs in g p ra c tic e , it is c ritic a l to n o w a c k n o w le d g e th e c o lle c tiv e im p a c t o f a ll o f these to g e th e r in th e c o n te m p la tio n o f fu tu re d ire c tio n s in p ro fe s s io n a l n u rs in g p ra c tic e . In h e re n t in these challeng es is th e a c k n o w le d g m e n t o f th e c h a o tic , c o m ­ p le x c o n te x t o f h e a lth c a re systems a n d th e e m e rg in g use o f c o m p le x ity science in th e business, o rg a n iz a tio n , a n d m a n a g e m e n t o f h e a lth c are . T h e c o n v e r­ gence o f chaos a n d c o m p le x ity signals a tr a n s itio n b e tw e e n th e p a st, p re se n t, a n d th e fu tu re . T h is p h e n o m e n o n is tru e o f h e a lth c a re in s titu tio n s , e d u c a tio n a l in s titu tio n s , a n d th e p ra c tic e o f n u rs in g . E v id e n c e , as re fle c te d in q u a lity o u t­ com es, exists d a ily , s ig n a lin g th a t th e h e a lth c a re system a n d th e p ra c tic e o f n u rs in g are s tra in in g to a d a p t to th e forces o f chang e (H a r r is , 2 0 1 2 ) . I t is c r iti­ c al fo r n u rs in g to a n a ly z e e x is tin g evid en ce a n d c o n tro l n u rs in g ’s tra n s itio n fo r fu tu re success.

Nurse Shortage

N u r s in g is r ic h in h is to ry , r e s ilie n t in its jo u r n e y to d e v e lo p as a p ro fe s s io n a n d a d is c ip lin e , a n d a d a p tiv e in its p ra c tic e to m e e t th e h e a lth c a re needs o f th e p a tie n t. T h r o u g h o u t th e h is to ry o f n u rs in g , th e re a re id e n tifia b le p e rio d s o f tim e in w h ic h th e p ra c tic e a n d e d u c a tio n o f nurses re s p o n d e d to th e e v o lv in g chang es in h e a lth c are an d in s o cie ty. T o d a y , n u rs in g is a g a in a t th e crossroads o f a m a jo r tra n s itio n in its e d u c a tio n a n d p ra c tic e . A n a w a re ­ ness o f th e m e rg in g o f these issues creates u rg e n c y w h e n c o n te m p la tin g th e ro le , p ra c tic e , a n d e d u c a tio n o f nurses. T h is c h a p te r explores th e p h e n o m e n o n o f th e n u rs in g shortage, w o rk fo rc e issues a n d changes in p o p u la tio n d e m o g ra p h ic s , cost a n d access to c are , th e e d u c a tio n -p ra c tic e g a p , a n d th e ir c u m u la tiv e effe ct o n th e p ra c tic e o f n u rs in g an d fu tu re d ire c tio n s .

N u rs e S h o rta g e T h e s h o rta g e o f nurses is n o t a n e w issue; th e p re d ic te d s h o rta g e has been p r o m in e n t in th e m e d ia fo r m o s t o f n u r s in g ’ s h is to ry a n d m o re re c e n tly in th e p a s t s e v e ra l y e a rs . D a t a fr o m th e H e a lt h R e s o u rc e s a n d S ervices A d m in is tr a tio n , B u re a u o f H e a lt h P ro fessio n s, N a t io n a l C e n te r fo r H e a lt h W o r k f o r c e A n a ly s is ( “ th e c e n te r” ) e s ta b lis h th a t th e m o s t re c e n t n u rsin g s h o rta g e b e g an in th e y e a r 2 0 0 0 w h e n th e re w a s an e s tim a te d s u p p ly o f 1 .8 9 m illio n nurses a n d a p ro je c te d d e m a n d o f 2 m illio n , o r 6 % m o re th a n w h a t e xisted . T h e cen ter fu rth e r p ro je c te d th e a n tic ip a te d d e m a n d fo r nurses sh o u ld c o n tin u e to exceed th e s u p p ly u n til 2 0 1 0 w h e n th e shortage w o u ld re ac h 1 2 % . “ A t th a t p o in t d e m a n d w ill b e g in to exceed s u p p ly a t an a c c e le ra te d ra te a n d b y 2 0 1 5 th e s h o rta g e , a r e la tiv e ly m o d e s t 6 % in th e y e a r 2 0 0 0 , w i l l h a v e a lm o s t q u a d ru p le d to 2 0 % . I f n o t addressed, a n d i f c u rre n t tren d s c o n tin u e , th e s h o rta g e is p ro je c te d to g r o w to 2 9 % b y 2 0 2 0 ” (H e a lth R esources an d Services A d m in is tr a tio n [H R S A ] , 2 0 0 2 ) . M o r e re c e n tly , th e U .S . B u re a u o f L a b o r S tatistics e s tim a te d th a t m o re th a n 1 m illio n n e w a n d re p la c e m e n t nurses w o u ld be n eed ed b y 2 0 1 6 (D o h m & S h n ip e r, 2 0 0 7 ) . B u e rh a u s , A u e rb a c k , a n d S ta ig er (2 0 0 9 ) p ro je c t sh o rta g e o f nurses in th e U n ite d States c o u ld be as h ig h as 5 0 0 ,0 0 0 in 2 0 2 5 . T h e s e p ro je c tio n s a re based o n th e fo llo w in g tren d s : increase in p o p u la tio n , a la rg e r p r o p o r tio n o f e ld e rly perso ns, increases in te c h n o lo g y , a n d advances in m e d i­ c al science (H R S A , 2 0 0 2 ) . O th e r issues a ffe c tin g th e p ro je c te d s u p p ly o f nurses in c lu d e d e c lin e s in th e n u m b e r o f n u rs in g s c h o o l g ra d u a te s , a g in g o f th e R N w o rk fo rc e , declines in re la tiv e e a rn in g , a n d e m ergence o f a lte rn a tiv e jo b o p p o rtu n itie s , especially fo r w o m e n , w h o are th e p ro m in e n t gender in n u rsin g . H is to r y d o c u m e n ts a c yc lic p a tte rn o f n u rs in g s h ortages, m a k in g it d iff i­ c u lt to c o m p re h e n d th e seriousness o f th is sh o rtag e, especially v ie w e d th ro u g h

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th e lens o f h is to ry , th e c u rre n t e c o n o m ic s lo w d o w n , th e d ecreased vacancies in h e a lth c a re agencies, e s p e cia lly h o s p ita ls , a n d th e u n c e rta in ty o f th e conse­ quences o f h e a lth c a re re fo r m g iv e n th e A ffo r d a b le C a re A c t ( 2 0 1 0 ). In 2 0 0 9 , schools o f n u rs in g b e g an d o c u m e n tin g th a t s ig n ific a n t n u m b e rs — 5 4 ,0 0 0 — o f q u a lifie d n u rs in g sch o o l a p p lic a n ts w e re d e n ie d a d m is s io n to n u rs in g schools (A m e ric a n A s s o c ia tio n o f C olleges o f N u rs in g [ A A C N ] , 2 0 1 0 ) . In recent years, e m p lo ye rs in v a rio u s p a rts o f th e U n ite d States h a ve re p o rte d a decrease in the d e m a n d fo r R N s , a n d n u rs in g students re p o rt th a t it is m o re c h a lle n g in g a fte r g ra d u a tio n to fin d e m p lo y m e n t, w h e n s o m etim es it takes 6 m o n th s to a y e a r. T h e se fin d in g s le d m a n y p e o p le to q u e s tio n w h e th e r th e n u rs in g sh o rta g e s till exists. E x p e rts c la im th a t th e recession m ig h t h a v e g iv e n som e h o s p ita ls a te m p o ra ry re p rie v e fr o m c h ro n ic shortages, b u t it is n ’t c u rin g th e lo n g e r-te rm p ro b le m a n d m ig h t be m a k in g it w o rs e (R o b e rt W o o d J o h n s o n F o u n d a tio n [R W J F ], 2 0 0 9 ) . T h e T r i-C o u n c il fo r N u rs in g (2 0 1 0 ) released a jo in t s tatem e n t c a u tio n in g s ta k e h o ld e rs a b o u t d e c la rin g a n end to th e n u rs in g s h o rta g e . T h e s ta te m e n t says, “ T h e d o w n tu r n in th e e c o n o m y has le d to a n easing o f th e s h o rta g e in m a n y p a rts o f th e c o u n try , a re c e n t d e v e lo p m e n t m o s t analysts b e lie ve to be te m p o r a r y .” T h e c o u n c il raises serious co n ce rn s a b o u t s lo w ­ in g th e p ro d u c tio n o f R N s g iv e n th e p ro je c te d d e m a n d fo r n u rs in g services, p a rtic u la r ly as th e c o u n try considers h e a lth c a re r e fo r m . I t fu rth e r states th a t d im in is h in g th e p ip e lin e o f fu tu re nurses can p u t th e h e a lth o f m a n y A m e ric a n s a t ris k , p a rtic u la rly th ose fr o m r u r a l a n d u n d e rs erv e d c o m m u n itie s , a n d leave o u r h e a lth c a re d e liv e ry system u n p re p a re d to m e e t th e d e m a n d fo r essential n u rs in g services. W h e r e d o w e s tan d to d a y ? A r e p o rt fr o m th e B u re a u o f L a b o r S tatistics o n e m p lo y m e n t p ro je c tio n s id e n tifie s re g istere d n u rs in g w o rk fo rc e as th e to p o c c u p a tio n in te rm s o f jo b g ro w th th ro u g h 2 0 2 0 (B u re a u o f L a b o r S tatistics, 2 0 1 2 ) . T h e n u m b e r o f e m p lo y e d nurses is e xp e cted to g ro w fr o m 2 .7 4 m illio n in 2 0 1 0 to 3 .4 5 m illio n in 2 0 2 0 a n d a n eed fo r 4 9 5 ,5 0 0 re p la c e m e n ts in th e n u rs in g w o rk fo rc e is p ro je c te d fo r 2 0 2 0 . D a t a c o lle c te d in th e 2 0 0 8 N a t io n a l S a m p le S u rv ey o f R e g is te re d N u rs e s ( H R S A , 2 0 1 0 ) d o c u m e n t th a t th e a ve rag e age o f th e R N p o p u la tio n is 4 6 .8 y ea rs. I t is s ig n ific a n t to n o te th a t th e a ve rag e age o f th e R N p o p u la tio n d id n o t increase fr o m th e 2 0 0 4 su rve y. T h e p la te a u in th e a v e ra g e age reflects an increase in e m p lo y e d R N s y o u n g e r th a n 3 0 years o f age. B e tw e e n 1 9 8 8 a n d 2 0 0 4 , th e p e rc e n ta g e o f e m p lo y e d nurses y o u n g e r th a n 3 0 years fe ll fr o m 1 8 .3 % to 9 .1 % . T h e tre n d o f in c re a s in g e n ro llm e n ts in schools o f n u rs in g , e sp e cia lly b a c c a la u re a te p ro g ra m s , is c re d ite d fo r th e in crea se d e m p lo y m e n t o f y o u n g e r nurses (H R s A, 2 0 1 0 ) . A re c e n t r e p o r t fr o m th e A m e r ic a n A s s o c ia tio n o f C o lle g e s o f N u r s ­ in g show s th e e n ro llm e n t o f g e n eric b a c c a la u re a te students d o c u m e n te d an in c re a s e o f 5 .1 % in 2 0 1 1 - 2 0 1 2 a n d b y 1 7 % in th e p a s t 5 y ea rs ( A A C N , 2 0 1 2 b ) . Y e t , th e fo llo w in g s ta te m e n t is in c lu d e d w it h th e d o c u m e n ta tio n o f in c re a s e d e n ro llm e n t: “ A lth o u g h th e d ra m a tic rise in e n ro llm e n ts a n d th e

Nursing Practice and Workplace Environment

in crea se in g ra d u a tio n s o v e r th e p a st fiv e years are e n c o u ra g in g , m a n y m o re b a c c a la u re a te -p re p a re d nurses w ill be n e ed e d to m e e t th e h e a lth care needs o f th e p o p u la tio n ” ( A A C N , 2 0 1 2 b , p . 3 ). A n a tio n a l n u rse s h o rta g e s till exists. A lth o u g h n u rs in g s ch o o l e n r o ll­ m en ts a n d g ra d u a tio n s a re in c re a s in g a n d th e statistics o n y o u n g e r nurses in th e w o rk fo rc e a re e n c o u ra g in g , th e fo llo w in g fa c to rs m u s t be c o n sid e re d in a d d re ss in g th e fu tu re o f p ro fe s s io n a l n u rs in g p ra c tic e : B a c c a la u re a te a n d g ra d u a te p ro g ra m s in n u rs in g re p o rt th a t 7 5 ,5 8 7 q u a lifie d a p p lic an ts w e re n o t a d m itte d in to n u rs in g p ro g ra m s because o f la c k o f c lin ic a l space a n d fa c u lty s h o rta g e ; th e re is a p re d ic tio n th a t m o re th a n 3 2 m illio n A m e ric a n s w ill soon g a in access to h e a lth c a re services; th e a g in g p o p u la tio n is in crea sin g a n d needs m a n a g e m e n t o f th e ir c h ro n ic illnesses, a n d in s u ffic ie n t n u rse s ta ffin g results in h ig h n u rse tu rn o v e r ( A A C N , 2 0 1 2 b ) .

N u rs e F a c u lty S h o rta g e In p re v io u s cycles o f n u rs in g s h o rta g e , th e p r im a r y s o lu tio n w a s to increase th e e n ro llm e n t in n u rs in g p ro g ra m s . H o w e v e r , a m p le evid en ce s u p p o rts th e c o n c lu s io n th a t a n a tio n a l n u rsin g fa c u lty s h o rta g e also exists. In a su rvey c o n d u c te d b y th e A A C N in June 2 0 0 8 , a to ta l o f 1 ,0 8 8 fa c u lty vacancies w e re id e n tifie d a t 6 0 3 n u rs in g schools across th e n a tio n . In th e 2 0 1 1 - 2 0 1 2 survey, A A C N re p o rte d th a t th e p ro fe s s o ria te c o n tin u e s to age. T h e m e a n age o f d o c to ra l fa c u lty h o ld in g th e r a n k o f p ro fe s s o r is 6 1 years a n d th e m e a n age o f fa c u lty h o ld in g th e r a n k o f associate p ro fe s s o r is 5 7 .5 years. T h e n a tio n a l fa c u lty vacan cy ra te is re p o rte d a t 7 .7 % (6 0 3 vacancies). N in e ty -o n e p e rce n t o f th e re p o rte d vacancies in v o lv e d o c to ra l-p re p a re d fa c u lty . T h is shortage is lim ­ itin g s tu d e n t c a p a c ity in n u rs in g p ro g ra m s across th e n a tio n ( A A C N , 2 0 1 2 a ). T h e n u m b e r o f nurses e m p lo y e d in n u rs in g e d u c a tio n has c h a n g e d little since 1 9 8 0 , w it h 3 1 ,0 6 5 nurses w o r k in g as fa c u lty . W h e n th e n u m b e r o f nurse e d u c a to rs is c o m p a re d to th e increase in n u m b e r o f R N s , th e re s u lt is a c tu a lly a d e clin e ( 2 . 4 % ) in th e p e rce n tag e o f nurses w o r k in g in e d u c a tio n (H R S A , 2 0 1 0 ) . T h e statistics a ssociated w it h n u rs in g fa c u lty a re c o n c e rn in g , e sp ecially in c o n s id e ra tio n o f th e n u rs in g s h o rta g e a n d h e a lth c a re p ro je c tio n s o f n u rse d e m a n d in th e fu tu re .

N u rs in g P ra c tic e and W o rk p la c e E n v iro n m e n t G iv e n th e a n tic ip a t e d n u r s in g s h o rta g e a n d th e in c r e a s e d d e m a n d fo r nurses in th e tr a n s fo r m e d h e a lth c a re s y s te m , i t is im p o r t a n t to a d d re ss th e issues a s s o c ia te d w it h th e p ra c tic e o f n u rs in g a n d th e e n v ir o n m e n t w h e re

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n urses w o r k . I t is u n d e rs ta n d a b le h o w th e s h o rta g e o f n u rse s a ffe c ts th e p r a c tic in g n u rs e , e s p e c ia lly in s ta ff a n d p a tie n t ra tio s a n d w o r k lo a d a n d th e r e s u lt in g in flu e n c e s o n n u rs e t u r n o v e r r a te . H o w e v e r , o t h e r issues a s s o c ia te d w i t h th e n u rs e p r a c tic e s e ttin g r e s u lt in p r o b le m a t ic q u a lit y o u tc o m e s , such as n u rs e jo b d is s a tis fa c tio n , u n s a fe p a tie n t c a re , u n h e a lth y w o r k p la c e e n v ir o n m e n t, a n d u n c le a r ro le e x p e c ta tio n s . I t is e v id e n t th a t h e a lth care a n d h e a lth c a re d e liv e ry h a v e c h a n g e d s ig n ifi­ c a n tly in th e p a st tw o decades. M o s t o f these changes h a v e been associated w it h response to th e in c re a s in g cost o f c are , th e decreasin g cost o f re im b u rs e ­ m e n t to h e a lth c a re p ro v id e rs , in c re a s e d use o f te c h n o lo g y in p ra c tic e , a n d th e k n o w le d g e e x p lo s io n c o n c e rn in g disease m a n a g e m e n t. A fu ll discussion o f each o f th ese issues is b e y o n d th e scope o f th is c h a p te r . H o w e v e r , i t is im p o r ta n t to n o te th a t m o s t o f th e changes re s u lt fr o m a focus o n re d u c in g th e c o st o f h e a lth c a re . C o s t c o n ta in m e n t s tra te g ies a im to d e te rm in e th e s ettin g o f th e d e liv e ry o f c are , th e le n g th o f stay in th e h o s p ita l, th e cost r e im ­ b u rse d to p ro v id e rs o f c are , a n d th e d e s ig n a tio n o f th e a p p ro p r ia te p ro v id e r o f c are . T o d a te , it is fa ir to say th a t th e changes in h e a lth care h a v e re s u lte d in chaos a n d c o m p le x ity fo r b o th th e p ro v id e r a n d th e re c ip ie n t o f c are . E v i­ dence in d ic a te s th a t th is chaos a n d c o m p le x ity has c re a te d an e n v iro n m e n t th a t decreases access to c are , q u a lity o f c a re , a n d p a tie n t safe ty (A d a m s & C o rrig a n , 2 0 0 3 ; H a llin & D a n ie ls o n , 2 0 0 7 ; I O M , 2 0 0 0 , 2 0 0 4 ) a n d nurse jo b s a tis fa c tio n ( H R S A , 2 0 1 0 ) . H o s p ita ls re m a in th e m o s t c o m m o n e m p lo y m e n t settin g fo r R N s in th e U n ite d States, w it h 6 2 .2 % o f e m p lo y e d R N s re p o rtin g h o s p ita ls as th e ir p r i­ m a r y p lac e o f e m p lo y m e n t ( H R S A , 2 0 1 0 ) . C o n tr a r y to e a rlie r p re d ic tio n s , th e p e rc e n ta g e o f nurses w o r k in g in h o s p ita ls in crea se d fr o m 2 0 0 4 to 2 0 0 8 (H R S A , 2 0 1 0 ) . H o w e v e r , also n o te th a t th e p e rc e n ta g e o f nurses w o r k in g in h o m e h e a lth services has also in crea se d . D a t a fr o m th e n a tio n a l su rve y o f re g is te re d nurses re fle c t th a t th e p e rc e n ta g e o f nurses w o r k in g in h o s p ita ls decreases w it h age o f n u rse . O n ly 5 0 % o f R N s age 5 5 years a n d o ld e r w o r k in h o s p ita l settings. M o s t h o s p ita ls a re s till m a in ta in a h ie ra rc h ic a l o rg a n iz a tio n a l s tru c tu re , re s u ltin g in n u rs in g w o r k e n v iro n m e n ts b e in g c o n tro lle d b y s o m eo n e o th e r th a n th e nurses w h o w o r k in it. T h is p h e n o m e n o n creates system atic obstacles th a t p re v e n t o p tim a l p e rfo r m a n c e in n u rs in g p ra c tic e . D a t a fr o m surveys id e n tify th e s ys te m a tic b a rrie rs as ro u tin e a n d p re v a le n t (U lric h , B u e rh a u s , D o n e la n , N o r m a n , & D it tu s , 2 0 0 5 ) . E x a m p le s in c lu d e s e a rc h in g fo r s u p ­ p lie s , w a itin g o n m e d ic a l e q u ip m e n t to be d e liv e re d , de la y s in s c h e d u lin g tests a n d re c e iv in g results, delays associated w it h m e d ic a tio n a d m in is tra tio n , la c k o f s ta ff s u p p o rt, re c e iv in g o rd e rs , a n d tim e ly c o m m u n ic a tio n w it h o th e r h e a lth c a re p ro v id e rs (G urses & C a ra y o n , 2 0 0 7 ; L in & L ia n g , 2 0 0 7 ; S to rfje ll, O m n ik e , & O h ls o n , 2 0 0 8 ; Z u z e lo , G e ttis , H a n s e ll, & T h o m a s , 2 0 0 8 ) . N u rs e s in h o s p ita ls p ro v id e c are fo r p a tie n ts w h o are s ic ke r, o ld e r, a n d h ave m o re c o m p le x ph ysical, psychosocial, a n d e co n o m ic needs (B ro w n , 2 0 0 4 ;

C la r k , 2 0 0 4 ) . T h e c o m b in a tio n o f o ld e r p a tie n ts w it h h ig h e r a c u ity , s o p h is ­ tic a te d te c h n o lo g y , a n d s h o rte r h o s p ita l stays creates a c h a o tic e n v iro n m e n t a n d d e m an d s th a t nurses assum e g re a te r re s p o n s ib ility (G ra n d o , 2 0 0 6 ) . T h is c h ao s increa se s n o t o n ly th e ris k o f e rro rs in p a tie n t c a re b u t th e ris k o f h e a lth co n cern s fo r th e n u rse , such as th e th re a t o f in fe c tio n , n e ed le sticks, e v e r-in c re a s in g s e n s itiv ity to la te x , b a c k in ju rie s , a n d s tre s s -re la te d h e a lth p ro b le m s . I n a d d itio n to these h e a lth risks, nurses are susceptible to w o rk p la c e v io le n c e (e .g ., p h y s ic a l v io le n c e , h o r iz o n ta l v io le n c e ) a n d s ex u al h a ra s s m e n t (L o n g o & S h e rm a n , 2 0 0 6 ; R a y & R e a m , 2 0 0 7 ; S m ith -P ittm a n & M c K o y , 1 9 9 9 ; V a le n te & B u llo u g h , 2 0 0 4 ) . T h e issues a s s o c ia te d w it h th e h o s p ita l w o r k e n v ir o n m e n t h a v e b e en s h o w n to d o m in a te p ro b le m s a n d o u tco m e s associated w it h n u rs in g p ra c tic e . Because o f th is e n v iro n m e n t, th e p ro fe s s io n o f n u rs in g has been c h a lle n g e d to e v a lu a te its p ra c tic e a n d o u tc o m e s . In fa c t, a m a jo r ity o f nurses c o m p le tin g surveys s tated th a t th e y p e rce ive d th a t th e unsafe w o r k in g e n v iro n m e n t in te r ­ fe re d w it h th e ir a b ility to p ro v id e q u a lity p a tie n t care (H o u le , 2 0 0 1 ; P e llic o , D ju k ic , K o v n e r , & B re w e r , 2 0 0 9 ) . S ta ff nurses s tro n g ly d e sire a p ra c tic e settin g in w h ic h th e y feel th a t th e y h a v e th e a b ility to p ro v id e q u a lity p a tie n t care (S c h m a le n b e rg & K ra m e r, 2 0 0 8 ) a n d a w o r k e n v iro n m e n t th a t fa cilita te s c lin ic a l d e cis io n m a k in g . C o n fo u n d in g th e chaos o f th e w o rk p la c e e n v iro n m e n t is th e s h o rta g e o f q u a lifie d n o n n u rs e h e a lth c a re w o rk e rs , th e s u p e rv is io n o f u n lice n s ed p e rs o n ­ n e l, th e a p p r o p r ia te d e le g a tio n o f c a re , m a n d a to r y o v e rtim e , a n d s ta ffin g ra tio s . T h e d e b ate o v e r th e use o f u n lice n s ed p e rs o n n e l a n d th e use o f o th e r licensed p e rs o n n e l in p ro v id in g p a tie n t c are is w e ll d o c u m e n te d in th e lite r a ­ tu re ( A N A , 1 9 9 2 , 1 9 9 7 , 1 9 9 9 ; B a rte r & F u rm id g e , 1 9 9 4 ; M a n u e l & A ls te r, 1 9 9 4 ; Z im m e r m a n , 2 0 0 6 ) . R e s e a rc h studies in d ic a te th a t a decrease in R N s ta ff increases p a tie n t c are e rro rs , in fe c tio n ra te s, re a d m is s io n , a n d m o r b id ­ ity (A ik e n , C la rk e , S lo an e, S o c h a ls k i, & S ilb e r, 2 0 0 2 ; A ik e n , S m ith , & L a k e , 1 9 9 4 ; N e e d le m a n , B u e rh a u s , M a t t k e , S te w a rt, & Z e le v in s k y , 2 0 0 2 ; S o fer, 2 0 0 5 ; S ta n to n & R u th e r fo r d , 2 0 0 4 ) . G iv e n th a t rese arch in d ic a te s th a t a decrease in R N s ta ff o r use o f u n li­ c en s ed p e rs o n n e l a n d o th e r lic e n s e d p e rs o n n e l in flu e n c e p a tie n t q u a lit y o u tc o m e s , w h a t is a r a tio n a le fo r th is p ra c tic e ? O n e a n s w e r th a t is q u ic k ly p ro v id e d is th e in creased costs o f a h ig h e r R N - p a t ie n t ra tio . N u rs e s re p re se n t a b o u t 2 3 % o r m o re o f th e h o s p ita l w o r k fo r c e . T h e s a la ry o f a licensed R N is h ig h e r c o m p a re d to o th e r n o n p h y s ic ia n h e a lth c a re p ro v id e rs . T h u s , th e basic a s s u m p tio n is th a t to e m p lo y m o re u n lic e n s e d p e rs o n n e l o r o th e r licensed p e rs o n n e l ( L V N ) reduces th e cost o f care. T h is a s s u m p tio n is n o t n e c e s s a rily tr u e w h e n costs o th e r th a n s a la ry , such as costs o f h irin g , b e n efits, tr a in in g , s ta ff tu rn o v e r, a n d re s p o n s ib ilitie s th a t m u s t be assum ed b y a licensed care p ro v id e r, are c o n s id e re d . A ik e n et al. (2 0 0 2 ) fin d th a t nurses in h o s p ita ls w it h lo w n u r s e -p a tie n t ra tio s are m o re th a n tw ic e as lik e ly to exp e rien c e jo b -re la te d b u r n o u t a n d d iss a tisfac tio n w ith

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th e ir jobs w h e n c o m p a re d to nurses in h o s p ita ls w ith th e highest n u rs e -p a tie n t ra tio s . C o o p e r (2 0 0 4 ) a n d K a lis c h a n d K y u n g (2 0 1 1 ) n o te th a t lo w e r n u rs in g s ta ff ra tio s also in d ic a te h ig h e r costs in a p le th o ra o f areas th a t re fle c t th e a c tu a l re a lity o f n u rs in g p ra c tic e . M c C u e , M a r k , a n d H a rle s s (2 0 0 3 ) fin d th a t a 1 % increase in n o n n u rs e p e rs o n n e l increases th e o p e ra tin g costs b y 0 .1 8 % a n d d im in is h e s p ro fits b y 0 .0 2 1 % . A re these d a ta s ig n ific a n t in th e o v e ra ll b u d g e t, c o n s id e rin g th e ris in g costs o f h e a lth care? Z im m e r m a n (2 0 0 6 ) sug­ gests th a t th e c o n c e p t o f h e a lth c a re o rg a n iz a tio n s c o m p e tin g o n v a lu e , w h ic h in clu d es cost a n d q u a lity d im e n s io n s , has b e co m e a r e a lity . I n th e en d , th e q u e s tio n th a t m ig h t d riv e th e d e b ate c o n c e rn in g th e use o f n o n - R N p e rso n n el is w h a t th e s p en d in g p rio ritie s o f a h o s p ita l s h o u ld be (p . 3 2 5 ).

R e te n tio n T h e re is a c o n n e c tio n a m o n g nurse s a tis fa c tio n , w o r k e n v iro n m e n t, a n d nurse re te n tio n . T h e stro n g est p re d ic to r o f n u rse jo b d is s a tis fa c tio n a n d in te n t to lea ve a jo b is p e rs o n a l stress re la te d to th e p ra c tic e e n v iro n m e n t. T h e v a rio u s causes o f jo b stress in c lu d e p a tie n t a c u ity , w o r k schedules, p o o r p h y s ic ia n n u rse in te ra c tio n s , n e w te c h n o lo g y , s ta ff s hortages, u n p re d ic ta b le w o r k flo w o r w o r k lo a d , a n d th e p e rc e p tio n th a t th e care p ro v id e d is un safe (G ro ff-P a ris & T e rh a a r, 2 0 1 0 ) . Surveys o f p ra c tic in g nurses d o c u m e n t th a t jo b d issatisfac­ tio n , p a tie n t safe ty co n cern s, decreases in q u a lity c are , in a d e q u a te s ta ffin g , p a tie n t care d elays, a n d m a n d a te d o v e rtim e a re issues th a t n e g a tiv e ly a ffe c t n u rs in g p ra c tic e (A ik e n et a l., 2 0 0 2 ; A N A , 2 0 0 6 ; C o o p e r, 2 0 0 4 ; I O M , 1 9 9 6 ; P e llic o et a l., 2 0 0 9 ) . N u rs e s h a v e also re p o rte d th e ir c o n c e rn a b o u t th e ir o w n h e a lth a n d s a fe ty issues, w it h jo b stress th e m o s t fr e q u e n t h e a lth p ro b le m re p o rte d . O t h e r re p o rte d h e a lth p ro b le m s in c lu d e b a c k in ju rie s , H I V , a n d h e p a titis (H o u le , 2 0 0 1 ) . D e s p ite th e e ffo r t to address th e issues o f th e c h a o tic a n d p o te n tia lly h a rm fu l w o r k e n v iro n m e n t, strategies to address these issues h a ve fa lle n s h o rt o f th e ta rg e t, a n d th e d is s a tis fa c tio n o f h o s p ita l nurses persists. In n a tio n a l studies, 4 1 % o f nurses c u rre n tly w o r k in g re p o rt b e in g dissatisfied w it h th e ir jobs; 4 3 % score h ig h in a ra n g e o f b u r n o u t m easures; a n d 2 2 % a re p la n n in g to le a v e th e ir jo b s in th e n e x t y e a r. O f th e la tte r g ro u p , 3 3 % a re y o u n g e r th a n age 3 0 years (B e e c ro ft, D o r e y , & W e n t in , 2 0 0 8 ; T h e J o in t C o m m is s io n , 2 0 0 2 ; L a s c h in g e r, F in e g a n , & W e lk , 2 0 0 9 ) . T h e se fa c to rs h e lp to fu e l th e s h o rta g e o f nurses. I n 2 0 0 8 , 2 9 . 3 % o f R N s r e p o r te d t h a t th e y w e re e x tr e m e ly s a tis fie d w it h th e ir p rin c ip a l n u rs in g p o s itio n s , 5 0 .5 % w e re m o d e ra te ly satisfied , a n d 1 1 .1 % w e re dissatisfied (H R S A , 2 0 1 0 ) . N u rs e s w o r k in g in a c a d e m ic e d u c a ­ tio n , a m b u la to r y c a re , a n d h o m e h e a lth settings re p o rte d th e h ig h e s t ra te o f jo b s a tis fa c tio n ( 8 6 . 6 % , 8 5 . 5 % , a n d 8 2 . 8 % , re s p e c tiv e ly ). A lm o s t 1 2 %

Workplace Environment

o f R N s e m p lo y e d in h o s p ita ls re p o rte d m o d e ra te o r e x tre m e d is s a tis fa c tio n (H R S A , 2 0 1 0 ). T h e re te n tio n o f c o m p e te n t p ro fe s s io n a l nurses in jobs is a m a jo r p r o b ­ le m o f th e U .S . h e a lth c a re in d u s try , p a rtic u la r ly in h o s p ita ls a n d lo n g -te rm c are fa c ilitie s . A n a v e ra g e y e a rly n u rse tu rn o v e r ra te is re p o rte d as 5 - 2 1 % (P ric e w a te rh o u s e C o o p e r’s H e a lt h R e s e a rc h In s titu te , 2 0 0 7 ) . O t h e r research has fo u n d th a t d u rin g th e firs t y e a r o f p ro fe s s io n a l p ra c tic e n e w re g is te re d nurses e x p e rie n c e tu rn o v e r rates a ro u n d 3 5 - 6 1 % (A lm a d a , C a r a fo li, F la t ­ te ry , F ra n c h , & M c N a m a r a , 2 0 0 4 ) . K o v n e r a n d colleagues (2 0 0 7 ) fo u n d th a t 1 3 % o f n e w ly licensed R N s h a d c h an g ed p rin c ip a l jobs a fte r 1 y e a r, a n d 3 7 % re p o rte d th a t th e y fe lt re a d y to chang e jobs (H u n tin g to n et a l., 2 0 1 2 ; P ellico et a l., 2 0 0 9 ) . In a c o m p re h e n s iv e re p o rt in itia te d b y th e A g e n c y fo r H e a lth c a re R esearch a n d Q u a lity (2 0 0 7 ), th e a u th o rs fo u n d th a t th e shortage o f registered nurses, in c o m b in a tio n w it h a n in crea se d w o r k lo a d , poses a p o te n tia l th re a t to th e q u a lity o f c are . In a d d itio n , e ve ry 1 % increase in nurse tu rn o v e r costs a h o s p ita l a b o u t $ 3 0 0 ,0 0 0 a y e a r.

W o rk p la c e E n v iro n m e n t T h e h e a lth c a re w o r k p la c e has b een tr a n s fo r m e d o v e r th e p a s t 2 0 years in respo nse to e c o n o m ic a n d service pressures. H o w e v e r , som e o f these re fo rm s h a ve h a d u n d e s ira b le consequences fo r n u rse s ’ w o r k in h o s p ita ls a n d th e use o f th e ir tim e a n d s kills . A s th e pace a n d c o m p le x ity o f h o s p ita l c are increases, n u rs in g w o r k is e x p a n d in g a t b o th ends o f th e c o m p le x ity c o n tin u u m . N u rs e s o fte n u n d e rta k e tasks th a t less q u a lifie d s ta ff c o u ld d o , w h ile a t th e o th e r end o f th e s p e c tru m th e y a re u n a b le to use th e ir h ig h -le v e l skills a n d e x p e rtis e . T h is in e ffic ie n c y in th e use o f n u rs in g tim e c an also n e g a tiv e ly a ffe c t p a tie n t o u tc o m e s . N u rs e s ’ w o r k th a t does n o t d ire c tly c o n trib u te to p a tie n t c a re , engage h ig h e r-o rd e r c o g n itiv e s kills , o r p ro v id e o p p o rtu n ity fo r ro le e x p a n ­ sion c an decrease re te n tio n o f w e ll-q u a lifie d a n d h ig h ly s k ille d nurses in th e h e a lth w o rk fo rc e (D u ffie ld , G a rd n e r, & C a tlin g -P a u ll, 2 0 0 8 ) . T h e m a jo r b a rrie r to m a k in g pro gress in p a tie n t s afe ty a n d q u a lity is th e fa ilu re to a p p re c ia te th e c o m p le x ity o f th e w o r k in h e a lth c a re to d a y . C u rre n t research fo cu s in g o n w o r k c o m p le x ity a n d re la te d issues enables a n in creased u n d e rs ta n d in g o f R N d e cis io n m a k in g (th e in v is ib le , c o g n itiv e w o r k o f n u rs ­ in g ) in a c tu a l c are s itu a tio n s a n d d e m o n s tra te s h o w b o th th e k n o w le d g e a n d c o m p e te n c ie s o f R N s as w e ll as th e c o m p le x e n v iro n m e n ts in w h ic h R N s p ro v id e c are c o n trib u te to p a tie n t s afe ty , q u a lity o f c are , a n d h e a lth y w o r k e n v iro n m e n ts o r la c k th e re o f (E b rig h t, 2 0 1 0 ) . K r ic h b a u m et a l. ( 2 0 0 7 ) id e n tify a n u rse c a re -d e liv e ry e x p e rie n c e th e y te rm “ c o m p le x ity c o m p re s s io n ” a n d n o te th is e xp e rien c e occurs w h e n nurses a re e x p e c te d to assum e, in a c o n d e n se d tim e fra m e , a d d itio n a l, u n p la n n e d

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re sp o n sib ilities w h ile s im u lta n e o u s ly c o n d u c tin g th e ir o th e r m u ltip le resp o n si­ b ilitie s . N u rs e s re p o rt th a t p e rs o n a l, e n v iro n m e n ta l, p ra c tic e , a d m in is tra tiv e , system , a n d te c h n o lo g y fa c to rs , as w e ll as a u to n o m y a n d c o n tro l fa c to rs , a ll c o n trib u te to th is e x p e rie n c e . A s s o c i­ a te d w it h c o m p le x ity c o m p re s s io n is th e p h e n o m e n o n o f s ta c k in g . S ta c k in g is th e in v is ib le , d e c is io n -m a k in g w o r k o f R N s a b o u t th e w h a t, h o w , a n d w h e n o f d e liv e rin g n u rs in g care to a n assigned g ro u p o f p a tie n ts (E b rig h t, P a tte rs o n , C h a lk o , & R e n d e r, 2 0 0 3 ) . T h is process results in decisions a b o u t w h a t care is n e ed e d , w h a t c are is po ssib le, a n d w h e n a n d h o w to d e liv e r th is c are. A c o m m itm e n t to u n d e rs ta n d in g a n d a p p re c ia tin g th e c o m p le x ity in v o lv e d in R N w o r k is n e e d e d to g u id e th e m o re s u b s ta n tiv e a n d su stain ed im p ro v e m e n ts re q u ire d to a ch ieve s afe ty a n d q u a lity . A tte n tio n to a n d a c tio n based o n an u n d e rs ta n d in g o f th e c o m p le x ­ ity o f R N w o r k a n d th e v a lu e o f safe, q u a lity c are , d esired p a tie n t o u tco m e s, a n d n u rse re c ru itm e n t a n d re te n tio n h a v e th e p o te n tia l to a ch ieve th e goals o f h e a lth y w o r k e n v iro n m e n ts . U s in g c o m p le x ity science to u n d e rs ta n d th e w o r k o f n u rs in g is b e c o m in g in c re a s in g ly acc ep ted as a v e ry fittin g a p p ro a c h to e x p la in in g h e a lth c a re o rg a n iz a tio n a l d y n a m ic s a n d th e w o r k o f n u rs in g (L in d b e rg & L in d b e rg , 2 0 0 8 ) .

KEY COMPETENCY 15-1 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Systems-Based Practice Knowledge (K2a) Under­ stands the impact of macro­ system changes on planning, organizing, and delivering patient care at the work unit level Attitudes/Behaviors (A2a) Appreciates the complexity of the work unit environment Source: Massachusetts Department of Higher Education (2010), p. 19.

Role C la rity W it h th e in tr o d u c tio n o f n e w n u rs in g m o d e ls o f care to fill p e rc e iv e d gaps in h e a lth c a re p ro v is io n o r im p ro v e access, it is im p o r ta n t th a t th e p u b lic , o th e r h e a lth c a re p ro v id e rs , a n d in d e e d nurses them selves h a ve a c le ar u n d e rs ta n d in g o f th e v a rio u s n u rs in g roles (G a rd n e r, C h a n g , & D u ffie ld , 2 0 0 7 ) . T h e c o n fu ­ sion o v e r th e n a m in g o f n u rs in g roles a n d th e ir v a rio u s fu n c tio n s o r scopes o f p ra c tic e has c o n fo u n d e d n u rs in g a n d o th e r h e a lth c a re p ro fes s io n als fo r som e tim e a n d serves to feed ro le dissonance (B ry a n t-L u k o s iu s , D ic e n s o , & B ro w n e , 2 0 0 4 ; G a rd n e r et a l., 2 0 0 7 ; L o w e , P lu m m e r, O ’B rie n , & B o y d , 2 0 1 2 ) . F o r n u rse p ra c titio n e rs to h a v e a n im p a c t o n th e p ro v is io n o f h e a lth services, a c le a r u n d e rs ta n d in g o f th e ir p ra c tic e is also im p e ra tiv e . C la r ity is re q u ire d fo r re g u la tio n th a t p ro v id e s consistency in th e a p p ro a c h to h e a lth c are, e n su rin g a consistent, efficien t, a n d effective a p p ro a c h to access to care a n d q u a lity o f care.

C h anging D e m o g ra p h ic s D e s p ite n a t io n a l tr e n d s o f in c r e a s in g d iv e r s it y , w i t h e th n ic a n d r a c ia l m in o r itie s re a c h in g a lm o s t o n e -t h ir d o f th e U .S . p o p u la t io n , m in o r itie s a re o v e r a ll u n d e rre p re s e n te d in th e h e a lth c a re p ro fe s s io n . T h e 2 0 1 0 U .S .

C en s u s re p o rts t h a t 6 3 . 7 % o f th e p o p u la tio n is w h it e a n d n o n - H is p a n ic a n d 1 6 . 3 % a re n o n w h ite o r H is p a n ic . I n c o n tr a s t, th e re g is te re d n u rs e p o p u la t io n re m a in s p r e d o m in a n t ly fe m a le ( 9 4 . 2 % ) a n d 8 3 . 2 % w h it e , n o n - H is p a n ic ( H R S A , 2 0 1 0 ) . T h e S u lliv a n C o m m is s io n ( 2 0 0 4 ) h ig h lig h ts th e d iv e rs ity g a p in its h a llm a r k r e p o r t M is s i n g P e r s o n s : M in o r it ie s in t h e H e a l t h P r o fe s s i o n s . T o g e th e r , A f r ic a n A m e ric a n s , H is p a n ic A m e ric a n s , a n d A m e r ic a n In d ia n s m a k e u p m o re th a n 2 5 % o f th e U .S . p o p u la tio n b u t o n ly 9 % o f th e n a t io n ’ s n u rs e s , 6 % o f its p h y s ic ia n s , a n d 5 % o f d e n tis ts . S im ila r d is p a ritie s s h o w u p in th e fa c u ltie s o f h e a lth p ro fe s s io n a l s ch o o ls . F o r e x a m p le , m in o r itie s m a k e u p less th a n 1 0 % o f b a c c a la u re a te n u r s ­ in g fa c u ltie s , 8 .6 % o f d e n ta l s c h o o l fa c u ltie s , a n d o n ly 4 . 2 % o f m e d ic a l s c h o o l fa c u ltie s . I f th e tre n d s c o n tin u e , th e h e a lth w o r k f o r c e o f th e fu tu re w i l l re s e m b le th e p o p u la tio n e ve n less th a n it does to d a y . I f th ese d a ta a re v ie w e d in th e c o n te x t o f th e p r e d ic tio n t h a t n o r a c ia l o r e th n ic g ro u p w i l l c o m p o s e a m a jo r it y b y th e y e a r 2 0 5 0 , such a d e c lin e in a d ive rs e w o r k fo r c e c o u ld be c a ta s tro p h ic . I n 2 0 0 3 , th e I O M w a r n e d o f th e “ u n e q u a l tr e a tm e n t” m in o ritie s face w h e n e n c o u n te rin g th e h e a lth system . C u ltu r a l d iffere n c es , a la c k o f access to h e a lth c a re , h ig h rates o f p o v e r ty , a n d u n e m p lo y m e n t c o n trib u te to th e s u b s ta n tia l e th n ic a n d r a c ia l d is p a ritie s in h e a lth s tatu s a n d h e a lth o u t ­ com es ( I O M , 2 0 0 3 b ) . H e a lt h services re se arch show s th a t m in o r ity h e a lth p ro fe s s io n a ls a re m o re lik e ly to serve m in o r ity a n d m e d ic a lly u n d e rs e rv e d p o p u la tio n s . In c re a s in g th e n u m b e r o f u n d e rre p re s e n te d m in o ritie s in th e h e a lth pro fessio n s as w e ll as im p ro v in g th e c u ltu ra l c o m p e te n c y o f p ro v id e rs a re k e y strategies o f re d u c in g h e a lth d is p a ritie s (B e ta n c o u rt, G re e n , C a r r illo , & A n a n e h -F ire m p o n g , 2 0 0 3 ; I O M , 2 0 0 3 b ) . C u ltu ra l c o m p e te n c e in m u ltic u ltu r a l societies c o n tin u e s as a m a jo r i n i­ tia tiv e fo r h e a lth c are a n d n u rs in g , s p e c ific a lly . T h e m ass m e d ia , h e a lth c a re p o lic y m a k e rs , th e O ffic e o f M in o r it y H e a lth a n d o th e r g o v e rn m e n ta l o rg a n iz a ­ tio n s , p ro fe s s io n a l o rg a n iz a tio n s , th e w o rk p la c e , a n d h e a lth in s u ra n c e payers a re a d d re ss in g th e n e ed fo r in d iv id u a ls to u n d e rs ta n d a n d b e co m e c u ltu ra lly c o m p e te n t as one s tra te g y to im p ro v e q u a lity a n d e lim in a te ra c ia l, e th n ic , a n d g e n d e r d is p a ritie s in h e a lth c are (P u rn e ll & P a u la n k a , 2 0 0 8 ) . C u lt u r a lly c o m p e te n t h e a lth c a re p ro v id e rs re d u c e p a tie n t c a re e r r o r a n d in crea se access to a n d s a tis fa c tio n w it h h e a lth c a re . T h e b e g in n in g o f c u ltu ra l c o m p e te n c e is s e lf-aw are n e ss . C u ltu re has a p o w e r fu l u n c onscious im p a c t o n h e a lth p ro fes s io n als a n d th e c are th e y p ro v id e . P u rn e ll a n d P a u la n k a (2 0 0 8 ) b e lie ve th a t s e lf-k n o w le d g e a n d u n d e rs ta n d in g p ro m o te s tro n g p ro fe s s io n a l p e rc e p tio n s th a t free h e a lth c a re p ro v id e rs fr o m p re ju d ic e a n d fa c ilita te c u ltu ra lly c o m p e te n t c are. N u rs in g has a lo n g h is to ry o f in c o rp o ra tin g c u ltu re in to n u rs in g p ra ctice (D e S an tis & L ip s o n , 2 0 0 7 ) . In 2 0 0 8 , A A C N released a p u b lic a tio n id e n tify in g c u ltu ra l c o m p e te n c y in b a c c ala u rea te n u rs in g e d u c a tio n ( A A C N , 2 0 0 8 a ). Y e t, som e m a in ta in , n o m a tte r h o w c u ltu ra lly c o m p e te n t th e nurse m ig h t be, th e

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patient’s experience remains structured in the nurse’s culture (Dean, 2005). Despite nurses’ 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 nurse’s 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.

N u rsin g E d u c a tio n

KEY COMPETENCY 15-2 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Leadership Knowledge (K1) Identifies leadership skills essential to the practice of nursing Attitudes/Behaviors (A1) Recognizes the role of the nurse as a leader Source: Massachusetts Department of Higher Education (2010), p. 17.

The healthcare system of the 21st century is complex, technologically rich, ethically challenging, and ever changing. The roles of all healthcare provid­ ers 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 deci­ sions and take action in situations that are characterized by ambiguity and uncertainty (Cowan & Moorhead, 2011). Throughout the years, nursing education has made an effort to transition its curriculum and programs to accommodate the knowledge explosion and the advanced technology associated with health care. However, the transition within the programs of nursing has assumed a patchwork approach instead of significant reform. This is in part the result of the tradition associated with the history of nursing education, the inability to resolve the differences in prelicensure programs, and faculty propensity to be reluctant to “leave behind” what is no longer successful in a changing practice arena. In addition, nurse educators are caught in the “perfect storm” composed of a changing healthcare delivery system, changing practice models, nursing shortage, faculty shortage, changes in external standards of care and educational accredita­ tion, university budget cuts, and changes in external funding that support new nursing programs. In 200 3 , the IO M issued a report titled H ealth P rofessions E ducation: A Bridge to Quality (IOM, 2003a). This report, which focuses on knowledge that healthcare professionals need to provide quality care, states that students in the health professions are not prepared to address the shifts in the country’s 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 focuses intensely on education at the pre­ licensure level. The report identifies five core competencies that all clinicians should possess: (1) provide patient-centered care; (2) work in interdisciplin­ ary teams; (3) use evidence-based practice; (4) apply quality improvement and identify errors and hazards in care; and (5) utilize informatics (IOM, 2003a).

I n 2 0 0 5 , th e N a t io n a l C o u n c il o f S ta te B o a rd s o f N u r s in g ( N C S B N ) re le a s e d fiv e re c o m m e n d a tio n s re g a r d in g p re lic e n s u re c lin ic a l in s tru c tio n . T h e s e re c o m m e n d a tio n s address th e a p p ro p r ia te o r d esired settin g o f c lin ic a l e x p e rie n c e , th e scope o f c lin ic a l e x p e rie n c e , th e q u a lific a tio n s o f c lin ic a l fa c ­ u lty , th e ro le o f n u rs in g fa c u lty in c lin ic a l e d u c a tio n , a n d th e need fo r research. T h e N C S B N b o a rd has also d o n e w o r k a ssociated w it h p o s tg ra d u a te nurse c o m p e te n c e th a t in clu d es c lin ic a l re a s o n in g a n d ju d g m e n t, p a tie n t care d e liv ­ e ry a n d m a n a g e m e n t s kills, c o m m u n ic a tio n a n d in te rp e rs o n a l re la tio n s h ip s , a n d re c o g n iz in g lim its a n d seeking h e lp (L i, 2 0 0 7 ) . D e s p ite these u n p re c e d e n te d changes, n e w s ta n d a rd s o f in s tru c tio n , a n d n e w co m p eten c ies fo r p o s tg ra d u a te s , th e e d u c a tio n a l p re p a ra tio n o f nurses has re m a in e d v ir tu a lly u n c h a n g e d fo r m o re th a n 5 0 years. N u rs in g e d u c a tio n re m a in s c o n te n t fo cused a n d te a c h e r c e n te re d . F a c u lty feel p ressured to c o ve r th e c o n te n t th ro u g h lectu res r a th e r th a n in n o v a tiv e m o d a litie s th a t focus o n in q u iry , deep u n d e rs ta n d in g , a n d d e v e lo p m e n t o f n e w skills sets n eed ed fo r to d a y ’s p ra c tic e a re n a (B e n n e r, S tu tp h e n , L e o n a rd , & D a y , 2 0 1 0 ; V a lig a & C h am p ag n e, 2 0 1 1 ). R e c e n tly th e results o f tw o n a tio n a l studies re in fo rc e d th e b e lie f th a t n u rs in g e d u c a tio n m u s t be re fo rm e d . T h e tw o re p o rts , E du cat­ ing N urses: A Call fo r R ad ical T ran sform ation (B e n n e r et a l., 2 0 1 0 ) Landmark reports challenge a n d T h e Future o f N ursing: L ea d in g C hange, A dvancing H ealth nursing education to make ( I O M , 2 0 1 1 ) , e x p lo re th e issue o f w h e th e r nurses a re e n te rin g p ra c ­ reforms in preparation of tice e q u ip p e d w it h th e k n o w le d g e a n d skills fo r to d a y ’s p ra c tic e a n d new graduates in terms p re p a re d to c o n tin u e c lin ic a l le a rn in g fo r to m o r r o w ’s n u rs in g , g ive n of establishing new th e e n o rm o u s changes in a n d c o m p le x ity o f c u rre n t n u rs in g p ra c tic e competencies and outcomes a n d p ra c tic e settings. In b o th re p o rts th e respo nse is th a t nurses are for graduates, new curricula n o t p re p a re d fo r fu tu re h e a lth c a re c h an g e. B o th re p o rts c h allen g e designs, new pedagogy, better n u rs in g e d u c a tio n to m a k e re fo rm s in p re p a ra tio n o f n e w g r a d u ­ evaluation models, and new ates in te rm s o f e s ta b lis h in g n e w c o m p e te n c ie s a n d o u tc o m e s fo r models for clinical education. g ra d u a te s, n e w c u rric u lu m designs, n e w p ed ag o g y, b e tte r e v a lu a tio n m o d e ls , a n d n e w m o d e ls fo r c lin ic a l e d u c a tio n , such as re sid e n cy p ro g ra m s . T h e C a rn e g ie re p o rt o n e d u c a tin g nurses id e n tifie s fo u r shifts in fa c u lty th in k in g a n d a p p ro a c h to n u rs in g e d u c a tio n th a t n eed to o c cu r. T h e shifts in fa c u lty th in k in g a re (1 ) fr o m a focus o n c o v e rin g d e c o n te x tu a liz e d k n o w le d g e to a n em p h asis o n te a c h in g fo r a sense o f salience, s itu a te d c o g n itio n , a n d a c tio n in p a rtic u la r c lin ic a l s itu a tio n s ; (2 ) fr o m a s h arp s e p a ra tio n o f class­ r o o m a n d c lin ic a l te a c h in g to in te g ra tiv e te a c h in g in a ll settings; (3 ) fr o m an em phasis o n c ritic a l th in k in g to a n em phasis o n c lin ic a l reas o n in g a n d m u ltip le w a y s o f th in k in g th a t in c lu d e c ritic a l th in k in g ; a n d (4 ) fr o m a n em p hasis o n s o c ia liz a tio n a n d ro le ta k in g to an em phasis o n fo rm a tio n (B e n n er et a l., 2 0 1 0 , p . 8 9 ). O th e r re c o m m e n d a tio n s address e n try a n d p a th w a y s , s tu d e n t p o p u la ­ tio n , s tu d e n t e x p e rie n c e , te a c h in g , e n try to p ra c tic e , a n d n a tio n a l o v e rs ig h t (p p . 2 1 5 - 2 3 0 ) .

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In response to th e changes in h e a lth c a re d e liv e ry a n d th e c a ll fo r n e w roles in n u rs in g , th e A m e ric a n A s s o c ia tio n o f C o lle g e s o f N u rs in g p ro p o ses tw o n e w e d u c a tio n a l p ro g ra m s fo r n u rs in g . T h e firs t is th e c lin ic a l n u rse le a d e r (C N L ), an a d v a n c e d g e n eralist ro le p re p a re d a t th e m a s te r’s level o f e d u c a tio n . T h e C N L oversees th e c o o rd in a tio n o f c are fo r a g ro u p o f p a tie n ts , assesses c o h o rt ris k , p ro v id e s d ire c t p a tie n t c are in c o m p le x s itu a tio n s , a n d fu n c tio n s as a p a r t o f a n in te rd is c ip lin a ry te a m ( A A C N , 2 0 0 7 ) . T h e la te r a l in te g ra ­ tio n o f c are has been w h a t is m issin g in th e d e liv e ry o f care to p a tie n ts w it h c o m p le x needs. N o single p e rs o n oversees p a tie n t care la te ra lly a n d o v e r tim e a n d is a b le to in te rv e n e , fa c ilita te , o r c o o rd in a te care fo r th e e n tire p a tie n t e x p e rie n c e . T h e C N L w ill be in s tru m e n ta l in h e lp in g a ll d isc ip lin es see th e in te rd e p e n d e n c ie s th a t e x is t b e tw e e n a n d a m o n g th e m (B e g u n , H a m ilt o n , T o r n a b e n i, & W h it e , 2 0 0 6 ) . W h a t m ak e s th e C N L m o v e m e n t d iffe re n t fr o m p a st e ffo rts w it h in n u rs ­ ing? T h e re has b e en th o u g h tfu l a n d b ro a d e n g a g e m e n t in lo o k in g a t b o th th e e d u c a tio n a l a n d c o m p e te n c y needs o f n u rs in g to fu n c tio n in a n e n v iro n ­ m e n t th a t has c h a n g e d d r a m a tic a lly a n d b e c o m e e x tre m e ly c o m p le x . T h is c h an g e re q u ire s a d v a n c e d k n o w le d g e , n e w s kills , a n d in te rd e p e n d e n t re la ­ tio n s h ip s . T h e uniqueness o f th e in c e p tio n a n d im p le m e n ta tio n o f th e C N L is th e a p p ro a c h th a t is: (1 ) b e in g a d v a n c e d as a p a rtn e rs h ip w it h e d u c a tio n a n d p ra c tic e , (2 ) o c c u rrin g a t a b ro a d n a tio n a l level o f a c tiv ity , (3 ) b e in g s tru c tu red w it h m ile s to n e s fo r th e p a rtn e rs h ip s to a tta in , a n d (4 ) b e in g fa c ilita te d by nurses a n d a d m in is tra to rs a t th e h ig h e st levels w ith in h e a lth c a re o rg a n iz a tio n s (B e g u n et a l., 2 0 0 6 ) . A n o th e r n e w p ro g ra m w it h in n u rs in g is th e D o c to r o f N u rs in g P ra c tic e (D N P ). T h e n e e d fo r th is te r m in a l p ra c tic e d egree is based o n th e series o f re p o rts fr o m th e I O M th a t address q u a lity o f h e a lth c are , p a tie n t s afe ty , a n d e d u c a tio n a l re fo r m , as w e ll as fo llo w in g th e m o v e m e n t o f o th e r h e a lth c a re pro fessio n s to th e p ra c tic e d o c to ra te . In 2 0 0 2 , th e A A C N e sta b lish e d a ta s k fo rc e to e x a m in e th e c u rre n t status o f e x is tin g a d v a n c e d p ra c tic e p ro g ra m s , c u rre n t e x is tin g p ra c tic e d o c to ra te s , a n d fu tu re n e ed fo r such a p ro g ra m . T h e A A C N , in c o lla b o ra tio n w it h th e N a t io n a l O r g a n iz a tio n o f N u rs e P r a c titio ­ n e r F a c u ltie s , m e t w it h o th e r c o n s titu e n c ie s a n d h e ld re g io n a l m ee tin g s to discuss th e n a tu re o f th is te rm in a l degree a n d th e n e e d fo r a te rm in a l degree in p ra c tic e . A fte r m u c h n a tio n a l discu ssio n a n d d e b a te , it w a s d e te rm in e d th a t a p ra c tic e d o c to ra te w a s n eed ed th a t encom passes a n y fo r m o f n u rs in g in te rv e n tio n th a t influences h e a lth c a re o u tco m es fo r in d iv id u a l p a tie n ts , m a n ­ a g e m e n t o f c are fo r in d iv id u a ls a n d p o p u la tio n s , a d m in is tra tio n o f n u rs in g a n d h e a lth o rg a n iz a tio n , a n d th e d e v e lo p m e n t a n d im p le m e n ta tio n o f h e a lth p o lic y ( A A C N , 2 0 0 4 ) . I t is c le a rly s tated th a t th is p ra c tic e degree is n o t th e sam e as th e rese arch d o c to ra l degree a n d th a t g ra d u a te s w o u ld be p re p a re d to b le n d c lin ic a l, e c o n o m ic , o rg a n iz a tio n a l, a n d le a d e rs h ip skills a n d to use science in im p ro v in g th e d ire c t c are o f p a tie n ts , care o f p a tie n t p o p u la tio n s , a n d p ra c tic e th a t s u p p o rts p a tie n t c are (C h a m p a g n e , 2 0 0 6 ) .

T h e d e v e lo p m e n t o f th e D N P a n d th e C N L p ro g ra m s o f s tu d y re p re s e n t a b o ld e ffo r t b y th e p ro fe s s io n o f n u rs in g to address n e w roles o f n u rs in g a n d e d u c a tio n a l r e fo r m n e ed e d to p re p a re g ra d u a te s to m e e t th e h e a lth c a re needs o f th e fu tu re . A lth o u g h q u e stio n s a n d concerns re la te d to th e im p le m e n ta tio n o f these tw o n e w p ro g ra m s s till e xist, th e e v a lu a tio n o f th e im p le m e n ta tio n o f these p ro g ra m s is m o s tly p o s itiv e . O n e m u s t a p p la u d th e s p irit o f e v id e n c e based e d u c a tio n a l in n o v a tio n .

C o nclu sio n T h is c h a p te r s u p p o rts th e c o n c e p t th a t th e challeng es o f th e n u rs in g s h o rta g e , w o r k fo r c e issues, co st a n d access to c a re , th e e d u c a tio n -p ra c tic e g a p , a n d changes in p o p u la tio n d e m o g ra p h ic s h a v e m e rg e d to c rea te a crisis p o in t fo r th e p ro fe s s io n o f n u rs in g , e s p e cia lly in lig h t o f th e c o n s ta n t c h an g e in h e a lth c a re . In d iv id u a lly , each id e n tifie d c h a lle n g e in its e lf w o u ld c rea te a n e ed fo r som e degree o f ch an g e in th e p ra c tic e o f n u rs in g , a n d c o n s id e re d in d iv id u ­ a lly , n u rs in g w o u ld h a v e c o n tin u e d to p a tc h to g e th e r a respo nse. T o g e th e r, th e c o m p o u n d in g consequences o f these challeng es s ig n al th e n eed fo r m a jo r tr a n s fo r m a tio n in n u rs in g . T h e c u lm in a tin g results o f these issues h a v e been co n n e cte d to a d eclin e in q u a lity care, d iss a tisfac tio n in th e a ch ie ve d outcom es o f p ra c tic e , a n d a w id e r g a p b e tw e e n e d u c a tio n p re p a ra tio n a n d p e rfo rm a n c e in th e p ra c tic e settin g . T h e issue o f th e e m p lo y m e n t o f n o n - R N p e rs o n n e l fo r p a tie n t care is n o t one th a t w ill d is a p p e a r in th e fu tu re , g iv e n th e p re d ic te d in crea se in p a tie n t p o p u la tio n a n d th e n u rse s h o rta g e . C u rre n tly , 9 7 % o f h o s p ita ls e m p lo y U A P (Z im m e r m a n , 2 0 0 6 ) . T h e issue m ig h t in d e e d be h o w w ill n u rs in g p ra c tic e tra n s itio n ? W i l l th e m o v e c o n tin u e to be fr o m th e h o s p ita l to o th e r h e a lth ­ c a re settings? W i l l nurses re d e fin e w h o th e y a re a n d w h a t c o n s titu te s th e ir p ractice? T h e gap b e tw e e n e d u c a tio n and p ra c tic e lo o m s la rg e r as th e h e a lth c a re s ettin g c o n tin u a lly changes as a re s u lt o f a d v a n c e d te c h n o lo g y , k n o w le d g e e x p lo s io n , s h o rte r h o s p ita l stays, a n d r a p id changes in disease m a n a g e m e n t. E m p h a s is is n o w p la c e d o n e v id e n c e -b a s e d m e d ic in e a n d e v id e n c e -b a s e d p ra c tic e . In g e n e ra l, c u rric u lu m s in n u rs in g p ro g ra m s h a v e n o t e v o lv e d to k ee p p ace w it h chang es in th e p ra c tic e s ettin g . T h e reasons a re v a rie d a n d in c lu d e lim ite d fu n d in g sources, c o n fin e m e n t o f h ig h e r e d u c a tio n b o u n d a rie s a n d s tan d ard s, p a st success in e d u c a tio n a l o u tco m e s, in a b ility to d iffe re n tia te b e tw e e n levels o f n u rs in g p ra c tic e , m u ltip le e n try in to p ra c tic e a n d lice n su re, a n d p e d a g o g ic a l m e th o d s th a t e m p h a s ize re c e iv in g c o n te n t r a th e r th a n d is ­ c o v e ry o f e vid e n ce . T h e c u rre n t em p h asis o n in te g ra tin g c lin ic a l s im u la tio n as a te a c h in g a n d e v a lu a tio n s tra te g y a n d th e d e v e lo p m e n t o f th e c lin ic a l n u rse le a d e r ( M S N g e n e ra lis t) a n d D o c t o r o f N u r s in g P ra c tic e a re steps in th e r ig h t d ire c tio n .

KEY COMPETENCY 15-3 Examples of Applicable Nurse of the Future: Nursing Core Competencies

Leadership Knowledge (K5) Explains the importance, necessity, and process of change Attitudes/Behaviors (A5b) Values new idea and inter­ ventions to improve patient care Skills (S5b) Anticipates con­ sequences, plans ahead, and changes approaches to get best results Source: Massachusetts Department of Higher Education (2010), p. 18.

E v id e n c e s u p p o rts th a t a b e tte r e d u c a te d n u rs e is n e e d e d in p ra c tic e . T h e in itia l e d u c a tio n a l p re p a ra tio n fo r th e la rg e s t p r o p o r tio n o f R N s is th e asso ciate d e g re e. In 2 0 0 8 , th e in it ia l e d u c a tio n a l le v e l o f re g is te re d nurses in d ic a te d th a t 2 0 .4 % w e re d ip lo m a , 4 5 .4 % w e re associate degree, a n d 3 4 .2 % w e re b a c c a la u re a te ( H R S A , 2 0 1 0 ) . In 2 0 0 4 , 3 3 . 7 % o f n urses ( 9 8 1 , 2 3 8 ) re p o r te d th e a ss o c ia te d e g re e as th e ir h ig h e s t le v e l o f n u rs in g e d u c a tio n , 3 4 . 2 % ( 9 9 4 , 2 7 6 ) re p o rte d th e b a c c a la u re a te d egree as th e ir h ig h e s t le v e l, a n d 1 3 % ( 3 7 6 ,9 0 1 ) re p o rte d a m a s te r’s o r d o c to ra l degree as th e ir h ig h e st lev el o f e d u c a tio n . L e a d e rs in n u rs in g e d u c a tio n m u s t id e n tify a w a y to m o v e y o u n g e r students to th e d esired g ra d u a te lev el o f e d u c a tio n m o re e x p e d ie n tly . C le a re r roles in p ra c tic e m u s t be d e ve lo p ed , a n s w e rin g th e q u e s tio n a b o u t w h a t nurses d o . T h e a n s w e r w ill p ro b a b ly be d iffe re n t fr o m th e tr a d itio n a l ro le o f n u rs in g p ra c tic e d b y th o se w h o a re n e a rin g re tire m e n t. A s th e fu tu re evolves, a n increase in th e m o v e m e n t o f nurses fr o m th e h o s p ita ls in to o th e r settings o f care w ill be re a liz e d . E n tre p re n e u ria l o p p o rtu n itie s w ill be a v a ila b le fo r nurses, a n d nurses w ill be a b le to im p le m e n t th e ir th e o ry -b a s e d p ra c tic e in p ro v id in g q u a lity h e a lth c are to th e p o p u la tio n . T h e th e m e o f p r o m o tin g c u lt u r a l c o m p e te n c e in h e a lth c a re w i l l be e x p lo re d fr o m tw o p ersp ectives: c re a tin g p ra c tic e e n v iro n m e n ts th a t s u p p o rt c u ltu ra lly c o m p e te n t c are a n d d e v e lo p in g e d u c a tio n a l p ro g ra m s th a t fo ste r c u ltu ra l a w aren ess a n d s e n s itiv ity a m o n g students in th e h e a lth c a re p ro fe s ­ sions. A s th e p o p u la tio n c o n tin u e s to b e co m e m o re d iverse, c u ltu ra lly c o m ­ p e te n t c are w ill be th e basis fo r q u a lity c are , access to c are , a n d a lle v ia tio n o f h e a lth d is p a ritie s , th u s p ro m o tin g h e a lth ie r p o p u la tio n o u tco m e s. T h e n u rsin g pro fession m u s t be able to n a vig a te the high-speed, c o n v o lu te d pace o f th e c u rre n t h e a lth c a re d e liv e ry system . N u rs es m u s t be c o m p e te n t to m ee t th e dem an d s o f th e c u rre n t p a tie n t p o p u la tio n , th e c o m p le x te ch n o lo g y , m o re resp o n sib ility, a n d c o st-c o n ta in ed care. In re a lity , the changes in advanced tech n o lo g y, the updates in p h a rm a c o lo g ic a l in te rv en tio n s, th e k n o w le d g e e x p lo ­ sion, a n d th e a d van cem en ts in gene th e ra p y w ill s ig n ific a n tly change n o t o n ly th e p ra ctice o f th e nurse b u t th a t o f a ll h e a lth c a re p ro v id e rs . T h e in n o v a tio n in te c h n o lo g y , th e c u ltu re o f v io le n c e , te rro ris m , a n d th e increase in n a tu ra l disasters re s u ltin g fr o m g lo b a l w a rm in g w ill change th e p ra c tic e o f n u rsin g . W h e r e d o w e go fr o m here? T h e I O M r e p o r t T h e F u t u r e o f N u r s i n g : L e a d i n g C h a n g e , A d v a n c in g H e a lth p ro v id e s us w it h a b lu e p rin t. T h e I O M a n d R o b e r t W o o d J o h n s o n F o u n d a tio n p a rtn e re d to access a n d re s p o n d to th e n e ed to tr a n s fo r m n u rs in g to ensure th a t th e n u rs in g w o rk fo rc e has th e c a p a c ity , in te rm s o f n u m b e rs , s kills , a n d c o m p e te n c e , to m e e t th e p re s e n t a n d fu tu re h e a lth c a re needs o f th e p u b lic . T h is tr a n s fo r m a tio n w o u ld e n ab le n urses to be p a rtn e rs a n d le a d e rs in th e a d v a n c in g h e a lth fo r th e fu tu r e . T h e k e y messages a n d re c o m m e n d a tio n s o f th e s tu d y are: (1 ) N u rs e s s h o u ld p ra c tic e to th e fu ll e x te n t o f th e ir e d u c a tio n a n d tra in in g ; (2 ) nurses s h o u ld achieve h ig h e r levels o f e d u c a tio n a n d tr a in in g th ro u g h a n im p ro v e d e d u c a tio n system th a t p ro m o te s seamless aca d em ic p ro gression ; (3 ) nurses s h o u ld be fu ll

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p a rtn e rs , w it h p h y sic ia n s a n d o th e r h e a lth pro fes s io n s, in re d e s ig n in g h e a lth c are in th e U n ite d States; (4 ) e ffe c tiv e w o rk fo rc e p la n n in g a n d p o lic y m a k in g re q u ire b e tte r d a ta c o lle c tio n a n d a n im p ro v e d in fo r m a t io n in fr a s tru c tu r e ( I O M , 2 0 1 1 , p . 4 ). R e c o m m e n d a tio n s fr o m th e s tu d y are: (1 ) re m o v e scopeo f-p ra c tic e b a rrie rs ; (2 ) e x p a n d o p p o rtu n itie s fo r nurses to le a d a n d d iffu s e c o lla b o ra tiv e im p ro v e m e n t e ffo rts ; (3 ) im p le m e n t nurse re sid e n cy p ro g ra m s ; (4 ) increase th e p r o p o r tio n o f nurses w it h a b a c c a la u re a te degree to 8 0 % b y 2 0 1 0 ; (5 ) d o u b le th e n u m b e r o f nurses w it h a d o c to ra te b y 2 0 1 0 ; (6 ) ensure th a t nurses engage in life lo n g le a rn in g ; (7 ) P re p a re a n d e n a b le nurses to le a d ch an g e to a d v a n c e h e a lth ; a n d (8 ) b u ild a n in fra s tru c tu re fo r th e c o lle c tio n a n d analysis o f in te rp ro fe s s io n a l h e a lth c a re w o rk fo rc e d a ta . I t is im p e r a tiv e th a t p ro fe s s io n a l nurses c o n tro l th e ir W W W ] CRITICAL THINKING QUESTIONS V fu tu re a n d red efin e th e ir roles in p ra ctice . N o e l T ic h y (1 9 9 7 ) states, “ In th e fu tu re , th e re a l core c o m p e te n c e o f o rg a n i­ Based on the trends and recommendations z a tio n s w i l l be th e a b ility to c o n tin u o u s ly a n d c re a tiv e ly presented in this chapter, what do you think d estro y a n d re m a k e th em selves.” T h e sam e m ig h t be a p p lie d nursing education will look like in 2025? to th e p ro fe s s io n o f n u rs in g . A re y o u re a d y to be a p a r t o f What do you think the profession of nursing tra n s fo rm in g p ro fe s s io n a l n u rs in g p ra c tic e as w e tra n s itio n will look like in the year 2025? V o u r p ro fe s s io n in to th e fu tu re ?

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Appendix A

American Nurses Association Standards of Nursing Practice Standards of Care (Use of the Nursing Process) Standard 1 A ssessm ent: T h e re g is te re d n u rse collects c o m p re h e n s iv e d a ta p e rtin e n t to th e h e a lth c a re c o n s u m e r’s h e a lth a n d /o r th e s itu a tio n . Standard 2

D ia g n o s is : T h e re g is te re d n u rse a n a ly ze s th e assessm ent d a ta to d e te rm in e th e diagnoses o r issues.

Standard 3

O u tc o m e s i d e n t i f i c a t i o n : T h e re g is te r e d n u rs e id e n tifie s e x p e c te d o u tco m e s fo r a p la n in d iv id u a liz e d to th e h e a lth c a re c o n s u m e r o r th e s itu a tio n .

Standard 4

P la n n in g : T h e re g is te re d n u rse d evelops a p la n th a t prescribes strategies a n d a lte rn a tiv e s to a tta in e x p e c te d o u tc o m e s .

Standard 5 Im p le m e n ta tio n : T h e re g is te re d n u rs e im p le m e n ts th e id e n ti­ fie d p la n o f c are. Standard 6

E v a lu a tio n : T h e re g is te re d n u rs e e v a lu a te s p ro g res s t o w a r d a tta in m e n t o f o u tco m e s.

Standards of Professional Performance (Professional Behavior) Standard 7

E th ic s: T h e re g istere d n u rse p ra ctice s e th ic a lly .

Standard 8

E d u c a t io n : T h e r e g is te r e d n u r s e a tta in s k n o w le d g e a n d c o m p e te n c e th a t reflects c u rre n t n u rs in g p ra c tic e .

Standard 9 E v id e n c e -b a s e d p ra c tic e a n d re s e a rc h : T h e re g is te re d n u rs e in te g ra te s evid en ce a n d re se arch fin d in g s in to p ra c tic e . Standard 10 Q u a l i t y o f p r a c tic e : T h e re g is te re d n u rs e c o n tr ib u te s to q u a lity n u rs in g p ra c tic e . Standard 11

C o m m u n ic a tio n : T h e re g is te re d n u rse c o m m u n ic a te s e ffe c ­ tiv e ly in a ll areas o f p ra c tic e . 371

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Standard 12 L e a d e rs h ip : T h e re g is te re d n u rse d e m o n s tra te s le a d e rs h ip in th e p ro fe s s io n a l p ra c tic e settin g a n d p ro fe s s io n . Standard 13 C o l la b o r a t i o n : T h e r e g is te r e d n u r s e c o lla b o r a te s w i t h h e a lth c a re c o n s u m e r, fa m ily , a n d o th ers in th e c o n d u c t o f n u rs in g p ra c tic e . Standard 14

P ro fe s s io n a l p ra c tic e e v a lu a tio n : T h e re g is te re d n u rs e e v a l­ u ates h e r o r his o w n n u rs in g p ra c tic e in r e la tio n to p ro fe s s io n a l p ra c tic e s tan d ard s a n d g u id e lin e s , re le v a n t s ta tu te s , ru le s , a n d re g u la tio n s .

Standard 15

R e s o u rc e u t iliz a t io n : T h e re g is te re d n u rs e u tiliz e s a p p r o ­ p r ia t e re s o u rc e s to p la n a n d p r o v id e n u r s in g s e rv ic e s t h a t a re s a fe , e ffe c tiv e , a n d fin a n c ia lly re sp o n sib le .

Standard 16

E n v ir o n m e n ta l h e a lth : T h e re g is te re d n u rs e p ra c tic e s in an e n v iro n m e n ta lly safe a n d h e a lth y m a n n e r.

S ou rce: © 2 0 1 0 by American Nurses Association. Reprinted with permission. All rights reserved.

Appendix B

American Nurses Association Code of Ethics Provision 1 T h e n u rs e , in a ll p ro fe s s io n a l re la tio n s h ip s , p ra c tic e s w it h c o m p a s s io n a n d respect fo r th e in h e re n t d ig n ity , w o r th , a n d un iq u en ess o f e v e ry in d iv id u a l, u n re s tric te d b y c o n d itio n s o f s o c ia l o r e c o n o m ic s tatu s , p e rs o n a l a ttrib u te s , o r th e n a tu re o f h e a lth p ro b le m s . Provision 2 T h e n u rs e ’s p r im a r y c o m m itm e n t is to th e p a tie n t, w h e th e r an in d iv id u a l, fa m ily , g ro u p , o r c o m m u n ity . Provision 3 T h e n u rse p ro m o te s , a d vo c ates fo r, a n d strives to p ro te c t th e h e a lth , s afe ty , a n d rig h ts o f th e p a tie n t. Provision 4 T h e n u rs e is a c c o u n ta b le a n d re s p o n s ib le f o r i n d iv id u a l n u rs in g p ra c tic e a n d d e te rm in e s th e a p p ro p r ia te d e le g a tio n o f tasks consis­ te n t w it h th e n u rs e ’s o b lig a tio n to p ro v id e o p tim u m p a tie n t c are. Provision 5 T h e n u rse ow es th e sam e d u tie s to self as to o th e rs , in c lu d in g th e re s p o n s ib ility to pre se rv e in te g rity a n d s afe ty , to m a in ta in c o m p e te n c e , a n d to c o n tin u e p e rs o n a l a n d p ro fe s s io n a l g ro w th . Provision 6 T h e n u rs e p a r tic ip a te s in e s ta b lis h in g , m a in t a in in g , a n d im p ro v in g h e a lth c a re e n v iro n m e n ts a n d c o n d itio n s o f e m p lo y m e n t c o n d u ­ cive to th e p ro v is io n o f q u a lity h e a lth c a re a n d c o n sis te n t w it h th e values o f th e p ro fe s s io n th ro u g h in d iv id u a l a n d c o lle c tiv e a c tio n . Provision 7 T h e n u rs e p a rtic ip a te s in th e a d v a n c e m e n t o f th e p ro fe s s io n th ro u g h c o n trib u tio n s to p ra c tic e , e d u c a tio n , a d m in is tr a tio n , a n d k n o w l ­ edge d e v e lo p m e n t. Provision 8 T h e n u rs e c o lla b o ra te s w it h o th e r h e a lth p ro fe s s io n a ls a n d th e p u b lic in p r o m o tin g c o m m u n ity , n a tio n a l, a n d in te r n a tio n a l e ffo rts to m e e t h e a lth needs.

373

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APPENDIX B

Provision 9 T h e p ro fe s s io n o f n u r s in g , as re p re s e n te d b y a s s o c ia tio n s a n d th e ir m e m b e rs , is re s p o n s ib le f o r a r t ic u la t in g n u r s in g v a lu e s , fo r m a in ta in in g th e in te g rity o f th e p ro fe s s io n a n d its p ra c tic e , a n d fo r s h ap in g social p o lic y . T h e A N A C o d e o f E th ic s w ith I n t e r p r e t iv e S ta te m e n ts is a v a ila b le in its e n tire ty in p r in t fr o m th e A m e ric a n N u rs e s A s s o c ia tio n a n d is also a v a ila b le in its e n tire ty a t w w w .n u r s in g w o r ld .o r g /M a in M e n u C a te g o r ie s / E th ic s S ta n d a rd s /C o d e o fE th ic s fo rN u rs e s /C o d e -o f-E th ic s .p d f. S ou rce: © 2 0 0 1 by American Nurses Association. Reprinted with permission. All rights reserved.

Glossary

5-year plan: A p la n th a t has c le a r o b je c tiv e s a n d fo llo w s specific steps to m e e t th ose o b je ctiv es w h ile a llo w in g fo r fle x ib ility in a d ju s tin g to c h a n g in g life c irc u m s ta n ce s. Academic Center for Evidence-Based Nursing (ACE) Star Model of Knowledge Transformation: T h is m o d e l in v o lv e s fiv e steps: d is c o v e ry , s u m m a ry , tra n s ­ la tio n , im p le m e n ta tio n , a n d e v a lu a tio n .

Access to care: L iv in g in r u r a l areas has u n iq u e c o n ce rn s re g a rd in g access to c a re . A s fin a n c e s in flu e n c e th e c lo s in g o f m a n y r u r a l h o s p ita ls , m o re c o m m u n itie s fin d th em selves s tru g g lin g to fin d p r im a r y c are p ro v id e rs w h o w ill w o r k in th o se areas.

Active euthanasia: A c tiv e e u th a n a s ia occurs w h e n a p e rs o n takes an a c tio n to e n d a life (in c lu d in g o n e ’s o w n life ) . A c tiv e e u th a n a s ia c a n in c lu d e a le th a l dose o f m e d ic a tio n , such as in p h y sic ia n -as sisted suicide.

Administrative or regulatory law: T h e re g u la to ry process is its e lf g o v e rn e d b y s ta tu to ry la w c a lle d a d m in is tra tiv e p ro c e d u re acts a t b o th fe d e ra l a n d s ta te le v e ls . T h e s e acts p r o v id e t h a t b e fo re re g u la tio n s c a n be a d o p te d a p u b lis h e d n o tic e o f th e p ro p o s e d ru le s a n d w h e re th e y a re a v a ila b le m u s t o c c u r. T h e p u b lis h e d n o tic e a n d a v a ila b ility o f th e p ro p o s e d ru les p ro v id e c o n c e rn e d p e rs o n s w i t h th e o p p o r t u n it y to c o m m e n t o n a n d s u g g e st c h an g es to th e ru le s b e fo re fin a l a d o p tio n . W h e n ru le s a re a d o p te d , th e y b e c o m e a d m in is tra tiv e la w w it h in a set p e rio d o f tim e . T h u s , th e process has th re e steps: (1 ) p ro p o s a l o f re g u la tio n s , (2 ) c o n s id e ra tio n o f p ro p o s e d re g u la tio n s , a n d (3 ) a d o p tio n o f re g u la tio n s w it h o r w it h o u t changes.

Advance directive: A w r it te n e xp re ss io n o f a p e rs o n ’s w ishes a b o u t m e d ic a l c are , e sp e cia lly care d u rin g a te rm in a l o r c ritic a l illness.

Advanced beginner: In B e n n e r’s stage 2 , th e a d v a n c e d b e g in n e r, th e s tu d e n t is a b le to f o r m u la t e p r in c ip le s t h a t d ic t a t e a c tio n . F o r e x a m p le , th e a d v a n c e d b e g in n e r w o u ld grasp th e r a tio n a le b e h in d w h y d iffe re n t m e d ic a ­ tio n s re q u ire d iffe re n t in je c tio n te ch n iq u es .

Advocacy: T h e n u rs e sp ea ks fo r th e p a tie n t o r m a in ta in s th e p a t ie n t ’ s rig h ts in th e fa ce o f th e h e a lth c a re s y s te m . A s th e n u r s e -c lie n t r e la t io n ­ s h ip d e v e lo p s , th e n u rs e needs p ro fe s s io n a l k n o w le d g e to assist c lie n ts in th e ir d e cis io n m a k in g . T h e n u rse fills th e ro le o f a d v o c a te in th e d e liv e ry o f 375

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GLOSSARY

h e a lth c a re , in te rv e n in g in crises o f A ID S , hom elessness, d ru g a n d a lc o h o l a b u se , te e n a g e p re g n a n c y , c h ild a n d spouse ab u se, a n d in c re a s in g h e a lth ­ c a re costs. A c lie n t a d v o c a te is a p e rs o n w h o p le a d s th e cause fo r c lie n ts ’ rig h ts .

Age-related changes: C h an g es in c o g n itio n , v is io n , a n d h e a rin g th a t o c cu r as one ages. R e s e a rc h has d e m o n s tra te d th a t te a c h in g is n o t as e ffe c tiv e i f it does n o t a c c o m m o d a te fo r a g e -re la te d c o g n itiv e a n d sensory changes.

AGREE instrument: A fr a m e w o r k fo r d e te rm in in g th e q u a lity o f g u id e lin e s fo r diag noses, h e a lth p r o m o tio n , tre a tm e n ts , o r c lin ic a l in te rv e n tio n s .

Alternative program: A lt e r n a t iv e p r o g r a m s f o r n u rs e s w i t h d r u g a n d a lc o h o l a d d ic tio n s e x is t. N u rs e s m u s t q u a lify fo r th e p ro g ra m . American Journal of Nursing (AJN ): M a r y A d e la id e N u t t in g , L a v in ia L . D o c k , S o p h ia P a lm e r , a n d M a r y E . D a v is w e r e in s t r u m e n ta l in d e v e l­ o p in g th e firs t n u rs in g jo u r n a l, th e A m e r i c a n J o u r n a l o f N u r s i n g ( A J N ) in O c to b e r o f 1 9 0 0 . T h r o u g h th e A N A a n d th e A J N , nurses th e n h a d a p ro fe s s io n a l o rg a n iz a tio n a n d a n a tio n a l jo u r n a l w it h w h ic h to c o m m u n i­ cate w it h each o th e r.

American Nurses Association (ANA): T h e A N A is th e o n ly fu ll-s e r v ic e p r o fe s s io n a l o r g a n iz a t io n r e p r e s e n tin g th e n a t i o n ’ s 2 .9 m i ll i o n r e g is ­ te r e d n u rs e s ( R N s ) th r o u g h its 5 4 c o n s t it u e n t m e m b e r a s s o c ia tio n s . T h e A N A a d v a n c e s th e n u r s in g p ro fe s s io n b y fo s te rin g h ig h s ta n d a rd s o f n u r s in g p r a c t ic e , p r o m o t in g th e r ig h ts o f n u rs e s in th e w o r k p la c e , p r o je c t in g a p o s itiv e a n d r e a lis t ic v ie w o f n u r s in g , a n d lo b b y in g th e C o n g re s s a n d r e g u la t o r y a g e n c ie s o n h e a lth c a r e issues a ffe c tin g n u rse s a n d th e p u b lic .

Andragogy: I n i t i a l l y d e fin e d as “ th e a r t a n d s cien ce o f h e lp in g a d u lts le a r n ,” a n d ra g o g y has ta k e n o n a b ro a d e r m e a n in g o v e r th e p a s t 3 5 years a n d is c u rre n tly used to re fe r to le a rn e r-fo c u s e d e d u c a tio n fo r p e o p le o f a ll ages.

Assumptions: A s s u m p tio n s d e sc rib e co n cep ts o r c o n n e c t tw o co n cep ts a n d re p re s e n t v a lu e s , b e lie fs , o r g o a ls. W h e n a s s u m p tio n s a re c h a lle n g e d , th e y b e co m e p ro p o s itio n s .

Asynchronous: N o t o c c u rrin g in re a l tim e . Autonomy: In v o lv e s o n e ’s a b ility to s e lf-ru le a n d to g e n e ra te p e rs o n a l d e c i­ sions in d e p e n d e n tly .

Barton, Clara: In 1 8 8 2 , B a rto n w a s a b le to c o n v in c e C ongress to r a tify th e T r e a ty o f G e n e v a , th us b e c o m in g th e fo u n d e r o f th e A m e ric a n R e d C ross. Basic dignity: In tr in s ic , o r in h e re n t, a n d d w e lls w it h in a ll h u m a n s , w it h a ll h u m a n s b e in g a sc rib ed th is m o r a l w o r th . Beliefs: B eliefs in d ic a te w h a t w e v a lu e a n d o fte n h a v e a fa ith c o m p o n e n t. T h r e e c ateg o ries o f beliefs in c lu d e : e x is te n tia l, e v a lu a tiv e , a n d p re s c rip tiv e / p ro s c rip tiv e beliefs.

GLOSSARY

Beneficence: Im p lie s t h a t n u rse s ta k e a c tio n s to b e n e fit p a tie n ts a n d to fa c ilita te th e ir w e ll-b e in g .

Best interest standard: B ased o n th e g o a l o f th e s u rro g a te ’s d o in g w h a t is best fo r th e p a tie n t o r w h a t is in th e best in te re s t o f th e p a tie n t. Bioethics: A specific d o m a in o f ethics th a t is fo cu s ed o n m o r a l issues in th e fie ld o f h e a lth c are. Black Death: D u r in g th e M i d d l e A g e s , a series o f h o r r ib le e p id e m ic s , in c lu d in g th e B la c k D e a th o r b u b o n ic p la g u e , ra v a g e d th e c iv iliz e d w o r ld . I n th e 1 3 0 0 s , E u ro p e , A s ia , a n d A fr ic a s a w n e a rly h a lf th e ir p o p u la tio n s lo s t to th e b u b o n ic p la g u e . Bolton, Frances Payne: T h is c o n g re s s io n a l re p re s e n ta tiv e fr o m O h io is c re d ­ ite d w it h th e fo u n d in g o f th e C a d e t N u rs e C o rp s th ro u g h th e B o lto n A c t o f 1 9 4 5 . B y th e e n d o f W o r ld W a r I I , m o re th a n 1 8 0 ,0 0 0 n u rs in g students h a d been tr a in e d th ro u g h th is a ct, w h ile a d v a n c e d p ra c tic e g ra d u a te nurses in p s y c h ia try a n d p u b lic h e a lth n u rs in g h a d re c e iv e d g ra d u a te e d u c a tio n to increase th e n u m b e rs o f n u rse e d u ca to rs. Boundaries: In n u rs in g , b o u n d a rie s c a n be th o u g h t o f in te rm s o f a p p r o ­ p ria te p ro fe s s io n a l b e h a v io r th a t serves to m a in ta in tru s t b e tw e e n p a tie n ts a n d nurses a n d to m a in ta in n urses’ g o o d s ta n d in g w it h in th e ir p ro fe s s io n . Breckenridge, Mary: F o u n d e r o f th e F ro n tie r N u rs in g S ervice. Brewster, Mary: A c o lle a g u e o f L i l li a n W a l d , B re w s te r e s ta b lis h e d th e H e n r y S tre e t S e ttle m e n t in th e s a m e n e ig h b o r h o o d in 1 8 9 3 . She q u it m e d ic a l schoo l a n d d e v o te d th e re m a in d e r o f h e r life to “ visio n s o f a b e tte r w o r ld ” fo r th e p u b lic ’s h e a lth . Brown Report: N u r s i n g f o r t h e F u t u r e o r th e B r o w n R e p o r t, a u th o r e d b y E s th e r L u c ille B r o w n in 1 9 4 8 a n d s p o n s o re d b y th e R u s s e ll Sage F o u n ­ d a tio n , w a s c ritic a l o f th e q u a lity a n d s tru c tu re o f n u rs in g schoo ls in th e U n ite d S ta te s. T h e B r o w n R e p o r t b e c a m e th e c a ta ly s t fo r th e im p le m e n ­ ta tio n o f e d u c a tio n a l n u rs in g p ro g ra m a c c re d ita tio n th ro u g h th e N a t io n a l L e a g u e fo r N u rs in g . Burnout: O c c u rs w h e n n u rse s c a n n o lo n g e r c o p e w i t h th e stresses a n d s tra in s o f p ro fe s s io n a l n u rs in g a n d c h o o s e to le a v e th e p ro fe s s io n to seek e m p lo y m e n t els ew h e re.

Cadet Nurse Corps: W o r l d W a r I I a n d th e r e s u ltin g severe s h o rta g e o f nurses o n th e h o m e fr o n t re s u lte d in th e d e v e lo p m e n t o f th e C a d e t N u rs e C o rp s .

Capitalistic society: P ro fit m o tiv a te d . E v e n th o u g h w e liv e in a c a p ita lis tic s o cie ty, n u rs in g in th e U n ite d States has b een p ro te c te d a g a in s t th e d e ta ils o f h e a lth c a re fin a n c e .

Career management: A p la n n e d lo g ic a l p ro g re s s io n o f o n e ’s p ro fe s s io n a l lif e t h a t in c lu d e s c le a r ly d e fin e d g o a ls a n d o b je c tiv e s a n d a p la n fo r a c h ie v e m e n t.

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Case law: E s ta b lis h e d fr o m c o u rt d e cis io n s, w h ic h m ig h t e x p la in o r in te r ­ p re t th e o th e r sources o f la w .

Case management: A c u rre n t n u rs in g m o d e l o f n u rs in g c are d e liv e ry , case m a n a g e m e n t re lie s o n c lin ic a l p a th w a y s to e v a lu a te c a re . T h e c r it ic a l p a th w a y re fe rs to e x p e c te d o u tc o m e s a n d in te rv e n tio n s th a t th e c o lla b ­ o ra tiv e p ra c tic e te a m establishes. T h e p ro fe s s io n a l n u rse is re s p o n s ib le fo r in itia tin g a n d u p d a tin g th e p la n o f c are , care m a p , o r c lin ic a l p a th w a y used to c o n s is te n tly g u id e a n d e v a lu a te c lie n t c are. Case manager: O rg a n iz e s p a tie n t c a re b y m a jo r d iag n o se s o r D R G s a n d focuses o n specific tim e fra m e s to ach ie ve p re d e te rm in e d p a tie n t o u tco m e s a n d c o n ta in costs. T h e case m a n a g e r m a k e s re fe rra ls to o th e r h e a lth c a re p ro v id e rs a n d m an ag e s th e q u a lity o f c are.

Chadwick Report: E d w in C h a d w ic k b e c a m e a m a jo r fig u re in th e d e v e lo p ­ m e n t o f th e fie ld o f p u b lic h e a lth in G r e a t B r ita in b y d r a w in g a tte n tio n to th e c o s t o f th e u n s a n ita ry c o n d itio n s t h a t s h o rte n e d th e life s p a n o f th e la b o rin g class a n d th e th re a ts to th e w e a lth o f B rita in . O n e consequence o f th e r e p o r t w a s th e e s ta b lis h m e n t o f th e firs t b o a rd o f h e a lth , th e G e n e ra l B o a rd o f H e a lt h fo r E n g la n d , in 1 8 4 8 .

CINAHL: T h e a u th o r it a t iv e re s o u rc e fo r n u rs in g a n d a llie d h e a lth p ro fe s ­ s io n als, stu d en ts, e d u c a to rs , a n d researchers.

Civil law: T h e la w o f c iv il o r p riv a te rig h ts , as o p p o s e d to c rim in a l la w . Clinical judgment: U se o f th e c lin ic ia n ’s e x p e rie n c e a n d k n o w le d g e in assess­ m e n t, d iag n o sis , p la n n in g , in te rv e n tio n , a n d e v a lu a tio n .

Clinical nurse leader (CNL): A n a d v a n c e d g e n e ra lis t ro le p re p a re d a t th e m a s te r’s lev el o f e d u c a tio n .

Clinical practice guidelines: D e v e lo p e d to g u id e c lin ic a l p ra c tic e a n d re p re ­ sent a n e ffo r t to p u t a la rg e b o d y o f evid en ce in to a m a n a g e a b le fo rm .

Cochrane Library: T h e C o c h ra n e L ib r a r y is a c o lle c tio n o f d a ta b a s e s th a t c o n ta in h ig h -q u a lity , in d e p e n d e n t e v id e n c e to in fo r m h e a lth c a re d e c is io n m a k in g .

Collaboration: T o w o r k jo in tly w it h o th ers . Collaborative critical pathway: R e fe rs to e x p e c te d o u tc o m e s a n d in te r v e n ­ tio n s t h a t th e c o lla b o r a tiv e p ra c tic e te a m e s ta b lis h e s , e m p h a s iz in g th e in te rd is c ip lin a ry c o lla b o ra tio n o f th e c ritic a l p a th w a y .

Collaborative practice: T h e p u rp o s e o f c o lla b o r a tio n is to a c h ie v e h ig h q u a lity c lie n t c are a n d c lie n t s a tis fa c tio n . A c o lla b o ra tiv e fr a m e w o r k w it h a n in te r d is c ip lin a r y te a m c a n a ls o li m i t costs as w e ll as im p r o v e q u a lity o f c are.

Comanagement: C o m a n a g e m e n t a n d re fe rra l re p re s e n t th e h ig h e s t le v e l o f c o lla b o ra tio n , in w h ic h p ro v id e rs a re re sp o n sib le a n d a c c o u n ta b le fo r th e ir

GLOSSARY

o w n aspects o f c are , a n d th e n p a tie n ts a re d ire c te d to o th e r p ro v id e rs w h e n th e p ro b le m is b e y o n d th e ir e xp e rtis e.

Communication, N urse o f the Future Nursing Core Com petencies : T h e N u r s e o f th e F u tu r e w i l l in te r a c t e ffe c tiv e ly w it h p a tie n ts , fa m ilie s , a n d c o lle a g u e s , fo s te r in g m u t u a l re s p e c t a n d s h a re d d e c is io n m a k in g , to e n h an ce p a tie n t s a tis fa c tio n a n d h e a lth o u tc o m e s . Competent: B e n n e r’s stage 3 , c o m p e te n t, is c h a ra c te riz e d b y th e a b ility to a n a ly z e p ro b le m s a n d p r io r it iz e . T h e n u rs e has a s o lid g ra s p o f th e ru les a n d p rin c ip le s . T h e n u rs e a t th is stage has h a d e x p e rie n c e in a v a r ie ty o f c lin ic a l s itu a tio n s a n d is a b le to d r a w o n p r io r k n o w le d g e a n d e x p e rie n c e .

Complementary and alternative medicine: C o m p le m e n ta ry m e d ic in e re fers to a n a p p r o a c h t h a t c o m b in e s c o n v e n tio n a l m e d ic in e w it h less c o n v e n ­ tio n a l o p tio n s , w h e re a s a lte rn a tiv e m e d ic in e is a n a p p ro a c h used in s te a d o f c o n v e n tio n a l m e d ic in e .

Complex adaptive systems (CASs): A c o lle c tio n o f in d iv id u a l agents th a t are fre e to a ct in w a y s n o t to ta lly p re d ic ta b le a n d w h o s e a ctio n s a re in te rc o n ­ n e c te d so th a t o n e a c tio n changes th e c o n te x t fo r o th e r agents o r u n its .

Concept: A c o n c e p t is a te r m o r la b e l th a t d escrib es a p h e n o m e n o n . T h e p h e n o m e n o n d esc rib ed b y a c o n c e p t m ig h t be e ith e r e m p iric a l o r a b s tra c t.

Concept mapping: In n u rs in g , c o n c e p t m a p p in g is used to o rg a n iz e a n d lin k in f o r m a t io n a b o u t a p a tie n t's h e a lth p ro b le m s so t h a t th e n u rs e c a n see re la tio n s h ip s a m o n g a p a tie n t’s p ro b le m s a n d p la n in te rv e n tio n s th a t c an address m o re th a n o n e p ro b le m . Conceptual model: D e fin e d as a set o f c o n c e p ts a n d s ta te m e n ts th a t in te ­ g ra te th e concepts in to a m e a n in g fu l c o n fig u ra tio n .

Confidentiality: T o f u lf il l th e ir s o c ia l c o n tr a c t to p r o v id e n u r s in g c a re , n urses m u s t o fte n g a th e r s e n s itiv e in f o r m a t io n fr o m p a tie n ts . T h u s , th e n u rs e , a lo n g w it h o th e r c a re g iv e rs , has th e o b lig a tio n to k e e p h e a lth c a re in fo r m a tio n c o n fid e n tia l. P riv a c y is th e r ig h t o f th e p a tie n t. C o n fid e n tia lity is th e o b lig a tio n o f a ll h e a lth c a re p ro v id e rs .

Consultations: O b ta in in g th e o p in io n o f a s p ecialist o r o th e r c a re g iv e r. Consumerism: T h e c o n c e p t o f c o n s u m e rs h a v in g m o re c o n tr o l o f th e ir h e a lth c a re e xp erien ces.

Continuous quality improvement (CQI): A s tru c tu re d o rg a n iz a tio n a l process t h a t in v o lv e s p e rs o n n e l in p la n n in g a n d im p le m e n tin g th e c o n tin u o u s flo w o f im p ro v e m e n ts in th e p ro v is io n o f q u a lity h e a lth c are th a t m eets o r exceeds e x p e c ta tio n s . Core values: T h o s e v alu e s th a t a re m o s t im p o r t a n t to us; th e v alu e s th a t define w h o w e a re as h u m a n beings. In 1 9 9 8 , th e A m e ric a n A s s o c ia tio n o f C olleges o f N u rs in g d e v e lo p e d five core values to fa c ilita te th e d e v e lo p m e n t

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o f p ro fe s s io n a l n u rs in g valu es. T h e core values e m b ra c e d b y th e A A C N are h u m a n d ig n ity , in te g rity , a u to n o m y , a ltru is m , a n d social justice.

Critical pathway: R e fe rs to e x p e c te d o u tc o m e s a n d in te rv e n tio n s th a t th e c o lla b o ra tiv e p ra c tic e te a m establishes.

Critical thinking: T h e a b ility to th in k in a s y s te m a tic a n d lo g ic a l m a n n e r , s o lv e p r o b le m s , m a k e d e c is io n s , a n d e s ta b lis h p r io r it ie s in th e c lin ic a l s e ttin g . C r itic a l th in k in g is th e c o m p e te n t use o f th in k in g s kills a n d a b ili­ ties to m a k e s o u n d c lin ic a l ju d g m e n ts a n d safe decisions.

Cultural competence: T h e a b ilit y to in te r a c t e ffe c tiv e ly w i t h p e o p le o f d iffe re n t c u ltu re s . C u ltu r a l c o m p e te n c e c o m p rise s a w a ren e s s o f o n e ’s o w n w o r ld v ie w s , a ttitu d e t o w a r d c u lt u r a l d iffe re n c e s , k n o w le d g e o f d iffe r e n t c u ltu ra l p ra ctice s, a n d c ro s s -c u ltu ra l s kills.

Databases: A c o lle c tio n o f e le c tro n ic d a ta o f in d iv id u a l re c o rd s th a t a re s y s te m a tic a lly o rg a n iz e d , in d e x e d , a n d c ro ss -refe re n ce d . A d a ta b a s e a llo w s fo r th e ra p id c o lle c tio n , o rg a n iz a tio n , m a n ip u la tio n , a n d analysis o f d a ta . Deaconesses: N u r s in g w a s m o s t in flu e n c e d b y C h r is tia n ity w it h th e b e g in ­ n in g o f deaconesses, o r fe m a le s erv an ts, d o in g th e w o r k o f G o d b y m in is ­ te rin g to th e needs o f o th e rs . T h is ro le o f th e deaconess in th e c h u rc h w a s c o n s id e re d a fo r w a r d step in th e d e v e lo p m e n t o f n u rs in g , a n d in th e 1 8 0 0 s w o u ld s tro n g ly in flu e n c e th e y o u n g F lo re n c e N ig h tin g a le . Delano, Jane A.: D ir e c t o r o f n u r s in g in th e A m e r ic a n R e d C ro s s , she in itia t e d a n a tio n a l p u b lic ity c a m p a ig n to r e c r u it y o u n g w o m e n to e n te r nurses’ tra in in g . Delegation: T h e p ro c e s s b y w h ic h r e s p o n s ib ilit y a n d a u t h o r it y f o r p e rfo r m in g a c e rta in ta s k a re tra n s fe rre d to a n o th e r in d iv id u a l. Deontology: R e fe rs to a c tio n s t h a t a re d u ty b a s e d , n o t b a s e d o n th e ir re w a rd s , h a p p in e s s , o r c onsequences. O n e o f th e m o s t in flu e n tia l p h ilo s o ­ ph e rs fo r th e d e o n to lo g ic w a y o f th in k in g w a s Im m a n u e l K a n t, a G e rm a n p h ilo s o p h e r fr o m th e 1 7 0 0 s . Dignity: I n g e n e ra l te rm s , a p e rs o n has d ig n ity i f h e o r she is in a s itu a tio n w h e re his o r h e r c a p a b ilitie s c a n be e ffe c tiv e ly a p p lie d . Disaster preparedness: P la n s d e s ig n a tin g re s p o n s e d u r in g a n e m e rg e n c y a n d o fte n c o o r d in a te d b y lo c a l, s ta te , a n d fe d e ra l g ro u p s . F ir e fig h te r s , p o lic e o ffice rs , a n d h e a lth c a re p ro fes s io n als are p a r t o f respo nse te am s . Dix, Dorothea Linde: A B o s to n s c h o o lte a c h e r, D i x b e c a m e a w a r e o f th e h o rre n d o u s c o n d itio n s in p ris o n s a n d m e n ta l in s titu tio n s . F o r th e re st o f h e r life , D o r o th e a D i x s to o d o u t as a tireless z e a lo t fo r th e h u m a n e tr e a t­ m e n t o f th e in s a n e a n d im p ris o n e d . She h a d e x c e p tio n a l s a v v y in d e a lin g w it h leg is lato rs. Dock, Lavinia Lloyd: B ec am e a m ilit a n t s u ffra g is t, lin k in g w o m e n ’s ro les as nurses to th e e m e rg in g w o m e n ’s m o v e m e n t in th e U n ite d States.

GLOSSARY

Doctor of Nursing Practice (DNP): T h is p ra c tic e d e g re e e n co m p a s se s a n y fo r m o f n u rs in g in te rv e n tio n th a t in flu e n ce s h e a lth c a re o u tc o m e s fo r in d i­ v id u a l p a tie n ts , m a n a g e m e n t o f c a re fo r in d iv id u a ls a n d p o p u la tio n s , a d m in is tr a tio n o f n u rs in g a n d h e a lth o r g a n iz a tio n , a n d th e d e v e lo p m e n t a n d im p le m e n ta tio n o f h e a lth p o lic y . T h is p ra c tic e degree is n o t th e sam e as th e re s e a rc h d o c to r a l d e g re e, a n d g ra d u a te s a re p re p a re d to b le n d c lin ­ ic a l, e c o n o m ic , o r g a n iz a t io n a l, a n d le a d e rs h ip s k ills a n d to use science in im p r o v in g th e d ire c t c a re o f p a tie n ts , c a re o f p a tie n t p o p u la tio n s , a n d p ra c tic e th a t s u p p o rts p a tie n t c a re .

Durable power of attorney: T h e le g a l d o c u m e n t w it h th e m o s t s tre n g th , th is is a w r it te n d ire c tiv e in w h ic h a d e sig n a te d p e rs o n is a llo w e d to m a k e e ith e r g e n e ra l o r h e a lth c a re decisions fo r a p a tie n t. EBSCO Publishing: A n e le c tro n ic jo u rn a ls service a v a ila b le to b o th a c a d e m ic a n d c o rp o ra te s u b s c rib e rs . I t aggregates access to e le c tro n ic jo u rn a ls fr o m v a rio u s p u b lis h e rs .

Electronic health record: R e p re s e n ts m u ltip le system s th a t a re in te rfa c e d to s h a re d a ta a n d n e tw o r k e d to s u p p o r t in f o r m a t io n m a n a g e m e n t a n d c o m m u n ic a tio n w it h in a h e a lth c a re o rg a n iz a tio n . Email: A m e th o d o f c o m p o s in g , s e n d in g , re c e iv in g , a n d s to rin g m essages o v e r e le c tr o n ic c o m m u n ic a tio n s y s te m s ; th e m o s t c o m m o n use o f th e In te rn e t.

Environment: O n e o f th e fo u r concepts o f th e m e ta p a ra d ig m o f n u rs in g ; th e e n v iro n m e n t w it h in w h ic h th e p e rs o n exists.

ERIC: T h e E d u c a tio n a l R e s o u rc e In fo r m a t io n C e n te r is a n a tio n a l in fo r m a ­ tio n system s u p p o rte d b y L ib r a r y o f E d u c a tio n , a n d m e n t. I t p ro v id e s access C u r r e n t In d e x o f J o u rn a ls

th e U .S . D e p a r tm e n t o f E d u c a tio n , th e N a t io n a l th e O ffic e o f E d u c a tio n a l R e s e a rc h a n d Im p r o v e ­ to in f o r m a t io n fr o m jo u r n a ls in c lu d e d in th e in E d u c a tio n a n d R esources in E d u c a tio n In d e x .

Ethic of care: P e rs o n a l re la tio n s h ip s a n d r e la tio n s h ip re s p o n s ib ilitie s a re e m p h a s ize d in th is e th ic . Im p o r t a n t concepts in th is a p p ro a c h a re c o m p a s ­ s io n , e m p a th y , s y m p a th y , c o n c e rn fo r o th e rs , a n d c a rin g fo r o th ers .

Ethical dilemma: A n e th ic a l d ile m m a is a s itu a tio n in w h ic h a n in d iv id u a l is c o m p e lle d to m a k e a c h o ic e b e tw e e n tw o a c tio n s th a t w i l l a ffe c t th e w e ll­ b e in g o f a s e n tie n t b e in g a n d b o th a c tio n s c a n be re a s o n a b ly ju s tifie d as b e in g g o o d , n e ith e r a c tio n is r e a d ily ju s tifia b le as g o o d , o r th e goodness o f th e a c tio n s is u n c e rta in . O n e a c tio n m u s t be ch o se n , th e re b y g e n e ra tin g a q u a n d a ry fo r th e p e rs o n o r g ro u p w h o m u s t m a k e th e ch o ice .

Ethical principlism: A p o p u la r a p p ro a c h to e th ics in h e a lth c a re . In v o lv e s usin g a set o f e th ic a l p rin c ip le s th a t are d ra w n fr o m th e c o m m o n o r w id e ly sh ared c o n c e p tio n o f m o r a lity . T h e fo u r p rin c ip le s th a t are m o s t c o m m o n ly used in b io e th ic s a re a u to n o m y , beneficence, n o n m a le fic e n c e , a n d ju stice .

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GLOSSARY

Ethics: T h e s tu d y o f id e a l h u m a n b e h a v io r a n d id e a l w a y s o f b e in g . T h e a p p ro a c h e s to ethics a n d th e m e a n in g s o f e th ic a lly re la te d c o n ce p ts h a v e v a r ie d o v e r tim e a m o n g p h ilo s o p h e rs a n d e th ic is ts . A s a p h ilo s o p h ic a l d is c ip lin e o f s tu d y , e th ic s is a s y s te m a tic a p p r o a c h to u n d e r s ta n d in g , a n a ly z in g , a n d d is tin g u is h in g m a tte rs o f r ig h t a n d w r o n g , g o o d a n d b a d , a n d a d m ira b le a n d d e p lo ra b le as th e y e xist a lo n g a c o n tin u u m a n d as th e y re la te to th e w e ll-b e in g o f a n d th e re la tio n s h ip s a m o n g s e n tie n t beings.

Evidence-based practice: A llo w s nurses to p ro v id e h ig h -q u a lity p a tie n t care b a se d o n re s e a rc h e v id e n c e a n d k n o w le d g e r a th e r th a n tr a d it io n , m y th s , h u n c h e s , a d v ic e fr o m p e e rs , o u td a te d te x tb o o k s , o r e ve n w h a t th e n u rse le a rn e d in schoo l 5 , 1 0 , o r 15 years a go. Evidence-based practice, Nurse of the Future Nursing Core Competencies: T h e N u r s e o f th e F u tu r e w i l l id e n tify , e v a lu a te , a n d use th e best c u rre n t evid en ce c o u p le d w it h c lin ic a l e x p e rtis e a n d c o n s id e ra tio n o f p a tie n t’s p r e f­ erences, e x p e rie n c e , a n d values to m a k e p ra c tic e decisions. Expert: B e n n e r’s fin a l stage, e x p e rt, has m o v e d b e y o n d a fix e d set o f ru le s. T h e re is a n in te rn a liz e d u n d e rs ta n d in g g ro u n d e d in a w e a lth o f e x p e rie n c e as w e ll as d e p th o f k n o w le d g e . T h e e x p e rt is a lw a y s le a rn in g a n d a lw a y s q u e s tio n in g usin g su b jec tive a n d o b je c tiv e k n o w in g . Expert witness: S o m e o n e w h o has c o m p le x k n o w le d g e b e y o n d th e g e n e ra l k n o w le d g e o f m o s t p e o p le in th e c o u rt o r o n th e ju ry . Feedback: In f o r m a t io n t h a t w e re c e iv e f r o m o th e rs a b o u t th e im p a c t o f o u r b e h a v io r o n th e m ; it a llo w s us to v ie w o u rs e lv e s f r o m a n o th e r ’s p e rsp ec tive . Formation: A pro cess th a t o ccurs o v e r tim e th a t d e n o te s th e d e v e lo p m e n t o f p e rc e p tu a l a b ilitie s , th e a b ility to d r a w o n k n o w le d g e a n d s k ille d k n o w ­ h o w , a n d a w a y o f b e in g a n d a c tin g in p ra c tic e a n d in th e w o r ld . Frontier Nursing Service: T h e firs t o rg a n iz e d m id w ife r y service in th e U n ite d S tates w a s th e F r o n tie r N u r s in g S e rv ic e . I t s e rv e d is o la te d A p p a la c h ia n c o m m u n itie s o n h o rs e b a c k u n til W o r ld W a r I I . Functional nursing: I n th e fu n c t io n a l n u r s in g s y s te m , c lie n t n e e d s a re d iv id e d in to ta sk s , a n d each ta s k is assig ned to R N s , L P N s , o r U A P s . T h is sys te m is a d v a n ta g e o u s because e ac h ass ig n ed c a re g iv e r b e co m e s h ig h ly e ffic ie n t in p e rfo r m in g th e assigned tasks. Futile care: W h e n a tr e a tm e n t has n o p h y s io lo g ic b e n e fit fo r a te r m in a lly ill p e rs o n .

Gap between education and practice: G a p th a t lo o m s la rg e r as th e h e a lth ­ c a re s e ttin g c o n t in u a lly c h a n g e s as a r e s u lt o f a d v a n c e d te c h n o lo g y , k n o w le d g e e x p lo s io n , s h o rte r h o s p ita l stays, a n d r a p id changes in disease m a n a g e m e n t.

GLOSSARY

Gerogogy: T h e t r a n s f e r r in g o f e s s e n tia l i n f o r m a t i o n t h a t h a s b e e n d e sig n e d , m o d ifie d , a n d a d a p te d to a c c o m m o d a te fo r th e p h y s io lo g ic a n d p s y c h o lo g ic changes in e ld e rly perso ns b y ta k in g in to a c c o u n t th e p e rs o n ’s disease process, a g e -re la te d chang es, e d u c a tio n a l le v e l, a n d m o tiv a tio n .

Global aging: In th e p o s t- W o r ld W a r I I e ra, fe r tility rates h a v e in crea se d as d e a th rates decreased in b o th d e v e lo p e d a n d d e v e lo p in g c o u n trie s , le a d in g to th e a g in g o f th e g lo b a l p o p u la tio n a t a n u n p re c e d e n te d ra te .

Goldmark Report: A s ig n ific a n t r e p o r t , k n o w n s im p ly as T h e G o ld m a r k R e p o r t, N u r s i n g a n d N u r s i n g E d u c a t io n in th e U n ite d S ta tes, w a s released in 1 9 2 2 a n d a d v o c a te d th e e s ta b lis h m e n t o f u n iv e rs ity schoo ls o f n u rs in g to tr a in n u rs in g lead ers.

Goodrich, Annie: F irs t d e an o f th e A r m y S ch o o l o f N u rs in g . Greek era: T h e p e rio d s o f G r e e k h is to ry in c la ss ica l a n tiq u ity , la s tin g ca. 7 5 0 b . c . (th e a rc h a ic p e rio d ) to 1 4 6 b . c . (th e R o m a n c o n q u e s t). I t is g e n e r­ a lly c o n s id e re d to be th e s e m in a l c u ltu re th a t p ro v id e d th e fo u n d a tio n o f W e s te rn c iv iliz a t io n . T im e o f H ip p o c r a te s , fa th e r o f m e d ic in e . In G r e e k s o cie ty, h e a lth w a s c o n s id e re d to re s u lt fr o m a b a la n c e b e tw e e n m in d a n d body.

Group discussions: G r o u p d is c u s s io n s c a n a s s is t n u r s in g s tu d e n ts in c o n n e c tin g c lin ic a l events o r d e cis io n s w it h in fo r m a t io n o b ta in e d in th e c la s s ro o m . T h is fo r m o f c o o p e ra tiv e le a rn in g o c cu rs w h e n g ro u p s w o r k to g e th e r to m a x im iz e th e ir o w n a n d each o th e r ’s le a rn in g . Health: O n e o f th e fo u r c o n c e p ts o f th e m e t a p a r a d ig m o f n u r s in g ; th e h e a lth -illn e s s c o n tin u u m w it h in w h ic h th e p e rs o n fa lls a t th e tim e o f th e in te ra c tio n w it h th e n u rse . Health Belief Model (HBM): T h is m o d e l w a s o r ig in a lly d e v e lo p e d to p re d ic t th e lik e lih o o d o f a p e rs o n fo llo w in g a re c o m m e n d e d a c tio n a n d to u n d e r­ s ta n d th e p e r s o n ’ s m o t iv a t io n a n d d e c is io n m a k in g r e g a r d in g s e e k in g h e a lth services. Health literacy: T h e a b il i t y to r e a d , u n d e r s ta n d , a n d a c t o n h e a lt h in fo r m a tio n .

Health Source: T h e N u r s in g /A c a d e m ic E d it io n p ro v id e s m o re th a n 5 5 0 s c h o la rly f u ll- t e x t jo u rn a ls , in c lu d in g m o re th a n 4 5 0 p e e r-re v ie w e d jo u r ­ n a ls fo c u s in g o n m a n y m e d ic a l d is c ip lin e s , in c lu d in g n u rs in g a n d a llie d h e a lth .

Healthcare delivery system: T h e h e a lth c a re d e liv e ry s ys te m has c h a n g e d p r o fo u n d ly o v e r th e p a s t s ev era l decades fo r s e v e ra l re a s o n s . P o p u la tio n s h ifts (d e m o g r a p h ic c h a n g e s ), c u ltu r a l d iv e rs ity , th e p a tte rn s o f diseases, a d v a n c e s in te c h n o lo g y , a n d e c o n o m ic c h a n g e s h a v e a ll a ffe c te d th e d e liv e ry o f h e a lth c are.

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Henry Street Settlement: T h e H e n r y S tre e t S e ttle m e n t w a s a n in d e p e n ­ d e n t n u rs in g service w h e re W a ld liv e d a n d w o r k e d . T h is la te r b e c a m e th e V is itin g N u rs e A s s o c ia tio n o f N e w Y o r k C ity , w h ic h la id th e fo u n d a tio n fo r th e e s ta b lis h m e n t o f p u b lic h e a lth n u rs in g in th e U n ite d States.

HIPAA: T h e H e a lt h In s u ra n c e P o r ta b ility a n d A c c o u n ta b ility A c t ( H IP A A ) w a s e n a c te d b y th e U .S . C ongress in 1 9 9 6 . I t w a s in te n d e d to im p ro v e th e e ffic ie n c y a n d e ffe c tiv e n e s s o f th e h e a lth c a re sys te m b y e n c o u ra g in g th e d e v e lo p m e n t o f a h e a lth in fo r m a t io n s ys te m . S e v e ra l areas a re a d d re ss ed b y th e a c t, in c lu d in g s im p lify in g h e a lth c a re c la im s , d e v e lo p in g s ta n d a rd s fo r d a ta tra n s m is s io n , a n d im p le m e n tin g p riv a c y re g u la tio n s . Holistic care: H o lis tic c are is a p h ilo s o p h ic a l a p p ro a c h th a t em p h asizes th e un iq u en ess o f th e in d iv id u a l, in w h ic h in te ra c tin g w h o le s are m o re im p o r ­ ta n t th a n th e s u m o f each p a r t. T h a t is, th e w h o le p e rs o n is g re a te r th a n m e r e ly e a c h c o m p o n e n t p a r t o f th e c lie n t: b io p h y s ic a l, p s y c h o lo g ic a l, s o cia l, a n d s p iritu a l p a rts . Idealism: Id e a lis m c o n ta in s th es e a s s u m p tio n s : T h e w o r ld is e v o lv in g . T h e re is m o re th a n m eets th e eye. T h e s o cia l w o r ld is c re a te d . R e a lit y is a c o n c e p tio n p e rc e iv e d in th e m in d . T h in k in g is d y n a m ic a n d c o n s tru c tiv e . Incivility: B u lly in g th a t c an in c lu d e b e h a v io rs such as c ritic is m , h u m ilia tio n in fr o n t o f o th e rs , u n d e rv a lu e d e ffo rts , a n d te as in g . Informatics and technology, Nurse of the Future Nursing Core Competencies: T h e N u rs e o f th e F u tu re w ill use in fo r m a tio n a n d te c h n o lo g y to c o m m u n i­ c ate , m a n a g e k n o w le d g e , m itig a te e rro r, a n d s u p p o rt d e cis io n m a k in g . Informed consent: M a n d a te s to th e p h y s ic ia n o r in d e p e n d e n t h e a lth c a re p r a c t itio n e r th e s e p a ra te le g a l d u ty to d is c lo s e n e e d e d m a t e r ia l fa c ts in te rm s th a t p a tie n ts c a n re a s o n a b ly u n d e rs ta n d so t h a t th e y c a n m a k e an in fo r m e d c h o ic e . M e a n in g f u l in f o r m a t io n m u s t be d is c lo s e d e ve n i f th e c lin ic ia n does n o t b e lie ve th a t th e in fo r m a tio n w ill be b e n e fic ia l. Integrity: M a in t a in in g in te g r ity in v o lv e s a c tin g c o n s is te n tly w it h p e rs o n a l v a lu e s a n d th e v a lu e s o f th e p ro fe s s io n . I n a h e a lth c a r e s y s te m o fte n b u r d e n e d w i t h c o n s tra in ts a n d s e lf-s e rv in g g ro u p s a n d o r g a n iz a tio n s , th re a ts to in te g rity c an be a serious p itf a ll fo r nurses. Interdisciplinary healthcare team: T h e in te r d is c ip lin a r y h e a lth c a re te a m c a n be e s p e c ia lly e ffe c tiv e in o u t p a t ie n t serv ice s. H e r e , th e p h y s ic ia n o r n u rse p ra c titio n e r sees th e c lie n t, a n d c o n s u lta tio n s a re p u t in to p ra c tic e as n e e d e d . T h e te am s d e a l w it h c lie n t-re la te d p ro b le m s a n d h e lp th e p a tie n ts progress th ro u g h th e c lin ic a n d h o s p ita l e ffic ie n tly . Interpersonal role conflict: C a n o c c u r w h e n in d iv id u a ls a re w o r k i n g to g e th e r a n d th e e x p e c ta tio n s a re in c o m p a tib le a n d c a n a ffe c t in te r d is c i­ p lin a r y c o lla b o ra tio n .

GLOSSARY

Iowa Model of Evidence-Based Practice: R es em b le s a d e c is io n -m a k in g tree th a t id e n tifie s e ith e r p ro b le m -fo c u s e d o r k n o w le d g e -fo c u s e d trig g e rs th a t in itia te th e process in th e o rg a n iz a tio n . Jenner, Edward: I n B r ita in , E d w a r d Jen n e r d is c o v e re d a n e ffe c tiv e m e th o d o f v a c c in a tio n a g a in s t th e d re a d e d s m a llp o x v iru s in 1 7 9 8 .

Journaling: T h e p ro c e s s b y w h ic h o n e sits d o w n q u ie tly o n a d a ily o r r e g u la r basis to t h in k a n d re c o r d o n e ’s th o u g h ts a n d id e a s in w r it in g . K e e p in g a jo u r n a l o f c lin ic a l experiences th a t w e re m e a n in g fu l o r tr o u b lin g to y o u is a re c o m m e n d e d w a y to h e lp e n h an ce a n d d e v e lo p re a s o n in g skills.

Justice: T h e fa ir d is t r ib u t io n o f b e n e fits a n d b u rd e n s . In re g a r d to p r in c ip lis m , ju s tic e m o s t o fte n re fe rs to th e d is t r ib u t io n o f scarce h e a lth c a re resources.

Klebs, Edwin: E d w in K le b s ( 1 8 3 4 - 1 9 1 3 ) p r o v e d th e g e rm th e o r y , t h a t is, th a t g e rm s a re th e causes o f in fe c tio u s diseases. T h is d is c o v e ry o f th e b a c te ria l o rig in o f diseases c a n be c o n s id e re d th e g re a te s t a c h ie v e m e n t o f th e 1 8 0 0 s . Koch, Robert: R o b e r t K o c h ( 1 8 4 3 - 1 9 1 0 ) , a p h y s ic ia n k n o w n f o r h is re s e a rc h in a n th r a x , is re g a rd e d as th e fa th e r o f m ic r o b io lo g y . B y id e n ti­ fy in g th e o rg a n is m th a t c au s ed c h o le ra , V ib r io c h o l e r a e , h e also d e m o n ­ s tra te d its tra n s m is s io n b y w a te r, fo o d , a n d c lo th in g . Leadership, Nurse of the Future Nursing Core Competencies: T h e N u rs e o f th e F u tu re w i l l in flu e n c e th e b e h a v io r o f in d iv id u a ls w it h in th e ir e n v ir o n ­ m e n t in a w a y th a t w ill fa c ilita te th e e s ta b lis h m e n t a n d a c q u is itio n /a c h ie v e m e n t o f sh are d goals. Learning domains: Id e n tific a tio n o f th e le a rn in g d o m a in re flec ts th e ty p e o f le a rn in g d e s ire d as a re s u lt o f th e p a tie n t e d u c a tio n p ro ce ss . L e a rn in g occurs in th re e d o m a in s : th e c o g n itiv e , th e p s y c h o m o to r, a n d th e a ffe c tiv e .

Learning style: A p a r t ic u la r m e th o d o f in te r a c t in g w it h , ta k in g in , a n d p ro ce ss in g in fo r m a t io n th a t a llo w s a n in d iv id u a l to le a rn . L e a rn in g styles a re g e n e ra lly c a te g o riz e d as v is u a l, a u d ito ry , o r ta c tile /k in e s th e tic . Licensure: T h e g ra n tin g o f p e rm is s io n to p e r fo r m p ro fe s s io n a l a ctio n s th a t m a y n o t be le g a lly p e rfo rm e d b y perso ns w h o d o n o t h a ve th is p e rm is s io n . Life management: E n ta ils d e te rm in in g w h a t is tr u ly im p o r t a n t to y o u a n d m a k in g p o s itiv e c h o ic e s a b o u t h o w , w h e r e , a n d w i t h w h o m y o u s p e n d y o u r p re c io u s h o u rs . Lifelong learning: A p ro fe s s io n a l a n d p e rs o n a l a p p r o a c h t h a t e m b ra c e s o p p o rtu n itie s to in c re a s e o n e ’s u n d e rs ta n d in g a n d s kills th r o u g h o u t o n e ’s c a re e r a n d life . Lister, Joseph: J o s e p h L is te r ( 1 8 2 7 - 1 9 1 2 ) w a s a p h y s ic ia n w h o set o u t to decrease th e m o r t a lit y re s u ltin g fr o m in fe c tio n a fte r s u rg e ry . H e used

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P a s te u r’s re s e a rc h to e v e n tu a lly a rriv e a t a c h e m ic a l a n tis e p tic s o lu tio n o f c a rb o lic a c id fo r use in s u rg e ry . W id e ly re g a rd e d as th e fa th e r o f m o d e rn s u rg e ry, he p ra c tic e d his a n tis e p tic su rg e ry w it h g re a t resu lts, a n d th e L is te r ia n p rin c ip le s o f asepsis c h a n g e d th e w a y p h y s ic ia n s a n d nurses p ra c tic e to th is d a y .

Listservs: A fo r m o f g ro u p e m a il th a t p ro v id e s a n o p p o r tu n ity fo r p e o p le w it h s im ila r interests to share in fo r m a tio n . Living will: A f o r m a l le g a l d o c u m e n t t h a t p ro v id e s w r it t e n d ire c tio n s c o n c e rn in g m e d ic a l care th a t is to be p ro v id e d in specific c irc u m s ta n ce s. Lobbyist: P erso n w h o d e ve lo p s e x p e rtis e o n p ro p o s e d le g is la tio n a n d p re s ­ ents to leg is lato rs th a t in fo r m a t io n c le a rly a n d c o n cisely.

Malpractice: T h e fa ilu re o f a p ro fe s s io n a l to use such c are as a re a s o n a b ly p ru d e n t m e m b e r o f th e p ro fe s s io n w o u ld use u n d e r s im ila r c irc u m s ta n c e s , w h ic h leads to h a rm .

Managed care: M a n a g e d c a re is a m a r k e t a p p r o a c h b a s e d o n m a n a g e d c o m p e titio n as a m a jo r s tra te g y to c o n ta in h e a lth c a re costs a n d is s till th e d o m in a n t a p p ro a c h to d a y .

Manager: A ll nurses a re m a n a g e rs . T h e y d ire c t th e w o r k o f p ro fe s s io n a ls a n d n o n p ro fe s s io n a ls to ach ie ve e x p e c te d o u tco m e s o f care.

Medical directive: A m e d ic a l d ire c tiv e is n o t a fo r m a l le g a l d o c u m e n t b u t p ro v id e s specific w r it te n in s tru c tio n s c o n c e rn in g th e ty p e o f care a n d tr e a t­ m en ts th a t in d iv id u a ls w a n t to receive i f th e y b e co m e in c a p a c ita te d .

MEDLINE: T h e la rg e s t b io m e d ic a l lite r a tu re d a ta b a s e th a t p ro v id e s a u th o r i­ ta tiv e m e d ic a l i n f o r m a t io n o n m e d ic in e , n u r s in g , d e n tis tr y , v e te r in a r y m e d ic in e , th e h e a lth c a re system , a n d p re c lin ic a l sciences.

Mental health: A le v e l o f c o g n itiv e o r e m o tio n a l w e ll-b e in g . T h e d e fin itio n o f m e n ta l h e a lth is a ffe c te d b y c u ltu ra l d iffe re n c e s , s u b je c tiv e assessm ents, a n d c o m p e tin g p ro fe s s io n a l th e o rie s . A s p ro fe s s io n a l nurses e x p e rie n c e th e stresses th a t c o m e w it h to d a y ’s h e a lth c a re e n v iro n m e n t, th e y are o b lig e d to assess th e ir o w n m e n ta l h e a lth needs.

Mentoring: A d e v e lo p m e n ta l, e m p o w e r in g , a n d n u r t u r in g r e la tio n s h ip th a t e xte n d s o v e r tim e a n d in w h ic h m u tu a l s h a rin g , le a rn in g , a n d g ro w th o c cu r in a n a tm o s p h e re o f respect, c o lle g ia lity , a n d a ffirm a tio n .

Metaparadigm: T h e m o s t g lo b a l p e rs p e c tiv e o f a d is c ip lin e ; acts as a n e n c a p s u la tin g u n it, o r fr a m e w o r k , w it h in w h ic h th e m o re re s tric te d s tru c ­ tu res d e v e lo p .

Mind mapping: T h e te c h n iq u e o f a rra n g in g ideas a n d th e ir in te rc o n n e c tio n s v is u a lly ; a p o p u la r b r a in s to r m in g te c h n iq u e . I t is used to g e n e ra te , v is u ­ a liz e , s tru c tu r e , a n d c la s s ify id ea s a n d is used as a n a id in o r g a n iz a tio n , p ro b le m s o lv in g , a n d d e c is io n m a k in g .

GLOSSARY

Mission statement: A c le a r, concise s ta te m e n t o f w h o y o u are a n d w h a t y o u a re a b o u t in life . I t c a n be a p o w e r fu l to o l fo r h e lp in g y o u fin d m e a n in g a n d g ive d ire c tio n to y o u r life .

Models of patient care delivery: N u rs e s a re le a d e rs a n d m a n a g e rs w it h in v a rio u s m o d e ls o f p a tie n t c a re d e liv e ry . T h e m e th o d s m ig h t d iff e r s ig n ifi­ c a n tly fr o m o n e o r g a n iz a tio n to a n o th e r. T h e p u rp o s e o f a n u rs in g c are d e liv e ry system is to p ro v id e a f r a m e w o r k fo r nurses to d e liv e r c a re to a specific g ro u p o f p a tie n ts .

Moral reasoning: P e rta in s to m a k in g decisions a b o u t h o w h u m a n s o u g h t to be a n d act.

Moral right: T h e r ig h t to p e r f o r m c e r t a in a c tiv itie s (1 ) b e c a u s e th e y c o n fo r m to th e a c c e p te d s ta n d a rd s o r id eas o f a c o m m u n ity (o r o f a la w , o r o f G o d , o r o f c o n s c ie n c e ); o r (2 ) because th e y w i l l n o t h a r m , c o e rc e , re s tra in , o r in frin g e o n th e interests o f o th ers ; o r (3 ) because th e re a re g o o d r a tio n a l a rg u m e n ts in s u p p o rt o f th e v a lu e o f such a c tiv itie s .

Moral suffering: C a n be e x p e rie n c e d w h e n nurses a tte m p t to s o rt o u t th e ir e m o tio n s w h e n th e y fin d them selves in s itu atio n s th a t are m o ra lly u n satisfac­ to r y o r w h e n forces b e y o n d th e ir c o n tro l p re v e n t th e m fr o m in flu e n c in g o r c h an g in g these p e rceived u n s a tis fa c to ry m o ra l s itu atio n s. S u ffe rin g c an occur because nurses believe th a t situ atio n s m u s t be c h an g ed to b rin g w e ll-b e in g to them selves a n d others o r to a lle v ia te th e s u ffe rin g o f them selves a n d others.

Morals: S p e c ific b e lie fs , b e h a v io rs , a n d w a y s o f b e in g b a se d o n p e rs o n a l ju d g m e n ts d e riv e d fr o m o n e ’s e th ics . O n e ’s m o ra ls a re ju d g e d to be g o o d o r b a d th ro u g h s ys te m a tic e th ic a l analysis.

Multiculturalism: T h e r e is d iv e r s ity a m o n g th e m e m b e rs o f th e n u r s in g p ro fe s s io n in ra c e , age, a n d s o c io e c o n o m ic b a c k g ro u n d s . H o w e v e r , th e pre se n c e o f th is m u ltic u lt u r a lis m fo rc e c a n le a d to p e o p le fe e lin g t h r e a t­ e n e d , e s p e c ia lly i f th e c u ltu r e w it h in th e p ro fe s s io n does n o t e n c o u ra g e m u tu a l respect a n d a ccep tan ce.

National Guideline Clearinghouse: In c lu d e s s t r u c t u r e d s u m m a r ie s c o n ta in in g in f o r m a t io n a b o u t e ac h g u id e lin e , in c lu d in g c o m p a ris o n s o f g u id e lin e s c o v e rin g s im ila r to p ic s th a t s h o w areas o f s im ila rity a n d d iff e r ­ ences; fu ll te x t o r lin k s to fu ll te x t; o r d e r in g d e ta ils fo r fu ll g u id e lin e s ; a n n o ta te d b ib lio g ra p h ie s o n g u id e lin e d e v e lo p m e n t, e v a lu a tio n , im p le m e n ­ ta tio n , a n d s tru c tu re ; w e e k ly e m a il u p d a te s; a n d g u id e lin e archives. Negligence: D e fin e d as th e fa ilu r e to a c t as a re a s o n a b ly p r u d e n t p e rs o n w o u ld h a ve a c te d in a specific s itu a tio n . Networking: T h e pro cess b y w h ic h y o u g e t to k n o w p e o p le w it h in y o u r o rg a n iz a tio n a n d w it h in y o u r p ro fe s s io n .

Nightingale, Florence: N ig h t in g a le w a s id e n t if ie d as a tr u e “ a n g e l o f m e r c y ,” h a v in g r e fo r m e d m ilit a r y h e a lth c a re in th e C r im e a n W a r a n d

387

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h a v in g used h e r p o litic a l savvy to fo re v e r ch an g e th e w a y so ciety v ie w s th e h e a lth o f th e v u ln e ra b le , th e p o o r , a n d th e fo rg o tte n . She is p e rh a p s one o f th e m o s t w r itte n a b o u t w o m e n in h is to ry .

Nonmaleficence: T h e in ju n c t io n to “ d o n o h a r m ” is o fte n p a ir e d w it h beneficence, b u t a d iffe re n c e exists b e tw e e n th e tw o p rin c ip le s . B eneficence re q u ire s ta k in g a c tio n to b e n e fit o th e rs , w h e re a s n o n m a le fic e n c e in v o lv e s re fra in in g fr o m a c tio n th a t m ig h t h a rm o th ers . Nonvoluntary euthanasia: O c c u rs w h e n p e rs o n s a re n o t a b le to e xp ress th e ir d e cis io n a b o u t d e a th .

Novice: B e n n e r’s m o d e l id e n tifie s th e stages o f n o v ic e , a d v a n c e d b e g in n e r, c o m p e te n t, p ro fic ie n t, a n d e x p e rt th a t are based o n th e n u rs e ’s e x p e rie n c e in p ra c tic e . T h e firs t stage, n o v ic e , is c h a ra c te riz e d b y a la c k o f k n o w le d g e a n d e x p e rie n c e . I n th is stag e, th e fa c ts , ru le s , a n d g u id e lin e s fo r p ra c tic e a re th e fo cu s . R u le s fo r p ra c tic e are c o n te x t fre e , a n d th e s tu d e n t’s ta s k is to a c q u ire th e k n o w le d g e a n d skills. Nurse-managed centers: A ls o c a lle d n u r s in g c lin ic s a n d n u rs e p ra c tic e a rr a n g e m e n ts , th es e h e a lth c a r e d e liv e r y o p tio n s a re m e e tin g n e ed s in c o m m u n itie s across th e c o u n tr y . B ased o n th e p h ilo s o p h y o f p r im a r y care a n d e d u c a tio n , nurses a re o ffe rin g v ita l services a t a lo w e r cost.

Nursing: ( 1 ) A t t e n t io n to th e f u ll r a n g e o f h u m a n e x p e rie n c e s a n d respo nses to h e a lth a n d illn e s s w it h o u t re s tr ic tio n to a p ro b le m -fo c u s e d o r ie n ta tio n ; (2 ) in te g ra tio n o f o b je c tiv e d a ta w it h a n u n d e rs ta n d in g o f th e s u b jec tive e x p e rie n c e o f th e p a tie n t; (3 ) a p p lic a tio n o f s cien tific k n o w le d g e to th e processes o f d iag n o sis a n d tre a tm e n t; (4 ) p ro v is io n o f a c a rin g r e la ­ tio n s h ip th a t fa c ilita te s h e a lth a n d h e a lin g ; a n d (5 ) o n e o f th e fo u r concepts o f th e m e ta p a ra d ig m o f n u rs in g ; th e n u rs in g actio n s th em selves. Nursing ethics: S o m e tim es v ie w e d as a s u b c a te g o ry o f th e b ro a d e r d o m a in o f b io e th ic s , ju s t as m e d ic a l ethics is a s u b c a te g o ry o f b io e th ic s . H o w e v e r , c o n tro v e rs y c o n tin u e s a b o u t w h e th e r n u rs in g has u n iq u e m o r a l p ro b le m s in p ro fe s s io n a l p ra c tic e . Nursing faculty shortage: T h is s h o rta g e is lim it in g s tu d e n t c a p a c ity in n u rs in g p ro g ra m s across th e n a tio n . Nursing informatics (NI): T h e syn th esis o f c o m p u te r scien ce, in fo r m a t io n science, a n d n u rs in g science in th e o rg a n iz a tio n a n d c o m p re h e n s io n o f d a ta th a t directs n u rs in g p ra c tic e . Nursing process: T h e n u rs in g pro cess is th e to o l b y w h ic h a ll n urses c an b e co m e e q u a lly p ro fic ie n t a t c ritic a l th in k in g . T h e n u rs in g process c o n ta in s th e fo llo w in g c rite ria : (1 ) assessm ent, (2 ) d iag n o sis , (3 ) p la n n in g , (4 ) im p le ­ m e n ta tio n , a n d (5 ) e v a lu a tio n . Nursing shortage: B e c a u s e o f th e g r o w in g c o m p le x it y o f h e a lth c a re , l im it e d e d u c a tio n a l o p p o r tu n it ie s f o r n u r s in g s tu d e n ts , th e a g in g o f th e p o p u la tio n , a n d th e o v e ra ll g r o w th o f th e p o p u la tio n , a s h o rta g e o f

GLOSSARY

re g is te re d n urses has o c c u rre d a n d w i l l c o n tin u e to w o rs e n . T h e c u rre n t n u r s in g s h o rta g e b e g a n in th e y e a r 2 0 0 0 w h e n th e re w a s a n e s tim a te d s u p p ly o f 1 .8 9 m illio n n urses a n d a p ro je c te d d e m a n d o f 2 m illio n , o r a 6 % s h o rtfa ll. Nursing's Agenda for Health Care Reform: A d e m a n d fo r h e a lth c a re re fo r m in th e la te 1 9 8 0 s . T h e n u rs in g p ro fe s s io n h e ra ld e d th e w a y in h e a lth c a re r e fo r m w it h a n u n p re c e d e n te d c o lla b o ra tio n o f m o re th a n 7 5 n u rs in g asso­ c ia tio n s , le d b y th e A m e ric a n N u rs e s A s s o c ia tio n a n d th e N a t io n a l L e a g u e f o r N u r s in g , in th e p u b lic a t io n o f N u r s i n g ’s A g e n d a f o r H e a l t h C a r e R e fo r m .

Objectives: S p e c ific m e a s u re s t h a t y o u w i l l ta k e to a c h ie v e y o u r g o a l. O b je c tiv e s s h o u ld be sp ecific a n d m e a s u ra b le , s e rv in g as m ile s to n e s th a t m a r k y o u r pro gress.

Osborne, Mary D.: S u p e rv is o r o f p u b lic h e a lth n u r s in g fo r th e s ta te o f M is s is s ip p i fr o m 1 9 2 1 to 1 9 4 6 , O s b o rn e h a d a v is io n fo r a c o lla b o r a tio n w it h c o m m u n ity nurses a n d g ra n n y m id w iv e s , w h o d e liv e re d 8 0 % o f th e A fr ic a n A m e ric a n bab ies in M is s is s ip p i.

Palliative care: P ro v id in g c o m fo r t r a th e r th a n c u ra tiv e m easures fo r te r m i­ n a lly ill p a tie n ts . Paradigm: T h e lens th ro u g h w h ic h y o u see th e w o r ld . P a ra d ig m s a re also p h ilo s o p h ic a l fo u n d a tio n s th a t s u p p o rt o u r a p p ro a ch e s to research . Passive euthanasia: O c c u rs w h e n a p e rs o n a llo w s a n o th e r p e rs o n to die b y n o t a c tin g to stop d e a th o r p ro lo n g life . A n e x a m p le o f th is ty p e o f e u th a ­ n a s ia is w ith h o ld in g tr e a tm e n t th a t is necessary to p re v e n t d e a th a t a p o in t in tim e . Pasteur, Louis: A F re n c h c h e m is t, P a s te u r firs t b e ca m e in te re s te d in p a th o ­ genic org anism s th ro u g h his studies o f th e diseases o f w in e . H e discovered if w in e w a s h e a te d to a te m p e ra tu re o f 5 5 - 6 0 ° C , th e process k ille d th e m ic ro ­ organism s th a t spoiled w in e . T h is discovery w as c ritic a l to th e w in e in d u s try ’s success in F ra n c e . T h is process o f p a s te u riz a tio n le d P a s te u r to in v e s tig a te m a n y fields a n d save m a n y lives fr o m c o n ta m in a te d m ilk a n d fo o d . Paternalism: N u rs e s m ig h t d e cid e to a ct in w a y s t h a t th e y b e lie v e a re fo r a p a t ie n t ’s “ o w n g o o d ” r a th e r th a n a llo w in g p a tie n ts to e x e rc is e th e ir a u to n o m y . T h e d e lib e ra te o v e rrid in g o f a p a tie n t’s a u to n o m y in th is w a y is c a lle d p a te rn a lis m .

Patient-centered care, Nurse of the Future Nursing Core Competencies: T h e N u rs e o f th e F u tu re w ill p ro v id e h o lis tic c are th a t re co g n ize s an in d iv id u ­ a l’s p re fe re n c e s , v a lu e s , a n d needs a n d respects th e p a tie n t o r d esignee as a fu ll p a rtn e r in p ro v id in g c o m p a s s io n a te , c o o rd in a te d , age a n d c u ltu r a lly a p p ro p r ia te , safe a n d e ffe c tiv e care. Patient education: A n y set o f p la n n e d , e d u c a tio n a l a c tiv itie s d e s ig n e d to im p ro v e p a tie n ts ’ h e a lth b e h a v io rs , h e a lth status, o r b o th .

389

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GLOSSARY

Patient Self-Determination Act: L e g is la tio n desig n ed to fa c ilita te th e k n o w l­ edge a n d use o f a d v a n c e d ire ctiv es .

Patient teaching: A c tiv itie s a im e d a t im p r o v in g k n o w le d g e a re k n o w n as p a tie n t te a c h in g .

PDAs: P e rs o n a l d ig ita l a ss is ta n ts (P D A s ) a re h a n d h e ld devices th a t h a v e w ire le s s c o n n e c tiv ity a n d c a n s y n c h ro n iz e d a ta a n d in fo r m a t io n b e tw e e n th e P D A a n d a c o m p u te r. U se o f th e P D A is b e c o m in g w id e ly p o p u la r in h e a lth care a n d n u rs in g . Performance improvement: C o lla b o r a tio n a n d e v id e n c e -b a s e d p ra c tic e a re k e y elem en ts o f successful q u a lity p ro g ra m s , o r p e rfo rm a n c e im p ro v e m e n t p ro g ra m s . Person: O n e o f th e fo u r c o n c e p ts o f th e m e t a p a r a d ig m o f n u r s in g ; th e p e rs o n re c e iv in g th e n u rs in g . Personal dignity: O f te n m is ta k e n ly e q u a te d w it h a u to n o m y ; ju d g in g o th ers a n d d e s c rib in g b e h a v io rs as d ig n ifie d o r u n d ig n ifie d a re o f a n e v a lu a tiv e n a tu re . Philosophy: T h e d is c ip lin e c o n c e rn e d w it h q u e s tio n s o f h o w o n e s h o u ld liv e ; w h a t sorts o f th in g s e x is t a n d w h a t a re th e ir e ss en tia l n a tu re s ; w h a t c o u n ts as g e n u in e k n o w le d g e ; a n d w h a t a re th e c o r r e c t p r in c ip le s o f re a s o n in g . P h ilo s o p h ie s set f o r t h th e g e n e r a l m e a n in g o f n u r s in g a n d n u r s in g p h e n o m e n a th r o u g h re a s o n in g a n d th e lo g ic a l p r e s e n ta tio n o f id e a s . P h ilo s o p h ie s a re b r o a d a n d a d d re ss g e n e ra l id ea s a b o u t n u rs in g . B ecause o f its b re a d th , n u rs in g p h ilo s o p h y c o n trib u te s to th e d is c ip lin e b y p ro v id in g d ire c tio n , c la rify in g v a lu e s , a n d fo rm in g a fo u n d a tio n fo r th e o ry d e v e lo p m e n t. Physician-assisted suicide: A c c o rd in g to O r e g o n ’s D e a th w it h D ig n it y A c t, “ le th a l m e d ic a tio n s , e xp ressly p re s c rib e d b y a p h y s ic ia n fo r th a t p u rp o s e .”

PICO: A n a c ro n y m th a t assists in th e fo r m a t tin g o f c lin ic a l q u e s tio n s : P = P a tie n t, P o p u la tio n , o r P ro b le m ; I = In te r v e n tio n o r E x p o s u re o r T o p ic o f In te re s t; C = C o m p a r is o n o r A lte r n a te In te r v e n tio n ( i f a p p r o p r ia te ); O = O u tc o m e . U s in g th is fo r m a t h elp s th e n u rse to ask p e rtin e n t c lin ic a l q ues­ tio n s , focus o n a s k in g th e r ig h t q u e stio n s, a n d choose re le v a n t g u id e lin e s .

Practitioner, caregiver, advocate, educator, leader, manager, collaborator, and researcher: S everal o f th e roles o f nurses. Primary nursing care: T h e p r im a r y n u rs in g care m o d e l o f d e liv e ry w a s d e ve l­ o p e d in th e 1 9 6 0 s a fte r te a m n u rs in g firs t becam e p o p u la r a n d w a s designed to p u t th e n u rse b a c k a t th e b e d sid e . P r im a r y n u rs in g a llo w s th e n u rse to p ro v id e c are to a s m a ll n u m b e r o f c lie n ts fo r th e ir e n tire s tay . T h e n u rse p ro v id e s a n d is a c c o u n ta b le fo r c are , c o m m u n ic a te s w it h c lie n ts a n d th e ir fa m ilie s a n d o th e r h e a lth c a re p ro v id e rs , a n d p e rfo rm s d isc h a rg e p la n n in g . T h e a c tu a l care is g ive n b y th e p rim a ry R N o r associate nurses (o th e r R N s ).

GLOSSARY

Privacy: T h e r ig h t o f a p e rs o n to be free fr o m u n w a n te d in tr u s io n in to th e p e rs o n ’s p e rs o n a l a ffa irs . Professionalism, Nurse of the Future Nursing Core Competencies: T h e N u rs e o f th e F u tu re w ill d e m o n s tra te a c c o u n ta b ility fo r th e d e liv e ry o f s ta n d a rd b a se d n u rs in g c a re th a t is c o n s is te n t w it h m o r a l, a ltr u is tic , le g a l, e th ic a l, re g u la to ry , a n d h u m a n is tic p rin c ip le s . Professional values: B eliefs o r id ea ls th a t g u id e in te ra c tio n s w it h p a tie n ts , c o lle a g u e s , o th e r p ro fe s s io n a ls , a n d th e p u b lic . Proficient: B e n n e r’s stage 4 re fe rs to th e p ro fe s s io n a l w h o is a b le to g ra sp th e s itu a tio n c o n te x tu a lly a n d as a w h o le . S u ch nurses h a v e a s o lid grasp o f th e n o rm s as w e ll as s o lid e xp e rien c es th a t shed lig h t o n th e v a ria tio n s fr o m th e n o r m . In c o r p o r a te d in to p ra c tic e is th e a b ility to test k n o w le d g e a g a in s t s itu a tio n s th a t m ig h t n o t fit a n d to solve p ro b le m s w it h a lte rn a tiv e a p p ro a c h e s . Propositions: P ro p o s itio n s are statem e n ts th a t describe re la tio n s h ip s a m o n g events, s itu a tio n s , o r actio n s. PsycINFO: C o n ta in s n e a r ly 2 m illio n c ita tio n s a n d s u m m a rie s o f jo u r n a l a rtic le s , b o o k c h a p te rs , b o o k s , d is s e rta tio n s , a n d te c h n ic a l re p o rts , a ll in th e fie ld o f p s y c h o lo g y .

Public speaking: B y b e in g a sp o ke sp ers o n fo r th e o rg a n iz a tio n , a n u rse c an in c re a s e his o r h e r v is ib ility d r a m a tic a lly . T h is a d a u n tin g ta s k fo r m a n y nurses w h o a re o th e rw is e fearless in th e ir o th e r p ro fe s s io n a l a c tiv itie s . Pure autonomy standard: D e c is io n s m a d e o n b e h a lf o f a n in c o m p e te n t p e rs o n based o n decisions th a t th e fo rm e rly c o m p e te n t p e rs o n m a d e . Quality improvement: Q I focuses o n system s, pro cesses, s a tis fa c tio n , a n d cost o u tc o m e s , u s u a lly w it h in a specific o rg a n iz a tio n .

Quality improvement, Nurse of the Future Nursing Core Competencies: T h e N u rs e o f th e F u tu re uses d a ta to m o n ito r th e o u tc o m e s o f c are processes, a n d uses im p ro v e m e n t m e th o d s to design a n d test changes to c o n tin u o u s ly im p ro v e th e q u a lity a n d safe ty o f h e a lth c a re system s.

Rathbone, William: A w e a lt h y s h ip o w n e r a n d p h ila n th r o p is t, R a th b o n e is c re d ite d w it h th e e s ta b lis h m e n t o f th e firs t v is itin g n u rse service, w h ic h e v e n tu a lly e v o lv e d in to d is t r ic t n u r s in g in th e c o m m u n ity . H e w a s so im p re ss ed w it h th e p riv a te d u ty n u rs in g c are th a t his sick w ife h a d re ce ive d a t h o m e th a t he set o u t to d e v e lo p a “ d is tric t n u rs in g serv ice ” in L iv e rp o o l, E n g la n d . Rational suicide: S e lf-s la y in g th a t is c a te g o riz e d as v o lu n ta r y a c tiv e e u th a ­ n a sia .

Readiness to learn: P a tie n t’s readiness o r e vid e n ce o f m o tiv a tio n to receive in fo r m a tio n a t th a t p a rtic u la r tim e .

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Realism: R e a lis m c o n ta in s these a ss u m p tio n s : T h e w o r ld is s ta tic . Seeing is b e lie v in g . T h e s o cia l w o r ld is a g iv e n . R e a lity is p h y s ic a l a n d in d e p e n d e n t. L o g ic a l th in k in g is s u p e rio r. Referral: T h e p ra c tic e o f s e n d in g a p a tie n t to a n o th e r p r a c t it io n e r fo r c o n s u lta tio n o r service. Reflective thinking: T h e p ro c e s s o f a n a ly z in g , m a k in g ju d g m e n ts , a n d d ra w in g co n clu s io n s to c rea te a n u n d e rs ta n d in g th ro u g h o n e ’s e xp erien ces a n d k n o w le d g e a n d e x p lo rin g p o te n tia l a lte rn a tiv e s . Reformation: R e lig io u s c h a n g e s d u r in g th e R e n a is s a n c e w e re to i n f l u ­ ence n u rs in g p e rh a p s m o re th a n a n y o th e r a s p e c t o f s o c ie ty . D u r in g th e R e fo r m a tio n , th e m o n a s te rie s w e re a b o lis h e d . T h e effects o n n u rs in g w e re d ra s tic : M o n a s tic - a f filia te d in s titu tio n s , in c lu d in g h o s p ita ls a n d s ch o o ls , w e re closed, a n d ord ers o f n u n s , in c lu d in g nurses, w e re dissolved.

Research utilization: In v o lv e s th e c ritic a l analysis a n d e v a lu a tio n o f research fin d in g s a n d th e n d e te rm in in g h o w these fin d in g s fit in to c lin ic a l p ra c tic e . Respondeat superior: T h e d o c trin e th a t in d ic a te s th e e m p lo y e r m a y also be re sp o n sib le i f th e n u rse w a s fu n c tio n in g in th e e m p lo y e e ro le a t th e tim e o f th e in c id e n t.

Robb, Isabel Hampton: I n 1 8 9 6 , she fo u n d e d th e N u r s e s ’ A s s o c ia te d A lu m n a e , w h ic h in 1 9 1 1 o ffic ia lly b e ca m e k n o w n as th e A m e ric a n N u rs e s A s s o c ia tio n ( A N A ) . Role transition: T h e tr a n s itio n fr o m th e ro le o f n u rs in g s tu d e n t to th e ro le o f re g is te re d n u rs e is s o m e tim e s d e s c rib e d in te rm s o f r e a lity s h o c k . T h e e x p e rie n c e o f m o v in g fr o m th e k n o w n ro le o f s tu d e n t to th e ro le o f p ra c ­ tic in g p ro fe s s io n a l is k n o w n as ro le tr a n s itio n s h o ck . Roman era: T h e p e rio d s o f R o m a n h is to ry in c la s s ic a l a n tiq u ity , la s tin g c a. 1 4 6 b . c . (th e R o m a n c o n q u e s t o f G re e c e ) o r 3 1 b . c . (d e fe a t o f M a r k A n to n y b y A u g u s tu s a t th e B a ttle o f A c t iu m ) to c a. a . d . 4 7 6 (f a ll o f th e R o m a n E m p ir e ). R o m a n c iv iliz a tio n is o fte n g ro u p e d in to c la ss ica l a n tiq ­ u ity w it h a n c ie n t G re e c e , a c iv iliz a t io n th a t in s p ire d m u c h o f th e c u ltu re o f a n c ie n t R o m e . T h e d e v e lo p m e n t o f p o lic y , la w , a n d p r o te c tio n o f th e p u b lic ’s h e a lth w a s a n im p o r t a n t p re c u rs o r to o u r m o d e rn p u b lic h e a lth system s. Rule of double effect: U s u a lly d e fin e d n a r r o w ly in h e a lth c are as th e use o f h ig h doses o f p a in m e d ic a tio n to lessen th e c h ro n ic a n d in tra c ta b le p a in o f te r m in a lly ill p a tie n ts even i f d o in g so hastens d e a th . Safety, Nurse of the Future Nursing Core Competencies: T h e N u r s e o f th e F u tu re w ill m in im iz e ris k o f h a r m to p a tie n ts a n d p ro v id e rs th ro u g h b o th system effectiveness a n d in d iv id u a l p e rfo rm a n c e . Saint Vincent de Paul: In 1 6 3 3 , S a in t V in c e n t de P a u l fo u n d e d th e Sisters o f C h a r it y in F ra n c e , a n o rd e r o f n u n s w h o tr a v e le d fr o m h o m e to h o m e v is itin g th e sick.

GLOSSARY

Sanger, Margaret: M a r g a r e t S an g er w o r k e d as a n u rse o n th e L o w e r E a s t S ide o f N e w Y o r k C it y in 1 9 1 2 w it h im m ig r a n t fa m ilie s . She w a s a s to n ­ ished to fin d w id e s p re a d ig n o ra n c e a m o n g these fa m ilie s a b o u t c o n c e p tio n , p re g n a n c y , a n d c h ild b ir th . A fte r a h o r r ify in g e x p e rie n c e w it h th e d e a th o f a w o m a n fr o m a fa ile d s e lf-in d u c e d a b o r tio n , S a n g e r d e v o te d h e r life to te a c h in g w o m e n a b o u t b ir th c o n tro l. A s ta u n c h a c tiv is t in th e e a rly fa m ily p la n n in g m o v e m e n t, S an g er is c re d ite d w it h fo u n d in g P la n n e d P a re n th o o d o f A m e ric a .

Scales, Jessie Sleet: Scales is c o n s id e re d th e firs t A fr ic a n A m e ric a n p u b lic h e a lth n u rs e . Scales p r o v id e d d is tr ic t n u r s in g c a re to N e w Y o r k C it y ’ s A fr ic a n A m e ric a n fa m ilie s a n d is c re d ite d w it h p a v in g th e w a y fo r A fric a n A m e ric a n nurses in th e p ra c tic e o f c o m m u n ity h e a lth .

Search engines: S ea rc h engines assist in fin d in g specific to p ic s o n th e W e b b y c o m p ilin g a d a ta b a s e o f In te rn e t sites.

Self-care: A c k n o w le d g in g a n d m e e tin g y o u r o w n p h y s ic a l, p s y c h o lo g ic a l, social, a n d s p iritu a l needs. I t m ean s c a rin g fo r y o u rs e lf b e fo re y o u c are fo r o th e rs , n o t a fte r y o u h a v e te n d e d to e v e ry o n e else.

Self-efficacy: A p e rs o n b e lie ve s th a t h e o r she is c a p a b le o f p e r fo r m in g a b e h a v io r.

Shattuck Report: L e m u e l S h a ttu c k , a B o s to n b o o k s e lle r a n d p u b lis h e r w h o h a d a n in te re s t in p u b lic h e a lth , o rg a n iz e d th e A m e ric a n S ta tis tic a l S o ciety in 1 8 3 9 a n d issued a census o f B o s to n in 1 8 4 5 . S h a ttu c k ’s census re v e a le d h ig h in f a n t m o r t a lit y ra te s a n d h ig h o v e r a ll p o p u la tio n m o r t a lit y ra te s . In his R e p o r t o f t h e M a s s a c h u s e t t s S a n it a r y C o m m is s i o n in 1 8 5 0 , S h a ttu c k n o t o n ly o u tlin e d his fin d in g s o n th e u n s a n ita ry c o n d itio n s b u t m a d e re c o m m e n d a tio n s fo r p u b lic h e a lth r e fo r m . H e also c a lle d fo r services fo r w e ll-c h ild c are , s ch o o l-ag e c h ild r e n ’s h e a lth , im m u n iz a tio n s , m e n ta l h e a lth , h e a lth e d u c a tio n fo r a ll, a n d h e a lth p la n n in g . T h e re p o rt w a s re v o lu tio n a r y in its scope a n d v is io n fo r p u b lic h e a lth .

Snow, John: J o h n S n o w , a p r o m in e n t p h y s ic ia n , is c re d ite d w i t h b e in g th e firs t e p id e m io lo g is t b y d e m o n s tra tin g in 1 8 5 4 th a t c h o le ra ra te s w e re lin k e d w it h w a te r p u m p use in L o n d o n .

Social justice: A v ir tu e th a t g u id e s us in c re a tin g th o s e o rg a n iz e d h u m a n in te ra c tio n s w e c a ll in s titu tio n s . I n tu r n , s o c ia l in s titu tio n s , w h e n ju s tly o rg a n iz e d , p r o v id e us w i t h access to w h a t is g o o d fo r th e p e rs o n , b o th in d iv id u a lly a n d in o u r a ssociations w it h o th e rs . S o c ia l ju stice also im poses o n e a c h o f us a p e rs o n a l r e s p o n s ib ility to w o r k w i t h o th e rs to d e s ig n a n d c o n tin u a lly p e rfe c t o u r in s titu tio n s as to o ls fo r p e rs o n a l a n d s o c ia l d e v e lo p m e n t. Social learning theory: I f a p e rs o n b e lie v e s t h a t h e o r she is c a p a b le o f p e r fo r m in g a b e h a v io r (s e lf-e ffic a c y ) a n d also b e lie ve s th a t th e b e h a v io r w ill le a d to a d e s ira b le o u tc o m e , th e p e rs o n w ill be m o re lik e ly to p e rfo r m th e b e h a v io r.

393

394

GLOSSARY

Social media: In te rn e t-b a s e d a p p lic a tio n s th a t e n a b le p e o p le to c o m m u n i­ cate a n d share resources a n d in fo r m a tio n .

Socialization: P ro fe s s io n a l s o c ia liz a t io n in v o lv e s a p ro c e s s b y w h ic h a p e rs o n a cq u ire s th e k n o w le d g e , s kills , a n d sense o f id e n tity th a t are c h a ra c ­ te ris tic o f a p ro fe s s io n . Standard of substituted judgment: U s e d to g u id e m e d ic a l d e c is io n s th a t in v o lv e f o r m e r ly c o m p e te n t p a tie n ts w h o n o lo n g e r h a v e a n y d e c is io n ­ m a k in g c a p a c ity .

Statutory law: C o n sis ts o f e v e r-c h a n g in g ru le s a n d re g u la tio n s c re a te d b y th e U .S . C o n g re ss , state le g is la to rs , lo c a l g o v e rn m e n ts , a n d c o n s titu tio n a l la w . T h e s ta tu te s a re th e r ig h ts , p riv ile g e s , o r im m u n itie s s e c u re d a n d p ro te c te d fo r each c itiz e n b y th e U .S . C o n s titu tio n .

Stereotypes: A s ta n d a r d iz e d m e n ta l p ic tu r e t h a t is h e ld in c o m m o n b y m e m b e rs o f a g ro u p a n d th a t re p re se n ts a n o v e rs im p lifie d o p in io n , p r e ju ­ d ic e d a ttitu d e , o r u n c r itic a l ju d g m e n t. F o r e x a m p le , N ig h tin g a le d e fin e d n u rs in g as “ fe m a le w o r k . ” N u rs e s n e ed to fa ce th e s tereo typ e s p re s e n t in o u r so ciety a n d erase th e lines th a t d e fin e us.

Success: Success in life c a n be d e fin e d as d o in g w h a t y o u w a n t , w h e re y o u w a n t , a n d w it h th e p e o p le y o u w a n t to d o it w it h . T h is im p lie s b a la n c e w it h in th e v a rio u s a ren a s o f y o u r life : p ro fe s s io n a l, p e rs o n a l, s o c ia l, a n d s p iritu a l. Systems-based practice, Nurse of the Future Nursing Core Competencies: T h e N u rs e o f th e F u tu re w i l l d e m o n s tra te a n a w a ren e s s o f a n d respo nsiveness to th e la rg e r c o n te x t o f th e h e a lth c a re s ys te m , a n d w i l l d e m o n s tra te th e a b ility to e ffe c tiv e ly c a ll o n m ic ro s y s te m resou rces to p ro v id e c a re th a t is o f o p tim a l q u a lity a n d v a lu e .

Team nursing: T h e te a m n u rs in g m o d e l o f c are is used in th e U n ite d States m o s t fr e q u e n tly in h o s p ita ls a n d in lo n g -te rm a n d e x te n d e d -c a re fa c ilitie s . T h is a rra n g e m e n t e v o lv e d a fte r th e fu n c tio n a l n u rs in g o f th e 1 9 4 0 s . W it h th is a p p ro a c h , th e n u rs in g s ta ff is d iv id e d in to te a m s , a n d to ta l p a tie n t care is p ro v id e d to a g ro u p o f p a tie n ts .

Teamwork and collaboration, Nurse of the Future Nursing Core Competen­ cies: T h e N u rs e o f th e F u tu re w ill fu n c tio n e ffe c tiv e ly w it h in n u rs in g a n d in te r d is c ip lin a r y te a m s , fo s te rin g o p e n c o m m u n ic a tio n , m u tu a l re s p e c t, s h are d d e cis io n m a k in g , te a m le a rn in g , a n d d e v e lo p m e n t.

Telehealth: U s in g e le c tro n ic c o m m u n ic a tio n fo r t r a n s m ittin g h e a lth c a re in f o r m a t io n such as h e a lth p r o m o tio n , disease p r e v e n tio n , p ro fe s s io n a l o r la y e d u c a tio n , d ia g n o s is , o r a c tu a l tr e a tm e n ts to p e o p le lo c a te d a t a d iffe re n t g e o g ra p h ic a l lo c a tio n . Terminal sedation (TS): W h e n a s u f f e r i n g p a t i e n t is s e d a te d to u n c o n s c io u s n e s s , u s u a lly t h r o u g h th e o n g o in g a d m i n i s t r a t i o n o f

GLOSSARY

b a r b itu r a te s o r b e n z o d ia z e p in e s . T h e p a tie n t th e n dies o f d e h y d r a tio n , s t a r v a t io n , o r s o m e o t h e r in te r v e n in g c o m p lic a t io n , as a ll o th e r lif e s u s ta in in g in te rv e n tio n s a re w ith h e ld .

Theory: A th e o ry is a n o rg a n iz e d , c o h e re n t, a n d s y s te m a tic a r tic u la tio n o f a set o f s ta te m e n ts re la te d to s ig n ific a n t q u e s tio n s in a d is c ip lin e th a t are c o m m u n ic a te d in a m e a n in g fu l w h o le .

Tort: R e fe rs to acts th a t re s u lt in h a rm to a n o th e r. Total patient care: A s e a rly as th e 1 9 2 0 s , th e firs t m o d e l o f p a tie n t c are d e liv e ry w a s to ta l p a tie n t c a re . I n th is m o d e l, th e R N has th e re s p o n s ib ility fo r a ll aspects o f c a re o f th e p a tie n t(s ). T h e R N w o r k s d ire c tly w it h th e c lie n t, o th e r n u rs in g s ta ff, a n d p h y s ic ia n in im p le m e n tin g a p la n o f c a re . T h e o b je c tiv e o f to ta l p a tie n t c are is to h a v e one n u rse p ro v id e a ll c are to th e sam e p a tie n t(s ) fo r th e e n tire s h ift. C u r r e n tly , th is m o d e l is p ra c tic e d in a reas such as c ritic a l c a re u n its o r p o s ta n e s th e s ia re c o v e ry u n its , w h e re a h ig h lev el o f e x p e rtis e is re q u ire d .

Tyler, Elizabeth: L illia n W a ld h ire d A fr ic a n A m e ric a n nurse E liz a b e th T y le r in 1 9 0 6 as e v id e n c e o f h e r c o m m itm e n t to c u lt u r a l d iv e rs ity . A lt h o u g h u n a b le to v is it w h ite c lie n ts , T y le r m a d e h e r o w n w a y b y “ fin d in g ” A fric a n A m e ric a n fa m ilie s w h o n e ed e d h e r service.

Unavoidable trust: Z a n e r ’s c o n te n tio n th a t p a tie n ts , in m o s t cases, h a v e n o o p tio n b u t to tr u s t nurses a n d o th e r h e a lth c a re p ro fe s s io n a ls w h e n th e p a tie n t is a t th e p o in t o f n e e d in g c are. Utilitarianism: C o n tr a s te d w it h d e o n to lo g y , th e e th ic a l a p p ro a c h o f u t il i ­ ta ria n is m is to p ro m o te th e g re ates t g o o d th a t is possible in s itu a tio n s (i.e ., th e g re ates t g o o d fo r th e g re ates t n u m b e r).

Values: R e fe r to a g r o u p ’ s o r in d i v i d u a l ’s e v a lu a tiv e ju d g m e n ts a b o u t w h a t is g o o d o r w h a t m a k e s s o m e th in g d e s ira b le . V a lu e s re fe r to w h a t th e n o r m a tiv e s ta n d a rd s h o u ld b e , n o t n e c e s s a rily to h o w th in g s a c tu a lly a re . V a lu e s a re th e p rin c ip le s a n d id e a ls th a t g iv e m e a n in g a n d d ire c tio n to o u r s o c ia l, p e rs o n a l, a n d p ro fe s s io n a l life . P ro fe s s io n a l v alu e s a re in te ­ g ra l to m o r a l re a s o n in g . V a lu e s in n u rs in g encom pass a p p re c ia tin g w h a t is im p o r ta n t fo r b o th th e p ro fe s s io n a n d nurses p e rs o n a lly , as w e ll as w h a t is im p o r ta n t fo r p a tie n ts .

Values clarification: T h e process o f values c la rific a tio n c an o c cu r in a g ro u p o r in d iv id u a lly a n d h e lp s us u n d e rs ta n d w h o w e a re a n d w h a t is m o s t im p o r ta n t to us. T h e o u tc o m e o f values c la rific a tio n is p o s itiv e because th e o u tc o m e is g ro w th .

Violence: T h e e x e r tio n o f p h y s ic a l fo rc e so as to in ju r e o r a b u s e . O b je c ­ tives to w a r d th e p re v e n tio n o f v io le n c e a n d abuse a re in c lu d e d in H e a lt h y P e o p le 2 0 1 0 .

Virtues: A r e t e in G re e k ; re fe r to excellences o f in te lle c t o r c h a ra c te r.

395

396

GLOSSARY

Voluntary euthanasia: O c c u rs w h e n p erso n s w it h a s o u n d m in d a u th o r iz e a n o th e r p e rs o n to ta k e th e ir life o r to assist th e m in a c h ie v in g d e a th . A ls o , th is ty p e c a n in c lu d e th e ta k in g o f o n e ’s o w n life .

Wald, Lillian: A w e a lth y y o u n g w o m a n w it h a g re a t social conscience, W a ld g ra d u a te d fr o m th e N e w Y o r k H o s p it a l S c h o o l o f N u r s in g in 1 8 9 1 a n d is c re d ite d w it h c re a tin g th e title “ p u b lic h e a lth n u rs e .”

Wholeness of character: P e rta in s to k n o w in g th e v a lu e s o f th e n u r s in g p ro fe s s io n a n d o n e ’s o w n a u th e n tic m o r a l v a lu e s , in te g r a tin g th ese tw o b e lie f system s, a n d e xp re ss in g th e m a p p ro p r ia te ly . In te g r ity is a n im p o r ta n t fe a tu re o f w h o len e ss o f c h a ra c te r.

Index

Boxes, figures, and tables are indicated by b, f, and t following the page number.

A d v e rsity , c o p in g w ith , 1 8 4 - 1 8 5 A d v ocacy, 2 0 4 , 2 5 3 , 2 9 4 A ffe c t iv e le a r n in g , 3 0 6 - 3 0 7

A

A f f o r d a b le C a r e A c t , 1 3 9 , 1 4 0 , 1 4 4 , 3 0 0 , 3 5 0

AACN.

See

A m e r ic a n A s s o c ia t io n o f C o lle g e s o f

A f r i c a n A m e r ic a n n u r s e s .

See also

C u lt u r a l a n d e t h n ic

d iv e r s ity

N u r s in g A b a n d o n in g v a lu e s , 9 7

a c c e p ta n c e b y A N A , 3 9

A c a d e m ic C e n t e r f o r E v id e n c e -B a s e d N u r s in g (A C E )

e a r ly in v o lv e m e n t in n u r s in g p r o f e s s io n , 2 1 , 3 2 , 3 3 ,

S t a r M o d e l o f K n o w le d g e T r a n s f o r m a t io n , 244 A c c e s s t o h e a lt h c a r e , 1 3 6 - 1 4 0 d ig ita l, 3 4 0 - 3 4 1 in e q u a lity o f , 2 5 8 - 2 6 1

132 e x c lu d in g f r o m n u r s in g p r o f e s s io n , 2 7 a s g r a n n y m id w iv e s , 3 6 A g e n c y f o r H e a lt h c a r e R e s e a r c h a n d Q u a l i t y ( A H R Q ) c l i n i c a l r e s e a r c h c la s s if ic a tio n s o f , 2 4 1

in s u r a n c e , l a c k o f , 1 9 7

o n d is p a r itie s in h e a lt h c a r e , 1 3 6

f o r o ld e r a d u lts , 1 4 3 - 1 4 5

m o d e l o f e v id e n c e -b a s e d n u r s in g , 2 4 5

A c c o u n ta b ilit y , p r o f e s s io n a l c r i t i c a l t h in k in g a n d , 2 1 8

o n n u r s in g s h o r ta g e , 3 5 7 o n p a t i e n t s a fe ty a n d q u a lity , 2 3 0

d e le g a t io n a n d , 2 0 5 - 2 0 6 , 2 9 6 - 3 0 0

A ge o f n u rses, 1 4 6 , 3 5 2

in f o r m e d c o n s e n t , 2 9 2 - 2 9 4

A g e -r e la te d c h a n g e s in h e a lt h , 3 1 6 , 3 1 7 - 3 1 8 b

m is t a k e s , 1 8 5

A g in g , g l o b a l , 1 4 3 - 1 4 4

p r iv a c y a n d c o n f id e n t ia lit y , 2 9 4 - 2 9 6 A c c r e d i t a t i o n f o r n u r s in g , 2 8 , 2 8 3 , 2 8 7 A C E S t a r M o d e l o f K n o w le d g e T r a n s f o r m a t io n , 2 4 4

A G R E E II in s tr u m e n t , 2 4 2 - 2 4 3 AHRQ.

See A g e n c y

f o r H e a lt h c a r e R e s e a r c h a n d

Q u a lit y

A c q u ir in g v a lu e s , 9 7

Air, Water and Places ( H i p p o c r a t e s ) , A J N (American Journal o f Nursing),

A c t in g o n v a lu e s , 9 9

A lc o h o l a b u se o f n u rse s, 1 8 8 , 2 9 0 , 2 9 2

A c t io n s a s d is c ip lin a r y c a t e g o r ie s , 2 9 0 - 2 9 1

A l lo c a t io n o f h e a lt h c a r e r e s o u r c e s , 2 5 8 - 2 6 1

A c k n o w le d g e d d e p e n d e n c e , 2 5 3

5 28

A c tiv e e u t h a n a s i a , 2 6 3

A lte r n a t iv e m e d ic in e , 1 4 9 - 1 5 0 , 1 9 8 - 1 9 9

A c u it y a p p lic a t io n s s y s te m s , 3 3 6

A lte r n a t iv e p r o g r a m s f o r n u r s e s , 2 9 2

A d a p ta tio n m o d e l (R o y ), 6 0 - 6 2 , 6 0 t

A m e r ic a n A c a d e m y o f N u r s e P r a c t it i o n e r s , 1 3 8 - 1 3 9

A d d ic tio n , 1 8 8 , 2 9 0 , 2 9 2

A m e r ic a n A s s e m b ly f o r M e n in N u r s in g , 1 3 1

A d m in is t r a t iv e la w , 2 7 7 - 2 7 8

A m e r ic a n A s s o c i a t io n o f C o lle g e s o f N u r s in g ( A A C N )

A d m is s io n , d is c h a r g e , a n d t r a n s f e r s y s te m , 3 3 6

o n c r i t i c a l t h in k in g , 2 3 0

A D N ( A s s o c ia t e D e g r e e in N u r s in g ) , 2 8

c u lt u r a l a n d e t h n ic d iv e r sity , 1 3 3

A d u lt/ G e ri N u r s e P r a c t it io n e r , 1 4 4

c u lt u r a l c o m p e te n c y , 3 5 9 - 3 6 0

A d v a n c e d b e g in n e r s ta g e o f n u r s in g , 1 6 1

f u t u r e o f n u r s in g , 3 5 0

A d v a n c e d ir e c tiv e s , 2 5 6 - 2 5 7

le g is la t io n , p r o m o t in g , 2 7 6 - 2 7 7

397

398

INDEX

A m e r ic a n A s s o c ia t io n o f C o lle g e s o f N u r s in g

(Cont.)

A m e r ic a n S t a t i s t ic a l S o c ie ty , 1 4

See

o n m ilita r y h e a lt h c a r e , 1 3 8 - 1 3 9

ANA.

o n n u r s in g f a c u l t y s h o r ta g e , 3 5 3

A N C C (A m e r ic a n N u r s e s C r e d e n tia lin g C e n t e r ) , 3 3 0

n u r s in g in f o r m a t i c s a n d d ir e c tio n f o r f u t u r e , 3 2 7

A n c illa r y s y s te m s , 3 3 6

o n p a t i e n t e d u c a t io n , 3 0 5

A n d ra g o g y , 3 0 7

r e f o r m o f n u r s in g e d u c a t io n , 3 2 7

A n e s th e s ia m a lp r a c t ic e , 2 8 5 t

r o le s o f p r o f e s s io n a l n u r s e , 1 6 3

A N I A (A m e r ic a n N u r s in g I n f o r m a t i c s A s s o c i a t io n ) ,

s c r e e n in g p o t e n t i a l e m p lo y e r s , 1 7 6

A m e r ic a n N u r s e s A s s o c ia t io n

326

ta s k fo rc e f o r a d v a n ce p ra c tic e p ro g ra m s, 3 6 2

A n n u a l e m p lo y e e p e r fo r m a n c e a p p r a is a l, 1 8 1 - 1 8 5 , 1 8 3 t, 2 1 1

A m e r ic a n A s s o c ia t io n o f C r it i c a l - C a r e N u r s e ’s (A A C N ) S y n e r g y M o d e l f o r P a tie n t C a r e ,

A n t is e p t ic su rg e ry , e m e r g e n c e o f , 1 0

7 6 -7 7 , 7 7 t

A O N E (A m e r ic a n O r g a n iz a t i o n o f N u r s e E x e c u t iv e s ) , 350

A m e r ic a n H o s p it a l A s s o c i a t io n , 1 4 7

American Journal o f Nursing

(A JN ), 2 8

A p p e a lin g n e g a tiv e p e r f o r m a n c e a p p r a is a ls , 1 8 5

A m e r ic a n M e d i c a l A s s o c i a t io n , 2 9 3

A p p lic a n t s t o n u r s in g s c h o o l , 3 5 2 , 3 5 3

A m e r ic a n N u r s e s A s s o c i a t io n (A N A )

A p p r a is a l, e m p lo y e e p e r f o r m a n c e , 1 8 1 - 1 8 5 , 1 8 3 t , 211

A f r ic a n A m e r ic a n n u r s e s a c c e p t a n c e i n t o , 3 9 o n b u lly in g in w o r k p l a c e , 1 4 1 , 3 0 1

A p p r a is a l o f G u id e lin e s f o r R e s e a r c h a n d E v a lu a tio n

c e r t i f ic a t i o n f o r n u r s e s , 4 0

Code o f Ethics for Nurses with Interpretive Statements, 3 7 3 - 3 7 4 . See also C o d e s o f

( A G R E E II) in s tr u m e n t , 2 4 2 - 2 4 3 A q u in a s , T h o m a s , 9 2 , 1 1 0 e th ic s

fo r n u rses

A ris to tle , 9 1 , 1 0 7 - 1 0 8 , 1 1 0 A rm y N u rse C o rp s, 3 5 , 3 7

o n c r i t i c a l t h in k in g , 2 2 3

A r m y S c h o o l o f N u r s in g , 2 9

d e fin itio n o f n u r s in g , 9 5 - 9 6

A s c le p ia s ( G r e e k g o d ), 5

o n d e le g a t io n , 2 0 6 , 2 9 6 , 3 0 0

A s e p s is , 1 0

o n d is a s te r p r e p a r e d n e s s , 1 5 1

A s s a u lt, 2 7 9

o n e n d - o f -life c a r e , 2 6 8

A s s e s s m e n t.

f o u n d in g o f , 2 8

A s s o c ia t e d e g r e e in n u r s in g ( A D N ) , 2 8 , 3 6 4

f u tu r e o f n u r s in g , 3 5 0

A s s u m p tio n s , d e fin e d , 4 8

H a ll o f F a m e , m e n in , 1 3 1

A s y n c h r o n o u s c o m m u n ic a t i o n , 3 3 8

l o b b y in g e f f o r t s , 2 7 6 - 2 7 7

A t tit u d e o f n u r s e s , 1 0 0

o n m ilita r y h e a lt h c a r e , 1 3 8 - 1 3 9

A t tit u d e t o w a r d n u r s in g , 1 6 8 - 1 6 9 , 1 6 9 t .

See

See also

o n n u r s in g e d u c a t io n , 3 9 - 4 0

P a tie n t a s s e s s m e n t; S e lf - a s s e s s m e n t

S o c i e t a l v ie w o f n u r s in g

o n p a t i e n t e d u c a t io n , 3 0 5

A u d ito r y le a r n in g s ty le , 3 1 0

r e f o r m o f n u r s in g e d u c a t io n , 3 2 7

A u g u s tin e o f H ip p o , 9 2

o n r o le o f n u r s e , 2 0 3

A u to n o m y

Scope and Standards o f Nursing Informatics Practice, 3 2 6

a s b io e th ic s p r in c ip le , 1 1 3 e n d - o f -life d e c is io n m a k in g a n d , 2 6 6 - 2 6 7

s o c ia l m e d ia , p r in c ip le s f o r u se o f , 3 3 8 - 3 3 9

a s e t h ic a l issu e in n u r s in g p r a c t i c e , 2 5 5 - 2 5 7

S t a n d a r d s o f N u r s in g P r a c t ic e , 2 8 2 , 3 7 1 - 3 7 2

r e s p e c t fo r , 1 1 3 , 1 2 0 t

v a lu e s , 1 0 0 , 1 0 8 - 1 0 9

t h r o u g h c o ll a b o r a t i v e p r a c t i c e , 2 0 7

as v o ic e o f n u r s in g , 1 8 6 A m e r ic a n N u r s e s C r e d e n tia lin g C e n te r ( A N C C ) , 3 3 0

a s v a lu e o f p r o f e s s i o n a l n u r s in g , 1 5 8 A v ia n in flu e n z a , 1 5 1

A m e r ic a n N u r s in g I n f o r m a t i c s A s s o c i a t io n (A N I A ) , 326 A m e r ic a n O r g a n iz a t i o n o f N u r s e E x e c u t iv e s ( A O N E ) , 350 A m e r ic a n R e d C r o s s , 3 4 - 3 5

B “ B a b y b o o m ” g e n e r a tio n , 3 9 B a c c a la u re a te d eg ree, 7 9 , 1 8 5 - 1 8 6 B a c k in ju r ie s o n jo b , 3 5 6

INDEX

B a la n c e , w o rk / life , 1 7 2 , 1 8 8 , 1 8 9 , 1 9 0

B ro w n R e p o rt, 2 8

B a r r ie r s

B u b o n i c p la g u e , 9

a g e - r e la te d f o r le a r n in g , 3 1 6 , 3 1 7 - 3 1 8 ^

B u lly in g a n d in c iv ility , 1 4 1 , 3 0 0 - 3 0 1

t o c o m m u n ic a t i o n , 2 8 5

B u n d lin g o f c a r e , 2 1 1

t o d e le g a tio n , 2 9 8 - 2 9 9

B u rd en o f p ro o f, 2 8 1

t o e v id e n c e -b a s e d p r a c t i c e , 2 3 7

B u r e a u o f H e a lt h P r o f e s s io n s , 3 5 1

t o h e a lt h c a r e , 1 3 6 - 1 3 9 , 1 9 7 , 3 1 9

B u r e a u o f L a b o r S t a t i s t ic s , 3 9 , 3 5 1 , 3 5 2

t o p r o g r e s s in p a t i e n t s a fe ty , 3 5 7

B u rn o u t, 1 4 5 - 1 4 6 , 1 8 8 - 1 8 9 , 3 5 5 - 3 5 6

B a r to n , C la r a , 3 4 - 3 5 B a s i c d ig n ity , 1 0 9

C

B a tte r y , 2 7 9

C a d e t N u rse C o rp s, 3 7

B eau ch am p , T om , 1 1 2

C a lv in , J o h n , 1 1

B e h a v io r

C a m p a ig n o f N u r s i n g ’s F u t u r e ( J o h n s o n & J o h n s o n ) , 130

h e a lt h s e e k in g , 7 4 , 3 0 6 o f p a t ie n t , c h a n g in g , 3 0 8 - 3 0 9 , 3 1 6

C a p i t a l is m , 1 3 9

p ro fe s s io n a l, 2 5 1 - 2 5 2

C a r a tiv e f a c t o r s ( W a ts o n ), 5 2 - 5 3 C a r e e r m a n a g e m e n t, 1 6 7 - 1 9 1

R o y ’s a d a p t a t i o n m o d e l a n d , 6 1 B e h a v io r a l sy s te m m o d e l ( J o h n s o n ) , 6 5 - 6 6 ,

65t

B e h a v io r -s p e c ific c o g n i t i o n s , 7 1 B e lie f s .

See also

c o m m it m e n t t o p r o f e s s io n , 1 8 5 - 1 8 6 c o m m it m e n t t o s e lf

S p ir it u a l n e e d s

s e lf -c a r e , 1 8 9 - 1 9 0

c u lt u r a l c o n s i d e r a t io n s in p a t i e n t e d u c a t io n , 3 1 9

s tr e s s a n d , 1 4 5 - 1 4 6 , 1 8 7 - 1 8 8

m o ra ls as, 1 0 6

tim e m a n a g e m e n t , 1 9 0 - 1 9 1 c o p in g w ith a d v e rs ity , 1 8 4 - 1 8 5

p h ilo s o p h y a n d , 9 4 - 9 6 , 1 0 0 B e n e f ic e n c e , 1 1 3 , 1 2 0 t

d e fin e d , 1 6 8

B e n n e r , P a t r ic i a , 5 3 - 5 5 , 5 5 t , 1 6 0 - 1 6 1

e v a lu a t in g p e r f o r m a n c e , 1 8 1 - 1 8 4

B e n n e r ’s p h ilo s o p h y o n n u r s in g , 5 5 t

e x p a n s i o n o f n u r s in g p r o f e s s io n , 3 8

B e n th a m , Je re m y , 1 1 1

m a x im iz in g v is ib ility , 1 7 7 - 1 7 9

B e st in te re s t sta n d a rd , 2 6 7

m e n t o r in g , 1 8 0 - 1 8 1

B io e t h i c s , 1 0 6 - 1 0 7 , 1 1 2 - 1 1 4

m y th s a n d m is c o n c e p t io n s , 1 6 9 - 1 7 0 , 1 7 0 t

B io lo g ic a ll y b a s e d t h e r a p ie s , 1 5 0

n e tw o r k in g , 1 7 9 - 1 8 0

B io t e r r o r is m , i n f o r m a t i c s a n d , 3 4 3

o c c u p a t i o n v s. c a r e e r , 1 6 8 - 1 6 9 , 1 6 9 t

B ir th c o n t r o l , 2 9

p e r s o n a l g o a ls , s e t t in g , 1 7 0 - 1 7 3 , 1 7 3 t , 2 0 7

B ir th r a t e e x p a n s i o n , 3 9

p r o m o t io n o f s e lf, 1 3 1 s t r a t e g ie s fo r, 1 7 3 - 1 7 7

B la c k D e a t h , 9 B lo o d le s s su rg e ry , 2 6 0 - 2 6 1 , 3 4 3

C a r e g iv e r , r o le o f n u r s e a s , 2 0 3

B N A (B r it is h N u r s e s A s s o c i a t io n ) , 2 4

C a r in g

B o a r d s o f n u r s in g

m o d e l f o r c r i t i c a ll y ill p a t ie n t , 7 6 - 7 7

c o m p o s i t i o n a n d r o le o f , 2 8 9 - 2 9 0

a s n u r s in g v a lu e , 1 5 8 , 1 6 3

d is c ip lin e o f n u r s e s , 2 8 1 , 2 9 0 - 2 9 2

S w a n s o n ’s t h e o r y o f , 7 2 - 7 3 , 7 3 t

lic e n s u r e f r o m , 2 8 7 - 2 8 8

C a r n e g ie F o u n d a t i o n R e p o r t , 3 2 7 , 3 6 1

B o lto n , F ra n c e s P ay n e, 3 7 B o u n d a r ie s , p r o f e s s i o n a l , 2 5 1 - 2 5 2 .

C A S ( c o m p l e x a d a p tiv e s y s te m s ), 1 9 8

See also

p r a c ti c e B r a in d e a th , 2 6 2 B r e c k e n r id g e , M a r y , 3 5

E t h ic a l

C a s e -b a s e d a p p r o a c h t o e t h ic a l a n a ly s is , 1 1 9 - 1 2 1 , 1 2 0 t C a s e la w , 2 7 8 C a s e m a n a g e m e n t m o d e l o f p a t i e n t c a r e d e liv e ry , 2 0 1 -2 0 2

B r e w s te r , M a r y , 3 1

“ C a s s a n d r a ” ( N ig h t in g a le ), 1 8

B r itis h N u r s e s A s s o c i a t io n ( B N A ) , 2 4

C e n te r s f o r D is e a s e C o n t r o l a n d P r e v e n tio n ( C D C ) ,

B r o w n , E s t h e r L u c ille , 2 8

1 5 1 -1 5 2

399

400

INDEX

Centers fo r M edicare and M ed icaid Services (C M S ), 342 C entralized/decentralized approach to chain of com m and, 197 C ertification fo r nurses, 4 0 , 7 6, 2 8 8 , 330. See also Licensure, nursing C hadw ick R eport, 1 3 -1 4 C hain o f com m and, 1 85 , 197, 2 99 Challenges fo r nurses. See also Future directions of nursing; Self-care; Shortage o f nurses bullying and incivility, 1 41 , 3 0 0 -3 0 1 com plem entary and alternative approaches, 1 4 9 -1 5 0 consumerism, 1 4 7 -1 4 9 delegation, 2 0 5 -2 0 6 , 2 9 6 -3 0 0 disaster preparedness, 1 5 1 -1 5 2 finding a job, 352 global aging, 1 4 3 -1 4 5 m ental health needs, 1 4 2 -1 4 3 research needs, 152 supply and dem and o f nursing, 1 4 5 -1 4 7 technological changes, 1 5 0 -1 5 1 violence in w orkplace, 1 4 1 -1 4 2 C haracter o f nurse, 2 3 , 2 7 , 1 09 , 281 C hildbearing, role o f nurse in, 3, 3 5 -3 6 C hild labor, 15 Childress, James, 112 C hiropractic m anipulation, 150 C holera, 16 Christianity, influence of, 8, 1 1 -1 2 , 92 C hristm an, Luther, 131 C IN A H L (C um ulative Index o f N ursing and A llied H ea lth Literature), 331 C iudad, John, 132 C iv il law, 2 7 8 -2 8 1 C iv il W ar, U.S., 2 2 , 34 C larifying values, 9 9 -1 0 0 Classical era, 3 -8 Classicism, 9 1 -9 2 Classifications o f evidence, 241 Clients. See Patients C linical docum entation systems, 336 C linical judgm ent. See C ritical thinking C linical nurse leaders (C N L s ), 362 C linical pathw ays, 201 C linical practice guidelines, 2 4 2 -2 4 3 C linician O utreach and C om m unication A ctivity (C O C A ), 1 5 1 -1 5 2

Clinics, 1 3 9 -1 4 0 , 197 C M S (Centers fo r M edicare and M e d ica id Services), 342 Cochrane Library, 2 4 0 , 331 Codes o f ethics fo r nurses Code o f Ethics for Nurses (IC N ) adoption o f and revisions to, 116 patient advocacy, 2 53 respect fo r rights, 159 responsibility o f nurse to patient, 115

Code o f Ethics for Nurses with Interpretive Statements (A N A ), 3 7 3 -3 7 4 adoption o f and revisions to, 115 boundaries in nursing, 251 delegation, 2 0 6 dignity, 2 5 2 education and practice, integrating into, 163 end-of-life care, 2 6 8 , 269 m oral respect, 117 patient advocacy, 2 53 privacy and confidentiality, 295 relationships in professional practice, 2 4 9 -2 5 0 rule o f double effect, 2 6 6 values o f nursing profession, 96, 1 0 8 -1 0 9 , 158 C ognator-regulator subsystem o f adaptive process, 61 Cognitive changes in older adults, 316, 3 1 7 -3 1 8 ^ Cognitive learning, 3 0 6 -3 0 7 C ollaboration. See also T eam w ork collaborative critical pathw ays, 2 0 1 -2 0 2 collaborative practice, 2 0 3 , 2 0 6 -2 1 0 , 2 0 8 f, 2 1 2 -2 1 4 continuum o f collaboration, 2 0 8 , 2 0 8 f as core competency, 78 group discussions fo r critical thinking, 229 hiring practices, 1 3 5 -1 3 6 interprofessional, 96 m ultiprofessional, 149 C ollaborator, role o f nurse as, 2 0 3 , 208 Collective bargaining, 116 C om anagem ent, 208 C o m fo rt, K olcaba’s theory of, 7 3 -7 4 , 7 4 t C om m itm ent to learning, 158 to profession, 1 8 5 -1 8 6 to self self-care, 1 8 9 -1 9 0 stress and, 1 4 5 -1 4 6 , 1 8 7 -1 8 8 tim e m anagem ent, 1 9 0 -1 9 1

INDEX

C o m m o n la w , 2 7 8 , 2 8 3

401

K in g ’s i n t e r a c t in g s y s te m s f r a m e w o r k a n d t h e o r y o f g o a l a tta in m e n t, 6 4 - 6 5 , 6 4 *

C o m m u n i c a b l e d is e a s e s c h a n g e s in , 1 9 6

N e u m a n ’s s y s te m s m o d e l, 6 2 - 6 4 , 6 3 *

c o m b a t i n g , e a rly , 1 0 - 1 1 , 1 3

O r e m ’s s e lf -c a r e d e fic it th e o r y , 5 7 - 6 0 , 6 0 *

G r e e k e r a , d u r in g , 6

R o g e r s ’s t h e o r y o f u n ita r y h u m a n b e in g s , 5 5 - 5 7 , 56f

h is to r ic a l b a c k g r o u n d , 6 , 8 , 9 , 1 5 - 1 6

R o y ’s a d a p t a t i o n m o d e l, 6 0 - 6 2 , 6 0 *

In d u s t r ia l R e v o l u t i o n , d u r in g , 1 5 - 1 6 Je w is h tre a tm e n t o f, 4

C o n c e p t u a l t h in k in g , 2 2 0 - 2 2 1

M id d le A g e s , d u r in g , 8 , 9 C o m m u n ic a tio n .

See also

C o n f e r e n c e s , a t te n d in g , 2 1 0 , 2 3 8 C o n f id e n tia lit y , 2 9 4 - 2 9 6 , 3 3 4 - 3 3 5

C o ll a b o r a t i o n

C o n f l ic t

b a r r ie r s t o r e s u ltin g in m e d ic a l e r r o r s , 2 8 5 c o n s u l t a t i o n s w ith o t h e r s t a f f , 2 0 7 - 2 0 8 , 3 4 0

b u lly in g a n d in c iv ility , 1 4 1 , 3 0 0 - 3 0 1

a s c o r e c o m p e te n c y , 7 8

c o p in g w ith a d v e rs ity , 1 8 4 - 1 8 5

d o c u m e n ta t io n a n d , 3 2 0

e th ic a l, 1 1 7 - 1 1 8 , 2 6 6 , 2 6 9

e l e c t r o n i c h e a lt h r e c o r d s c o n t r i b u t i n g t o , 3 3 5

in n u r s in g r e l a t io n s h ip s , 2 5 0 , 2 5 4

e m p lo y e e p e r f o r m a n c e a p p r a is a l, 1 8 1 - 1 8 5 , 1 8 3 *

p h y s i c ia n - n u r s e r e l a t i o n s h i p , 1 1 4 - 1 1 5 , 2 5 0 - 2 5 1

F o u r T o p ic s M e t h o d f o r A n a ly s is in C l i n i c a l E th ic s C ases, 1 1 9 - 1 2 1 , 1 2 0 *

v a lu e s y s te m s , 9 8 C o n f o r m it y , 2 5 5

in f o r m e d c o n s e n t a s , 2 9 2 - 2 9 4

C o n s e n t a g r e e m e n ts , 2 9 1

la n g u a g e b a r r ie r s , 1 3 4 , 1 3 8 , 3 1 9

C o n s e q u e n c e s f o r m is c o n d u c t , 2 8 0 , 2 9 0 - 2 9 2 , 2 9 1 , 334, 339

l e tt e r w r itin g , 1 7 8 - 1 7 9 m e e tin g s , 1 7 9 - 1 8 0 , 1 8 0 *

C o n s is te n c y o f e v id e n c e , 2 4 1

o n lin e , 3 3 6 , 3 3 7 - 3 4 0

C o n s u l t a t i o n s w ith o t h e r s t a f f , 2 0 7 - 2 0 8 , 3 4 0

fo r p a tie n t e d u c a tio n , 3 0 6

C o n s u m e r is m , 1 4 7 - 1 4 9

t o p r e v e n t le g a l p r o b le m s , 3 0 1

C o n t a g io u s d is e a s e s .

t e c h n iq u e s fo r, 1 9 6 - 1 9 7

C o n t e x t u a l t h in k in g , 9 8

tru th th ro u g h , 9 3

C o n t in u in g e d u c a t io n r e q u ir e m e n t s , 2 8 8 - 2 8 9

See also

C o m m u n ic a b le d is e a s e s

C o n t i n u i t y o f h e a lt h c a r e , 1 3 6 - 1 3 7 , 1 9 8 - 1 9 9 , 2 1 2

C o m m u n ity h e a lt h n u r s in g , 3 0 - 3 3 , 1 9 9 , 3 0 0 C o m p e te n c y .

See

C o n t i n u o u s q u a lity im p r o v e m e n t ( C Q I ) , 2 0 1 ,

C r it i c a l t h in k in g

f o r c li n i c i a n s , 3 6 0

2 1 0 -2 1 4 C o n t in u u m o f c o l l a b o r a t i o n , 2 0 8 , 2 0 8 f

c o n t in u in g e d u c a t io n a n d , 2 8 9 c u lt u r a l, 1 3 3 - 1 3 6 , 3 5 9 - 3 6 0 , 3 6 4

C o n t in u u m o f r e a lis m a n d id e a lis m , 9 3 - 9 4 ,

g u id e lin e s f o r t w e n t y - f ir s t c e n tu r y , 1 4 8 , 1 4 8 - 1 4 9 b

C o n t r a c t la w , 2 7 9

in in f o r m a t ic s a n d t e c h n o lo g y , 3 2 8 , 3 2 9 - 3 3 0

C o n t r a c t u a l a g r e e m e n t o f d e le g a t io n , 2 0 6

o f N u r s e o f th e F u t u r e , 7 8 - 7 9 , 2 3 0 , 2 3 5

C o p in g

C o m p e t e n t s ta g e o f n u r s in g , 1 6 1

94b

w ith a d v e rsity , 1 8 4 - 1 8 5

C o m p e t i t io n o f v a lu e s , 9 8

p r o c e s s fo r , 6 1

C o m p la in t s t o b o a r d s o f n u r s in g , 2 9 1

w ith s tr e s s , 1 8 8

C o m p le m e n t a r y a n d a lte r n a t iv e a p p r o a c h e s t o c a r e ,

C o r e c o m p e t e n c ie s .

See also

C o m p e te n c y

fo r c lin ic ia n s , 3 6 0

1 4 9 -1 5 0 , 1 9 8 -1 9 9 C o m p l e x a d a p tiv e s y s te m s ( C A S s ), 1 9 8

o f N u r s e o f th e F u t u r e , 7 8 - 7 9 , 2 3 0 , 2 3 5

C o m p l e x i t y s c ie n c e , 1 9 8

C o r e v a lu e s , 1 7 2

C o m p lia n c e , 3 0 8 , 3 3 5

C o s t o f h e a lt h c a r e , 4 0 , 1 9 7 , 2 5 8 - 2 5 9 , 3 5 4 - 3 5 6

C o n c e p t , d e fin e d , 4 7 C o n c e p t m a p p in g a s c r i t i c a l t h in k in g s k ill, 2 2 7 ,

“ C o x c o m b s ” o f N ig h t in g a le , 2 0

228f

C o n c e p t u a l m o d e ls

C Q I ( c o n tin u o u s q u a lit y i m p r o v e m e n t) , 2 0 1 , 2 1 0 - 2 1 4 C r e a tiv it y a s t h in k in g p r o c e s s , 2 2 2

d e fin e d , 4 8

C r im e a n W a r, 1 8 - 1 9

J o h n s o n ’s b e h a v io r a l sy s te m m o d e l, 6 5 - 6 6 , 6 5 *

C r im i n a l b a c k g r o u n d c h e c k s , 2 8 8

402

INDEX

C r im in a l la w , 2 8 1

m o r a l c o n f lic t s a n d , 2 6 9 - 2 7 0

C r it i c a l ly ill p a t ie n t s , m o d e l f o r c a r in g fo r, 7 6 - 7 7

m o r t a lit y , a w a r e n e s s o f , 7 5

C r it i c a l p a t h w a y s

p a llia t iv e c a r e , 2 6 5 - 2 6 6

f o r c o ll a b o r a t i v e c a r e , 2 0 1 - 2 0 2

P a tie n t S e lf - D e t e r m in a t i o n A c t , 2 5 6 - 2 5 7

sy s te m fo r , 3 3 6

p h y s ic ia n - a s s is t e d s u ic id e , 2 6 8 - 2 6 9

C r it i c a l t h in k in g , 2 1 7 - 2 3 3 .

See also

D e c is io n

m a k in g

r a t i o n a l s u ic id e , 2 6 4 r e fu s in g t r e a t m e n t , 2 6 6

a s s e s s m e n t, 2 2 4 - 2 2 5

te a m a p p ro a c h to , 1 1 8 - 1 1 9

c h a ra c te ris tic s o f, 2 2 0 - 2 2 2

t e r m in a l s e d a t io n , 2 6 8

c o n c e p t m a p p in g , 2 2 7

w ith h o ld in g / w ith d r a w in g t r e a t m e n t , 2 6 7 - 2 6 8

d e fin e d , 2 1 8 - 2 2 0

D e a t h w ith D ig n it y A c t , 2 6 9

d e v e lo p in g s k ills in , 1 5 9 , 2 2 3 - 2 2 9

D e c is io n m a k in g

d ia g n o s is , 2 2 5

a d v a n c e d ir e c tiv e s , 2 5 6 - 2 5 7

e v a lu a t io n , 2 2 6 - 2 2 7

A G R E E II in s tr u m e n t fo r, 2 4 2 - 2 4 3

See

f a c i li t a t i n g , 1 1 9 - 1 2 1 , 1 2 0 t

a u to n o m y .

g r o u p d is c u s s io n s a n d r e f le c t io n , 2 2 9

c o m p l e x i t y c o m p r e s s io n in , 3 5 7 - 3 5 8

i m p le m e n t a t io n , 2 2 5 - 2 2 6

c r i t i c a l t h in k in g .

im p o r t a n c e o f , 2 3 0 - 2 3 2

d e le g a t io n d e c is io n - m a k in g t r e e , 3 0 0

jo u r n a l i n g , 2 2 7 - 2 2 9

e n d -o f-life .

n e w n u rses a n d , 2 1 7 - 2 1 8

e t h ic s a n d , 1 1 7 - 1 2 2

See

A u to n o m y

See

C r it i c a l t h in k in g

D e a t h a n d e n d - o f -life c a r e

n u r s in g p r o c e s s a n d , 2 2 3 - 2 2 4

o f fa m ily f o r p a t i e n t , 1 1 8 - 1 2 2 , 2 6 6 - 2 6 8

p la n n in g , 2 2 5

m o d e ls o f e v id e n c e -b a s e d p r a c ti c e fo r,

C r o s s t r a in in g n u r s e s , 1 9 7

2 4 3 -2 4 6

C ru zan , N an cy, 2 6 7

P a tie n t S e lf - D e t e r m in a t i o n A c t , 2 5 6 - 2 5 7

C u lt u r a l a n d e t h n ic d iv e r s ity L e in in g e r ’s th e o r y , 6 8 - 6 9 ,

s y s te m a t ic a p p r o a c h fo r , 2 3 5

68t

t e c h n o lo g y fo r , 7 8

in n u r s in g p o p u l a t io n , 1 3 3 - 1 3 5 , 3 5 8 - 3 6 0

D e fa m a tio n o f c h a ra c te r, 2 7 9

in p a t i e n t e d u c a t i o n , 3 1 9

D e f in it io n o f n u r s in g ( H e n d e r s o n ), 5 0 - 5 1

o f p o p u l a t io n s e r v e d , 1 9 6

D e g r e e s f o r n u r s in g

r e c r u it in g a n d r e t a in in g m in o r it y n u r s e s , 1 3 5 -1 3 6 s e n s itiv ity t o , 1 3 1 , 3 6 4 C u lt u r a l c o m p e t e n c e , 1 3 3 - 1 3 6 , 3 5 9 - 3 6 0 , 3 6 4 C u lt u r a l d iv e r s ity a n d u n iv e r s a lity t h e o r y ( L e in in g e r ), 6 8 -6 9 , 6 8 t C u m u la t iv e I n d e x o f N u r s in g a n d A llie d H e a lt h L it e r a t u r e ( C I N A H L ) , 3 3 1

ad v an ced , 1 7 1 , 2 8 0 - 2 8 1 , 2 8 8 a s s o c ia t e d e g r e e , 2 8 , 3 6 4 c li n i c a l n u r s e le a d e r ( C N L ) , 3 6 2 D o c t o r o f N u r s in g P r a c t ic e ( D N P ) , 3 6 2 G e r i a t r i c N u r s e P r a c t it i o n e r ( G N P ) , 1 4 4 u n d e rg ra d u a te , 7 9 , 1 8 5 - 1 8 6 D e l a n o , J a n e A ., 2 9 D e le g a t io n a c c o u n t a b il i t y a n d , 2 9 6 - 3 0 0

D

d e c is io n - m a k in g t r e e , 3 0 0

D a r k p e r io d o f n u r s in g , 1 2

a s m a n a g in g s tr a te g y , 2 0 5 - 2 0 6

D a ta b a s e s , e le c tr o n ic , 3 3 1 - 3 3 2

D e L e llis , C a m illu s , 1 3 2

D a v is , M a r y E ., 2 8

D e liv e r y o f h e a lt h c a r e .

D eaco n esses, 8 D e a t h a n d e n d - o f -life c a r e , 2 6 1 - 2 7 0 d e c id in g f o r o t h e r s , 2 6 6 - 2 6 8

See

H e a lt h c a r e d e liv e r y

sy s te m s D e m o g r a p h ic c h a n g e s in n u r s in g , 3 5 8 - 3 6 0 .

See also

M in o ritie s

d e fin in g d e a th , 2 6 1 - 2 6 3

D e m o g r a p h ic s , 3 5 8 - 3 6 0 .

e a r ly a t tit u d e t o w a r d , 3 - 4

D e o n t o lo g y , 1 1 0 - 1 1 1

e u th a n a s ia , 2 6 3 - 2 6 4

D e P a u l, V i n c e n t , 1 1

See also

M in o ritie s

INDEX

Dependence acknowledged, 253 stage of cognitive development, 1 5 9 -1 6 0 D epersonalization, 146 Depression, 188 D erham , James, 132 Diagnosis, 225 Diagnosis-related groups (D R G s ), 197 Dickens, Charles, 12, 15 D ig ital consultations, 340 D ig ital divide, 333 D ig ital reference fo r patient inform ation, 3 4 1 -3 4 2 D ignity, 1 09 , 159, 2 5 2 -2 5 3 , 2 6 5 , 269 D im inished capacity (patient), 333 Disaster preparedness, 1 5 1 -1 5 2 , 340 Discharge o f patient, 2 1 2 -2 1 3 Discipline o f nurses, 2 8 1 , 2 9 0 -2 9 2 Disclosure. See Inform ed consent Diseases. See Com m unicable diseases Disparities in health care system, 136, 2 6 0 -2 6 1 , 300 D istrict nursing service, 2 4 -2 5 Diversity in nursing profession. See C u ltu ra l and ethnic diversity D ix , D orothea Linde, 34 D N R . See Do-not-resuscitate order D ock, Lavinia Lloyd, 28 “The doctor-nurse gam e,” 2 5 0 D o cto r o f N ursing Practice (D N P ), 362 D octrine o f the fo ur hum ors, 5 -6 D ocum entation clinical, 336 obligation for, 203 o f patient education, 320 D om ains of learning, 3 0 6 -3 0 9 “ D o no h a rm ” principle, 114 Do-not-resuscitate (D N R ) order, 265 D ouble effect, 2 6 5 -2 6 6 D reyfus m odel o f skill acquisition, 54 Drugs abuse of. See Addiction early, 4 - 7 errors and, 2 9 0 , 311 euthanasia and, 2 6 3 -2 6 4 selling or stealing, 281 technological changes in, 3 8 -3 9 , 2 8 7 treatm ent program s fo r nurses, 2 9 2 D urable pow er o f attorney, 2 5 7

D u ty behavior based on, 1 1 0 -1 1 1 , 114 breach o f to patient, 284 defined, 282

E Ebers Papyrus, 3 EB SCO Publishing, 331 Econom ic barriers to health care, 137 Econom y affecting nursing profession, 2 8 -2 9 , 139, 1 4 5 -1 4 6 , 1 6 9 -1 7 0 , 3 5 1 -3 5 2 Education. See a lso Degrees fo r nursing alternative and com plem entary therapies, 1 4 9 -1 5 0 appealing to younger generation, 147 career m anagem ent and, 171 com m itm ent to learning, 1 59 , 1 8 5 -1 8 6 continuing education requirements, 2 8 8 -2 8 9 cross training nurses, 197 cultural competence, 1 3 4 -1 3 5 fo r disaster preparedness, 1 5 1 -1 5 2 enrollm ent in nursing school, 3 5 2 -3 5 3 externships, 1 6 2 -1 6 3 fram ew o rk for, 79 funding for, 135 future directions of, 4 1 , 2 3 0 -2 3 1 , 3 6 0 -3 6 4 gap between practice and, 363 gerontology, 1 4 4 -1 4 5 history of, 12, 2 3 -2 4 , 2 7 -2 9 , 3 9 -4 0 international, 131 fo r m ilita ry health care, 1 3 8 -1 3 9 occupation vs. career and, 1 6 8 -1 6 9 , 1 6 9 f patient. See Patient education reality of, 126 reform of, 2 8 7 , 3 2 6 -3 2 9 , 361 self-education, 149 skills gained from , 2 3 0 -2 3 1 teachers and professors for, 1 47 , 353, 3 59 , 360 values in, integration of, 96 Educational m aterials, readability of, 3 1 2 -3 1 4 , 3 1 3 -3 1 4 ^ Educational Resource Inform ation Center (E R IC ), 332 Educational socialization, 1 5 9 -1 6 0 Educator, role o f nurse as, 2 9 , 149, 151, 203 Efficacy, 3 0 8 -3 0 9 Egyptian health care (Classical era), 3 -4 E H R s . S ee Electronic health records Einthoven, W ille m , 262 E-journals, 331

403

404

INDEX

E ld e r ly p e o p le a n d h e a lt h c a r e , 1 4 3 - 1 4 5 , 1 9 6 , 3 1 6 , 3 1 7 -3 1 8 b

E R I C ( E d u c a t i o n a l R e s o u r c e I n f o r m a t i o n C e n te r ), 332

E l e c t r o n i c d a ta b a s e s , 3 3 1 - 3 3 2

E rro rs o f n u rse, 1 5 0 , 1 8 5 , 2 8 5 - 2 8 6 , 2 9 0 .

E l e c t r o n i c h e a lt h r e c o r d s ( E H R s ) , 3 2 5 , 3 3 4 , 3 3 5 - 3 3 7 ,

See also

M a l p r a c t i c e ; N e g lig e n c e

E t h ic a l a n a ly s is ( 4 - B o x A p p r o a c h ), 1 1 9 - 1 2 1 , 1 2 0 t

342

E t h ic a l d ile m m a s , 1 1 7 - 1 1 8 , 1 1 9 - 1 2 1 , 1 2 0 t ,

E l e c t r o n i c in d e x e s , 2 3 9 E le c tr o n ic re s o u rc e s, 2 4 0

257, 264

E m a il, 3 3 7 - 3 3 8

E t h ic a l p r a c t i c e , 1 0 5 - 1 2 2 , 2 4 9 - 2 7 0

E m e r g e n c y r e s p o n d e r , n u rs e a s , 1 5 1 - 1 5 2

a n a ly s is a n d d e c is io n m a k in g , 1 1 7 - 1 2 2

E m o t i o n a l c o n f lic t s , 1 0 9 , 1 1 8 , 1 2 2

b io e th ic s , 1 0 6 - 1 0 7 , 1 1 2 - 1 1 4

E m o tio n a l e x h a u s tio n , 1 4 6 .

See also

B u rn o u t

E m p ir ic is m , 9 0 ,

92b,

d e o n to lo g y , 1 1 0 - 1 1 1

241

E m p lo y e e p e r fo r m a n c e a p p r a is a l, 1 8 1 - 1 8 5 , 1 8 3 t E m p lo y e r s .

See also

d e a th a n d e n d - o f -life c a r e , 2 6 1 - 2 7 0 d e fin e d , 1 0 6

E m p ed o d es o f A crag as, 5 - 6

C a r e e r m a n a g e m e n t ; N u r s in g

e t h i c a l p r in c ip lis m , 1 1 2 - 1 1 4 e t h ic o f c a r e , 1 1 2 in e v e r y d a y life , 1 0 6

s h o r ta g e c o n t in u in g e d u c a t io n r o le o f , 2 8 9

f e m in is t e t h ic s , 1 1 2

e x p a n s io n o f n u r s in g , 3 8

m o r a l r e a s o n in g , 1 0 7 - 1 0 8

l ia b ilit y f o r n u r s e , 2 8 3 , 2 8 4

m o r a l r ig h ts a n d a u to n o m y , 2 5 5 - 2 5 7

q u itt in g a b r u p tly / a b a n d o n in g , 2 9 1

n a t u r a l la w th e o r y , 1 1 0

s c r e e n in g o f p o t e n t i a l , 1 7 6

n u r s in g e t h ic s , 1 0 7 o rg a n tr a n s p la n ta tio n , 2 6 0 - 2 6 1

s o c ia l m e d ia p a g e s o f , 3 3 9

p r o f e s s io n a l c o d e s a n d , 1 1 4 - 1 1 7

E m p o w e r in g th e p a t i e n t , 1 4 7 E n d - o f - l if e c a r e .

See

D e a t h a n d e n d - o f -life c a r e

r e l a t io n s h ip s in p r o f e s s i o n a l p r a c t i c e , 2 4 9 - 2 5 4

E n d o r s e m e n t f o r lic e n s u r e , 2 8 8

s o c ia l ju s t i c e , 2 5 7 - 2 6 1

E n e r g y fie ld s , 5 5

th e o r ie s a n d a p p r o a c h e s , 1 0 9 - 1 1 4

E n e r g y t h e r a p ie s , 1 5 0

u t i l it a r i a n is m , 1 1 1 - 1 1 2

E n f o r c e m e n t o f la w , 2 7 8 - 2 8 1

v a lu e s in n u r s in g , 1 0 8 - 1 0 9 v ir tu e e t h ic s , 1 1 0

E n v ir o n m e n t as c e n t r a l c o n c e p t o f n u r s in g , 4 8 ,

52t, 55t, 56t, 60t,

6 3 - 6 5 1, 6 8 - 6 9 1, 7 1 1, 7 3 - 7 5 t , 7 7 t , 9 5 i n t e r a c t i o n w ith , 7 0 - 7 2

E t h ic a l p r in c ip lis m , 1 1 2 E t h n i c d iv e r sity .

See

C u lt u r a l a n d e t h n ic d iv e r s ity ;

M in o ritie s

in R o y a d a p t a t i o n m o d e l, 6 2

E u th a n a s ia , 1 1 5 , 2 6 3 - 2 6 4

w o rk p la c e

E v a lu a tio n

a s s e s s in g b e fo r e e m p lo y m e n t , 1 7 6 - 1 7 7

a s c r i t i c a l t h in k in g s k ill, 2 2 6 - 2 2 7

b u rn o u t and , 1 4 6

e v id e n c e , 2 4 0 - 2 4 1

c o m p le x ity o f, 3 5 7 - 3 5 8

p a t i e n t le a r n in g , 3 1 9 - 3 2 0

c o n tr ib u tin g to e rro r, 2 8 5 - 2 8 6

p e r fo r m a n c e o f s e lf, 1 8 1 - 1 8 4

h o s p it a ls a s , 3 5 4 - 3 5 5

w e b s it e s , 3 3 0 - 3 3 1 E v id e n c e -b a s e d p r a c t i c e , 2 3 5 - 2 4 8

s a fe ty o f , 3 5 3 - 3 5 6 s tr e s s in , 1 8 7 - 1 8 8

b a r r ie r s t o , 2 3 7

E n v ir o n m e n t a l c o m f o r t , 7 3

a s c o r e c o m p e te n c y , 7 9

E n v ir o n m e n t a l t h e o r y o f n u r s in g ( N ig h t in g a le ),

m e d ic in e a n d , 3 6 3

E p id e m ic s , 9 , 1 4 , 1 5 , 1 6 , 2 9

m o d e ls o f , 2 4 3 - 2 4 6

E p id e m io lo g y , 5 , 1 6 E q u a l a c c e s s t o h e a th c a r e , 2 5 8 . h e a lt h c a r e

d e fin e d , 2 3 5 - 2 3 7 e v a lu a t in g e v id e n c e , 2 4 0 - 2 4 1

4 9 -5 0 , 49t

See also

A ccess to

p e r fo r m a n c e im p r o v e m e n t, 2 1 1 s e a r c h in g f o r e v id e n c e , 2 3 8 - 2 4 0

INDEX

strategies to prom ote, 2 3 7 -2 3 8 using evidence, 2 4 2 -2 4 3 Evidence standards o f care, 2 8 3 -2 8 7 E xam fo r licensure, 2 88 Exhaustion em otional, 1 46 . See also Burnout fatigue, 285 Existentialism , 93 E xp ert stage o f nursing, 161 E xp ert witnesses, 2 8 1 -2 8 2 , 2 8 3 , 2 8 4 Externships, 1 6 2 -1 6 3 Extrinsic values, 97

F Faculty, nurse, 147, 3 53 , 359, 360 False im prisonm ent, 279 Fam ily decision m aking of, 1 1 8 -1 2 2 , 2 6 6 -2 6 8 relationship w ith . See N u rs e -p a tie n t-fa m ily relationships serving as nurse (Classical era), 3, 5 Fam ily planning, educating on, 29 Fatigue, 2 85 Federal laws and rules adm inistrative law, 2 7 7 -2 7 8 case law, 278 fo r patient privacy, 2 9 5 , 339 statutory law, 2 7 6 -2 7 7 , 2 8 3 , 289 Federal Register, 278 Feedback, 1 8 1 -1 8 5 , 1 83 t, 209 Felonies, 2 8 1 , 2 9 0 Fem inist ethics, 112 Fem inization o f nursing, 27 Films about nurses, 38 Financial systems, 336 First impressions, 1 7 5 -1 7 7 Five C ’s o f caring, 163 Five-year career plan, 173 Flu epidemic, 2 9 , 151 Foreign nurses, 131 Forensic nurses, 142 Forgoing treatm ent, 266 Form ation (socialization process), 157 Form ist thinking, 98 4-B ox A pproach fo r critical thinking, 1 1 9 -1 2 1 , 120t Four Topics M e th o d fo r ethical analysis, 1 1 9 -1 2 1 , 120t

Fram ew o rk fo r theory-based nursing practice. See Theories o f nursing Fraud, 279 Fro ntier N ursing Service, 35 Full m oral standing, 2 6 2 Funding fo r nurse-managed centers, 140 Futile care, 2 6 7 Future directions o f nursing, 3 4 9 -3 6 5 . See also Evidence-based practice changing demographics, 3 5 8 -3 6 0 com plem entary and alternative approaches, 1 4 9 -1 5 0 , 1 9 8 -1 9 9 consumerism, 1 4 7 -1 4 9 disaster preparedness, 1 5 1 -1 5 2 , 340 education, 4 1 , 2 3 0 -2 3 1 faculty shortage, nurse, 353 global aging, 1 4 3 -1 4 5 in health care delivery systems, 1 9 6 -1 9 9 incivility and bullying, 141 inform atics and technology, 3 2 6 -3 2 9 , 3 4 2 -3 4 3 m ental health needs, 1 4 2 -1 4 3 nurse-managed centers, 1 3 9 -1 4 0 nurse shortage, 1 4 5 -1 4 7 , 3 5 1 -3 5 3 nursing core competencies, 7 7 -7 9 nursing education, 3 6 0 -3 6 4 prom oting positive image, 130 research needs, 1 49 , 152 retention, 3 5 6 -3 5 7 role clarity, 358 technological changes, 1 5 0 -1 5 1 , 1 9 6 -1 9 7 , 3 3 5 -3 3 7 transitioning to professional practice, 163 w orkplace environm ent com plexity of, 3 5 3 -3 5 6 safety of, 3 5 7 -3 5 8

The Future o f Nursing: Leading Change, Advancing Health (IO M ), 4 1 , 1 3 9 -1 4 0 , 141, 3 50 , 364

G Galen o f Pergamum, 7 Gender bias, 1 08 , 112, 133 Gender gap in nursing, 1 3 0 -1 3 3 G eneral Board o f H ea lth fo r England, 14 Geographic barriers to health care, 1 3 7 -1 3 8 G eriatric Nurse Practitioners (G N P s), 144 G erm theory, 1 0 -1 1 Gerogogy in patient education, 316 Gerontology, 1 4 4 -1 4 5

405

406

INDEX

Gero-Psychiatric M e n ta l H ea lth Nurse Practitioner, 144 G illigan, C aro l, 108, 112 G lob al aging, 1 4 3 -1 4 5 G lob al nursing philosophy, 102 G lob al nursing theory, 4 7 G N P (G eriatric N urse Practitioner), 144 Goals goal attainm ent theory (K ing), 6 4 -6 5 , 6 4 t of nursing inform atics, 335 patient learning goals, 3 1 4 -3 1 5 setting personal, 1 7 0 -1 7 3 , 1 73 t, 2 0 7 G o ld m ark R eport, 2 7 -2 8 “ G ood death,” 263 G oodrich, A nnie, 29 “ G ood w ill” profile o f nurse, 281 Google Scholar, 332 G ordon, Suzanne, 127 G rand theories o f nursing. See C onceptual models G ranny m idwives, 3 5 -3 6 Grants fo r nurse-managed centers, 140 G reat Depression, 3 7 -3 8 Greatest good (U tilitarianism ), 1 1 1 -1 1 2 Greek era, 5 -6 , 91 Gretter, Lystra, 114 Groundwork o f the Metaphysics o f Morals (Kant), 110 G roup discussions and reflection, 229 Guidelines. See also Ethical practice fo r clinical practice, 2 4 2 -2 4 3 N a tio n a l Guideline Clearinghouse, 2 40 fo r n u rse -p a tien t-fam ily relationships, 5 2 -5 3 fo r responding to trends and developments, 148, 1 4 8 -1 4 9 ^ fo r sending em ail, 3 3 7 -3 3 8 fo r use of social m edia, 339

H H aberm as, Jurgen, 93 H a lo effect, 1 82 , 1 8 3 t H andh eld devices, 3 4 1 -3 4 2 H a rd in M D (H a rd in M e ta D irectory), 333 H a rm , negligence and m alpractice resulting in, 2 8 3 -2 8 7 H a rtfo rd Institute fo r G eriatric N ursing, 145 H a rv a rd M e d ica l School, 2 6 2 H B M (H ealth Belief M o d e l), 3 0 7 -3 0 8 H C O s (heathcare organizations), 198 H ealing space, 5 2 t

H ealth as central concept o f nursing, 4 8 , 5 2 t, 5 5 t, 5 6 t, 60t, 6 3 -6 5 t, 6 8 -6 9 1, 7 1 1, 7 3 -7 5 t, 7 7t, 95 as a value, 9 9 -1 0 0 H ea lth 2 .0 Developer Challenge, 334 H ea lth and H u m an Services D epartm ent (H H S ), 2 8 3 , 2 8 4 , 2 9 5 , 335 H ea lth Belief M o d e l (H B M ), 3 0 7 -3 0 8 H ea lth care. See also Access to health care; H is to ry of health care and nursing allocation and rationing of, 2 5 8 -2 6 1 cost of, 4 0 , 197, 2 5 8 -2 5 9 , 3 5 4 -3 5 6 delivery of. See H ea lth care delivery systems ethics, 1 0 6 -1 0 7 legislation affecting, 2 7 6 -2 7 7 , 3 00 , 350 reform of, 4 0 -4 1 , 145, 300 transform ation of, 147 H ea lth Care and Education A ffo rd ab ility Reconciliation A ct (2 0 1 0 ), 350 H ea lth care delivery systems, 1 9 5 -2 1 4 changes in, 1 9 6 -1 9 9 continuous quality im provem ent, 2 1 0 -2 1 4 models o f patient care in, 1 9 9 -2 0 2 role o f nurse in, 2 0 3 -2 1 0 in U.S., 1 39 , 258 H ealthcare organizations (H C O s ), 198 H ea lth inform ation online, 3 3 2 -3 3 4 protection of, 2 7 9 , 2 9 4 -2 9 6 , 3 3 4 -3 3 5 , 3 37 , 339 H ea lth In fo rm atio n Technology (H ealth IT ) Initiatives, 3 26 , 342 H ea lth insurance, 39, 136, 1 45 , 1 97 , 300 H ea lth Insurance P ortability and A ccountability A ct (H IP A A ), 2 9 5 , 3 29 , 3 3 4 -3 3 5 , 3 41 , 342 H ea lth literacy o f patient, 3 1 1 -3 1 2 , 314 H ea lth m aintenance organizations (H M O s ), 41 H ea lth o f nurse. See also Self-care addiction, 188, 2 9 0 , 292 m ental health, 34, 1 4 2 -1 4 3 , 291 risks to, 355 H ea lth on the N e t Foundation (H O N ) , 333 H ea lth policy, 1 4 4 -1 4 5

Health Professions Education: A Bridge to Quality (IO M ), 360 H ea lth prom otion environm ental stim uli and, 62 H ealth Belief M o d e l, 3 0 7 -3 0 8 Pender’s m odel, 7 0 -7 2 , 7 1 1

INDEX

H ea lth records, 325, 3 34 , 3 3 5 -3 3 7 , 342. See also H ealth Insurance P ortability and A ccountability A ct (H IP A A ) H ea lth Resources and Service A dm inistration, 351 H ea lth seeking behaviors, 7 4, 306 H ea lth Source, 332 H ea lth visitors, 2 5, 30 H ea lth y People 2 0 1 0 , 2 5 8 , 343 H ea lth y People 2 0 2 0 , 142, 143*, 1 44 , 2 5 8 , 343 H earing im pairm ent in older adults, 3 16 , 3 1 7 -3 1 8 b H earings fo r disciplinary actions, 291 H ebrew s, early m edicine of, 4 H elicy principle, 5 5 -5 6 H enderson’s philosophy and art o f nursing, 5 0 -5 1 , 52* H en ry Street Settlement, 3 1 -3 2 H epatitis of nurses, 356 H eraclitus, 91 H erb ert, Sidney, 1 8 -1 9 H ero ine, nurse as, 38 H H S . See H ealth and H u m an Services D epartm ent H ierarchical organization structure of hospitals, 354 H ierarch y o f values, 9 8, 9 9 -1 0 0 H ig h er brain death, 263 H IP A A . See H ea lth Insurance P ortability and A ccountability A ct Hippocrates, 5 H ip pocratic O a th , 255 H irin g practices, 1 3 5 -1 3 6 . See also Employers; Jobs, nursing H isto ry of health care and nursing, 3 -4 2 advancement o f science and health o f public, 1 0 -1 1 , 3 8 -3 9 C hadw ick R eport, 1 3 -1 4 Classical era, 3 -8 codes and, 1 1 4 -1 1 5 dark period o f nursing, 12 early leaders in, 2 8 -3 5 early organized care, 13 education and organization, 2 7 -2 8 , 114 epidemiology, 16 evolution o f nursing in U .S., 2 8 -4 0 future o f nursing, 41 G reat Depression, 3 6 -3 8 home visiting, 11, 2 4 -2 5 , 3 0 -3 3 Industrial R evolution, 1 4 -1 6 licensure, 2 8 , 2 9 , 2 8 7 -2 8 9 managed care and health care reform , 4 0 -4 1

m en in, 39, 132 M id d le Ages, 8 -9 m idwives, 3 5 -3 6 N ightingale, Florence, 1 6 -2 7 R eform ation, 1 1 -1 2 Renaissance, 9 -1 0 revolution, protest, and new order, 3 9 -4 0 science, changes in, 3 8 -3 9 Shattuck R eport, 1 3 -1 4 W o rld W a r II, 3 6 -3 8 H IV o f nurses, 356 H olistic approach to care, 199, 2 0 0 , 203 H o m e care nursing, 2 1 2 -2 1 3 H om eop ath ic m edicine, 150 H o m e visiting, 11, 2 4 -2 5 , 3 0 -3 3 H O N (H ealth on the N e t Foundation), 333 H o rizo n ta l violence, 2 5 4 H orns effect, 1 82 , 183* H ospital de la Purisim a Concepcion, 13 Hospitals. See also H ea lth care delivery systems; W orkplace environm ent history of, 7, 8, 11, 13 as prim ary w o rk environm ent, 3 5 4 -3 5 5 self-governance, 177 H ospital Value-Based Purchasing (VBP) Program , 342 H o te l-D ie u (France), 8 H um anbecom ing theory (Parse), 6 6 -6 8 , 6 8* H u m a n dignity, 159 H um anistic nursing values, 9 6 -9 7 H ygeia (G reek goddess), 5 H ypothetical im peratives, 111

I Ia*reia, 7 IC N . See International C ouncil o f Nurses Idealism , 93, 94b, 162 Ignorance principle, 2 58 The Iliad, 6 Im age o f nursing. See Public image o f nursing Im m ig ratio n and public health, 13, 1 5 -1 6 Im m o ra l behavior, 110 Im m unizations, 10, 13, 14 Im plem entation as critical thinking skill, 2 2 5 -2 2 6 In a Differen* Voice (G illiagan), 108 Incivility and bullying, 141, 3 0 0 -3 0 1 Indexes, electronic, 239 Individual nursing philosophy, 1 0 0 -1 0 2 , 101b Industrial R evolution, 1 4 -1 6

407

408

INDEX

Inequality in health care access, 2 5 8 -2 6 1 Infectious diseases. See Com m unicable diseases Influenza epidemic, 2 9 , 151 Inform atics and technology, 3 2 5 -3 4 8 competencies in, 3 2 9 -3 3 0 confidentiality, security, and privacy (H IP A A ), 3 3 4 -3 3 5 curriculum changes based on, 360 decision m aking and, 78 electronic databases, 3 3 1 -3 3 2 electronic health records, 3 3 5 -3 3 7 em ail, 3 3 7 -3 3 8 handheld devices, 3 4 1 -3 4 2 health inform ation online, 3 3 2 -3 3 4 im pact on health care, 3 8 -3 9 , 1 49 , 1 9 6 -1 9 7 , 364 interactive patient-engagem ent in education programs, 134 Internet resources, 330 listserv groups and m ailing lists, 338 need fo r increased education and, 2 8 7 in nursing, 1 5 0 -1 5 1 nursing inform atics, defined, 3 2 5 -3 2 6 social m edia, 3 3 8 -3 4 0 telehealth, 3 4 0 -3 4 1 trends and future directions, 3 2 6 -3 2 9 , 3 4 2 -3 4 3 website evaluation, 3 3 0 -3 3 1 Inform atics nurse specialists (INSs), 3 2 9 -3 3 0 , 3 4 2 -3 4 3 In fo rm atio n systems, 336 In fo rm atio n technology (IT ), 3 2 6 -3 2 9 , 342. See also Inform atics and technology Inform ed consent, 2 5 5 -2 5 6 , 2 9 2 -2 9 4 Informing the Future: Critical Issues in Health (IO M ), 286 Institute o f M edicine (IO M ) adequacy o f nursing education, 360 D N P program based on reports from , 362 education, call fo r advances in, 41 future o f nursing profession, 350, 364 im portance o f critical thinking, 2 3 0 incivility and bullying, 141 m inorities, unequal treatm ent of, 359 reducing practice errors, 2 8 6 reform o f nursing education, 327 requisite skills fo r nursing, 160 role of nurse, 1 3 9 -1 4 0 Insurance, 300 health, 39, 1 36 , 1 45 , 197 m alpractice, 2 8 3 , 2 8 4 , 2 8 6 -2 8 7

Integrality principle, 56 Integrity, 1 09 , 115 Interacting systems fram e w o rk (K ing), 6 4 -6 5 , 6 4 t Interactive patient-engagem ent technology, 134 Interdependence in educational socialization, 160 as m ode of behavior, 61 Interdisciplinary heathcare teams, 2 0 7 -2 1 0 International C ouncil of Nurses (IC N ), 1 1 4 -1 1 5 , 116, 1 59 , 160, 2 5 3 . See also Codes o f ethics fo r nurses International Red Cross, 34 Internet. See also Websites access to, 3 41 , 343 educating patient on use of, 151 evidence-based practice, use in, 2 3 9 -2 4 0 health inform ation on, 3 3 2 -3 3 4 job hunting on, 174 resources fo r use of, 330 search engines, 330 website evaluation fo r inform atics and technology, 3 3 0 -3 3 1 Interpersonal relations, theory o f (Peplau), 6 9 -7 0 , 6 9 t Interprofessional collaboration, 96 Intervention program s as alternative to discipline, 2 9 2 Interview ing fo r jobs, 1 7 5 -1 7 6 Intrinsic values, 97

An Introduction to the Principles o f Morals and Legislation (Bentham ), 111 Invasion o f privacy, 279 IO M . See Institute o f M edicine Io w a M o d e l of Evidence-Based Practice, 244 IT. See In fo rm atio n technology

J Jenner, E dw ard , 10 Jewish health care (Classical era), 4 -5 Jobs, nursing. See also Career m anagem ent; Em ployers burnout from , 1 4 5 -1 4 6 , 1 8 8 -1 8 9 dissatisfaction w ith , 3 5 6 -3 5 7 economy affecting, 1 39 , 1 4 5 -1 4 6 , 1 6 9 -1 7 0 , 352 interview ing for, 1 7 5 -1 7 6 quitting abruptly/abandoning, 291 Johns H opkins N ursing Evidence-Based Practice M o d e l, 2 4 5 -2 4 6 Johnson’s behavioral system m odel, 6 5 -6 6 , 6 5 t Joining Forces initiative, 138

INDEX

Joint Com m ission on A ccreditation of H ealthcare O rganizations assessing patient preferences, 319 continuous quality im provem ent (C Q I), 211 cultural and ethnic diversity in nursing, 134 on patient education, 3 05 , 316 reform o f nursing education, 327 screening potential employers, 1 7 6 -1 7 7 standard o f care evidence, 283 Jonsen, A lb ert, 106 Journaling as critical th inking skill, 2 2 7 -2 2 9 setting personal goals and, 1 7 2 -1 7 3 Justice. See Social justice

K K ahun Papyrus, 3 K ant, Im m anuel, 1 1 0 -1 1 1 K eep in g Patients S afe: T ran sform in g th e W ork E nviron m en t o f N urses (IO M ), 2 8 6

Keyes, John M a y n a rd , 349 Kinesthetic learning style, 3 1 0 -3 1 1 K in g’s interacting systems fram ew o rk and theory of goal attainm ent, 6 4 -6 5 , 6 4 t Klebs, E dw in , 1 0 -1 1 K nowledge, skills, and attitudes (KSAs), 328 Koch, R obert, 10 K ohlberg, Lawrence, 108 K olcaba’s theory o f com fort, 7 3 -7 4 , 7 4 t

L Language barriers, 134, 138 Lateral integration o f care, 362 Lateral violence, 2 5 4 L a w and professional nursing, 2 7 5 -3 0 2 accountability delegation, 2 9 6 -3 0 0 inform ed consent, 2 9 2 -2 9 4 privacy and confidentiality, 2 9 4 -2 9 6 adm inistrative law, 2 7 7 -2 7 8 bullying in w orkplace, 3 0 0 -3 0 1 case law, 278 classification and enforcement o f law, 2 7 8 -2 8 1 health care reform , 300 m alpractice and negligence, 2 8 1 -2 8 3 codes fo r m alpractice act or omission, 2 8 5 t evidence o f standards o f care used in court, 2 8 3 -2 8 7

o f nurse, 2 0 3 , 2 9 4 , 301 nursing licensure alternative program s, 2 9 2 function o f boards o f nursing, 2 8 9 -2 9 2 history of, 2 8 7 -2 8 9 o f physician, 2 9 2 -2 9 4 preventing legal problem s, 301 sources o f law, 2 7 6 -2 7 8 statutory law, 2 7 6 -2 7 7 , 2 8 3 , 289 Leadership role o f nurse, 7 8, 203 Learning com m itm ent to, 158 domains of, 3 0 6 -3 0 7 objectives o f patient, 315 styles of, 3 1 0 -3 1 1 Learning domains, 3 0 6 -3 0 9 Legal nurse consultants (L N C s ), 142 Legislation affecting nursing profession, 2 7 6 -2 7 7 , 3 00 , 350 Leininger’s cultural diversity and universality theory, 6 8 -6 9 , 6 8 t, 1 3 4 -1 3 5 Letters o f reference and support, 1 7 8 -1 7 9 L iab ility insurance for, 2 8 3 , 2 8 4 , 2 8 6 -2 8 7 issues o f delegation, 206 Liberty rights, 255 Licensure, nursing, 2 8 7 -2 9 2 alternative program s, 2 9 2 function o f boards o f nursing, 4 0, 2 8 9 -2 9 2 history of, 2 8 , 2 9 , 2 8 7 -2 8 9 N ightingale on, 24 renew al, 289 revoking, 281 Life, balance in, 1 72 , 188, 1 89 , 190 Lifelong learning, 1 8 5 -1 8 6 Life m anagem ent, 1 9 0 -1 9 1 Lister, Joseph, 10 Listservs, 338 Literacy o f patient, assessing, 3 1 1 -3 1 2 Living w ills, 2 5 6 L N C s (legal nurse consultants), 142 Lobbyists, 2 7 7 Login process to protect inform ation, 334 Loyalty, 116, 1 21 , 299 L-S oft searchable listserv database, 338 Luther, M a rtin , 11 Luther C hristm an A w ard, 131

409

410

INDEX M

K o l c a b a ’s t h e o r y o f c o m f o r t , 7 4 t

M a g i c a n d m e d ic in e , 4 , 8

L e in in g e r ’s c u lt u r a l d iv e r s ity a n d u n iv e r s a lity th e o r y , 6 8 t

M a i l i n g lis ts , 3 3 8

N e u m a n ’s s y s te m s m o d e l, 6 3 t

M a le n u rses, 2 7 , 3 9 , 1 3 1 - 1 3 3

N ig h t i n g a l e ’s e n v ir o n m e n ta l th e o r y , 4 9

M a lp r a c tic e , 2 8 1 - 2 8 7 , 2 8 5 t

t

d e fin e d , 2 8 3

N u r s e o f th e F u t u r e , 7 7 1

in f o r m e d c o n s e n t a n d , 2 9 3 - 2 9 4

O r e m ’s s e lf -c a r e d e fic it t h e o r y o f n u r s in g , 6 0 t P a r s e ’s h u m a n b e c o m in g th e o r y , 6 8 t

le g a l r e f o r m a n d , 1 4 5

P e n d e r ’s h e a lt h p r o m o t io n m o d e l, 7 1

M a n a g e d ca re c o ll a b o r a t i v e p r a c ti c e a n d , 2 0 7

t

P e p la u ’s t h e o r y o f in t e r p e r s o n a l r e l a t i o n s , 6 9 t

d e fin e d , 4 0

R e e d ’s s e lf -t r a n s c e n d e n c e th e o r y , 7 5 1

h e a lt h c a r e r e f o r m a n d , 4 0 - 4 1

R o g e r s ’s t h e o r y o f u n ita r y h u m a n b e in g s , 5 6 t R o y ’s a d a p ta t io n m o d e l, 6 0 t

p u b lic r e s p o n s e t o , 2 5 9 M a n a g e r , r o le o f n u r s e a s , 2 0 1 , 2 0 4 - 2 0 6 , 2 9 1 M a n u f a c t u r e r ’s i n s tr u c t io n s a s e v id e n c e o f s ta n d a r d

S y n e r g y M o d e l f o r P a tie n t C a r e , 7 7 t W a t s o n ’s p h ilo s o p h y a n d s c ie n c e o f c a r e , 5 2 t

o f ca re , 2 8 3 M a p p in g , c o n c e p t , 2 2 7 ,

S w a n s o n ’s t h e o r y o f c a r in g , 7 3 t

228f

M e ta p h y s ic s , 9 1

M a s s a c h u s e t t s D e p a r t m e n t o f H ig h e r E d u c a tio n (M D H E ), 4 1 , 7 7 - 7 9 ,

77t

M id d le A g e s , 8 - 9 , 3 9 M id d le - r a n g e t h e o r ie s o f n u r s in g

M a s s a g e th e r a p y , 1 5 0

K o l c a b a ’s t h e o r y o f c o m f o r t , 7 3 - 7 4 , 7 4 t

M a t e r i a l s f o r p a t i e n t e d u c a t io n , 3 1 2 - 3 1 6 , 3 1 3 - 3 1 4 ^

L e in in g e r ’s c u lt u r a l d iv e r s ity a n d u n iv e r s a lity th e o r y , 6 8 - 6 9 , 6 8 t

M a te rn a l ca re , 3 , 3 5 - 3 6 M e a n i n g in H u m a n b e c o m in g T h e o r y , 6 7 - 6 8

P a r s e ’s h u m a n b e c o m in g th e o r y , 6 6 - 6 7 , 6 8 t

M e c h a n is t i c t h in k in g , 9 8

P e n d e r ’s h e a lt h p r o m o t io n m o d e l, 7 0 - 7 2 , 7 1 1

M e d i a ’s in flu e n c e o n s o c i e t a l v ie w o f n u r s in g , 1 2 , 3 8 ,

P e p la u ’s t h e o r y o f in t e r p e r s o n a l r e l a t i o n s , 6 9 - 7 0 , 69t

1 2 8 -1 3 0 , 186

R e e d ’s s e lf -t r a n s c e n d e n c e th e o r y , 7 4 - 7 5 , 7 5 t

M e d i c a l d ir e c tiv e s , 2 5 7 M e d i c a l e r r o r s , s tu d y o n , 2 8 5 - 2 8 6

S w a n s o n ’s t h e o r y o f c a r in g , 7 2 - 7 3 , 7 3 t

M e d ic a l re c o rd s, 2 9 0 , 2 9 5 - 2 9 6 , 3 3 4 - 3 3 5

M id w iv e s , 3 5 - 3 6

M e d ic a re an d M e d ic a id , 3 9 , 1 4 4 , 1 9 7 , 2 5 9 , 3 0 0 , 3 4 2

M i l i t a r y h e a lt h c a r e

E H R I n c e n tiv e P r o g r a m s , 3 4 2 M e d i c i n e a n d m e d i c a t io n .

See

D ru g s

access to , 1 3 8 a d v a n c e s in , 1 9 7

M E D L IN E , 3 3 2

A rm y N u rse C o rp s, 3 5 , 3 7

M e d lin e P lu s , 3 3 3

C iv il W a r, U .S ., 2 2

M e e t i n g s , a t te n d in g , 1 7 9 - 1 8 0 , 1 8 0 t

C r im e a n W a r, 1 8 - 1 9

M e n in n u r s in g , 2 7 , 3 9 , 1 3 1 - 1 3 3

N ig h t i n g a l e ’s in flu e n c e o n , 2 1 , 2 2

Men in Nursing

(Jo u r n a l), 1 3 1 - 1 3 2

M e n t a l h e a lt h a f fe c t in g n u r s in g p r a c t i c e , 2 9 1 need s o f n u rses, 1 4 2 - 1 4 3 r e f o r m m o v e m e n t fo r , 3 4

in R o m a n e r a , 7 - 8 S p a n is h -A m e r ic a n W a r in C u b a , 3 4 - 3 5 W o r ld W a r I, 2 9 W o r ld W a r II, 3 7 - 3 8 M ilita r y r a n k o f n u rse s, 2 9

M e n to r in g , 1 8 0 - 1 8 1

M ill, Jo h n S tu a rt, 1 1 1

M e ta p a r a d ig m c o n c e p ts

M i n d - b o d y in t e r v e n t io n s , 1 5 0

B e n n e r ’s p h ilo s o p h y , 5 5 t

M i n d m a p p in g t e c h n i q u e , 2 2 7 , 2 2 8 f

d e fin e d , 4 8

M in o ritie s

H e n d e r s o n ’s p h ilo s o p h y , 5 2 t

c h a n g in g d e m o g r a p h ic s o f n u r s in g , 3 5 8 - 3 6 0

J o h n s o n ’s b e h a v io r a l sy s te m m o d e l, 6 5 t

c u r r e n t s t a t is tic s o n , 1 3 1 , 1 3 3 - 1 3 4

K in g ’s in t e r a c t i n g s y s te m s f r a m e w o r k , 6 4 t

e a r ly in v o lv e m e n t o f in n u r s in g , 2 1 , 3 2 , 3 3 , 3 6 , 3 9

INDEX

excluding fro m nursing profession, 2 7 recruiting and retaining, 1 34 , 1 3 5 -1 3 6 Minority Nurse Magazine, 135 M isdem eanors, 281 Misericordia as virtue, 253

Missing Persons: Minorities in the Health Professions (Sullivan C om m ission), 359 M ission statement, personal, 172 M istakes of nurse, 185. See also M alpractice; Negligence M o d e lin g fo r patient efficacy, 3 0 8 -3 0 9 M odels of evidence-based practice, 2 4 3 -2 4 6 M odels of nurse staffing, 152 M odels of patient care, 1 9 9 -2 0 1 M o n ito rin g practice o f nurses, 2 9 0 , 2 9 2 M o n ta g , M ild re d , 28 M o ra l friends, 2 5 4 M o ra l reasoning, 1 0 7 -1 0 8 M o ra ls . See also Ethical practice code o f nursing and, 115 defined, 106 deontology and, 1 1 0 -1 1 1 ethical principlism and, 1 1 2 -1 1 4 gender bias in research, 108, 112 inform ed consent, 2 5 5 -2 5 6 Patient Self-D eterm ination A ct, 2 5 6 -2 5 7 virtue ethics and, 110 M o ra l standing, 2 6 2 M o ra l suffering, 1 18 , 119 M o tiv a tio n behavioral system m odel and, 65 ethics and, 115 evidence-based practice and, 2 3 7 health prom otion m odel and, 71 patient education and, 307 values and, 97 M u ltic u ltu ra lism , 133 M ultiprofessional collaboration, 149 M u tu a lity , 1 5 9 -1 6 0 , 161 M y th s and misconceptions o f career m anagem ent, 1 6 9 -1 7 0 , 1 7 0 t

N N a tio n a l A dvisory C ouncil on N urse Education and Practice (N A C N E P ), 134 N a tio n a l Association o f C olored G raduate Nurses, 39 N a tio n a l Center fo r C om plem entary and A lternative M edicine, 1 4 9 -1 5 0

N a tio n a l Center fo r H ealth W orkforce Analysis, 351 N a tio n a l C om m ittee fo r Q u a lity Assurance, 134 N a tio n a l C ouncil o f State Boards of N ursing (N C S B N ) delegation, 2 0 6 , 2 9 6 , 2 9 7 -2 9 8 , 300 licensure exam of, 288 prelicensure clinical instruction, 361 social m edia, guidelines fo r use of, 339 N a tio n a l Guideline Clearinghouse, 2 40 N a tio n a l League fo r N ursing (N L N ) accreditation o f nursing program s by, 28 future o f nursing, 3 2 7 -3 2 8 , 350 m ilita ry health care, 1 3 8 -1 3 9 position statements, 327 N a tio n a l O rganization o f N urse Practitioner Faculties, 362 N a tio n a l Practitioners D ata Bank, 2 8 3 , 2 8 4 N a tio n a l Q u a lity Forum , 211 N a tio n a l security nursing inform atics and, 343 nursing shortage and, 146 N a tio n a l Vaccination Board, 13 N a tu ra l law theory, 110 N atu ro p a th ic m edicine, 150 N a v y N urse Corps, 37 N C L E X - R N test plan, 2 8 8 -2 8 9 N C S B N . See N a tio n a l C ouncil o f State Boards of N ursing Negative/independence stage o f cognitive developm ent, 159 N egative perform ance appraisal, 1 8 5 -1 8 6 Negligence, 2 8 1 -2 8 7 , 2 8 5 t N eoplatonism , 9 1 -9 2 N etw o rk in g , 1 7 9 -1 8 0 N e u m a n ’s systems m odel, 6 2 -6 4 , 6 3 t N I. See N ursing inform atics Nicomachean Ethics (A ristotle), 107 N ig htingale, Florence environm ental theory of, 4 9 -5 0 , 4 9 t legacy of, 2 5 -2 7 on licensure, 3 8 -3 9 , 2 8 7 life of, 1 6 -1 8 , 1 9 -2 0 , 2 7 -2 8 on m en in nursing profession, 132 m ilita ry reforms and, 22 political reform s, 2 1 -2 2 sanitation and, 1 9 -2 1 wellness m ovem ent and, 2 4 -2 5 N ightingale Pledge, 114

411

412

INDEX

N ightingale School o f N ursing at St. Thom as, 2 3 -2 4 , 114 N ig h t shift, 177 N L N . See N a tio n a l League fo r N ursing N on-E nglish speaking patients, 134, 138 Nonm aleficence, 1 14 , 1 2 0 t N onnurse healthcare w orkers, 2 9 6 -2 9 7 , 355 N o n vo lu n ta ry euthanasia, 263 Notes on Hospitals (N ightingale), 21

Notes on Nursing: What It Is and What It Is Not (N ightingale), 2 3 , 24 N ovice stage of nursing, 161 NPs (nurse practitioners), 40 N urem b erg Code, 106 N urse. See also Responsibility o f nurse; Role of professional nurse; Self-care career. See Career m anagem ent characteristics of, 76 character of, 2 3 , 2 7, 1 09 , 281 cross training, 197 culture of, 3 5 9 -3 6 0 as defendant in civil case, 2 7 9 -2 8 0 , 2 8 0 f as defendant in crim inal case, 281 as expert witness, 2 8 1 -2 8 2 , 2 8 3 , 284 leadership role of, 7 8, 203 m anager role of, 2 0 1 , 2 0 4 -2 0 6 , 291 political involvem ent of, 300 self-assessment evaluating perform ance, 1 8 1 -1 8 5 , 1 8 3 t values clarification and, 9 9 -1 0 0 self-awareness fo r cultural competency, 359 Nurse faculty, 1 47 , 353, 359, 360 Nurse Licensure C om pact, 288 N urse-m anaged centers, 1 3 9 -1 4 0 N urse-m idw ives, 3 5 -3 6 N urse-nurse relationships cultural sensitivity in, 131 ethical issues in, 254 incivility and bullying, 141, 3 0 0 -3 0 1 letters o f support, 178 m entoring, 1 8 0 -1 8 1 team nursing, 2 0 0

Nurse o f the Future: Nursing Core Competencies (M D H E ), 4 1, 7 7 -7 9 , 7 7 t N u rs e -p a tie n t-fa m ily relationships advocate fo r patient, 2 0 4 , 253 boundaries, 252 code o f ethics fo r nursing and, 1 1 5 -1 1 7

dignity, 2 5 2 -2 5 3 disciplinary actions resulting from , 2 9 0 -2 9 1 guidelines for, 5 2 -5 3 phases in, 70 team approach to care, 1 1 8 -1 2 2 Theory o f Caring, 7 2 -7 3 Theory o f C om fo rt, 7 3 -7 4 Theory o f G o al A ttain m en t (K ing), 6 4 -6 5 , 6 4 t Theory o f Interpersonal Relations, 6 9 -7 0 unavoidable trust, 251 values and, 99 N u rs e-p atie n t ratios, 3 5 5 -3 5 6 N urse-physician relationships collaborative practice, 2 0 7 ethical issues in nursing and, 2 5 0 -2 5 1 history of, 1 1 4 -1 1 5 interdisciplinary healthcare team , 2 0 7 -2 1 0 preventing practice of m idwives, 35 Nurse Practice Act, 2 8 9 , 2 9 2 Nurse practitioners (N Ps), 40 Nurse-stewardess, 38 N ursing beyond authorized scope, 2 9 1 , 2 9 7 central concepts of, 4 8 , 5 2 t, 5 5 t, 5 6 t, 6 0t, 6 3 -6 5 t, 6 8 -6 9 t, 7 1 1, 7 3 -7 5 1, 7 7t, 95 collaborative, 2 0 3 , 2 0 6 -2 1 0 , 2 0 8 f, 2 1 2 -2 1 4 core competencies, 7 7 -7 9 , 2 3 0 , 2 3 5 , 360 dark period of, 12 defined, 5 0 -5 1 , 9 5 -9 6 error reduction, 2 86 evolution of, 7, 8, 12 first century o f profession, 2 8 -4 0 gap between education and practice, 363 history of. See H istory o f health care and nursing philosophies of, 4 9 -5 5 , 8 9 -1 0 3 preventing legal problem s, 301 relationship o f theory to practice, 7 9 -8 0 social context of. See Social context o f nursing societal view of, 38, 1 2 8 -1 3 0 , 1 86 , 281 stages of, 1 6 0 -1 6 1 standards of, 2 8 2 , 2 9 4 , 3 7 1 -3 7 2 supply and dem and, 1 4 5 -1 4 7 theories of. See Theories o f nursing

Nursing and Nursing Education in the United States (G o ld m ark R eport), 2 7 -2 8 N ursing career. See Career m anagem ent N ursing faculty shortage, 353 Nursing for the Future (B row n R eport), 28

INDEX

N ursing inform atics (N I), 3 2 5 -3 2 9 N ursing licensure. See Licensure, nursing N ursing literature as evidence o f standards o f care, 2 83 N ursing process. See also Theories o f nursing as critical th inking skill, 2 2 3 -2 2 4 used to prevent legal problems, 301 Nursing’s Agenda for Health Care Reform (A N A ), 40 Nursing’s Agenda for the Future (A N A ), 100 N ursing shortage after W W II, 2 8 , 39 delegation because of, 298 future trends, 1 4 5 -1 4 7 , 3 5 1 -3 5 3 as job security indicator, 1 6 9 -1 7 0 reasons for, 356 R eform ation’s creation of, 11 stress in w o rk environm ent caused by, 187 during W W II, 37 N ursing theory. See Theories o f nursing N ursing W orkforce D iversity A w ard, 135 N u ttin g , M a ry A delaide, 2 8, 29

O Obedience, 115 Objectives fo r behavioral change, 315 career m anagem ent, 1 7 2 -1 7 3 , 1 7 3 t fo r prevention of violence and abuse, 1 42 , 1 4 3 t O ccupational hazard, burnout as, 1 4 5 -1 4 6 , 1 8 8 -1 8 9 Occupation vs. career, 1 6 8 -1 6 9 , 1 6 9 t Office of M in o rity H ealth , 261 Office of the N a tio n a l C o ordinator o f H ealth In fo rm atio n Technology (O N C ), 333, 342 O ld e r adults and health care, 1 4 3 -1 4 5 , 1 96 , 316, 3 1 7 -3 1 8 ^ O n line databases, 331 O n line resources. See also Inform atics and technology health inform ation , 3 3 2 -3 3 4 Internet resources, 330 job hunting, 174 O rd e r entry systems, 336 Oregon Nurses Association, 2 69 O re m ’s self-care deficit theory o f nursing, 5 7 -6 0 , 6 0 t O rganic thinking, 98 O rgan transplantation, 2 6 0 -2 6 1 , 343 Osborne, M a ry D ., 36

P Pain m edication. See Drugs Palliative care, 2 6 5 -2 6 6 Palmer, Sophia, 28 Panacea (G reek goddess), 5 Paradigms, philosophy and, 9 3 -9 4 Parmenides, 91 Parse’s hum anbecom ing theory, 6 6 -6 8 , 6 8 t P artially com pensatory system, 59 Passive euthanasia, 2 63 Pasteur, Louis, 10 Paternalism , 113, 147 Patient advocacy, 2 0 4 , 2 53 Patient assessment as critical thinking skill, 2 2 4 -2 2 5 learning needs of, 3 0 9 -3 1 0 , 319

The Patient Care Partnership: Understanding Expectations, Rights, and Responsibilities (Am erican H ospital Association), 1 47 , 148^ Patient-centered care, 78 Patient education, 3 0 5 -3 2 0 assessment, 3 0 9 -3 1 0 cultural considerations, 319 docum entation of, 320 evaluating, 3 1 9 -3 2 0 health literacy, 3 1 1 -3 1 2 im plem entation, 3 1 5 -3 1 6 learning styles, 3 1 0 -3 1 1 older adults, considerations for, 3 1 6 -3 1 9 , 3 1 7 -3 1 8 ^ overview, 3 0 5 -3 0 6 planning, 3 1 4 -3 1 5 process o f patient education, 3 0 9 -3 1 6 assessment, 3 0 9 -3 1 0 health literacy, 3 1 1 -3 1 2 im plem entation, 3 1 5 -3 1 6 learning styles, 3 1 0 -3 1 1 planning, 3 1 4 -3 1 5 readability o f education m aterials, 3 1 2 -3 1 4 , 3 1 3 -3 1 4 ^ readiness to learn, 311 readability of education m aterials, 3 1 2 -3 1 4 , 3 1 3 -3 1 4 ^ readiness to learn, 311 theories and principles o f learning, 3 0 6 -3 0 9 web-based inform ation , 3 3 0 -3 3 1 Patient Protection Act, 300, 350

413

414

INDEX

P a tie n ts .

See also

N u r s e - p a t i e n t - f a m i l y r e la t io n s h ip s ;

R e c o r d s , p a t ie n t

P E T ( J o h n s H o p k in s N u r s in g E v id e n c e -B a s e d P r a c t ic e M o d e l), 2 4 5 - 2 4 6

a s s e s s in g a s c r i t i c a l t h in k in g s k ill, 2 2 4 - 2 2 5

P e w H e a lt h P r o f e s s io n s C o m m is s io n , 1 4 8

c h a n g e s in c a r e o f , 1 9 8 - 1 9 9

P h a r m a c e u ti c a l s .

c h a ra c te ris tic s o f, 7 6

P h ilo s o p h ie s o f n u r s in g , 4 9 - 5 5 , 8 9 - 1 0 3

See

D ru gs

c o n s u m e r is m a n d , 1 4 7 - 1 4 8

b e lie f s , 9 4 - 9 6

c r i t i c a ll y ill, m o d e l f o r c a r in g fo r, 7 6 - 7 7

B e n n e r ’s p h ilo s o p h y , 5 3 - 5 5 , 5 5 t

c u lt u r a l a n d e t h n ic d iv e r s ity o f , 6 8 - 6 9 , 1 9 6

d e fin e d , 4 9

e d u c a t io n o f .

See

P a tie n t e d u c a t io n

d e v e lo p in g p e r s o n a l, 1 0 0 - 1 0 2 , 1 0 1

b

e a r ly p h ilo s o p h y a s b a s is fo r, 9 1 - 9 3

in f o r m e d c o n s e n t , 2 5 5 - 2 5 6 , 2 9 2 - 2 9 4 m o d e ls o f c a r e fo r , 1 9 9 - 2 0 2

H e n d e r s o n ’s p h ilo s o p h y , 5 0 - 5 1 , 5 2 t

n e g lig e n c e a n d m a lp r a c t ic e r e s u ltin g in h a r m ,

N ig h t i n g a l e ’s e n v ir o n m e n ta l th e o r y , 4 9 - 5 0 , 4 9 t

2 8 3 -2 8 7

p a r a d ig m s , 9 3 - 9 4

as p l a i n t i f f in c iv il c a s e , 2 7 9 - 2 8 0

v a lu e s , 9 6 - 1 0 0

p r iv a c y a n d c o n f id e n t ia lit y fo r, 2 7 9 , 2 9 4 - 2 9 6 ,

W a t s o n ’s p h ilo s o p h y , 5 1 - 5 3 , 5 2 t P h ilo s o p h y , d e fin e d , 9 0 , 1 0 0

3 3 4 -3 3 5 , 339 r e f e r r in g f o r c a r e , 2 1 2 - 2 1 3

P h r o n e s is , 1 0 8

s a fe ty o f , 2 3 0 , 2 5 4 , 3 5 7

P h y s ic a l a g g r e s s io n o f n u r s e , 2 9 0

s e lf -c a r e , 5 7 - 5 9

P h y s ic a l c o m f o r t , 7 3

s p ir it u a l n e e d s o f , 5 0

P h y s ic a l c o m p e te n c y , 2 9 1

s ta n d a r d o f c a r e , 1 5 2 , 2 8 0 - 2 8 1

P h y s ic a l r e a c t i o n t o s tr e s s , 1 8 8

s u p p o r t g r o u p s o n lin e fo r, 3 3 8

P h y s ic ia n - a s s is te d s u ic id e , 1 1 5 , 2 6 8 - 2 6 9

t e c h n o lo g y u s e fo r, 1 5 0 - 1 5 1 , 1 9 7

P h y s ic ia n s

v u ln e r a b ility o f , 2 5 3

c o ll a b o r a t i v e p r a c ti c e a n d , 1 4 9 , 2 0 6 - 2 1 0

“ A P a t i e n t ’s B ill o f R i g h t s ” (A m e r ic a n H o s p i t a l A s s o c i a t io n ) , 1 4 7

e a rly , 4 - 7 in f o r m e d c o n s e n t , im p o r t a n c e o f , 2 9 2 - 2 9 4

P a tie n t S e lf - D e t e r m in a t i o n A c t o f 1 9 9 0 , 2 5 6 - 2 5 7

p r e v e n tin g p r a c t i c e o f m id w iv e s , 3 5 r e la t io n s h ip w ith n u r s e s , 1 1 4 - 1 1 5 , 2 5 0 - 2 5 1

P a tt e r n in g a c t iv it ie s , 5 7 P D A s ( p e r s o n a l d ig ita l a s s is ta n t s ) , 3 4 1 - 3 4 2

P h y s io lo g ic - p h y s ic a l m o d e o f b e h a v io r , 6 1

P e d ia t r ic s , 4 0

P IC O fo rm a t fo r re se a rch , 2 3 8 - 2 3 9 , 2 4 5

P e n d e r ’s h e a lt h p r o m o t io n m o d e l, 7 0 - 7 2 ,

71t

P la g u e , 6 , 9 , 1 3

P e n ic illin , 3 6

P la n n e d P a r e n t h o o d o f A m e r ic a , 2 9

P e p la u ’s t h e o r y o f i n t e r p e r s o n a l r e l a t i o n s , 6 9 - 7 0 , 6 9 t

P la n n in g a s c r i t i c a l t h in k in g s k ill, 2 2 5

P e r f o r m a n c e a c c o m p lis h m e n t s f o r p a t i e n t e ffic a c y ,

P la n n in g p r o c e s s f o r p a t i e n t e d u c a t io n , 3 1 4 - 3 1 5

3 0 8 -3 0 9

P la t o , 6 , 9 1 - 9 2

P e r f o r m a n c e a p p r a is a l, e m p lo y e e , 1 8 1 - 1 8 5 , 1 8 3 t

P o lit ic s , in v o lv e m e n t o f n u r s e s in , 3 0 0

P e r s o n , a s c e n t r a l c o n c e p t o f n u r s in g , 4 8 , 5 2 t , 5 5 t ,

P o o r ju d g m e n t a s d is c ip lin a r y c a te g o r y , 2 9 1

5 6 t , 6 0 t , 6 3 - 6 5 1, 6 8 - 6 9 t , 7 1 1, 7 3 - 7 5 t , 7 7 t , 9 5

P o p u la t io n g r o w t h , 1 4 3 - 1 4 4

P e r s o n a l a c c o m p lis h m e n t , d e c r e a s e d , 1 4 6

P o stg ra d u a te n u rse co m p e te n c e , 3 6 1

P e r s o n a l d a ta

P o s t m o d e r n is m , 9 3

m a r k e tin g o f , 2 9 6

P o s t s t r u c t u r a lis m , 9 3

p ro te c tio n o f, 2 9 4 - 2 9 6

P o v e r ty a n d a c c e s s t o h e a lt h c a r e , 1 3 7

P e r s o n a l d ig ita l a s s is ta n t s (P D A s ), 3 4 1 - 3 4 2

P o w e r o f a tto r n e y , 2 5 7

P e r s o n a l d ig n ity , 1 0 9

P r a c t ic e , n u r s in g .

P e r s o n a l g o a ls , s e ttin g , 1 7 0 - 1 7 3 , 1 7 3 t , 2 0 7

See

E t h ic a l p r a c t i c e ; E v id e n c e -b a s e d

p r a c t i c e ; N u r s in g

P e r s o n a l p h ilo s o p h y , 1 0 0 - 1 0 2 , 1 0 1 b

P r a c t it io n e r , r o le o f n u r s e a s , 2 0 3

P e r s o n h o o d , d e a th a s lo s s o f , 2 6 3

P r e fe r r e d p r o v id e r o r g a n iz a tio n s ( P P O s ) , 4 1

P e s th o u s e s , 1 3

P r e lic e n s u r e in s t r u c t io n , 3 6 0 - 3 6 1

INDEX

Prevention-based nursing practice, 2 4 -2 5 , 33, 36 Preventive health care, 1 36 , 1 43 t, 144, 1 9 8 -1 9 9 Principles o f Biomedical Ethics (Beauchamp), 112 Privacy, 2 7 9 , 2 9 4 -2 9 6 , 3 3 4 -3 3 5 , 339. See also C onfidentiality Problem-focused triggers, 2 4 4 Problem solving. See C ritical thinking Professional accountability. See A ccountability, professional Professional behavior, 7 8, 175, 2 5 2 -2 5 3 Professional nurses associations, 127. See also Am erican Nurses Association (A N A ) Professional organizations, 1 86 , 2 7 7 Professional perform ance standards (A N A ), 2 8 2 Professional socialization. See Socialization to professional nursing role Professional values, 1 5 8 -1 5 9 . See also Values Professors and teachers fo r nursing. See Faculty, nurse Proficient stage of nursing, 161 Prolonged preceptor clinical experiences, 1 6 2 -1 6 3 Prom oting heath H ealth Prom otion M o d e l, 7 0 -7 2 through com m unity nursing centers, 199 through environm ental stim uli, 62 Prom oting nursing profession, 1 2 6 -1 2 7 Propositions, defined, 48 Protection o f health inform ation, 2 7 9 , 2 9 4 -2 9 6 , 3 3 4 -3 3 5 , 337, 339 Prudence, 108 Psychiatric illness o f nurses, 290 Psychiatry, developm ent of, 10 Psychobiological experiences, 70 Psychomotor learning, 3 0 6 -3 0 7 Psychospiritual com fort, 73 P sycIN FO , 332 Public health, 7 -8 , 1 0 -1 1 education for, 340 emergence of, 30 funding for, 38 im m igration and urbanization affect on, 13, 1 4 -1 6 N ig htingale’s influence on, 21 reform in U .S., early, 14 W ald and, 3 0 -3 3 Public image o f nursing m edia’s influence on, 12, 38, 1 2 8 -1 3 0 , 186 overview, 1 2 6 -1 2 7 positive, 187, 281 Public school nurses, 3 2 -3 3 , 38

Public speaking, 178 Pure autonom y standard, 2 6 7

Q Q u a lity and quantity of evidence, 241 Q u a lity and Safety Education fo r Nurses (Q S E N ), 2 3 5 , 327, 328 Q u a lity im provem ent in health care delivery systems, 7 8, 2 0 1 , 2 1 0 -2 1 4 , 2 3 6 Q uarantine, 9 Q u in la n , Karen A nn, 2 5 6 , 2 6 7 Q u ittin g nursing job, 146, 2 9 1 , 356

R R acial discrim ination in nursing profession, 2 1 , 2 7, 32, 33, 39. See also A frican Am erican nurses R apid Estim ate o f A d u lt Literacy in M edicine, 312 R athbone, W illia m , 2 4 -2 5 R ation al suicide, 2 6 4 R ationing health care resources, 2 5 8 -2 6 1 R aw ls, John, 2 5 7 -2 5 8 R eadability o f education m aterials, 3 1 2 -3 1 4 , 3 1 3 -3 1 4 b Readiness to learn, 311 Reading level, 3 11 , 313b Realism , 9 3, 94b, 134 R eality shock o f professional nursing, 1 6 2 -1 6 3 Reasonable standard o f care, 279 Reasoning process in nursing. See C onceptual models Records, patient destruction or alteration of, 290 electronic health records (E H R ), 325, 334, 3 3 5 -3 3 7 , 342 H IP A A rules and, 2 9 5 -2 9 6 Recruiting and retaining nurses issues affecting, 3 5 6 -3 5 7 m en, 131 m inorities, 1 34 , 1 3 5 -1 3 6 fo r nursing shortage, 146 Red Cross, 3 4 -3 5 Reed’s self-transcendence theory, 7 4 -7 5 , 7 5 t Reference, letters of, 179 R eferring patient fo r care, 2 1 2 -2 1 3 Reflective thinking, 2 2 1 , 229 R eform ation, 1 1 -1 2 Refusing treatm ent, 266 Registered nurses (R N s), 3 8 -3 9 , 2 8 7 R egulator subsystem o f adaptive process, 61

415

416

INDEX

R egulatory or adm inistrative law, 2 7 7 -2 7 8 Relationship of theory to nursing practice, 7 9 -8 0 Relationships in professional practice, 2 4 9 -2 5 4 . See also N urse-nurse relationships; N u rs e p a tie n t-fa m ily relationships; N urse-physician relationships Religious preferences o f patient, 319 Renaissance, 9 -1 0 Renew al o f license, 289 R eporting issues, 1 97 , 2 1 1 -2 1 2

Report o f the Massachusetts Sanitary Commission (Shattuck), 14

Report on an Inquiry into the Sanitary Conditions o f the Laboring Population o f Great Britain (C hadw ick), 1 3 -1 4 Representing your organization, 1 78 , 179 The Republic (Plato), 6 R eputation o f nursing. See Public image o f nursing Research characteristics o f researcher, 20 needs for, 1 49 , 152 process fo r evidence-based nursing, 2 3 8 -2 4 0 role of nurse, 203 utilization , 2 3 6 Reserve nurses, 35 Resonancy principle, 56 Respect fo r autonom y, 1 13 , 1 2 0 t fo r person, 301 fo r self, 117 Respondeat superior , 2 8 4 Responsibility of nurse bullying and incivility, 3 0 0 -3 0 1 fo r career. See Career m anagem ent “com plexity com pression” and, 3 5 7 -3 5 8 delegating as, 2 0 5 -2 0 6 fo r errors and mistakes, 185 evaluating patient learning, 3 1 9 -3 2 0 fo r m alpractice or negligence, 2 8 4 fo r patient, 1 15 , 1 9 9 -2 0 2 fo r self-health. See Self-care supporting nursing profession, 1 49 , 1 86 , 2 7 7 Rest and sleep, 1 89 , 2 85 Resume, 174, 175 Retaining nurses. See Recruiting and retaining nurses Revoking nursing license, 281 R hythm icity in hum anbecom ing theory, 6 7 -6 8

Rights o f delegation, 2 0 6 , 2 9 7 -2 9 8 health as, 9 9 -1 0 0 privacy and confidentiality as, 2 9 4 -2 9 6 respect for, 159 R N s. See Registered nurses R obb, Isabel H am p to n , 2 8 , 114 R obert W ood Johnson Foundation (RW JF) on future o f nursing, 327, 3 50 , 364 handbook fo r patient safety and quality, 2 3 0 healthcare reform , 300 on nursing shortage, 147 research needs, 152 Robotics fo r nursing support, 2 6 0 -2 6 1 , 343 Rogers’s theory o f unitary hum an beings, 5 5 -5 7 , 5 6 t Role clarity, 358 Role discrepancy, 162 Role function m ode of behavior, 61 Role o f professional nurse. See also Socialization to professional nursing role A A C N list of, 163 advocate, 2 0 4 , 2 5 3 , 2 9 4 caregiver, 2 03 in childbearing, 3, 3 5 -3 6 in collaborative practice, 2 0 6 -2 1 0 , 2 0 8 f com m on good of com m unity and, 2 6 0 conflict of, 162 in early times, 3 -1 3 educating others, 1 3 6 -1 3 7 , 1 39 , 151 educating patient. See Patient education elim inating health disparities, 261 health policy and, 144 inform atics and, 326, 342 manager, 2 0 1 , 2 0 4 -2 0 6 new roles, call for, 3 6 2 -3 6 3 nurse-patient relationship, 70, 116 self-care, 26 transition to, 1 6 2 -1 6 3 violence and, 142 R om an era, 6 -8 R o y ’s adaptation m odel, 6 0 -6 2 , 6 0 t Rule o f double effect, 2 6 5 -2 6 6 Rules fo r nursing, 9 6, 1 1 4 -1 1 7 , 161, 2 9 3 . See also Codes o f ethics fo r nurses; Guidelines R ural health care providers, 1 3 6 -1 3 7 RWJF. See R obert W ood Johnson Foundation

INDEX S Safety as core competency, 78 o f healthcare, im proving, 343 o f patient, 2 3 0 , 2 5 4 , 3 3 4 -3 3 5 o f w o rk environm ent, 3 5 3 -3 5 6 Salary, 175, 355 SA NEs (sexual assault nurse exam iners), 142 Sanger, M a rg a ret, 29 Sanitation, historical background of, 4, 1 3 -1 5 , 1 9 -2 1 Scales, Jessie Sleet, 33 Schiavo, Terri, 2 6 7 -2 6 8 School nurses, public, 3 2 -3 3 , 38 Schools fo r nursing. See Education Science and health care, 3 9 -4 0 , 149 Science o f nursing, 5 5 , 2 0 3 , 326 S cop e an d Standards o f N ursing In form atics P ractice

(A N A ), 3 2 6 -3 2 7 Screening potential employers, 176 Seacole, M a ry G rant, 21 Search engines, 330 Searching fo r evidence, 2 3 8 -2 4 0 Security o f patient, 3 3 4 -3 3 5 Self-assessment, 1 8 1 -1 8 5 , 1 8 3 t Self-awareness fo r cultural competency, 359 Self-care burnout, 1 4 5 -1 4 6 , 1 8 8 -1 8 9 com m itm ent to ourselves, 187 N ightingale on, 26 in nursing codes o f ethics, 1 15 , 117 O re m ’s theory of, 5 7 -5 8 , 6 0 t stress causing job dissatisfaction, 3 5 6 -3 5 7 causing m edical error, 2 8 5 -2 8 6 m anaging, 1 8 9 -1 9 0 at w o rk , 1 8 7 -1 8 8 tim e m anagem ent, 1 9 0 -1 9 1 Self-concept-group identify mode o f behavior, 61 Self-efficacy, 3 0 8 -3 0 9 Self-governing o f organizations, 177 Self-m edication, 1 88 , 2 8 6 , 2 9 0 Self-transcendence theory (Reed), 7 4 -7 5 , 7 5 t Senior citizens and health care, 1 4 3 -1 4 5 , 1 96 , 316, 3 1 7 -3 1 8 ^ Sexual assault nurse examiners (SA N Es), 142 Sexual m isconduct, 291 Shamans, 4 Shattuck R eport, 1 3 -1 4

Shortage of nurses after W W II, 2 8 , 39 delegation because of, 2 98 future directions for, 3 5 1 -3 5 3 as job security indicator, 1 6 9 -1 7 0 reasons for, 356 R eform ation’s creation of, 11 stress in w o rk environm ent caused by, 187 as trend in nursing, 1 4 5 -1 4 7 during W W II, 37 Sick nursing, 24 Sin as cause of illness (Classical era), 4 -5 Sisters o f C harity (France), 11 Sleep and rest, 1 89 , 285 Sm allpox virus, 10, 13 S M O G readability fo rm ula, 312, 3 1 3 -3 1 4 ^ Snow, John, 16 SNTs (standardized nursing term inologies), 343 Social context o f nursing, 1 2 5 -1 5 3 access to health care, 1 3 6 -1 4 0 cultural and ethnic diversity, 1 3 3 -1 3 6 gender gap, 1 3 0 -1 3 3 m edia’s influence on, 38, 1 2 8 -1 3 0 public image, 1 2 6 -1 2 7 trends, 1 4 0 -1 5 2 Socialization to professional nursing role, 1 5 7 -1 6 4 educational socialization, 1 5 9 -1 6 0 novice to expert, 1 6 0 -1 6 1 process of, 1 5 9 -1 6 1 professional socialization, 160 reality shock of, 1 6 2 -1 6 3 transition to professional practice, 163 values of professional nursing, 1 5 8 -1 5 9 Social justice allocation and rationing o f health care resources, 2 5 8 -2 6 1 as bioethics principle, 114 definition and theories of, 2 5 7 -2 5 8 Social learning theory, 3 0 8 -3 0 9 Social m edia, 3 3 8 -3 4 0 Social needs, 1 8 9 -1 9 0 Social reform s, 14, 15, 4 0 -4 1 Social Security A ct, 39, 144 Societal values, 9 9 -1 0 0 Societal view o f nursing, 38, 1 2 8 -1 3 0 , 1 86 , 281 Sociocultural barriers to health care, 1 3 8 -1 3 9 Sociocultural com fort, 73 Socrates, 91

417

418

INDEX

S o u r c e s o f la w

S y s te m s - b a s e d p r a c t i c e , 7 8 S y s te m s m o d e l ( N e u m a n ), 6 2 - 6 4 , 6 3 t

a d m in is t r a t iv e la w , 2 7 7 - 2 7 8 c a s e la w , 2 7 8

T

s t a t u t o r y la w , 2 7 6 - 2 7 7 , 2 8 3 , 2 8 9 S p a n is h -A m e r ic a n W a r in C u b a , 3 4 - 3 5

T a c t il e le a r n in g s ty le , 3 1 0 - 3 1 1

S p e a k in g p u b lic ly , 1 7 8

T A K E P R I D E C a m p a ig n , 1 3 5

S p ir it u a l n e e d s

“ T a ll p o p p y s y n d r o m e ,” 2 5 4

o f n u rse, 1 8 9 - 1 9 0

T eam w o rk .

See also

C o lla b o r a tio n

a p p r o a c h t o e t h ic s , 1 1 8 - 1 2 2

o f p a tie n t, 5 0 , 7 2 S t a b il i z e r - i n n o v a t o r s u b s y s te m o f a d a p tiv e p r o c e s s , 6 1

C N L w o r k in g in , 3 6 2

S t a c k i n g p r o c e s s in d e c is io n - m a k in g , 3 5 8

in te r d is c ip lin a r y , 2 0 7 - 2 1 0

S t a f fin g r a t i o s , 1 5 2

m o d e l o f p a tie n t c a re , 2 0 0

See

S ta n d a r d iz e d n u r s in g t e r m in o lo g ie s ( S N T s ), 3 4 3

T e c h n o lo g y .

S t a n d a r d o f s u b s titu te d ju d g m e n t, 2 6 6 - 2 6 7

T e c h n o lo g y I n f o r m a t i c s G u id in g E d u c a ti o n R e f o r m

I n f o r m a t i c s a n d t e c h n o lo g y

( T I G E R ) I n it ia tiv e , 3 2 7

S ta n d a rd s o f c a re , 1 5 2 , 2 7 9 , 2 8 0 - 2 8 1 , 2 8 3 - 2 8 7

n u r s in g i n f o r m a t i c s a n d d ir e c tio n f o r f u tu r e ,

S t a n d a r d s o f N u r s in g P r a c t ic e ( A N A ), 3 7 1 - 3 7 2

3 2 8 -3 2 9

S ta n d a rd s o f p ra c tic e , 2 8 2 , 2 9 4 S t a r M o d e l o f K n o w le d g e T r a n s f o r m a t io n ( A C E ) , 2 4 4

T e le h e a lt h , 1 9 7 , 3 4 0 - 3 4 1

S t a t e B o a r d T e s t P o o l, 2 8

T e r m in a lly ill p a t ie n t s .

S t a t u t o r y la w , 2 7 6 - 2 7 7 , 2 8 3 , 2 8 9

T e r m in a l s e d a t io n ( T S ) , 2 6 8

S te re o ty p e s, 2 1 - 2 2 , 1 2 8 , 1 3 0 , 1 3 2 - 1 3 3

T h e o r i e s a n d p r in c ip le s o f le a r n in g

See

D e a t h a n d e n d - o f -life c a r e

an d ra g o g y , 3 0 7

S te v e n s , K a th le e n , 2 4 4 S te w a rd e ss, n u rses a s, 3 8

d o m a in s o f le a r n in g , 3 0 6 - 3 0 7

S t im u li in e n v ir o n m e n t, 6 2

h e a lt h b e lie f m o d e l ( H B M ) , 3 0 7 - 3 0 8 s o c ia l le a r n in g th e o r y , 3 0 8 - 3 0 9

S t o r ie s o f n u r s e s , 1 2 7

T h e o r i e s o f c o g n itiv e d e v e lo p m e n t, 1 5 9 - 1 6 0

S tr e s s jo b d is s a t is f a c t i o n f r o m , 3 5 6 - 3 5 7

T h e o r i e s o f n u r s in g , 4 7 - 8 2

m a n a g in g , 1 8 9 - 1 9 0

B e n n e r ’s p h ilo s o p h y , 5 3 - 5 5 , 5 5 t

m e d ic a l e r r o r c a u s e d b y , 2 8 5 - 2 8 6

e t h i c a l th e o r y .

at w o rk , 1 4 5 - 1 4 6 , 1 8 7 - 1 8 8

H e n d e r s o n ’s p h ilo s o p h y , 5 0 - 5 1 , 5 2 t

See

E t h ic a l p r a c tic e

S u b s ta n c e a b u s e , 1 8 8 , 2 9 0 - 2 9 1

J o h n s o n ’s b e h a v io r a l sy s te m m o d e l, 6 5 - 6 6 , 6 5 t

S u b s ta n d a r d n u r s in g p r a c t i c e , 2 9 0

K in g ’s i n t e r a c t in g s y s te m s f r a m e w o r k a n d t h e o r y o f g o a l a tta in m e n t, 6 4 - 6 5 , 6 4 t

Su ccess d e fin e d , 1 7 2

K o l c a b a ’s t h e o r y o f c o m f o r t , 7 3 - 7 4 , 7 4 t

n u r s e - n u r s e r e l a t io n s h ip s a n d , 2 5 4

L e in in g e r ’s c u lt u r a l d iv e r s ity a n d u n iv e r s a lity th e o r y , 6 8 - 6 9 , 6 8 t

S u f fe r in g , m o r a l , 1 1 8 S u ic id e .

See

N e u m a n ’s s y s te m s m o d e l, 6 2 - 6 4 , 6 3 t

D e a t h a n d e n d - o f -life c a r e

S u lliv a n C o m m is s io n , 3 5 9

N ig h t i n g a l e ’s e n v ir o n m e n ta l th e o r y , 4 9 - 5 0 , 4 9 t

S u n r is e m o d e l ( L e in in g e r ), 6 9

O r e m ’s s e lf -c a r e d e fic it th e o r y , 5 7 - 6 0 , 6 0 t P a r s e ’s h u m a n b e c o m in g th e o r y , 6 6 - 6 7 , 6 8 t

S u p p ly a n d d e m a n d in n u r s in g , 1 4 5 - 1 4 7 .

See also

P e n d e r ’s h e a lt h p r o m o t io n m o d e l, 7 0 - 7 2 , 7 1

S h o rta g e o f n u rses

69t

S u p p o r t g r o u p s f o r p a t ie n t s o n lin e , 3 3 8 S u p p o r t iv e - e d u c a t iv e s y s te m , 5 9

R e e d ’s s e lf -t r a n s c e n d e n c e th e o r y , 7 4 - 7 5 , 7 5 t r e la t io n s h ip t o n u r s in g p r a c t i c e , 7 9 - 8 0

S u r r o g a te d e c is io n m a k e r s , 2 6 6 - 2 6 8 S w a n s o n ’s t h e o r y o f c a r in g , 7 2 - 7 3 ,

t

P e p la u ’s t h e o r y o f in t e r p e r s o n a l r e l a t i o n s , 6 9 - 7 0 ,

S u p p o r t , le tte r s o f , 1 7 8 - 1 7 9

73t

R o g e r s ’s t h e o r y o f u n ita r y h u m a n b e in g s , 5 5 - 5 7 ,

56f

S y m p a t h e t ic jo y , 2 5 4 S y n e r g y M o d e l f o r P a tie n t C a r e ( A A C N ) , 7 6 - 7 7 ,

771

R o y ’s a d a p ta t i o n m o d e l, 6 0 - 6 2 , 6 0 t

INDEX

Swanson’s theory o f caring, 7 2 -7 3 , 7 3 t W atson’s philosophy, 5 1 -5 3 , 5 2 t Theories o f social justice, 2 5 7 -2 5 8 Theory, defined, 48 A Theory o f Justice (R aw ls), 2 5 7 -2 5 8 T h in k in g skills. See C ritical thinking Tichy, N o el, 365 T IG E R . See Technology Inform atics G uiding Education R eform Initiative Tim e m anagem ent, 1 9 0 -1 9 1

U niversality and cultural diversity theory (Leininger), 6 8 -6 9 , 6 8 t Unlicensed assistive personnel (U A P ), 1 70 , 2 9 6 -2 9 7 , 355 Unsafe w o rk environm ent, 3 5 3 -3 5 6 U rbanization and public health, 13, 1 4 -1 6 U tilitarianism , 111 Utilitarianism (M ill), 111

To Err Is Human: Building a Safer Health System

Vaccines, 10, 13, 14, 343 Values clarifying, 9 9 -1 0 0 core values, 172 emotions and, 97, 109 ethics and, 1 0 8 -1 0 9 philosophy and, 9 6 -9 8 o f professional nursing, 1 5 8 -1 5 9 Vassar Training C am p fo r Nurses, 29 V B P (H ospital Value-Based Purchasing Program ), 342 “V eil of ignorance,” 2 5 7 -2 5 8 V erbal persuasion fo r patient efficacy, 3 0 8 -3 0 9 Veterans A dm inistration, 197 V icarious experience fo r patient efficacy, 3 0 8 -3 0 9 Violence in w o rkplace, 1 4 1 -1 4 2 , 2 5 4 , 2 90 V irtu a l appointm ents, 340 V irtu e ethics, 1 10 , 114, 2 5 3 , 2 5 7 V isibility, m axim izing, 1 7 7 -1 7 9 V isiting Nurse Association o f N e w Y o rk City, 32 V isual aids in patient education, 315, 319 V isual changes in older adults, 3 16 , 3 1 7 -3 1 8 ^ V isualizing to achieve goal, 1 7 2 -1 7 3 V isual learning style, 310 Voice o f nurses on heath issues, 1 2 8 -1 2 9 Voice o f nursing profession, 186 V o lu n tary euthanasia, 263 V olunteering, career m anagem ent strategy of, 1 7 7 -1 7 8 V u ln erab ility o f patient, 7 4 -7 5 , 253

(IO M ), 2 8 6 T o rt law, 279 Total patient care m odel, 2 0 0 -2 0 1 T ra d itio n a l concept o f death, 2 6 2 Transcendence in hum anbecom ing theory, 6 7 -6 8 Transcultural nursing, 68, 1 3 4 -1 3 5 Transform ation fro m student to nurse. See Socialization to professional nursing role Treatm ent programs fo r nurses, 281 Trends and future o f nursing. See Future directions of nursing T ria l process fo r civil procedures, 2 7 9 -2 8 0 , 2 8 0 f T R IC A R E , 138 T ri-C o u n cil fo r N ursing, 3 50 , 352 Trust between patient and nurse, 251 T ru th finding personal, 1 0 0 -1 0 2 , 1 01^ perspectives on, 9 1 -9 3 , 9 2 -9 3 t Truthfulness as virtue, 253 Turnover rate o f nurses, 3 53 , 357

Twenty-One Competencies for the TwentyFirst Century (Pew H ealth Professions C om m ission), 148, 1 4 8 -1 4 9 ^ Tyler, Elizabeth, 32

U U navoidable trust, 251 Underserved populations, health care for, 199 U nem ploym ent, 37, 38 U nethical actions as disciplinary category, 291 U n ifo rm D eterm ination o f D eath A ct (U D D A ), 2 6 2 U nintentional torts, 279 U n itary hum an beings, theory o f (Rogers), 5 5 -5 7 , 5 6 t U nited N e tw o rk fo r O rgan Sharing (U N O S ) C om m ittee, 2 6 0 Universal Dependence, 1 59 , 161

V

W W ald , Lillian , 2 9, 3 0 -3 3 , 31 b W ars affecting nursing profession C iv il W ar, U .S., 2 2 , 34 C rim ean W ar, 1 8 -1 9 Spanish-Am erican W a r in C uba, 3 4 -3 5 W o rld W a r I, 2 9 -3 0 W o rld W a r II, 2 8 , 3 7 -3 8

419

420

INDEX

W ater sources linked to disease, 16 W atson’s philosophy on nursing, 5 1 -5 3 , 5 2 t Websites A C E Star M o d e l o f Knowledge Transform ation, 244 A G R E E II instrum ent and training m aterials, 2 4 2 to assist in evidence-based nursing practice, 2 4 0 “ Bobby A p p ro ved ” icon on, 333 delegation decision-m aking tree, 300 diversity in nursing profession, 134 dom ain registration verification, 331 electronic health records agenda authorization, 335 evaluation fo r accuracy o f content, 3 3 0 -3 3 1 health inform ation websites, 3 3 2 -3 3 4 IC N Code o f Ethics fo r Nurses, 116 Io w a M o d e l o f Evidence-Based Practice, 2 4 4 m alpractice study report, 2 8 3 , 284 N eu m a n ’s systems m odel overview, 63 notice o f proposed regulations (federal), 2 78 fo r nursing inform atics, 3 2 6 -3 2 7 , 329 Office o f the N a tio n a l C o o rd in ato r o f H ealth In fo rm atio n Technology (O N C ), 342 fo r resume preparation, 175 searchable listserv database, 338 search engines, 330 social context o f professional nursing, 1 5 3 -1 5 4 social m edia guidelines fo r use, 339 W elfare rights, 255 W ell-being, Reed’s theory and, 7 4 -7 5 Wellness m odel, 6 2 -6 4 Wellness m ovem ent, N ightingale and, 2 4 -2 5

W estern medicine and alternative m edicine, 1 4 9 -1 5 0 W estern philosophy, 92 W h o le-b rain death, 2 6 2 W holeness of character, 109 W h o lly com pensatory system, 59 W ide-R ange Achievem ent Test— Revised, 312 W ith h o ld in g /w ith d ra w in g treatm ent, 2 6 7 -2 6 8 W om en in nursing, 8, 2 7, 1 3 0 -1 3 1 , 359 W om en’s health. See C hildbearing, role o f nurse in W oodhull Study on N ursing and the M e d ia , 129 W orkplace environm ent assessing before em ploym ent, 1 7 6 -1 7 7 burnout and, 146 com plexity of, 3 5 7 -3 5 8 contributing to error, 2 8 5 -2 8 6 hospitals as, 3 5 4 -3 5 5 safety of, 3 5 3 -3 5 6 stress in, 1 8 7 -1 8 8 W o rld H ealth O rgan ization, 2 5 5 , 265 W o rld Hypothesis Scale, 98 W o rld W a r I, 2 9 -3 0 W o rld W a r II, 2 8 , 3 7 -3 8 W o rth , evaluation determ ining, 320 W ritin g . See also Journaling letters o f support, 1 7 8 -1 7 9 online form s of, 3 3 7 -3 4 0 personal philosophy, 1 0 1 -1 0 2 , 101^ th ank you notes, 1 76 , 178

Y Year o f the O ld e r Person (1 9 9 9 ), 143 Y ellow fever, 13