Fundamentals Of Nursing PDF

# Fundamentals ## Chapter 1: The Profession of Nursing As you turn the pages of this textbook, you are preparing for a career in nursing. In this journey you will master many scientific, physiologic, psychosocial and fundamental facts. You will learn many things: how to touch people, assess for he...

# Fundamentals ## Chapter 1: The Profession of Nursing As you turn the pages of this textbook, you are preparing for a career in nursing. In this journey you will master many scientific, physiologic, psychosocial and fundamental facts. You will learn many things: how to touch people, assess for health, and observe for pain. You will learn to see the physical clues that a person is suffering from inadequate oxygenation or cardiac insufficiency. You will learn to hear how the heart sounds and how to listen for changes in the breathing of one who is dying. You will see the power of the human body as you witness the processes of labor and birth. You will experience the incredible abilities of technology to extend and improve human life. In the midst of such experiences, you will develop critical thinking and clinical judgment skills (see Chapter 5) that will enable you to place multiple factors into complex equations and arrive at appropriate conclusions. You will learn the importance of knowing yourself, your values, and how you arrive at decisions. You will need to consider the problems of today's society and issues involving healthcare allocation, the extent and use of technology, the treatment for disease, and the promotion of health. The word nursing calls to mind many ideas and images. For some these images are from traditional and perhaps outdated sources, including white uniforms, nursing caps, needles, and bedpans. For others, images of nursing include kindness, skill, compassion, and intelligence. Modern nursing practice involves many such images and also encompasses new and perhaps unique perspectives on what the profession involves. Many factors have affected the way the public, nursing professionals and their colleagues, and those beginning their nursing careers perceive nursing. History, especially the social, political and cultural events of the 20th century, has influenced today's practice. Evolving roles of women, portrayals of nursing in the media, and issues involving educational preparation have had a considerable impact on the image of nursing today. The roles and responsibilities of nurses are changing along with the evolving healthcare environment, and the profession must be prepared to face the challenges of the 21st century. ## Nursing: Caring, Commitment, and Dedication to Health Nursing is caring, commitment, and dedication to meeting the health needs of all people. Nurses direct care to promote, maintain, and restore health in various settings. They are prepared to identify and to assist with the healthcare needs of individuals, families, communities, and populations. As technology advances, society's healthcare needs increase in complexity, and the demands of the healthcare system change. At the same time, nurses provide a point of human contact in the face of this complexity. The need for educated nurses who are committed to maintaining expertise in the theory, art, and practice of professional nursing will continue to grow in response to such developments. Nursing care provided in settings other than hospitals, such as in the homes of patients or in ambulatory clinics, is now common. While 61% of nurses work in hospitals (U.S. Department of Labor, 2019), changes in reimbursement for healthcare services and cost-containment measures have moved nursing practice to areas beyond such settings. Nursing means caring for communities and populations of people and addressing issues with far-reaching social implications, such as human rights and access to healthcare. Nursing means being socially responsible, involved, and committed to the health of all people. ## Nursing: Challenging and Exciting Career Opportunities Nursing offers many challenging and exciting career opportunities. Students embarking on professional nursing careers accept responsibility for society's healthcare needs and for the advancement of nursing as a profession. Never in nursing's history has there been a more opportune time to move the profession forward and to make a difference in the healthcare of all people. This chapter provides a starting point for understanding where nursing has been, where it is now, and where it is headed. ## Highlights of the Historical Evolution of Professional Nursing Although nursing in some form has probably existed throughout history, documentation of the profession as we know it today has only been available for the last 150 years (Nightingale, 1860). Nursing probably began as women intuitively identified and provided for their families' healthcare needs. As certain individuals emerged with the desire and ability to nurture others and provide care for them, the profession of nursing began. This section highlights critical events that have shaped nursing's history and have influenced issues affecting today's profession. An overview of this historical evolution provides the background necessary to understanding current nursing practice (Table 1-1). For more in-depth discussions of nursing's historical evolution, examine textbooks dedicated solely to this topic. ## Ancient History Ancient history makes few references to nursing as its own disciplined; any discussions of nursing are blurred with those of medicine. Brief accounts of men and women engaging in practices that may be associated with nursing have been found. Around the world, women have long served as midwives. In ancient Babylonia, Egypt, and Samaria, rich families were the primary recipients of nursing care. If and when nursing care was available outside wealthy homes, nurses were primarily servants. Early hospitals were often founded by religious groups. The Greeks made significant contributions to the care of the sick and, to an extent, to the nursing profession. Hippocrates, the "father of medicine," made a major advance in medicine by rejecting the belief that diseases had supernatural causes. He has been credited with developing assessment standards for patients, establishing overall medical standards, and recognizing a need for nurses. In Western civilization, nursing grew with the continuing spread of Christianity, which had positive effects on cultural values and institutions. Christianity's influence also improved the status of nursing by attracting intelligent individuals from respected families. The Crusades resulted in the establishment of military nursing orders and the recruitment of men into nursing, which was well organized during this time. ## Florence Nightingale and the Crimean War Florence Nightingale has been called the founder of modern nursing. Stubborn and unyielding, Nightingale improved health laws, reformed hospitals, reorganized military medical services, and established nursing as a profession with two missions: sick nursing and health nursing. Nightingale viewed "sick nursing" as helping patients use their own reparative processes to get well and "health nursing" as preventing illness. Nightingale was born in 1820 in Florence, Italy, to a wealthy English family. She was educated in languages, philosophy, and the liberal arts. She entered the nursing profession against the wishes of her parents. Nightingale was the superintendent of nurses at King’s College Hospital until she left to care for soldiers during the Crimean War. Her efforts during this war were credited with decreasing the mortality rate by half and she soon became known as "the lady with the lamp" because of her midnight rounds to the soldiers. In 1859 Nightingale published *Notes on Nursing* and started the Nightingale Training School for Nurses. Nightingale was gracious and hardworking and her many contributions to nursing continue to influence the profession. ## Development of American Nursing During the American Civil War (1861-1865), more hospitals and better-prepared nurses were needed. Although she was not a nurse, Dorothea Dix established the Nurse Corps of the United States Army, further expanding nursing’s role. Another early nursing leader, Clara Barton, practiced nursing on Civil War battlefields. Barton founded the American Red Cross, an organization that continues to contribute significantly to contemporary healthcare needs. Military influences on nursing and nursing education in the 20th century have been numerous. During the Spanish American War, the Volunteer Nurse Corps (1898) was established and, in 1901, became the Army Nurse Corps. In 1908, the U.S. Congress authorized the Navy Nurse Corps. During World War I, nurses were transported to war areas in Europe and the Far East to care for the sick and wounded. The casualties of World War II brought a critical nursing shortage, prompting quick solutions to increase the number of nurses and causing a setback in the move toward university-based nursing education. During World War II, black nurses were first admitted to the nursing service. The Vietnam War saw many nurses involved in the Army and Navy Nurse Corps caring for the wounded. In addition, Air Force nurses were assigned to Vietnam. Conflicts in the Persian Gulf involved mobilization of nurses to Iraq, Afghanistan, and Saudi Arabia. The harsh environments in war-torn areas present challenges for patients and nurses. ## Nursing in the 21st Century Nursing’s history has influenced today's educational requirements practice settings, and roles. Likewise, when, how, and why the profession evolves will directly relate to the contributions of present and future nursing professionals. Social forces can be expected to influence future definitions of nursing, just as these forces have shaped nursing practice to date. Today’s nurses must be knowledgeable flexible, and innovative. Nurses care for patients in a wide range of settings and must adapt to the needs of diverse patients. Technology allows nurses to connect to patients in new ways, but it also provides new challenges such as maintaining patient privacy and developing human connections with patients we may never see face-to-face. ## Socialization to Professional Nursing Socialization is a process that involves learning theory and skills and internalizing an identity appropriate to a specific role. Internalizing a specific role allows one to participate as a member of a group. Professions generally have a specific body of knowledge, a set of values, and skills that differentiate them from one another. Professional nursing curricula teach foundations of the discipline. Theoretical and clinical instruction facilitates the development of a professional identity and prepares students to function as beginning nurses. Beyond this initial socialization, continuing socialization occurs as nurses gain experience in the workplace and perhaps pursue advanced education. In *From Novice to Expert,* Patricia Benner (1984) discussed socialization and skill acquisition in nursing. A nurse passes through five levels of proficiency when acquiring and developing nursing skill: novice, advanced beginner, competent, proficient, and expert. Differences in each level reflect changes in three areas of skill performance. In the first area, the nurse moves from relying on abstract principles to using concrete experiences. The second area involves a change from seeing situations in parts to seeing them more conceptually, or as a whole. Finally, in the third area, the nurse in no longer outside the situation observing but is directly involved. This process takes 5 to 10 years after graduation. ## Nursing and Professionalism Defined Because definitions of nursing reflect society’s values and influences, the profession is subject to misinterpretation. One common misconception is that nurses are inferior to physicians, simply following their orders. Instead, nurses have their own scope of practice and provide care within the scope of nursing practice. Beginning nursing professionals must develop a clear, accurate understanding professional practice if other members of the healthcare team and the pubic are to share this precise interpretation. Nursing is a multifaceted profession and, as such, has been defined in many ways,. Florence Nightingale defined nursing as "the act of utilizing the environment of the patient to assist him in his recovery" (Nightingale, 1860, 1992). The ANA developed the following definition of nursing: "Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations (ANA, 2015, p. 1). Despite the many definitions, common themes are evident. Holism, caring, teaching, advocacy, and supporting, promoting, maintaining, and restoring health are all components of nursing practice. Nursing care involves creativity, sensitivity, and applications based on evidence, All of these components are essential to the practice, but nurses should not limit themselves to these themes. ## Educational Preparation Nursing has a long history of debating over the educational preparation for its profession. This is continuing, as there is scope of practice that ranges from a practical nurse program to the doctorate of nursing practice. There are many levels between these as well as many specialties. ### Practical Nursing In the United States, people interested in a practical nursing career attend 1-year programs that prepare them to perform technical skills under the supervision of registered nurses (RNs). Students who successfully complete the program requirements may sit for the National Council Licensure Examination-Practical Nursing (NCLEX-PN) to become a licensed practical nurse (LPN) or licensed vocational nurse. LPNs are employed in hospitals, long-term care facilities, and rehabilitation centers, and by healthcare providers such as physicians. LPNs differ from RNs in two areas: educational preparation and scope of practice. LPNs always practice under the supervision of an RN. Practical nursing was established to prepare healthcare providers for patient care and to assist professional nurses with routine technical procedures. ### Registered Nursing Nursing in the United States continues to have three major routes leading to RN licensure. Educational preparation may be at the diploma, associate degree, or baccalaureate degree level. Programs are now emerging that have the master’s degree or doctorate as entry-level preparation. The issue of educational preparation for entry into practice has been debated since the 1930s and 1940s, when the Brown and Goldmark reports recommended two levels of nursing preparation. In 1965, the ANA adopted a resolution proposing that minimum preparation for beginning professional practice should be a baccalaureate degree in nursing and that minimum preparation for technical practice should be an associate degree in nursing. The debate over entry-level preparation continues to influence many critical issues. Included in this debate are the competencies of new nursing graduates, the public view of nursing roles, the need for professional status within the healthcare community, the organization of nursing education, and the supply and demand for nursing professionals. The Institute of Medicine (2011) partnered with the Robert Wood Johnson Foundation to examine the role of nursing in the future. They made five recommendations for nursing. As part of the second recommendation—that nurses achieve higher levels of education—the task force recommended that 80% of RNs be educated at the baccalaureate level or higher. Leaving open the issue of minimum education for entry into the profession, they focused on the educational level of practicing nurses. This approach acknowledges the benefit of diploma and associate degree programs in providing opportunities for those unable to access a baccalaureate program. ### Diploma Nursing Diploma nursing schools were the first type of educational preparation available for RNs. In the United States, diploma programs usually require 3 years of study. Typically, students earn some college credit, but college credit in not awarded for nursing courses. Clinical experience is extensive, which is an advantage of this route. Students who successfully complete diploma programs take the National Council Licensure Examination-RN (NCLEX-RN). Graduates of diploma programs work as beginning practitioners in acute, intermediate, long-term, and ambulatory healthcare facilities. Graduates demonstrate competency in the assessment, planning, implementation, and evaluation phases of the nursing process. The number of diploma programs has declined as nursing education moves into institutions of higher learning. This decline is also related to efforts to achieve professional status and control over nursing practice. ### Associate Degree Nursing Associate degree nursing (ADN) initially was developed in the 1950s in response to a nursing shortage, and it continues to thrive today. Students pursuing this degree attend a community or junior college for 2 years or more, receiving college credit for all classroom and clinical courses in nursing. Students who successfully complete the requirements of an ADN program also take the NCLEX-RN. As providers of nursing care, ADNs use the nursing process to formulate and maintain individualized patient plans of care. They also teach patients who need information or support to maintain health. ### Baccalaureate Degree Nursing The baccalaureate degree in nursing (or bachelor of science in nursing [BSN]) offers students a full college or university education with a background in liberal arts. The programs are rigorous and provide students with credits for nursing courses and clinical experiences in all areas of nursing practice. BSN programs emphasize community health, research, leadership, and management. Students who successfully complete the baccalaureate degree in nursing take the NCLEX-RN. Nurses are prepared as generalists to provide comprehensive services that assess, promote, and maintain the health of individuals, families, communities, and groups. ### Graduate Entry Programs Graduate entry programs are generally designed for people with baccalaureate degrees in fields of study other than nursing. The prelicensure nursing portion of the program is often at an accelerated pace; students may be able to sit for the NCLEX-RN after 12 to 18 months of study. Students then track directly into a master of science in nursing or a doctoral program. Students completing these programs have advanced clinical capabilities and some opportunity for clinical concentration in a nursing specialty. ## Advancing Education: Continuing Education Some states require nurses to obtain continuing education hours for ongoing licensure. Specialized certification for nurses (discussed later in this chapter) may also require continuing education. Continuing education courses range from an hour to days to weeks in length and may be offered by the nurse's employer, by local colleges or universities, or by independent companies offering continuing education. Courses may also be offered through nursing journals or online. Nurses must check their licensure renewal or certification requirements to determine the exact number of hours of education required and the types of courses accepted by the licensing or certification board. ## RN to BSN Graduates of diploma and ADN programs often elect to advance their education be earning a baccalaureate degree in nursing. Many colleges and universities offer these degree-completion programs. In some programs, the RNs may be integrated with traditional undergraduate students, taking some or all of the same coursework required for the traditional students. In other programs, the RNs may be in a completely separate track designed just for them, usually focused on those areas of study emphasized in baccalaureate programs, Once coursework is completed, students are awarded a BSN. ## Master’s Degree in Nursing Nurses interested in attaining advanced education in specialties may complete graduate programs in their specific area of interest. Graduate education prepares nurses for advanced, independent practice with continued emphasis on research. Graduate education requires independent critical thinking, and nurses pursuing graduate education must have solid scholastic abilities. A BSN usually is required for entry into these programs, Some programs admit diploma or ADN students if those RNs hold a bachelor’s degree in another field. Currently, advanced clinical practice pathways such as nurse practitioner (NP), clinical nurse specialist (CNS), nurse anesthetist, and nurse midwife are offered at some schools at the master’s levels. However, the profession is moving toward requiring doctorate-level preparation for those pathways. Nurse educators, nurse administrators, and clinical nurse leaders will likely continue to be prepared at the master’s level. Although people in those pathways may ultimately decide to pursue doctoral-level education, a doctorate is currently not typically required for entry into those nursing careers. ## Doctor of Nursing Practice The increased complexity of care, changing patient demographics, and shifting healthcare delivery systems are necessitating a transformation of graduate and advanced practice. The doctor of nursing practice (DNP) is proposed to replace the advanced practice master’s degree. The DNP focuses on preparing NPs, CNSs, nurse anesthetists, and nurse midwives as expert clinicians with enhanced leadership and research skills. ## Research Doctoral Degrees Students may earn a doctor of philosophy (PhD), doctor of education (EdD), or doctor of nursing science (DNS) degree. People interested in careers as nurse researchers or nurse educators usually must obtain doctoral degrees. Doctoral education has become more available to nurses, and the number of nurses earning doctoral degrees continues to increase. Nurses usually obtain doctoral education after completing master’s programs. Many PhD programs incorporate the master’s degree for students who enter directly from BSN programs without first earning a master’s degree. ## Certification Nurses can choose to become certified in a nursing specialty. The American Nurses Credentialing Center (ANCC) states that certification validates nursing specialty knowledge. Also, it builds confidence in nurses as professionals, demonstrating that they meet nationally recognized standards in the specialty. Certification is a voluntary process to provide professional recognition of the knowledge, skills, and abilities of certified nurses. ## Expanded Nursing Roles Accelerated changes in healthcare with an emphasis on primary care have intensified interest in advanced practice registered nursing (APRN). An example of an APRN is the NP. APRN regulation is by state statute or by certification. Regulation by statute involves modification of the state nurse practice act to regulate advanced nursing practice and involves issuance of a second license. Regulation by certification involves a process whereby professional boards validate an individual nurse’s advanced qualifications in a particular area of nursing. Many additional opportunities for career development and advancement are available for RNs. These opportunities, some of which require advanced education, lead to new and varied roles and exciting challenges. Some expanded nursing roles include NP, CNS, nurse midwife, nurse anesthetist, nurse researcher, nurse administrator, and nurse educator. The educational level of NPs, CNSs, nurse midwives, and nurse anesthetists is changing. While some continue to be prepared at the master’s level, many more of these APRNs have education at the doctoral level, most commonly in DNP programs. ### Nurse Practitioner A nurse practitioner is a nurse with advanced education who has graduated from an NP program. NPs function with more independence and autonomy than do other nurses and are highly skilled at doing nursing assessments, performing physical examinations, counseling teaching, and treating health problems. NPs have a specialty, such as obstetrics, pediatrics, geriatrics, or family care. The NP’s scope of practice is determined by the practice act of the state in which the NP is licensed; NPs in some states have broad scope of practice that includes ability to prescribe medications. ### Clinical Nurse Specialist A clinical nurse specialist has advanced experience and expertise in a specialized area of practice such as gerontology, pediatrics, critical care, or pulmonary disease. The CNS works in various settings, depending on his or her specialty. Roles of the CNS include clinician, educator, manager, consultant, and researcher. ### Nurse Midwife A nurse midwife has advanced education in nursing and midwifery and in the United States, is certified by the American College of Nurse Midwives. Nurse midwives provide independent care for women during normal pregnancy, labor, and delivery. They practice in conjunction with specific healthcare agencies from which medical services are available in the event a patient develops complications. Nurse midwives also may perform cancer screening tests gynecologic disease management, and family planning activities. ### Nurse Anesthetist A nurse anesthetist provides general anesthesia for patients undergoing surgery. Nurse anesthetists are RNs with advanced education in anesthesiology, They work in hospitals and outpatient surgery settings. ### Nurse Researcher A nurse researcher is responsible for the continued development refinement of nursing knowledge and practice through the investigation of nursing problems. Nurse researchers have advanced education, usually at the doctoral level. They tend to work in large teaching hospitals and research centers or in academic settings. All nurses have a responsibility to be involved in research and to use evidence-based findings to improve nursing care and to practice form a research basis. Even nurses without advanced preparation in research can work with individuals who have such training. ### Nurse Administrator A nurse administrator manages and controls patient care. Nurse administrators may be responsible for specific nursing units or may serve as the chief nursing executive for an organization. Nurse administrators typically are required to hold at least a master’s degree. This degree may be in nursing, but many organizations hire administrators with graduate degrees in fields such as business or healthcare administration. ### Nurse Educator The nurse educator role can be developed in many settings, including schools of nursing and hospital professional development departments. Clinically based educators and faculty teaching in practical nursing and associate degree RN programs usually need a master’s degree; faculty in baccalaureate, master’s, or doctoral programs usually need a doctoral degree. Nurse educators generally have specific clinical specialties and advanced clinical experience. People in this career role must continue to maintain expertise in the practice setting, develop expert knowledge of theory, perfect classroom teaching methods, and have in-depth knowledge of curriculum development and higher education. ## Professional Nursing Practice ### Standards of Practice As nursing became an independent profession, it began to develop its own standards of practice. Standards of practice are essential because they serve as guidelines for providing and evaluating nursing care. They help to ensure high-quality care and serve as criteria in legal questions of whether adequate care was provided. Standards of practice appear in The ANA's standards include two lists: standards of practice and standards of professional performance. Measurement criteria are printed in the ANA book *Nursing: Scope and Standards of Practice.* The standards of practice list designates professional nursing responsibilities such as assessment, diagnosis, outcome identification, planning, implementation, and evaluation, These responsibilities are inherent in the nursing process and are discussed throughout this text. Standards of professional performance include culturally congruent practice, collaboration, leadership, evidence-based practice and research, and quality of practice, All of these performance standards are integrated into this text under related discussions. ### Nurse Practice Acts The nurse practice act of each state defines the practice of nursing within that area. The board of nursing in each state sets requirements for licensure, New graduates must take and pass the NCLEX to qualify for a nursing license. Once licensed in one state, the nurse can gain licensure in another state through reciprocity, Reciprocity involves meeting the licensure requirements in the new state. As long as the nurse maintains licensure, the licensure exam does not need to be retaken. The Nurse Licensure Compact allows nurses licensed in a compact state to practice in other compact states without obtaining licensure in the new state. Twenty-seven states are currently members of the compact, with pending legislation in another nine states (National Council of State Boards of Nursing 2019). With the emergence of more autonomous and expanded roles for nurses, many states have started to revise their nurse practice acts to reflect the greater responsibilities associated with current nursing practice. ## Nursing Program Accreditation Although all nursing programs must be approved by the state in which they operate, nursing program accreditation is a voluntary process that demonstrates achievement of national standards of excellence. Three organizations are accredited by the U.S. Department of Education to accredit nursing programs. Some nursing programs are accredited by more than one organization. ### Commission for Nursing Education Accreditation The Commission for Nursing Education Accreditation (CNEA) is a subsidiary of the NLN. The NLN was the first national nursing organization in the Unites States, The main purpose of the NLN is to support nursing education with the goal of producing a well-prepared and diverse nursing workforce. Members of the NLN include nurses and other members of the health team, lay people, and agencies concerned with nursing education and service. The NLN works within the community and in association with individuals and groups outside nursing. The CNEA accredits practical nursing programs associate degree-, diploma-, and baccalaureate-level registered nursing programs; and master’s and doctoral programs in nursing. ### Commission on Collegiate Nursing Education The Commission on Collegiate Nursing Education (CCNE) is an autonomous accrediting agency established by the AACN. The AACN is focused on baccalaureate and higher degree programs in nursing This organization sets standards and publishes essential components of baccalaureate, master’s, and doctoral education in nursing. Accreditation by the CCNE is a nongovernmental peer review process that uses nationally recognized standards to evaluate the integrity of nursing programs and to foster continued improvement in nursing education programs and in professional practice. ### Accreditation Commission for Education in Nursing The Accreditation Commission for Education in Nursing (ACEN) is a third organization that provides accreditation services for nursing programs. Like CNEA, ACEN accredits nursing programs at all levels of education. ## Nursing Organizations As the nursing profession has developed and advanced, organizations integral to the profession have increased. The number of associations continues to grow at local, state, and national levels. Nursing organizations may be related to a specialty, or they may encompass all areas of nursing. The organizations that involve most nurses or nursing students are the ANA, Sigma, and the National Student Nurses’ Association (NSNA). ### American Nurses Association The American Nurses Association is nursing’s professional organization in the United States. Membership in state constituents of the ANA is open only to RNs. The ANA is important because it sets the standards of practice for nurses and makes decisions about the functions, activities, and goals of the nursing profession. The organization is a voice for nurses because it acts on issues and wishes expressed by its membership. The ANA's functions activities have been adapted or expanded in accordance with the changing needs of the profession and public. Its goals, as stated in the current bylaws, are to work for the improvement of health standards and the availability of healthcare services for all, to foster high standards of nursing, and to stimulate and promote the professional development of nurses and advance their economic and general welfare. ### Sigma Sigma (formerly known as Sigma Theta Tau International), the honor society of nursing, was founded in 1922 and is headquartered in Indianapolis, Indiana. The six nurse founders named the organization from the Greek words *Storgé, Tharsos, and Timé*, meaning "love," "courage," and "honor." Sigma Theta Tau International provides leadership and scholarship in practice, education, and research to enhance the health of all people. Membership is by invitation to students who demonstrate excellence in scholarship and to nurses in the community who demonstrate excellence in leadership. ### National Student Nurses' Association The NSNA, established in 1953, is the national organization for nursing students in the United States. Its goals are to contribute to nursing education to provide for the highest quality of healthcare; to provide programs representative of fundamental and current professional interests and concerns; and to aid in the development of the whole person, his or her professional role, and his or her responsibility for the healthcare of people in all walks of life. The NSNA is autonomous, student financed, and student run. It serves as the voice of nursing students, speaking out on issues of concern to the entire profession. ## Nursing Responsibilities Historically, the nurse’s sole duty was to provide care and comfort to the sick. Advances in technology, knowledge, health promotion, and prevention have expanded the functions of today’s nurses. Nursing functions include activities that nurses perform independently or collaboratively. For instance, nurses may initiate activities, such as turning or positioning bed patients every 2 hours, which are nurse-prescribed interventions. On the other hand, when physicians delegate actions (physician-prescribed interventions) that require nurses to use their own judgment, nurses are addressing collaborative problems. For example, although physicians must prescribe medications, they rely on the judgment of nurses for proper administration. Nurses must thoroughly understand medications, observe for side effects, and teach patients about medications. Nurse- and physician-prescribed interventions are discussed in later chapters of this text. In addition to these roles, the profession has many other requirements, including assertiveness; a sound knowledge base in the sciences, humanities, and arts; the ability to make safe judgments; the ability to communicate the healthcare needs of patients in written and oral form; and a spirit of collegiality with other members of the healthcare team. Professional nurses are autonomous and assume the responsibilities of caregivers, patient advocates, educators, decision-makers, managers and coordinators of healthcare needs, and communicators. ### Caregiver As providers of care, nurses assume responsibility for helping patients promote, restore, and maintain health and wellness, Nurses view each patient as unique and consider the whole person in the caring process. Nurses address not only physiologic concerns but also spiritual, emotional, and social needs. They must set priorities for care and assist patients in meeting all needs in the safest, most timely, and cost-effective matter possible while ensuring excellence. ### Patient Advocate Nurses act as patient advocates in many situations; examples include communicating the needs and concerns of patients and ensuring that patients understand their treatments. Nurses must promote safe environments that facilitate the restoration of health. They are responsible for thoroughly understanding their patents' health problems, histories, and potential problems. They consistently take responsibility for protecting patients and helping them assert their legal rights. ### Educator Health promotion and disease prevention are a growing concern and focus of the healthcare delivery system. Educating patients about diseases, prevention, nutrition, and healthy behaviors is essential. Nurses must explain treatments and procedures for which they are responsible, answer any questions patients have, and evaluate the progress of patients toward health. Education is involved in all nursing activities. ### Decision-Maker Nurses are continually identifying obstacles or difficulties in the promotion, restoration, and maintenance of health. Problem resolution requires the ability to make sound judgments and decisions. Nurses must choose the best approaches to patient care, help patients participate in decision-making and use safe and effective judgments when providing care. They also are responsible for involving other members of the healthcare team and the families of patients in decision-making to ensure that sound choices are made. ### Manager and Coordinator Promoting, restoring, and maintaining health involves coordinating the services of various healthcare professionals, In addition to managing their own time, nurses also must coordinate all activities or treatments that involve patients. The goal of their role as manager and coordinator is to complete patient care effectively efficiently, and in a manner that benefits the patient. ### Communicator Central to all other roles is the role of communicator, Because nurses usually are the healthcare professionals who spend the most time with patients, they have the best opportunity for observing, communicating, and identifying problems or improvements in the plan of care. Nurses are responsible for communicating findings to the healthcare team in oral and written form. The quality of this communication is critical to helping patients meet their healthcare needs; nurses must be knowledgeable, articulate, and capable of effective written and verbal expression. ## Nursing Competencies The Quality and Safety Education for Nurses (QSEN) initiative has identified key quality and safety competencies for nurses: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. These competencies support the responsibilities defined previously. Providing care focused on patients requires the nurse to balance patient advocacy with safety. Effective management and coordination of care requires teamwork and collaboration. Evidence-based practice leads to safe and effective care. Nurses must continually evaluate and improve the quality of care. Competence in informatics allows nurses to use the latest technology in the provision, documentation, and evaluation of care. Nurses who achieve these competencies are able to improve the quality and safety of patient care wherever they work. Each chapter in this book concludes with a discussion of one of the QSEN competencies as it relates to the chapter’s opening scenario. ## Nursing Theory A conceptual framework describes ideas about individuals, groups, situations, and events. The framework is a set of concepts and the propositions that integrate them. The four central concepts in nursing practice are the person, environment, health, and nursing (Butts & Rich, 2018). In a broad sense, the concept of person refers to all human beings. People are the recipients of nursing care; they include individuals, families, communities, and groups. Environment includes factors that affect individuals internally and externally. It means not only everyday surroundings but also settings where nursing care is provided. Health generally addresses the person’s state of well-being The concept of nursing is central to all nursing theories. Definitions of nursing describe what nursing is, what nurses do, and how nurses interact with patients. Most nursing theories address each of the four central concepts implicitly or explicitly, Propositions show the relationship of these four concepts The concepts and propositions of a conceptual framework are highly abstract and general. Nursing theory provides the foundation for nursing knowledge and gives direction to nursing practice. Theories go a step beyond conceptual frameworks. They are a way to relate concepts and the significant relationships between them, The concepts and propositions of a theory are much more specific than are those of a conceptual framework. Nursing theory should guide the development and future direction of nursing research. Table 1-3 lists each major nursing theorist, the central purpose of each theory, and each theorist’s definitions of the four major concepts. Each theory defines, relates, and emphasizes these concepts differently. ## Nonnursing Theories Used In Nursing ### General Systems Theory The general systems theory, or a systems framework, provides an approach for studying individuals in their environments and is used by many disciplines. General systems theory includes purpose, content, and process, breaking down the "whole" and analyzing the parts. The relationships between the parts of the whole are examined to learn how they work together. General systems theory assumes the following: * **All systems must be goal-directed.** * **A system is more than the sum of its parts.** * **A system is ever changing, and any change in one part affects the whole.** * **Boundaries of pursuing theories are implicit, and human systems are open and dynamic.** Examples of nursing theories that have used the systems approach to patient care include Roy's (1970) adaptation model; Neuman's (1972) healthcare systems model; Johnson's (1980) behavioral model; and Parse's (1981) theory for nursing. ## Human Needs Theory: Maslow's Hierarchy of Human Needs Human needs are any physiologic or psychological factors necessary for a healthy existence. The most prominent theorist to focus on human needs has been Abraham Maslow. Maslow’s hierarchy of human needs states that all humans are born with instinctive needs. These needs, grouped into five categories, are arranged in order of importance from those essential for physical survival to those necessary to develop a person’s fullest potential. Maslow’s hierarchy provides a framework for recognizing and prioritizing basic human needs. This hierarchy is constructed as a pyramid (Fig. 1-4). From the pyramid’s base to its apex, people must meet lower-level needs to some degree before they can address higher-level needs. A person is not motivated by all five categories of human needs at the same time. The category most relevant to the person’s circumstances at a particular time is the primary motivator . Meeting needs is dynamic process that involves continual resolution of , progression beyond, and return to any given category of needs. Human needs are motivational forces. Culture, socioeconomic factors, personal values, and health influence the motivational strength for and manner of expression of these needs. All people develop behaviors that help them meet their needs. They can learn to delay meeting their needs and modify the specific behaviors that satisfy needs, depending on each need’s motivational strength. If a need goes unmet, physical illness, psychological disequilibrium, or death can occur. ### Physiologic Needs Physiologic needs are fundamental motivating forces and provide the base for Maslow’s pyramid. Oxygen, food, water, elimination, activity, rest, temperature maintenance and sexuality are essential for existence. Nurses assess each patient’s ability to meet his or her physiologic needs and identify the nature and degree of nursing interventions necessary to enable the person to satisfy these needs. ### Safety Needs After meeting basic physiologic needs, the person must address safety needs. Humans need to be physically safe and free from the fear and anxiety that result from a lack of security and protection. Safety is often a dominant motivator,