Nursing Concepts Chapter 1 PDF

CHAPTER 1 Evolution of Nursing Thought & Action Learning Outcomes After completing this chapter, you should be able to: ➤ Define nursing in your own words. ➤ Describe how person-centered care is the foundation of professional nursing. ➤ Discuss the transitions that nursing education has undergone in the last century. ➤ Differentiate among the various forms of nursing education. ➤ Explain how nursing practice is regulated. ➤ Give four examples of influential nursing organizations. ➤ Name and recognize the four purposes of nursing care. ➤ Describe the healthcare delivery system in the United States, including sites for care, types of workers, regulations, and financing of healthcare. ➤ Name nine expanded roles for nursing. ➤ Discuss issues related to healthcare reform. ➤ Delineate the forces and trends affecting contemporary nursing practice. Key Concepts Contemporary nursing education Contemporary nursing practice Healthcare delivery system Nursing Nursing history Related Concepts See the Concept Map on Davis Advantage. Nurses Make a Difference... Then & Now Time: 1854, the Crimean Conflict (Russia). Place: Üsküdar (Scutari), Turkey, across the Bosporus Strait from Constantinople (Istanbul). The hospital in Scutari is several days' journey by ship from the battle in Crimea. The injured and dying lie on cots or on crowded floors covered with filth. There are few blankets; soldiers arrive muddy from battle and covered with crusted blood. Outside, the air is crisp, yet the barrack reeks of disease and death. For several weeks, the army physicians refuse to allow Florence Nightingale and her staff of 38 nurses to do any real nursing work. Meanwhile, the nurses review environmental conditions and note the health problems of the soldiers and the available supplies and equipment. They open windows to clear the fetid air, scrub all surfaces from ceiling to floor, prepare nutritious meals, bathe the wounded, sew bedclothes, and fashion bandages. As they prove their usefulness, they are allowed to dress wounds, feed the injured, and comfort those who are in pain or dying. They offer encouragement and emotional care to soldiers and help them write letters home. Within a few months, the mortality rate drops from 47% to 2%, and morale improves immeasurably. Time: 2023. Place: Your Local Hospital. While standing at the bedside verifying medications, Susan listens to the ventilator cycle. She notes that her client has begun to trigger breaths on his own. In the background, she hears the cardiac monitor sounds, which have become more irregular over the past hour. She mentally runs through her client assessment. "Why is his heart so irritable?" she wonders. She checks the results of the blood work on the computer. Susan notes that the potassium level is low (2.9 mEq/L). She notifies the provider of the laboratory results and the client's cardiac irritability, adding, "The client's potassium is low from the diarrhea he's had since we began the antibiotics." Together, they develop a plan to administer IV potassium to raise the client's potassium level and to check it every 8 hours. Several hours later, Susan documents in the electronic health record (EHR) that the ectopy (irregular heartbeat) has decreased to fewer than 2 beats/min. Time: 2050. Place: A Local Home. Yesterday, Mr. Samuels underwent robotic cardiac surgery. He was discharged to his home this morning and is now under your care. Since discharge, he has been monitored remotely via implanted technology. As a home health nurse, you have been reviewing and analyzing his physiological and biochemical data and adherence to provider guidelines (e.g., medication, dietary, and activity compliance). The provider has reviewed the networked data and guided you to focus on activity compliance and assessment of several incidences of spikes indicating anxiety or discomfort. Mrs. Samuels greets you at the front door. She tells you that her husband is reluctant to move for fear of pain. She looks frightened as she says, "I am not comfortable with the telemonitoring. I prefer to have the 'human touch' as my parents had many years ago." You explain that changes in technology and the healthcare system allow you to take care of clients in their own homes who would previously have been in the hospital. As you begin your assessments, you tell Mrs. Samuels, "Your husband's networked data are constantly evaluated. Any indication of problems will trigger emergency personnel immediately. We have 24/7 monitoring." You further explain that the data show that Mr. Samuels has not complied with the activity prescription that is important to prevent cardiac and respiratory complications. "We want you to feel comfortable with the technologies and the plan of care." In each of these scenarios, the nurses engaged in full-spectrum nursing; that is, they used their minds and their hands to improve the client's comfort and condition. Their actions exemplify caring. As the scenarios illustrate, nursing roles have changed over time, yet nursing remains a profession dedicated to care of the client. The actions of Florence Nightingale and her team exemplified person-centered care of the soldiers. They demonstrated compassion, respect, and individualized care. A plan of care was developed based on their assessment of the environment and needs of the soldiers, with interventions prioritized to promote optimal outcomes. Florence Nightingale communicated with key stakeholders (e.g., physicians, politicians) to obtain needed support and resources. Her meticulous notes and analysis of data became the foundation of evidence-based practice, as she continuously correlated interventions with outcomes. In addition to evidence, person-centered care incorporates clinical judgment. Florence Nightingale used clinical judgment to improve the care of wounded soldiers. She immediately assessed environmental conditions and the soldiers' needs to make decisions to promote safe, effective quality care. Similarly, Susan used her applied knowledge of cardiac dysrhythmias and laboratory data to obtain essential nursing care for the client. The home health nurse used advanced technologies in the care of her client. All of these scenarios highlight the need for a sound knowledge base to make safe clinical decisions. ThinkLike a Nurse 1-1: Clinical Judgment in Action The Institute of Medicine (IOM; now the National Academy of Medicine) identified core competencies for healthcare providers (Greiner & Knebel, 2003; see the accompanying Safe, Effective Nursing Care \[SENC\] box, "What Is Safe, Effective Nursing Care \[SENC\]?"). These competencies are the basis for the SENC competencies. You will see them used throughout this text. Which of these competencies did Florence Nightingale demonstrate? Explain your thinking. ABOUT THE KEY CONCEPTS The overarching concept for this chapter is nursing. As you come to understand other key concepts (i.e., nursing history, contemporary nursing education, contemporary nursing practice, healthcare delivery system), you will grasp how nursing has evolved into today's contemporary nursing practice. HISTORICAL LEADERS WHO ADVANCED THE PROFESSION OF NURSING Key Point: An understanding of how the actions of others have advanced the profession of nursing demonstrates how your actions and advocacy can make a difference. Florence Nightingale (Fig. 1-1) Historically, the military and religions have had positive impacts on the advancement of the nursing profession. Many individuals answered the call to promote quality healthcare for soldiers and wounded warriors. The most notable individual and advocate for quality healthcare is Florence Nightingale, also known as the "Founder of Modern Nursing." She transformed nursing into a widely respected profession. Her diligent efforts provided the foundation for research, evidence-based practice, and interprofessional communications. Safe, Effective Nursing Care What Is Safe, Effective Nursing Care (SENC)? Competencies: This table contains the competencies of the Institute of Medicine (IOM; now the National Academy of Medicine) and their parallels to safe, effective nursing care that a graduate nurse should be able to provide within the framework of the full-spectrum nursing model (see Chapter 2). To implement full-spectrum nursing, a nurse must demonstrate the model concepts (thinking, doing, and caring) that are aspects of every competency. National Academy of Medicine\* Core Competencies Safe, Effective Nursing Care (Thinking, Doing, Caring) Provide patient-centered care ➤ Respect clients' differences, values, preferences, and expressed needs ➤ Relieve pain and suffering ➤ Coordinate continuous care ➤ Communicate and provide client education ➤ Focus on health promotion and illness prevention Provide goal-directed, patient-centered care ➤ Establish mutual goals with clients ➤ Show respect for client values, religious beliefs, needs, and preferences ➤ Implement interventions to promote client comfort, promote health, prevent illness, or transition to a peaceful death ➤ Provide client education to foster informed decisions and involvement in care and to facilitate postdischarge health Work on interprofessional teams ➤ Collaborate, communicate, and jointly implement client care Collaborate with the interprofessional healthcare team ➤ Function as an essential member of the healthcare team ➤ Develop a comprehensive plan of client care that includes members of the interprofessional healthcare team ➤ Evaluate client care from a holistic, interprofessional approach Employ evidence-based practice ➤ Integrate research with clinical expertise and client values for optimal care ➤ Maintain knowledge of current research Validate evidence-based research to incorporate into practice ➤ Incorporate evidence-based findings into client care ➤ Evaluate client outcomes using valid and reliable research tools ➤ Utilize data/findings to generate research questions Apply quality improvement ➤ Identify and avoid care errors ➤ Design a framework that includes structure, process, and outcomes in relation to client and community needs ➤ Evaluate the framework Provide safe, quality client care ➤ Evaluate and use techniques/processes to avoid medical/nursing errors in the delivery of client care ➤ Design a "Thinking, Doing, Caring" framework that incorporates a holistic approach to client care ➤ Evaluate the framework, incorporating the structure, process, and outcomes components of quality improvement approaches ➤ Use data to foster improvements and implement innovative processes Utilize informatics ➤ Communicate, manage knowledge, mitigate error, and support decision making using information technology Embrace/incorporate technological advances ➤ Use technology to deliver safe, effective care ➤ Remain current in information technology ➤ Communicate with technology support systems to ensure optimal client outcomes ➤ Maintain accurate and comprehensive electronic health records \*Formerly Institute of Medicine (IOM). Source: Greiner, A., & Knebel, E. (Eds.). (2003). Health professions education: A bridge to quality. Institute of Medicine (US) Committee on the Health Professions Education Summit. The wounded soldiers in the hospital in Scutari were dying due to poor environmental conditions, poor nutrition, and lack of quality care. In spite of resistance from the medical community, Florence Nightingale persisted in her determination to provide and promote quality care to soldiers. Her primary focus was ensuring that she and her team of nurses addressed the care needs of the soldiers. Using a lantern for light, she would visit soldiers at night, earning her the name "Lady With the Lamp." She kept meticulous notes and statistics that were used to advocate for and obtain changes in healthcare. She used her clinical judgment, political connections, and social standing to ensure that nursing was recognized as a respectable profession. The Nightingale Home and Training School for Nurses was opened in 1860 and is considered the first official nursing program. FIGURE 1-1 Florence Nightingale (1820--1910). In her Notes on Hospitals (1863), Nightingale stated that air, light, nutrition, and adequate ventilation and space were essential for soldiers to recuperate. The hospitals she designed incorporated these ideas, which decreased mortality rates, lengths of hospital stays, and rates of nosocomial infection (infection associated with a healthcare facility, now more commonly called healthcare-associated infection). Other Leaders Nursing presence on the battlefield became more common during the Civil War when the U.S. government established the Army Nursing Service to organize nurses and hospitals and coordinate supplies for the soldiers. Thousands of laypersons also volunteered, including the following: Dorothea Dix served as superintendent of the U.S. Army Nurses. Clara Barton provided care in tents set up close to the fighting. When the war was over, Barton continued this universal care through the establishment of the American Red Cross. Other nurses who were instrumental in developing the roles of nursing as we now know it---promoting health, providing care, preventing illness, and advancing the profession---include the following: Lillian Wald and Mary Brewster, the pioneers of public health nursing, founded the Henry Street Settlement in New York to fight the spread of diseases among poor immigrants. Edward Lyon was the first male nurse to receive a commission as a reserve officer. Mary Mahoney, the first African American graduate nurse in the United States, cofounded the National Association of Colored Graduates in 1908, which eventually merged with the American Nurses Association (ANA). Lavinia Dock, a nurse, feminist, and social activist, compiled the first manual of drugs for nurses in 1890. She was a contributing editor to the American Journal of Nursing and helped establish the American Society of Superintendents of Training Schools for Nurses of the United States and Canada, now the National League for Nursing (NLN). Linda Richards, the first professionally trained nurse in America, created the first system for keeping individual medical records and promoted mental health nursing. Nursing Today: Full-Spectrum Nursing Nurses today are highly trained, well-educated, caring, and competent professionals. They are essential members of the healthcare team. The complexity of healthcare delivery requires that nurses use clinical judgment, communication, organizational, leadership, advocacy, and technical skills to ensure that clients receive safe and effective care. Safe, Effective Nursing Care Nursing education emphasizes quality and safety so that students will be able to deliver safe, effective nursing care in their practice after graduation. Nursing Practice. The IOM (now the National Academies of Sciences, Engineering, and Medicine) has identified quality and safety competencies that all health professionals are expected to demonstrate in their practice (Greiner & Knebel, 2003; see the SENC box "Quality Improvement Competency" later in this chapter). Nursing Education. The Quality and Safety Education for Nurses (QSEN) project is one of the organizations that has identified competencies that students are expected to acquire before graduation (Cronenwett et al., 2007). Others include the American Association of Colleges of Nursing (AACN) in the publication The Essentials: Core Competencies for Professional Nursing Education (2021) and the NLN Practical/Vocational Curriculum guidelines. Full-Spectrum Nursing and Safe, Effective Nursing Care. To implement quality care using the full-spectrum nursing model (Chapter 2), we will refer to "safe, effective nursing care" competencies (see the SENC boxes that appear in almost all chapters in this book). Application of Knowledge, Skill, and Caring Key Point: Nurses apply knowledge from the arts and sciences in their various roles to provide person-centered care (Table 1-1). Nurses use clinical judgment, critical thinking, and problem-solving as they care for clients. (You will learn more about full-spectrum nursing in the section titled What Is Full-Spectrum Nursing? in Chapter 2.) Table 1-1 ➤ Roles and Functions of the Nurse ROLE FUNCTION EXAMPLES Direct care provider Addressing the physical, emotional, social, and spiritual needs of the client Listening to lung sounds Giving medications Client teaching Communicator Using interpersonal and therapeutic communication skills to address the needs of the client, facilitate communication in the healthcare team, and advise the community about health promotion and disease prevention Counseling a client Discussing staffing needs at a unit meeting Collaborating with the provider about a client's condition Client/family educator Assessing and diagnosing the teaching needs of the client, group, family, or community. Once the diagnosis is made, nurses plan how to meet these needs, implement the teaching plan, and evaluate its effectiveness. Preoperative teaching Prenatal education for siblings Community classes on nutrition Client advocate Supporting clients' right to make healthcare decisions when they are able to voice their opinions and protecting clients from harm when they are unable to make decisions Helping a client explain to their family that they do not want to have further chemotherapy Counselor Using therapeutic communication skills to advise clients about health-related issues Counseling a client on weight-loss strategies Change agent Advocating for change on an individual, family, group, community, or societal level that enhances health. The nurse may use counseling, communication, and educator skills to accomplish this role. Working to improve the nutritional quality of the lunch program at a preschool Leader Inspiring others by setting an example of positive health, assertive communication, and willingness to improve Florence Nightingale Walt Whitman Harriet Tubman Malala Yousafzai Manager Coordinating and managing the activities of all members of the team Charge nurse on a hospital unit (e.g., assigns clients to staff nurses) Case manager Coordinating the care delivered to a client Coordinator of services for clients with mobility challenges Research consumer Applying evidence-based practice to provide the most appropriate care, identify clinical problems that warrant research, and protect the rights of research subjects Reading journal articles Attending continuing education; seeking additional education To be safe providers, nurses must carefully consider their actions and think carefully about the client, the treatment plan, the healthcare environment, the client's support system, the nurse's support system and resources, and safety. Clinical judgment requires a strong, solid knowledge base. It involves a process that consists of recognizing and analyzing the cues, prioritizing hypotheses, generating solutions, taking actions, and evaluating outcomes of the client's condition to determine whether change has occurred. It also involves careful consideration of the client's condition, medications, and treatment in the evaluation of their health status. Consider how clinical judgment was evident in each of the three scenarios. The nurses analyzed the cues present in each situation to implement actions to promote quality client care. The use of the nursing process, discussed in Chapter 3 and in each of the clinically focused chapters, facilitates the development of clinical judgment. Critical thinking is a reflective thinking process that involves collecting information, analyzing the adequacy and accuracy of the information, and carefully considering options for action. Nurses use critical thinking in every aspect of nursing care. Critical thinking is discussed at length in Chapter 2 and applied in every chapter in this text. Problem-solving is a process by which nurses consider an issue and attempt to find a satisfactory solution to achieve the best outcomes. You will often use problem-solving in your professional life. The nursing process (see Chapter 3) is one type of problem-solving process. Core Competencies for Professional Nursing. The AACN identified 10 domains that are essential to the practice of nursing (AACN, 2021). Integrated within various domains are concepts that reflect essential knowledge for professional nursing. You have already learned about some of these concepts (e.g., clinical judgment) and will gain knowledge of the others as you progress in your nursing courses. For example, you will be introduced to the concept of social determinants of health as you individualize care and consider how the environment in which patients live, work, play, and learn affect health risks and outcomes. ThinkLike a Nurse 1-2: Clinical Judgment in Action In the three scenarios of Nurses Make a Difference... Then & Now, describe how clinical judgment has evolved over time. CONTEMPORARY NURSING: EDUCATION, REGULATION, AND PRACTICE As a student about to enter your new professional life, you need a realistic grasp of the nature and demands of your chosen career. To help better acquaint you with nursing today, the remainder of this chapter discusses the current state of nursing, discusses nursing education, presents the trends affecting nursing, and provides an overview of the healthcare delivery system. How Is Nursing Defined? Based on historical and television depictions, many individuals have different images of nurses. That makes it difficult for the public to understand the reality of nursing. In addition, the various levels of nurses and their associated roles can be confusing to the public and to other members of the healthcare team. In addition, the constantly changing nature of nursing, healthcare, and society further complicates the definition of nursing. Key Point: It is important for nurses to articulate clearly, for themselves and for the public, what nursing is and what nurses do. The following sections articulate the views of two important nursing organizations in answer to the question, "What is nursing?" International Council of Nurses Definition The International Council of Nurses (ICN), an organization that represents nurses throughout the world, defined nursing in accordance with theorist Virginia Henderson as follows: 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 peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. (Henderson, 1966, p. 15) In the decades since the adoption of that definition, nursing throughout the world has changed. Advances in healthcare have altered the type of care required by clients, and nurses have taken on expanded roles. To reflect these changes, the ICN has revised its definition of nursing, as follows: Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles. (ICN, n.d.) ThinkLike a Nurse 1-3: Clinical Judgment in Action Look at the three scenarios of Nurses Make a Difference... Then & Now. What nursing actions did the nurses perform that are represented in the ICN definition of nursing? American Nursing Association Definition You can see similar changes in the approach of the ANA. In 1980, the ANA defined nursing as "the diagnosis and treatment of human responses to actual and potential health problems" (p. 2). Attempts to refine this definition have been difficult. Nurses are a widely varied group of people with varying skills. They perform activities designed to provide care ranging from basic to complex in numerous healthcare environments. Therefore, it is not easy to describe the boundaries of the profession. In 2010, the ANA acknowledged five characteristics of registered nursing: Nursing practice is individualized. Nurses coordinate care by establishing partnerships (with persons, families, support systems, and other providers). Caring is central to the practice of the registered nurse. Registered nurses use the nursing process to plan and provide individualized care to their healthcare consumers. A strong link exists between the professional work environment and the registered nurse's ability to provide quality healthcare and achieve optimal outcomes. (ANA, 2010, pp. 4--5) The ANA now defines professional nursing as follows: 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, 2015a, p. 1) Why Is a Definition Important? Nursing organizations and leaders have pushed for accurate definitions to (1) help the public understand the value of nursing, (2) describe what activities and roles belong to nursing versus other health professions, and (3) help students and practicing nurses understand what is expected of them within their role as nurses. From history, you can tell that nursing has undergone tremendous change, from a role limited to providing kindness and support to full-spectrum nursing, which is based in science but still focuses on care and nurturing. Box 1-1 lists several additional definitions of nursing for you to consider. As a student entering nursing, you can use definitions and descriptions to understand what is expected of you. To aid you in this task, refer to Table 1-1 and review the essential components of the nursing role. While in the clinical setting, you will observe nurses functioning in each of these capacities and identify the qualities listed in Box 1-2 that are essential for safe nursing practice. KnowledgeCheck 1-1 What factors make it difficult to define the term nursing? Based on the ICN definition of nursing, what does a nurse do? What is clinical judgment? Critical thinking? BOX 1-1 What Is Nursing? I use the word nursing, for want of a better. It has been limited to signify little more than the administration of medicines and the application of poultices. It ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper choosing and giving of diet---all at the least expense of vital power to the patient. (Nightingale, 1876, p. 5) Events that give rise to higher degrees of consideration for those who are helpless or oppressed, kindliness and sympathy for the unfortunate and for those who suffer, tolerance for those of differing religion, race, color, etc.---all tend to promote activities like nursing which are primarily humanitarian. (Dock & Stewart, 1938, p. 3) Nursing has been called the oldest of the arts and the youngest of the professions. As such, it has gone through many stages and has been an integral part of societal movements. Nursing has been involved in the existing culture---shaped by it and yet helping to develop it. (Donahue, 1985, p. 3) Nurses provide care for people in the midst of health, pain, loss, fear, disfigurement, death, grieving, challenge, growth, birth, and transition on an intimate front-line basis. Expert nurses call this the privileged place of nursing. (Benner & Wrubel, 1989, p. xi) Nurses provide and coordinate patient care, educate patients and the public about various health conditions, and provide advice and emotional support to patients and their family members. (U.S. Bureau of Labor Statistics, 2021b) Is Nursing a Profession, Discipline, or Occupation? One strategy used to describe a field of work is to categorize it as a profession, a discipline, or an occupation. Profession Although the term profession is freely used, a group must meet certain criteria to be considered a profession (see Table 1-2). Nursing appears to meet all criteria of a profession as defined by Starr (1982) and Miller et al. (1993). Discipline To be considered a discipline, a profession must have a domain of knowledge that has both theoretical and practical boundaries. The theoretical boundaries of a profession are the questions that arise from clinical practice and are then investigated through research. The practical boundaries are the current state of knowledge and research in the field---the facts that dictate safe practice (Meleis, 1991). A case can be made that nursing is both a profession and a discipline: It is a scientifically based and self-governed profession that focuses on the ethical care of others. It is a discipline, driven by aspects of theory and practice. It demands mastery of both theoretical knowledge and clinical skills. Occupation In spite of meeting criteria for both designations (profession and discipline), nursing is often described as an occupation, or job. Most physicians are in control of their practice environment, working conditions, and schedule. In contrast, most nurses are hourly wage earners. The employer, not the nurse, decides the conditions of practice and the nature of the work. Nevertheless, nurse practice acts do not prevent nurses from functioning more autonomously. Key Point: The following actions can strengthen nursing's classification as a profession: Standardize the educational requirements for entry into practice. Enact uniform continuing education requirements. Encourage the participation of more nurses in professional organizations. Educate the public about the true nature of nursing practice. BOX 1-2 Important Qualities for Nurses Critical-Thinking Skills Required Action: Monitor the client, note changes, and take actions to ensure safe and effective care. Example: Call the provider to obtain a stronger pain medication for a client who, 2 hours after receiving pain medication, rates their pain as 7 out of 10. Caring and Compassion Required Action: Show kindness, concern, and sincerity that convey to clients that you care about their well-being. Example: Sit with and hold the hand of a client who has just been told that they have a terminal illness. Detail Oriented Required Action: Pay attention to details to prevent and identify potentially harmful errors in care. Example: Seek clarification and correct a dosage that is written as "7 mg" that should be "0.7 mg." Organizational Skills Required Action: Prioritize and meet the needs of the most critical clients first. Example: Care for the postoperative client with difficulty breathing before performing a dressing change. Speaking Skills Required Action: Communicate correct and pertinent information to clients and members of the healthcare team. Example: Teach the client how to perform a dressing change at home after discharge from the hospital. Listening Skills Required Action: Listen to clients' concerns and feedback from the interprofessional healthcare team. Example: The interprofessional team is having a conference discussing the needs of your client after discharge. Patience Required Action: In stressful situations in the work environment, think clearly and take the correct actions. Example: Remain calm when a client's condition deteriorates, provide the needed care, and transfer the client to the intensive care unit. Competence Required Action: Obtain the knowledge and skills to ensure safe, quality client outcomes. Example: Recognize that the correct dose for the drug is 0.10 mg rather than 10 mg. Emotional Stability Required Action: Develop the ability to cope with human suffering, emergencies, and other stresses. Example: Provide care to a client accused of child abuse and to the child who suffered severe head injuries. Physical Stamina Required Action: Perform physical tasks and endure long hours walking and standing. Example: Assist another nurse in lifting a 300-lb client after working 10 hours of a 12-hour shift. \_\_\_\_\_\_\_\_\_\_\_ Source: Adapted from U.S. Bureau of Labor Statistics, U.S. Department of Labor (2021b). Registered nurses. In Occupational outlook handbook. https://www.bls.gov/ooh/healthcare/registered-nurses.htm ThinkLike a Nurse 1-4: Clinical Judgment in Action Evaluate the status of nursing. Is nursing a respected profession? Give examples to support your opinion. How Do Nurses' Educational Paths Differ? The transition into the nursing profession involves the concepts of formal and informal processes. Formal education consists of completing the initial and continuing education required for licensure. Informal education involves a gradual progression in skill and clinical judgment that allows the nurse to advance in the profession. Formal Education When the client calls out "Nurse," who can respond? To legally use the title nurse, a person must be a graduate of an accredited nursing education program and have successfully passed the National Council Licensure Examination (NCLEX®). Other personnel might respond to the client's call, but they cannot legally be considered nurses. Students may enter nursing through two paths: as a practical nurse or as a registered nurse. Practical and Vocational Nursing Education Practical nursing education prepares nurses to provide basic care to clients under the direction of a registered nurse (RN) or primary care provider. Practical nurses are known as licensed practical nurses (LPNs) or licensed vocational nurses (LVNs). Educational programs for LPNs/LVNs offer both classroom and clinical teaching and usually last 1 year. After completing the practical nursing education program, the graduate must pass the NCLEX-PN® examination to become licensed. LPNs/LVNs usually work in nursing and residential facilities, providers' offices, home healthcare, and hospitals. Employment growth is expected to increase 9% between 2020 and 2030 (U.S. Bureau of Labor Statistics, 2021a). Table 1-2 ➤ Nursing: Is It a Profession? STARR CRITERION EXAMPLES IN NURSING The knowledge of the group must be based on technical and scientific knowledge. Entry-level nursing education requires coursework in basic and social sciences, as well as humanities, arts, and general education. Nursing education and practice are increasingly based on research from nursing and related fields. The knowledge and competence of members of the group must be evaluated by a community of peers. State regulatory bodies define the criteria that nurses must meet to practice and monitor members for adherence to standards. The group must have a service orientation and a code of ethics. Nursing is clearly focused on providing service to others. The major professional organizations have developed ethical guidelines to guide the practice of nursing. Source: Starr, P. (1982). The social transformation of American medicine. Basic Books. Registered Nursing Entry Education Currently, various educational pathways lead to licensure as an RN. Graduates of all these programs must successfully complete the NCLEX-RN® examination to practice as RNs. Their job growth is expected to grow 9% between 2020 and 2030, based on the increased growth of the aging population (U.S. Bureau of Labor Statistics, 2021b). Diploma programs. Hospital-based programs, modeled after Nightingale's school of nursing apprenticeship style of learning, were the mainstay of nursing education until the 1960s. The typical program lasts 3 years and focuses on clinical experience in direct client care. Since the 1960s, the number of diploma programs has steadily decreased to less than 10% of RN programs (AACN, 2019a). Associate's degree. This type of program, conceptualized by Mildred Montag, emerged during the nursing shortage after World War II. Associate's degree (AD) programs are primarily offered in community colleges. Although the nursing component typically lasts two years, students are required to take numerous other courses in liberal arts and the sciences. Nurses with an associate's degree in nursing (ADN) are prepared to provide direct client care. Baccalaureate degree. The course of study in prelicensure bachelor of science in nursing (BSN) programs lasts at least eight semesters. Graduates are prepared to assume administrative responsibilities, address complex clinical situations, oversee and provide direct client care, work in community care, apply research findings, and enter graduate education. The IOM (2011), now the National Academy of Medicine, established a goal to increase the proportion of baccalaureate-prepared nurses to 80% by 2020. Of first-time U.S.-educated candidates taking the NCLEX-RN® in 2020, those with BSN degrees exceeded those with ADN degrees by 2,127 test-takers (National Council of State Boards of Nursing \[NCSBN\], 2021). The AACN recognizes the baccalaureate degree as the minimum education for professional-level nursing practice (2019). However, the AACN acknowledges support of licensure at the ADN level and is an advocate for educational advancement. RN to BSN. Graduates from ADN programs are increasingly enrolling in RN-to-BSN programs to obtain the BSN degree, in alignment with the IOM recommendation for an 80% baccalaureate-prepared workforce. Currently there are over 775 RN-to-BSN completion programs (AACN, 2019b). Within 4 to 6 months after graduation, 93% of entry-level nurses with BSN degrees had job offers; this trend is expected to continue because the AACN has embraced the RN-to-BSN articulation model, and employers show a preference for hiring BSN-prepared nurses (AACN, 2021). Accelerated BSN. This prelicensure program is designed for students who have a baccalaureate degree in another field and want to get a degree in nursing. The didactic component is usually online, but students must complete traditional skills laboratory and clinical rotations that are consistent with traditional prelicensure programs. Direct-entry master's degree. The typical student in these programs has a baccalaureate degree in another field and has entered nursing as a second career. Programs usually are completed in 3 years of full-time study, with the first year devoted to basic nursing content. At the program's completion, the student is eligible to take the NCLEX-RN and is awarded a master's degree in nursing. Direct-entry doctorate. A direct-entry doctoral program is usually designed for students who have a baccalaureate degree in another field and seek an accelerated path to the doctorate degree. Students take the NCLEX-RN while enrolled in the program. Some offer a nurse practitioner program of study that prepares students to take the certification examination to become licensed as an advanced practice registered nurse (APRN). Graduate Nursing Education Graduate education prepares the RN for advanced practice and an expanded role in other areas (e.g., research). A baccalaureate degree is required to enter a traditional master's program. Master's degree programs prepare RNs to function in a more independent and autonomous role, such as nurse practitioner, clinical specialist, nurse educator, nursing informatics, or nurse administrator. It typically takes 2 years to complete the master's degree. Doctoral programs in nursing offer professional degrees. A master's degree is required to enter a traditional doctoral program. Doctoral degree programs in nursing offer one of the following: Doctor of nursing practice (DNP)---a practice degree Doctor of philosophy (PhD)---a degree focused on scholarly research and knowledge generation Other Forms of Formal Education Advances in healthcare have a strong influence on nursing practice. You will become familiar with the concept of "nurses as lifelong learners" as the means to keep current in your practice. You will be expected to engage in continuing education to enhance your intellectual and practical knowledge throughout your nursing career. Continuing education (CE) is designed to help you stay current in your theoretical and clinical knowledge after graduation. CE programs are offered at work sites, in educational settings, at professional conferences, on the Internet, and in professional journals. In many states, renewal of the nursing license requires successful completion of a specified number---and in some cases, type of---CE courses. When you apply for your license, the state board of nursing will notify you about CE requirements (if any) that you must complete to receive, or later renew, your license. You should also know your state requirements. In-service education is another form of ongoing education. It is offered at the work site and usually does not count toward meeting the CE requirement for license renewal. In-service education is typically institution specific (e.g., change in policies) or product specific (e.g., use of new equipment). It is designed to enhance your continuing competence in knowledge, skills, and attitudes. Informal Education Socialization is the informal education that occurs as you move into your new profession. It is the knowledge gained from direct experience, real-world observations, and informal discussion with peers and colleagues. Key Point: Professional socialization begins when you enter the educational program and continues as you gain expertise throughout your career. Informal education complements formal education to create clinical competence and professional growth. Benner's Model Nursing theorist Patricia Benner (1984) described the process by which a nurse acquires clinical skills and judgment. Benner's model notes that expertise is a personal integration of knowledge that requires technical skill, thoughtful application, and insight. Key Point: That is what we mean in this text when we use the term full-spectrum nursing it involves thinking, doing, and caring. Benner's model has five stages: Stage 1: Novice. This phase begins with the onset of education. The novice has little clinical experience, is task oriented, and is focused on learning the rules and following the written sequential process. For example, when performing a sterile dressing change, the nurse may be so concerned with following the steps in the skills checklist that they forget to assess the client's reaction to the procedure. Stage 2: Advanced beginner. A new graduate usually functions at this level. An advanced beginner begins to focus on more aspects of a clinical situation and applies more facts. The nurse can distinguish abnormal findings but cannot readily understand their significance. For example, a new graduate assesses that the postoperative client's blood pressure has decreased, their pulse rate has increased, and they have become more restless during the last 2 hours. However, the nurse probably will not recognize that these signs/symptoms may indicate early blood loss. Through repeated experiences or mentoring, the nurse begins to readily attach meanings to findings. Stage 3: Competence. Nurses achieve competence after 2 to 3 years of nursing practice in the same area. Competent performers have gained additional experience and are able to handle their client load, deal with complexity, and prioritize situations while providing compassionate care. In the previous scenario, the competent nurse would immediately connect the changes in the vital signs with the surgical procedure, recognize possible early signs of shock, and conduct a more in-depth assessment. Stage 4: Proficient. The proficient nurse is able to quickly take in all aspects of a situation and immediately give meaning to the cluster of assessment data. Proficient nurses are able to see the "big picture" and can coordinate services and forecast needs. They are much more flexible and fluent within their role and able to adapt to the nuances of various client situations. Stage 5: Expert. Expert nurses understand what needs to be achieved and how to do it. They trust in and use their intuition while operating with a deep understanding of a situation, often recognizing a problem in the absence of its classic signs and symptoms. They have highly competent skills and are often consulted when others need advice or assistance. Benner's model deals with the development of clinical wisdom and competence. Keep in mind that this progression is not automatic. Nurses do not simply move through the stages as they gain experience. Instead, this model assumes that to improve in skill and judgment, you must also be attuned to each clinical situation. This requires the ability to process information from a variety of sources and notice subtle variations to guide decision making. Although expertise (stage 5) is a goal, not everyone can achieve this level. Nursing Organization Guidelines The ANA and other organizations are also involved in helping nurses to improve their practice by setting standards and articulating nursing values. For example, in the Code of Ethics for Nurses, the ANA provides guidelines, including acceptable and unacceptable behaviors, for how nurses should conduct themselves in their day-to-day practice (ANA, 2015b). Box 1-3 presents values and behaviors essential to nursing practice. See Chapter 5, Ethics & Values, for further discussion of nursing values and the ANA Code of Ethics for Nurses. BOX 1-3 Nursing Values and Behaviors The nurse's primary concern is the good of the client. Nurses should maintain professional competency. Nurses demonstrate a strong commitment to service. Nurses believe in the dignity and worth of each person. Nurses constantly strive to improve their profession. Nurses work collaboratively within the profession. Nurses adhere to a professional code of ethics. Nurses commit to lifelong learning and professional development. KnowledgeCheck 1-2 Compare and contrast formal and informal education. Name and describe five educational pathways leading to licensure as an RN. How Is Nursing Practice Regulated? Laws, standards of practice, and guidelines from professional organizations regulate the practice of nursing. Nurse Practice Acts In the United States, each state enacts its own nurse practice act, which is a compilation of laws that govern the practice of nursing and empower a state board of nursing to oversee and regulate nursing practice. Although there are minor variations, each board of nursing is responsible for the following: Defining the practice of professional nursing. This definition usually includes the scope of practice (i.e., activities that nurses are expected to perform and, by implication, those they may not). Approving nursing education programs Establishing criteria that allow a person to be licensed as an APRN, RN, or LPN/LVN Developing rules and regulations to provide guidance to nurses Enforcing the rules that govern the education of nursing and nursing practice Key Point: To practice nursing, you must be licensed as a nurse by the state board of nursing. All states require graduation from an approved nursing program and successful completion of the NCLEX. To receive licensure in another state, the nurse simply applies for licensure by endorsement (reciprocity) or follows the guidance of the mutual recognition model. For further details about licensing and the regulation of nursing practice, see Chapter 39, Legal Accountability. Standards of Practice Nursing is also guided by standards of practice, which "describe a competent level of nursing care as demonstrated by the critical thinking model known as the nursing process" (ANA, 2015a, p. 4). Standards are "authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty, are expected to perform competently" (ANA, 2015a, p. 3). They provide a guide to the knowledge, skills, and attitudes (KSAs) that nurses must incorporate into their practice to provide safe, quality care. As a student nurse, you will use the ANA standards to better define your nursing practice. Practicing nurses use the standards to judge their own performance, develop an improvement plan, and understand employers' expectations. Employers may incorporate the standards into annual employee evaluation tools. Professional organizations use the standards to educate the public about nursing, to plan for continuing education programs for nurses, and to guide their efforts at lobbying and other advocacy activities for nurses. Other professionals read the standards of practice to examine the boundaries between nursing and their professions. ThinkLike a Nurse 1-5: Clinical Judgment in Action What do you see as the relationship between the nurse practice acts and nursing values and behaviors (see Box 1-3)? What Are Some Important Nursing Organizations? Numerous organizations are involved in the profession of nursing. Some of the most influential are discussed here. American Nurses Association The ANA is the official professional organization for nurses in the United States. The ANA was formed in 1911 from an organization previously known as the Nurses' Associated Alumnae of the United States and Canada. Originally this organization focused on (1) establishing standards of nursing to promote high-quality care and (2) working toward licensure as a means of ensuring adherence to the standards. The ANA continues to promote the interests of the nursing profession and update its standards. Representatives are elected from the local branches of the state organizations to bring their concerns to the national level. Local representatives Track healthcare legislation Serve as liaisons with national government representatives Communicate the impact of enacted legislation on nursing in their area Develop and sponsor legislation expected to have a positive effect on nursing and client care Additionally, the ANA publishes educational materials on nursing news, issues, and standards. The official publication is The American Nurse. National League for Nursing Originally founded as the American Society of Superintendents of Training Schools for Nurses in 1893, the National League for Nursing (NLN) was the first nursing organization with a goal to establish and maintain a universal standard of education. The NLN Sets standards for all types of nursing education programs Studies the nursing workforce Lobbies and participates with other major healthcare organizations to set policies for the nursing workforce Aids faculty development Funds research on nursing education Publishes the journal Nursing Education Perspectives International Council of Nurses The ICN represents more than 27 million nurses on a global scale. It is composed of a federation of national nursing organizations from more than 130 nations. The ICN aims to ensure quality nursing care for all by Supporting global health policies that advance nursing and improve worldwide health Promoting knowledgeable and respected professionals Fostering a competent, satisfied workforce worldwide National Student Nurses' Association The National Student Nurses' Association (NSNA) represents nursing students in the United States. It is the student counterpart of the ANA. Like the ANA, this association comprises elected volunteers who advocate on behalf of student nurses. Local chapters are usually organized at individual schools. The official magazine of NSNA, Imprint, is dedicated to nursing student issues. Sigma Theta Tau International Sigma Theta Tau International (STTI) is the international honor society of nursing. Membership includes the clinical, education, and nursing research communities and senior-level baccalaureate and graduate programs. The goal of STTI is to foster nursing scholarship, leadership, service, and research to improve health worldwide. The official publication of STTI is the Journal of Nursing Scholarship. Specialty Organizations Numerous specialty organizations have developed around clinical specialties, group identification, or similarly held values. The following are some examples: Clinical specialty---Association of periOperative Registered Nurses (AORN), Academy of Medical-Surgical Nursing (AMSN), Emergency Nurses Association (ENA) Group identification---National Association of Hispanic Nurses (NAHN), American Association for Men in Nursing (AAMN), The American Association of Nurse Attorneys (TAANA), National American Arab Nurses Association (NAANA) Similar values---Nurses Christian Fellowship (NCF), Nursing Ethics Network (NEN) Nursing Practice: Caring for Clients Look again at the definitions of the term nursing in this chapter (e.g., see Box 1-1). Notice that they all agree that nursing is about caring for clients. Key Point: Research trends show that staffing and the educational preparation of the nurse are related to client outcomes. Hospitals with a higher percentage of baccalaureate-prepared RNs reported lower client complications (e.g., lower levels of pressure ulcers, client falls, urinary tract infections), shortened length of stays, and better-overall-quality client care (Djukic et al., 2019; Lasater et al., 2021). Smaller nurse-to-client ratios (i.e., when each nurse cared for fewer clients) were also related to positive client outcomes, lower client mortality, less nurse burnout, and higher job satisfaction for nurses (Ball et al., 2018; Halm, 2019; Hill, 2017). Nurses also use research results to guide their interventions in planning and implementing evidenced-based practice. Who Are the Recipients of Nursing Care? The recipients of nursing care may be individuals, groups, families, or communities. They can be referred to as patients, clients, or persons. Direct care involves personal interaction between the nurse and clients (e.g., giving medications or teaching a client about a treatment). Indirect care is working on behalf of clients to improve their health status (e.g., ordering unit supplies or serving on an ethics committee). A nurse may use independent judgment to determine the care needed or may work under the direct order of a primary care provider. As a nurse, you should view clients as active recipients of care. Key Point: Your role is to encourage clients to actively participate in decisions about their care and to collaborate with members of their healthcare teams. Toward Evidence-Based Practice Falls among hospitalized patients are a major safety concern. Current nursing practice on fall prevention is grounded in evidence-based research findings that have evolved over time from a single to a multifactorial approach, as demonstrated in the studies that follow. Brush, B. L., & Capezuti, E. (2001). Historical analysis of siderail use in American hospitals. Journal of Nursing Scholarship, 33(4), 381--385. https://doi.org/10.1111/j.1547-5069.2001.00381.x Siderails became a permanent fixture of the hospital bed as a way to decrease patient falls. Although research identified their negative effects (e.g., siderail-induced injuries, negative physical and emotional consequences of sustained bedrest), siderail use remained the norm in promoting patient safety. Spoelstra, S. L., Given, B. A., & Given, C. W. (2012). Fall prevention in hospitals: An integrative review. Clinical Nursing Research, 21(1), 92--112. https://doi.org/10.1177/1054773811418106 This study found that intervention programs that included a multiple-intervention approach to preventing client falls were more effective than relying on a single intervention. Fall-prevention programs should include staff education, fall-risk assessments, environmental assessments and modifications, alarm systems, and client assistance with transferring and toileting. Chu, R. (2017). Preventing in-patient falls: The nurse's pivotal role. Nursing2017, 47(3), 24--30. https://doi.org/10.1097/01.NURSE.0000512872.83762.69 Evidence-based interventions for fall prevention include an integrated plan that includes identification of high-risk patients (e.g., impaired gait, weak, poor vision); hourly rounding; communication to the team (e.g., report, color-coded bracelets, door signs), to the client (e.g., reinforce use of call device, nurses' role in providing assistance), and to the family (e.g., request assistance from nursing staff); bed in low position; bed alarms; and low nurse-to-patient ratios. In addition, centralized video monitoring decreased falls and is cost-effective. Turner, K., Staggs, V. S., Potter, C., Cramer, E., Shorr, R. I., & Mion, L. C. (2022). Fall prevention practices and implementation strategies: Examining consistency across hospital units. Journal of Patient Safety, 18(1), e236--e242. https://doi.org/10.1097/PTS.0000000000000758. Researchers investigated the consistency of fall-prevention practices and implementation strategies among medical and medical-surgical units across U.S. hospitals. The results revealed that resource-intensive strategies (hourly rounding, scheduled toileting, staying with patient in the bathroom) were used less consistently than less nonintensive ones (signage, patient bracelet, room door open). Among patient safety practices, nonskid socks and an accessible call light were used more consistently than having ambulatory aids accessible and ensuring a clutter-free floor. Maintaining the bed in a locked, lowered position, with an alarm and bedside commode, took precedence over a specialty low bed and bedside floor mat. The most-used quality management strategy was to increase awareness (posting fall rates, using dashboards), in contrast to feedback strategies (post-fall huddles among nurses and the interdisciplinary team, conduction of post-fall audits). Equipment (specialty low beds, bed/chair alarms) was more commonly used than people (sitters, replacement nursing personnel) to support fall-prevention efforts. Although the value of a multicomponent approach is recognized, considerable variations in the implementation of fall-prevention practices and implementation strategies exist among hospitals. 1. What current trends and factors might influence whether siderail use, as a fall-prevention strategy, will change in the near future? 2. What strategies would you include in a fall-prevention program? 3. What should be the focus of future research to decrease falls in hospitalized patients? What Are the Purposes of Nursing Care? Nurses provide care to achieve the goals of health promotion, illness prevention, health restoration, and end-of-life care. Together, these aspects of care represent a range of services that cover the health spectrum from complete well-being to death. Nurses Plan to ensure consistency of client care over time. Individualize care according to client needs. Ensure that holistic care is provided. Collaborate with the interprofessional health team for optimal client outcomes. Where Do Nurses Work? As a nurse, you will have the opportunity to work in a variety of settings. As a student, you will have assignments in many settings and environments that will allow you to see some of the options available to you after you obtain your nursing license. Approximately 61% of nurses work in hospitals. Others work in extended care facilities, providers' offices, ambulatory care, home health, correctional facilities, public health, the military, or schools (U.S. Bureau of Labor Statistics, 2021b). What Models of Care Are Used to Provide Nursing Care? Nursing care is structured in various ways. The organization of the nursing team reflects the philosophy and beliefs of the facility, as well as its prevailing views on nursing. The structure of the team is often referred to as the model of care. The most common models include the following: Case Method This is also called total care. Case method is one-to-one care; one nurse provides all aspects of care for one client during a single shift. In this method, the nurse and client work more closely together, the client's needs are quickly met, and the nurse has a greater degree of autonomy. Although satisfying for clients and nurses, the high costs limit its widespread use. The case method is used mainly in intensive care units (ICUs), labor and delivery, and private-duty care. Functional Nursing This requires a clear understanding of what tasks each member may perform (scope of practice). In functional nursing, care is compartmentalized, with each task assigned to a staff member with the appropriate knowledge and skills. For example, the RN is in charge and performs complex treatments, the LPN/LVN may distribute medications, and the nursing assistant may give bed baths and make beds. Although this approach is economical and efficient, it can make it difficult for the nurse to have the "whole picture" of the client and may result in fragmentation of care. Team Nursing This approach is efficient. It maintains the cost savings of functional nursing while limiting fragmentation. In team nursing, a licensed nurse (RN or LPN/LVN) is paired with an unlicensed assistive personnel (UAP). The team is then assigned to a group of clients. Teams led by RNs are assigned to high-acuity clients. Team nursing maximizes the contributions of each team member to provide safe, high-quality client care (Parreira et al., 2021). The team model, with its focus on levels of nursing proficiency, provided the foundation for establishing a pyramid staffing model to meet the needs of ICU patients during the COVID-19 hospitalization surge (Perlstein et al., 2021). Primary Nursing With this method, one nurse manages care for a group of clients. Primary nurses assess the client, develop a plan of care, and provide care while at work. Associate nurses deliver care and implement the plan developed by the primary nurse when the primary nurse is not available. Differentiated Practice A variation of primary care, differentiated practice recognizes that education and experience lead to differences in the care delivered by nurses. Each unit identifies the type of expertise needed by the clients and the nursing competencies required to deliver that care. Individual nurses develop a portfolio of their competencies and are assigned to clients who need those particular competencies. THE HEALTHCARE DELIVERY SYSTEM The healthcare delivery system in the United States is a complex collection of clients, providers, facilities, vendors, and rules. The rest of this chapter is designed to help you gain a beginner's understanding of this system. You will need to know the components of the system to understand the continuum of healthcare that clients receive, the providers involved in that care, and the factors that influence the type and amount of care that clients receive. What Types of Care Are Provided? Clients can receive acute care or long-term support services. Acute care is defined as the services used to "treat active sudden, often unexpected, urgent or emergent episodes of injury and illness that can lead to death or disability without rapid intervention (Hirshon et al., 2013, pg 386)." The six domains of acute care are (1) trauma care and acute care surgery, (2) emergency care, (3) urgent care, (4) short-term stabilization, (5) prehospital care, and (6) critical care. The goal is to prevent deterioration and restore health (Hirshon et al., 2013). Long-term support services (LTSSs) is an array of services provided to individuals with long-term chronic conditions, disabilities, or frailty and encompasses "human assistance, assistive technologies and devices, environmental modifications, care and service coordination (Nguyen, 2017)" on a regular or intermittent basis (Hado et al., 2019; Nguyen, 2017). LTSSs are provided in a variety of nonhospital settings, such as extended care facilities, ambulatory care centers, and home healthcare agencies. Clients are classified based on their admission status: Inpatient refers to a client who has been admitted to a healthcare facility. The length of stay is limited to the amount of time that the client requires 24-hour care. Outpatient refers to a client who receives treatment at a healthcare facility but does not stay overnight. Where Is Care Provided? The client's medical condition determines where care is provided. Acute care is provided in hospitals. Once stabilized, the client is discharged to home or, if further care is needed, to an extended care facility. The various types of care facilities are discussed next. Hospitals Hospitals are the most expensive and the most frequently used site for care. They provide a broad range of services to treat various injuries and disease processes (Fig. 1-2). Hospitals vary in size, ownership, and the services provided. Smaller hospitals offer basic services, whereas larger medical centers usually have an emergency department, diagnostic centers, and other units, such as intensive care, medical, surgical, pediatrics, and maternal/newborn. Hospitals employ a variety of healthcare providers (e.g., nurses, allied health therapists, hospitalists, case managers, pharmacists) to meet the around-the-clock needs of acute care clients. Extended Care Facilities Extended care facilities provide long-term care and support that can range from a few months to a lifetime. As the length of stay in hospitals continues to decline, extended care facilities deliver services that were previously provided in hospitals. Key Point: The distinction among extended care facilities is based primarily on whether they provide skilled or custodial care. Skilled care includes the services of trained professionals that are needed for a limited period of time after an injury or illness (e.g., wound care, IV infusions). Clients are expected to improve with these treatments. Custodial care, in contrast, consists of help with activities of daily living: bathing, dressing, eating, grooming, ambulation, toileting, and other care that people typically do for themselves (e.g., taking medications, monitoring blood glucose levels). The use of extended care facilities will continue to increase because of the aging population and increased longevity of clients with traumatic injuries and chronic diseases (Nguyen, 2017). Residents in extended care facilities are commonly older adults, but clients of any age who require assistance with self-care activities may live in these facilities. Extended care is delivered in nursing homes, skilled nursing facilities (also known as convalescent hospitals), and rehabilitation facilities. Nursing Homes These facilities provide custodial care for people who cannot live on their own but are not sick enough to require hospitalization. They may be permanent homes for people who require continual supervision to ensure their safety. Various services are offered to residents, such as recreational activities and salon services. Rehabilitation Centers These facilities provide extended care and treatment for clients with physical and mental illness. Rehabilitation involves an interprofessional, collaborative approach, with weekly team and family conferences to discuss the treatment plan. Types of services include alcohol and drug rehabilitation, physical rehabilitation services for clients who have experienced traumatic injuries, and rehabilitation of clients after stroke or heart attack. Nurses have an ongoing relationship with their clients due to the lengthy time of treatment. Assisted Living Facilities These were designed to bridge the gap between independence and institutionalization for older adults who have a decline in health status and cannot live independently. Residents of these facilities are able to perform self-care activities but require assistance with meals, housekeeping, or medications. Nurses have a limited presence at assisted living sites because skilled care is usually not required. Ambulatory Care Centers Ambulatory (or outpatient) care centers offer cost-effective healthcare to clients who are able to come and go from the facility for same-day or special services (e.g., chemotherapy, dialysis, surgery). Ambulatory care sites include medical offices, urgent care clinics, retail clinics, outpatient therapy centers, and hospitals (Fig. 1-3). FIGURE 1-2 Emergency departments may be the primary source of healthcare for many individuals. FIGURE 1-3 The shift to outpatient care is a cost-saving strategy. Home Healthcare Agencies After hospitalization, home healthcare agencies provide continuing care to clients in their homes. Services are usually coordinated by a home health or visiting nurse service and include nursing care as well as various therapies (e.g., physical, respiratory) and home assistance programs. Chapter 38, Community and Home Health Nursing, provides further discussion on home health nursing. Community/Public Health Centers Community or public health centers are community-based centers that provide care for the community at large. Community health nurses provide services to at-risk populations and devise strategies to improve the health status of the surrounding community (e.g., school-based pregnancy reduction programs, healthcare for the homeless). Community care is provided to client groups at various sites, such as churches, schools, shelters, workplaces, and public clinics. Chapter 38 provides further discussion of community healthcare. Independent Living Facilities Also known as retirement homes, independent living facilities are designed for seniors 55 years or older who (1) are independent in all aspects and (2) want to live in a community with other senior citizens. Services usually include a peer support network that provides socialization opportunities, structured recreational activities, transportation arrangements, fitness centers, pools, and quiet environments. Living facilities range from apartment-style homes to smaller separate residential homes. Nurses may provide periodic health screening and health information. How Is Healthcare Categorized? Because the boundaries of care have become fluid, it is useful to look at the system in a different light. Key Point: The complexity of care is no longer a predictor of where care will be delivered. Instead, regulators, finances, and the client's support system dictate where a client will be located in the system. On a basic level, healthcare is categorized as primary, secondary, and tertiary based on the complexity and the type of services needed. Primary Services Nursing and Health Promotion In 1948, the World Health Organization (WHO) defined health as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." The definition has not been amended since that time (WHO, 2006). Health-promotion activities foster the highest state of well-being of the recipient of the activities. The following are examples: Individual level---Counseling a pregnant client about the importance of adequate prenatal nutrition to promote health for the client and baby Group and family level---Teaching about nutrition during pregnancy in family education programs Community level---Advocating for prominent billboards highlighting the importance of prenatal care and nutrition; posting signs in grocery stores recommending the best foods for pregnant women Societal level---Working with international partners to establish worldwide prenatal nutrition standards Nursing and Illness Prevention The focus of illness prevention is the avoidance of disease, infection, and other comorbidities. Activities are targeted to minimize the risk of development of or exposure to disease. For example, pneumonia causes many deaths every year. It affects society's most vulnerable: the very young, the very old, and the very ill. Some nursing activities to decrease the risk of pneumonia include the following: Teaching the importance of hand hygiene Advocating for and administering pneumonia immunizations, especially to those at high risk Promoting smoking cessation Promoting adequate nutrition, including a diet high in vitamin C, to increase the person's resistance to the disease should exposure occur Secondary Services Secondary services are directed toward early diagnosis and treatment of illness, disease, and injury. Increasingly, these services are being performed in surgery centers, offices, and outpatient centers. The trend away from the hospital is related to containing costs, increasing specialization of hospitals, and growing evidence that hospitals often harbor medication-resistant infectious organisms. Nursing and Health Restoration Health-restoration activities foster a return to health for those already ill. The nurse provides direct care to ill individuals, groups, families, or communities to restore their health. The nursing role includes addressing the physical, mental, spiritual, and social dimensions of client care. Tertiary Services Tertiary services refer to long-term rehabilitation services and care for the dying. Historically, these services were provided in extended care facilities. Now, however, many tertiary care services are provided in the home or in outpatient settings. Nursing and End-of-Life Care Death is an inevitable destination on the journey of life. Nurses work with dying individuals, their family members and support persons, and organizations (hospice) that focus on the needs of the terminally ill to promote comfort, maintain quality of life, provide culturally relevant spiritual care, maintain dignity, and ease the emotional burden of death (see Chapter 14). KnowledgeCheck 1-3 Recall the last time that you had a cold. Identify health-promotion, illness-prevention, and health-restoration activities for individuals, families, groups, and communities in relation to the common cold. Who Are the Members of the Interprofessional Healthcare Team? As a nurse, you will be part of an interprofessional healthcare team consisting of numerous professionals whose primary role is to ensure quality client outcomes (Fig. 1-4). The composition of the team varies depending on the healthcare needs of the client. Each provider's role in the health team is covered in the discussion that follows. Physicians are licensed as medical doctors (MDs) or doctors of osteopathy (DOs). Their primary role is to diagnose and treat disease and illness through medical and surgical services. A physician may work independently, as part of a medical group, as an employee of a health facility, or as a hospitalist who leads the medical team to coordinate care for inpatients. Nurse practitioners (NPs) are independent practitioners with advanced education and training and are licensed to provide a broad range of medical and nursing care based on their specialty area. NPs engage in activities ranging from health promotion to caring for clients with acute or chronic healthcare problems. They can practice independently or in collaboration with a provider. Physician assistants (PAs) practice under the supervision of a physician to diagnose and prescribe treatments and medications to treat certain diseases and injuries. As an extension of the physician, nurses are permitted to follow a PA's prescriptions, unless this is prohibited by the state's nurse practice act or policies and procedures. RNs assess clients, administer treatments and medications, provide education, and modify nursing care plans based on client responses to treatment. They have the most direct contact with clients and provide holistic, continuous, and comprehensive nursing care. LPNs work under the supervision of the RN to provide noncomplex care, administer certain medications, and communicate client responses. UAP is a broad term that covers nursing assistants, aides, and technicians. UAPs provide custodial care under the direction of nurses and providers in a variety of settings. Key Point: Some UAPs introduce themselves to clients by stating, "I'm your nurse." Because they are not licensed nurses, they are making a false claim. Be sure to clarify your role and the UAP's role with all of your clients. Pharmacists prepare and dispense medications and therapeutic solutions in various health settings. They function as the leaders in pharmacological therapy. Pharmacists provide information about medication contraindications, side effects and adverse reactions, dosage, and administration tips. They also collaborate with nurses, providers, and other health-team members to ensure the selection of safe and effective medications in the treatment plan. Pharmacy assistants serve as support personnel for pharmacists. Therapists focus on a variety of rehabilitative needs of the client. The goal of the rehabilitative team is to treat and maximize functioning and/or assist the client in adapting to limitations and achieving optimal outcomes. Types of therapists include the following: Physiatrists function as the rehabilitative team leaders to improve mobility and strength and teach motor skills. Physical therapists (PTs) focus on the rehabilitation of muscles and bones to help clients use assistive devices and gain self-care skills for activities of daily living. Occupational therapists (OTs) work closely with PTs to help clients regain function and independence in everyday activities (e.g., work, school, social skills). Respiratory therapists (RTs) provide prescribed treatments for effective respiration and ventilation (e.g., oxygen therapy, mechanical ventilation). Speech and language therapists (SLTs) provide assistance to clients experiencing swallowing and speech disturbances from developmental or neurological impairment. Recreational therapists use leisure activities to promote the physical, social, and emotional well-being of clients. Marriage and family therapists provide counseling services to individuals, families, and groups. Technologists perform selected activities in hospitals, diagnostic centers, and emergency care facilities (e.g., laboratory technologists, radiology technologists). Registered dietitians/licensed nutritionists apply specialized knowledge of nutrition science to plan food treatments and goals to promote client health and treat illnesses. Social workers throughout healthcare systems provide psychosocial support and client services and coordinate continuity of care for clients after discharge. Spiritual care providers offer organized religious services, client visits, and family and staff support, particularly with serious illness or at the end of life. Alternative care providers, such as chiropractors, naturopaths, and herbalists, offer health services that are primarily outside the traditional healthcare system. FIGURE 1-4 Quality client outcomes require the collaboration of the entire healthcare team. How Is Healthcare Financed? Payers for healthcare in the United States include individuals, individual private insurance, employment-based group private insurance, the government, and charitable sources. Individuals Individuals are responsible for the costs of their healthcare services. We refer to payments made directly by individuals as direct payment of services and out-of-pocket expenses. Individuals with private or government insurance pay for services through cost sharing in the form of insurance deductibles, copayments, and coinsurance. Key Point: Individuals with and without insurance sometimes avoid or delay services because they cannot afford to pay the direct cost of services or the high cost-sharing out-of-pocket expenses. Individual Private Insurance Insurance is intended to protect persons from "medical bankruptcy" associated with the costs incurred by a major medical event (Fig. 1-5). It protects individuals from having to pay the entire costs associated with illness and hospitalization. A person with private insurance pays premiums to an insurance company. The insurance company then contracts with healthcare providers to deliver care to insured members at prearranged rates. Insured individuals are encouraged to obtain routine care from their provider to prevent additional out-of-pocket expenses. The costs associated with seeking nonemergency care at an emergency room can be 15 times higher than those for seeking treatment at the provider's office or at an urgent care facility (UHG, 2017). FIGURE 1-5 The high cost of healthcare is a barrier to early screening and prevention. Employment-Based Private Insurance Most private insurance in the United States is employment based, meaning the employer pays all or a portion of the costs (e.g., premiums) under a group plan that lowers costs. Because payment of employment-based insurance premiums is a major-cost fringe-benefit expense for employers, more costs are being shifted to employees. In the United States, the average annual total premium per enrolled employee was \$7,149, with the employer paying \$5,617 (79%) and the employee paying \$1,532 (21%; Kaiser Foundation, 2021). The cost of family coverage is much higher. The employer can deduct the costs of health insurance premiums as a business expense. In addition, healthy employees benefit employers because of reduced sick time and a full workforce to maintain productivity. Organization or Association Group Insurance Individuals can also obtain group insurance through organizations or associations. The AARP (formerly the American Association of Retired Persons) is an example of a group whose members share the cost of health insurance. Many of these organizations or associations contract with a third-party insurance vendor to offer their members health insurance. Having more members who pay premiums helps to lower the overall cost of individual premiums. Government (Public) Financing Key Point: Government-funded programs are paid for with revenue from federal, state, and local taxes on the citizenry. Programs include Medicare; Medicaid; and children's, specialty, and categorical programs. Medicare This is a federal insurance program created by Title XVIII of the Social Security Act of 1965. This act was designed to provide insurance for persons aged 65 years and older. It was later expanded to include younger people with permanent disabilities, such as end-stage renal disease, but provides only limited coverage for long-term care. Medicare is financed from a payroll tax levied on employers and employees and from premiums paid by Medicare subscribers (clients). Medicaid This was developed under Title XIX of the Social Security Act of 1965 to provide access to healthcare services for individuals with low incomes and minimal resources. Medicaid is a joint federal and state program; therefore, the eligibility criteria for Medicaid and the range of medical services offered vary from state to state. Medicaid offers a fairly comprehensive set of benefits, including prescription drugs, skilled care, and long-term care. Children's Health Insurance Program (CHIP) CHIP is a joint federal and state program. It provides health insurance to millions of children whose families have income levels that exceed Medicaid eligibility criteria but who cannot afford private insurance and whose children are not covered under a parent's policy. CHIP's goal is to ensure that children have health insurance and can access healthcare, either through an expansion of Medicaid or the development of a separate program. The continuation of CHIP is not guaranteed because it is based on federal and state funding that is subject to budgetary allocations. Specialty and Categorical Programs Categorical programs are designated by federal laws to provide access to healthcare for certain categories of people, such as immigrants or children in Head Start programs. Specialty programs target certain populations (e.g., Indian Health Service, military personnel and dependents). KnowledgeCheck 1-4 Compare and contrast private and government-funded health insurance. How might being uninsured affect a person's health status? Charitable Organizations Charitable organizations are an increasingly important funding source for healthcare. Community agencies that are funded through networks such as the United Way, Salvation Army, and Red Cross provide important resources to children, poor families, the aged, and vulnerable populations (e.g., the homeless, mentally ill, and victims of violence). Charitable organizations provide direct services and cover the costs for some traditional health services. How Are Supplies and Equipment Provided? Suppliers are the companies and corporations that bring goods to the healthcare industry. Pharmaceutical companies and medical equipment suppliers are the largest suppliers. The costs associated with the research, development, and testing of pharmaceuticals and medical equipment are passed on to consumers in the form of higher prices, rising insurance premiums, and increased out-of-pocket expenses. How Is Healthcare Regulated? Regulators are governing bodies that exert influence or control over the healthcare system or preparation of healthcare providers. They include accrediting agencies (e.g., Accreditation Commission for Education in Nursing, Commission on Collegiate Nursing Education, Commission for Nursing Education Accreditation), licensing agencies (boards of nursing), and legislators. The most prominent regulating body in the healthcare system is The Joint Commission, which establishes standards for hospitals to promote client safety. Legislators also affect the healthcare system by redefining eligibility criteria for government-funded health plans or establishing minimum nurse--client ratios in acute care hospitals. How Have Healthcare Reform Efforts Affected Care? Healthcare reform has affected not only access to care but also reimbursement rates for providers. The following are examples. Affordable Care Act (ACA) The Affordable Care Act (ACA), implemented in 2010, had a major impact in providing access to health insurance and thus healthcare. The number of uninsured people reached a historical low of 26.7 million in 2016 compared with 44.2 million in 2013 (Garfield et al., 2019). The number of people obtaining health coverage under ACA programs reached a record 31 million in 2021 (U.S. Department of Health and Human Services \[USDHHS\], 2021). People with insurance are more likely to seek essential primary care, such as screenings, chronic illness follow-ups, and prenatal care. Medicare and Public Policy When Medicare was initially created, health services were reimbursed using a retrospective system that paid hospitals based on the actual cost of providing services to individuals. With no cap on expenses, Medicare payments made to hospitals increased from \$3 billion in the early years of the program to \$37 billion by 1983. To slow the rising costs of healthcare, a prospective reimbursement system was created under the Social Security Amendments of 1983. Hospitals were reimbursed on a per-case, flat-rate basis determined by client groups having similar needs. These groups were called diagnostic-related groups (DRGs). If the client's hospital costs were greater than the reimbursed ("set") amounts, the hospital lost money. If the costs were less than the rate set by Medicare, the hospital made a profit. Private insurance companies, following the lead of Medicare, reimbursed in the same manner. The introduction of DRGs forced hospitals to consider new ways of delivering care and created a number of changes in client care, such as the following: The length of stay in hospitals decreased dramatically as care moved away from hospitals and out into the community and home. The cost of delivering nursing care became an expenditure. As a result, team nursing with UAPs replaced the comprehensive care provided by RNs at the bedside, even though research consistently supports fewer adverse client outcomes with a higher proportion of RNs on staff. Fewer choices for care resulted from corporate mergers and acquisitions in large regional facilities (e.g., fewer hospitals and nursing homes in a community). Reduced staffing and higher client acuity produced a more stressful work environment for nurses. Insurance premiums and cost-sharing increased, whereas availability of services decreased. This led to a growing number of people who could not afford needed care. Managed Care Managed care, designed to control healthcare costs, is a competitive approach to healthcare pricing. A managed care organization (MCO) contracts with medical providers to provide services at discounted rates or based on a predetermined fixed payment per individual covered under the plan (capitation). An employer contracts with the MCO and selects a type of health plan for its employees. The most common types of managed care plans are described next. Health Maintenance Organizations (HMOs) HMOs are a model of care based on capitated (per head) costs. Each HMO primary care provider receives a predetermined, fixed amount each month, regardless of whether the client receives healthcare services or not. The primary care provider coordinates all care, including referrals to specialists. Providers often choose to be part of an HMO because of the steady income it offers. HMOs are the least costly plans available, but the HMO will pay only for specified services and only if the client uses a provider on the HMO list ("in the network"). Preferred Provider Organizations (PPOs) The PPO has many of the features of an HMO, such as a network of providers who will provide healthcare at the established contracted rate. Compared with HMOs, the client pays more in premiums, deductibles, and coinsurance; however, the client has greater choice among in-network providers (including specialists), medications, and devices. Clients pay higher costs for out-of-network providers. Point of Service (POS) POS combines features from HMOs and PPOs. The client selects a physician from a list of network physicians who will be the POS for treatment and referrals to in-network specialists. There is limited out-of-network coverage, with higher coinsurance and copay rates. Integrated Delivery Networks (IDNs) IDNs are a consolidation of services into one healthcare system. Providers see only IDN clients, in IDN facilities, using IDN services and IDN-approved pharmaceuticals. The system is designed to promote a culture of collaboration, safety, and teamwork among the providers and limit barriers to services for clients (Feinberg et al., 2018). What Are the Issues Related to Healthcare Reform? The profound changes created by the transition of the healthcare system from a retrospective to a prospective fixed-rate payment system have created unprecedented leadership opportunities for nurse executives. ANA Principles for Health System Transformation In 2016, the ANA outlined several principles for transforming the health system: The need to ensure universal access to a standard package of essential healthcare services for all Provision of an adequate supply of skilled workers to provide quality healthcare services Promotion of ways to stimulate economical use of healthcare services that supports individuals who have limited resources to share in costs Optimization of primary, community-based, and preventive services that integrate the economical use of innovative, technology-driven, acute, hospital-based services Work Redesign Work redesign involves looking at the level of care required and the mix of personnel necessary to achieve the best client outcomes. The following concepts emerged: Critical pathways is an interprofessional approach that outlines the direction of client care. Based on scientific evidence, critical pathways allow the interprofessional team to implement best practices that yield the desired outcomes in the quickest manner to reduce the client's length of stay (Stark, 2019). (See Chapter 3 for more information on critical pathways.) Case management is the coordination of care across the healthcare system. Case managers assess clients, develop care goals, identify resources, and manage outcomes. Many hospitals, home health agencies, and insurance companies employ nurse case managers to ensure that a client receives efficient, quality care using the most cost-effective resources while hospitalized and after discharge. Is Healthcare a Right or a Privilege? Underlying all healthcare reform is the fundamental question of whether healthcare is a right or a privilege. This question raises more questions. For example, if healthcare is a right of all citizens, should noncitizens be offered coverage? Moreover, what responsibility does an individual have to preserve their own health through lifestyle changes (e.g., diet, exercise)? Should extensive and/or expensive therapies be offered if they have little likelihood of success? Finally, if you believe that healthcare should be affordable for all, are you willing to limit your salary and benefits to help control the costs of care? Are you willing to pay higher taxes? These fundamental questions will continue to emerge as debates on universal healthcare continue to evolve. KnowledgeCheck 1-5 Do you agree with the ANA's principle that a healthcare system "must ensure access to a standard package of essential healthcare services for all citizens and residents" (ANA, 2016)? What factors influence your answer to the previous question? (Draw on your self-knowledge to answer this question.) How Do Providers and Facilities Ensure Quality Care? As you learned previously, a number of accrediting bodies inspect healthcare organizations to ensure that clients receive safe, quality care. To promote safety, regulators establish a minimum competency level that must be met to receive accreditation. However, most healthcare organizations and professionals identify a goal of excellent care rather than merely meeting minimum standards. Continuous Quality Improvement Programs Continuous quality improvement (CQI) programs, used interchangeably with total quality management (TQM), focus on quality (excellent) care as an ongoing goal through an evaluation process that identifies problems, develops solutions, implements corrective plans, and evaluates effectiveness. Although CQI is a system-level approach, different methods are used at the unit level to promote quality improvement: Process reviews look at issues related to guidelines, policies, or procedures related to the delivery of care. For example, a CQI committee wants to reduce the time it takes nurses to implement all fall precautions based on the client's risk level. The committee may recommend a new process and evaluate the outcomes to determine whether it was efficient and cost-effective. Outcome reviews are conducted to determine whether the desired outcome was achieved and the influence of environmental or system factors. For example, a unit may set a goal that 100% of nurses' notes will state the reason why medication was not administered. If a retrospective audit of those records indicates the goal was not met, the evaluation process is initiated. Structure reviews investigate the adequacy, availability, and quality of resources (e.g., nursing personnel, supplies, bed capacity) and their effect on processes and outcomes. For more information on the quality improvement process, see the accompanying SENC box, Quality Improvement Competency. Safe, Effective Nursing Care Quality Improvement Competency Chapter Key Concept: Healthcare Delivery System Competency: Provide Safe, Quality Client Care Question. Based on work done by the Institute of Medicine (now the National Academy of Medicine), this textbook identifies quality improvement (QI) as a competency you should achieve during your nursing education. QI includes the ability to "evaluate and use techniques/processes to avoid medical/nursing errors" and to evaluate the framework used for care delivery, incorporating structure, process, and outcomes of the care. How do you think the staffing mix in a hospital might affect care quality? Research. Recent research shows that when the proportion of registered nurses (RNs) increases in an agency, the quality of care rises, and rates of death, falls, missed nursing care, and infection drop. Consider the following examples from various research findings (Aiken et al., 2017; Lasater et al., 2021; Leary et al., 2016; Livanos, 2018; Shang et al., 2019): ➤ Replacing six support workers with RNs on high-fall units significantly reduced patient falls. ➤ Higher client mortality rates, falls, and medication administration errors were associated with lower nursing staffing levels. ➤ The risk of mortality significantly increased with high bed occupancies and client transfers; however, an increase in the number of nurses decreased this risk. In addition, higher workloads were associated with increased client mortality. ➤ Hospitals with a higher proportion of RNs on staff performed better on a variety of performance measures, including decreased patient infections and shorter lengths of stay. ➤ An increase in the number of temporary RN staff members was associated with an increased rate of client falls and injuries. Think about it: How does the SENC competency of quality improvement relate to the chapter's key concept: healthcare delivery system? FACTORS THAT INFLUENCE CONTEMPORARY NURSING PRACTICE Factors that influence nursing practice include societal factors at large as well as factors within nursing and healthcare. What Are Some Trends in Society? In addition to our historical roots, nursing is influenced by trends in the economy---the growing number of older adults, increased consumer knowledge, legislation, the women's movement, and collective bargaining. The National Economy The national economy has a tremendous impact on nursing. Consider the following examples: Historically, in the United States, health insurance coverage has been linked to full-time employment with health insurance benefits. When the unemployment rate increases, the number of people without health insurance also increases. Uninsured people often delay seeking treatment or use the emergency department for healthcare. The ACA, which expanded health insurance coverage for unemployed persons, resulted in a greater demand for care and for more advanced practice nurses. Recessions can affect the nursing workforce. During recessions, many nurses at retirement age often remain employed, thus decreasing available positions for new nurse graduates. As the economy improves, these nurses retire, which can create a shortage of registered nurses. The healthcare system employs an enormous number and variety of people. In 2021, registered nurses numbered 5.1 million (NCSBN, 2022); physicians and surgeons, 1 million (Michas, 2021); pharmacists, 315,470 (Mikulic, 2021); and APRNs, 325,000 (American Association of Nurse Practitioners \[AANP\], 2021). Looking at these numbers, you begin to understand how large the healthcare system is when all other providers are added to the count. The Growing Proportion of Older Adults in the United States In 2019, 54.1 million individuals were 65 years and older (Centers for Disease Control and Prevention \[CDC\], 2022). This number is expected to increase to 80.8 million in 2040 and to 94.7 million in 2060. By 2030, baby boomers will have reached age 65 years and older, and by 20

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