Kozier & Erb's Fundamentals of Nursing Concepts, Chapter 1 PDF

1 Historical and Contemporary Nursing Practice LEARNING OUTC O M E S After completing this chapter, you will be able to: 1. Discuss historical factors and nursing leaders, female and male, who influenced the development of nursing. 2. Discuss the evolution of nursing education and entry into profe...

1 Historical and Contemporary Nursing Practice LEARNING OUTC O M E S After completing this chapter, you will be able to: 1. Discuss historical factors and nursing leaders, female and male, who influenced the development of nursing. 2. Discuss the evolution of nursing education and entry into professional nursing practice. 3. Describe the different types of educational programs for nurses. 4. Describe the major purpose of theory in the sciences and practice disciplines. 5. Identify the components of the metaparadigm for nursing. 6. Identify the role of nursing theory in nursing education, research, and clinical practice. 7. Explain the importance of continuing nursing education. 8. Describe how the definition of nursing has evolved since Florence Nightingale. 9. Identify the four major areas of nursing practice. 10. Identify the purposes of nurse practice acts and standards of professional nursing practice. 11. Describe the roles of nurses. 12. Describe the expanded career roles of nurses and their functions. 13. Discuss the criteria of a profession and professional identity formation. 14. Discuss Benner’s levels of nursing proficiency. 15. Describe factors influencing contemporary nursing practice. 16. Explain the functions of national and international nurses’ associations. KEY TERMS Alexian Brothers, 30 caregiver, 43 case manager, 44 change agent, 43 Clara Barton, 34 client, 41 client advocate, 43 communicator, 43 consumer, 41 continuing education (CE), 40 counseling, 43 Dorothea Dix, 30 environment, 40 Ernest Grant, 35 Fabiola, 30 Florence Nightingale, 33 governance, 45 Harriet Tubman, 30 health, 40 in-service education, 40 Knights of Saint Lazarus, 30 Lavinia L. Dock, 35 leader, 43 Lillian Wald, 34 Introduction Linda Richards, 34 Luther Christman, 35 manager, 43 Margaret Higgins Sanger, 35 Mary Breckinridge, 35 Mary Mahoney, 34 metaparadigm, 40 nursing, 40 patient, 41 Patient Self-Determination Act (PSDA), 49 practice discipline, 39 profession, 45 professional identity, 46 Sairey Gamp, 32 Sojourner Truth, 30 Standards of Practice, 43 Standards of Professional Performance, 43 teacher, 43 telehealth, 48 telenursing, 49 theory, 39 Nursing today is far different from nursing as it was practiced years ago, and it is expected to continue changing during the 21st century. To comprehend present-day nursing and at the same time prepare for the future, one must understand not only past events but also contemporary nursing practice and the sociologic and historical factors that affect it. professionalization. In recent decades, a renewed interest in nursing history has produced a growing amount of related literature. This section highlights only selected aspects of events that have influenced nursing practice. Recurring themes of women’s and men’s roles and status, religious (Christian) values, war, societal attitudes, and visionary nursing leadership have influenced nursing practice in the past. Many of these factors still exert their influence today. Historical Perspectives Women’s Roles Nursing has undergone dramatic change in response to societal needs and influences. A look at nursing’s beginnings reveals its continuing struggle for autonomy and Traditional female roles of wife, mother, daughter, and sister have always included the care and nurturing of other family members. From the beginning of time, women have 28 Chapter 1 cared for infants and children; thus, nursing could be said to have its roots in the home. Additionally, women, who in general occupied a subservient and dependent role, were called on to care for others in the community who were ill. Generally, the care provided was related to physical maintenance and comfort. Thus, the traditional nursing role has always entailed humanistic caring, nurturing, comforting, and supporting. Men’s Roles Men have worked as nurses as far back as before the Crusades. Although the history of nursing primarily focuses on the female figures in nursing, schools of nursing for men existed in the United States from the late 1880s until 1969. Male nurses were denied admission to the Military Nurse Corps during World War II based on gender. It was believed at that time that nursing was women’s work and combat was men’s work. During the 20th century, men were denied admission to most nursing programs. In 1971, registered nurse Steve Miller formed an organization called Men in Nursing, and in 1974, Luther Christman organized a group of male nurses. The two groups reorganized into the National Male Nurses Association with the primary focus of recruiting more men into nursing. In 1981, the organization was renamed the American Assembly for Men in Nursing (AAMN). The purpose of the AAMN is to “provide a framework for nurses, as a group, to meet, to discuss and influence factors, which affect men as nurses” (AAMN, n.d., “Vision,” para. 2). • Historical and Contemporary Nursing Practice 29 The percentage of men included in the nation’s nursing workforce does vary. For example, a survey by the National Council of State Boards of Nursing (Smiley et al., 2018) indicated a total of 9.1% male nurses in the workforce, an increase of 2.5% compared to the previous 2013 report. In 2017, the Health Resources and Services Administration (HRSA) reported 9.6%, which is less than the 12% male RNs as reported by Buerhaus, Skinner, Auerbach, and Staiger (2017b, p. 231). Men do experience barriers to becoming nurses. For example, the nursing image is one of femininity, and nursing has been slow to adopt a gender-neutral image. As a result, people may believe that men who choose the profession of nursing are emasculated, gay, or sexually deviant, which is not true (Hodges et al., 2017). Other barriers and challenges for male nursing students include the lack of male role models in nursing, stereotyping, and differences in caring styles between men and women (Zhang & Liu, 2016). Improved recruitment and retention of men and other minorities into nursing continues to be needed to strengthen the profession. This is illustrated by professional surveys. A 2016 National League for Nursing (NLN, 2017a) survey found that men in basic registered nursing programs represented 14% of the total enrollment, a 1% decrease compared to the 2012 survey. In comparison, bachelor of science in nursing (BSN) programs enrolled 15% male students, a 2% increase from 2012. In addition, a 2016 survey by the American Association of Colleges of Nursing (AACN, 2017) reflected that only 12% of students in baccalaureate and graduate programs were male. EVIDENCE-BASED PRACTICE Evidence-Based Practice What Motivates Men to Choose Nursing? Yi and Keogh (2016) state that “knowledge of the factors that motivate men to choose nursing will assist in the development of evidence-based recruitment strategies to increase the number of men entering the nursing profession” (p. 96). As a result, they conducted a systematic literature review of data from qualitative studies that described male nurses’ motivations for choosing nursing. A comprehensive search of over 11,000 citations and screening for inclusion criteria resulted in six studies being included in the review. Analytic processes resulted in four themes. The first theme described how early exposure to nursing and other healthcare professionals influenced the male nurses’ decision to become nurses. Examples consisted of where the men received encouragement from female and male friends and relatives who were nurses. Some men were exposed to nursing through experiences of caring for a sick or dying loved one, which became a factor in their decision-making process. The second theme described how the men chose nursing by chance, based on their circumstances at the time of the decision. For example, some men were looking for work and had friends who were nurses and thus decided to try nursing. Some chose nursing because they were not accepted into their preferred program. The third theme described extrinsic motivating factors such as job opportunity and salary. The fourth theme described intrinsic motivating factors such as personal satisfaction and enjoyment with helping people. Other intrinsic motivating factors included a sense of altruism and caring and their perception of nursing as a vocation. Implications A limitation expressed by the researchers was that the review would have provided a more comprehensive description if both quantitative and qualitative studies had been included. Three of the themes were congruent with previous literature reviews. However, the theme of entering nursing by chance, depending on the men’s circumstances, was new. As a result, the authors recommended that strategies to enhance retention within the nursing program be developed for those males who pursued nursing by chance. Examples could include providing male role models during clinical experiences and supporting male nurses’ caring abilities in a welcoming environment to promote intrinsic motivating factors during the program. 30 Unit 1 • The Nature of Nursing Religion Religion has also played a significant role in the development of nursing. Although many of the world’s religions encourage benevolence, it was the Christian value of “love thy neighbor as thyself” and Christ’s parable of the Good Samaritan that had a significant impact on the development of Western nursing. During the third and fourth centuries, several wealthy matrons of the Roman Empire, such as Fabiola, converted to Christianity and used their wealth to provide houses of care and healing (the forerunner of hospitals) for the poor, the sick, and the homeless. Women were not, however, the sole providers of nursing services. The Crusades saw the formation of several orders of knights, including the Knights of Saint John of Jerusalem (also known as the Knights Hospitalers), the Teutonic Knights, and the Knights of Saint Lazarus (Figure 1.1 ■). These brothers in arms provided nursing care to their sick and injured comrades. These orders also built hospitals, the organization and management of which set a standard for the administration of hospitals throughout Europe at that time. The Knights of Saint Lazarus dedicated themselves to the care of people with leprosy, syphilis, and chronic skin conditions. During medieval times, there were many religious orders of men in nursing. For example, the Alexian Brothers organized care for victims of the Black Plague in the 14th century in Germany. In the 19th century, they followed the same traditions as women’s religious nursing orders and established hospitals and provided nursing care. The deaconess groups, which had their origins in the Roman Empire of the third and fourth centuries, were suppressed during the Middle Ages by the Western churches. However, these groups of nursing providers resurfaced occasionally throughout the centuries, most notably in 1836 when Theodor Fliedner reinstituted the Order of Deaconesses and opened a small hospital and training school in Kaiserswerth, Germany. Florence Nightingale received her training in nursing at the Kaiserswerth School. Early religious values, such as self-denial, spiritual calling, and devotion to duty and hard work, have dominated nursing throughout its history. Nurses’ commitment to these values often resulted in exploitation and few monetary rewards. For some time, nurses themselves believed it was inappropriate to expect economic gain from their “calling.” War Throughout history, wars have accentuated the need for nurses. During the Crimean War (1854–1856), the inadequacy of care given to soldiers led to a public outcry in Great Britain. The role Florence Nightingale played in addressing this problem is well known. Nightingale and her nurses transformed the military hospitals by setting up sanitation practices, such as hand washing. Nightingale is credited with performing miracles; the mortality rate, for example, was reduced from 42% to 2% in 6 months (Donahue, 2011, p. 118). During the American Civil War (1861–1865), several nurses emerged who were notable for their contributions to a country torn by internal conflict. Harriet Tubman and Sojourner Truth (Figures 1.2 ■ and 1.3 ■) provided care and safety to slaves fleeing to the North on the Underground Railroad. Mother Biekerdyke and Clara Barton searched the battlefields and gave care to injured and dying soldiers. Noted authors Walt Whitman and Louisa May Alcott volunteered as nurses to give care to injured soldiers in military hospitals. Another female leader who provided nursing care during the Civil War was Dorothea Dix Figure 1.1 ■ The Knights of Saint Lazarus (established circa 1200) dedicated themselves to the care of people with leprosy, syphilis, and chronic skin conditions. From the time of Christ to the mid-13th century, leprosy was viewed as an incurable and terminal disease. Figure 1.2 ■ Harriet Tubman (1820–1913) was known as “The Moses of Her People” for her work with the Underground Railroad. During the Civil War she nursed the sick and suffering of her own race. Florilegius/Alamy Stock Photo. Universal Images Group/Getty Images. Chapter 1 • Historical and Contemporary Nursing Practice 31 Figure 1.3 ■ Sojourner Truth (1797–1883), abolitionist, Underground Railroad agent, preacher, and women’s rights advocate, was a nurse for more than 4 years during the Civil War and worked as a nurse and counselor for the Freedmen’s Relief Association after the war. National Portrait Gallery, Smithsonian Institution/Art Resources, NY. (Figure 1.4 ■). She became the Union’s superintendent of female nurses responsible for recruiting nurses and supervising the nursing care of all women nurses working in the army hospitals. The arrival of World War I resulted in American, British, and French women rushing to volunteer their nursing services. These nurses endured harsh environments and treated injuries not seen before. A monument entitled “The Spirit of Nursing” stands in Arlington National Cemetery (Figure 1.5 ■). It honors the nurses who served in the U.S. armed services in World War I, many of whom are buried in Section 21, which is also called the “Nurses Section” (Arlington National Cemetery, n.d.). Progress in healthcare occurred Figure 1.4 ■ Dorothea Dix (1802–1887) was the Union’s superintendent of female nurses during the Civil War. North Wind Picture Archives/Alamy Stock Photo. Figure 1.5 ■ A, Section 21 in Arlington National Cemetery honors the nurses who served in the Armed Services in World War I. B, “The Spirit of Nursing” monument that stands in Section 21. C, Monument plaque. Photos by Sherrilyn Coffman, PhD, RN. 32 Unit 1 • The Nature of Nursing Figure 1.7 ■ Vietnam Women’s Memorial. Four figures include a nurse tending to the chest wound of a soldier, another woman looking for a helicopter for assistance, and a third woman (behind the other figures) kneeling while staring at an empty helmet in grief. Courtesy of Sherrilyn Coffman, PhD, RN. Societal Attitudes Figure 1.6 ■ Recruiting poster for the Cadet Nurse Corps during World War II. John Parrot/Stocktrek Images, Inc./Alamy Stock Photo. during World War I, particularly in the field of surgery. For example, advancements were made in the use of anesthetic agents, infection control, blood typing, and prosthetics. World War II casualties created an acute shortage of caregivers, and the Cadet Nurse Corps was established in response to a marked shortage of nurses (Figure 1.6 ■). Also at that time, auxiliary healthcare workers became prominent. “Practical” nurses, aides, and technicians provided much of the actual nursing care under the instruction and supervision of better prepared nurses. Medical specialties also arose at that time to meet the needs of hospitalized clients. During the Vietnam War, approximately 11,000 American military women stationed in Vietnam were nurses. Most of them volunteered to go to Vietnam right after they graduated from nursing school, making them the youngest group of medical personnel ever to serve in wartime (Vietnam Women’s Memorial Foundation, n.d.). Near the Vietnam Veterans Memorial (“The Wall”) stands the Vietnam Women’s Memorial (Figure 1.7 ■). Nurses served in the Afghanistan and Iraq wars. A total of 6,326 nurses deployed to Afghanistan, Iraq, or both between September 1, 2001 and July 31, 2015. Of these deployed nurses, 55% were male. During this time six army nurses were killed, four in Afghanistan and two in Iraq (Berry-Caban, Rivers, Beltran, & Anderson, 2018). Society’s attitudes about nurses and nursing have significantly influenced professional nursing. Before the mid-1800s, nursing was without organization, education, or social status; the prevailing attitude was that a woman’s place was in the home and that no respectable woman should have a career. The role for the Victorian middle-class woman was that of wife and mother, and any education she obtained was for the purpose of making her a pleasant companion to her husband and a responsible mother to her children. Nurses in hospitals during this period were poorly educated; some were even incarcerated criminals. Society’s attitudes about nursing during this period are reflected in the writings of Charles Dickens. In his book Martin Chuzzlewit (1844), Dickens reflected his attitude toward nurses through his character Sairey Gamp (Figure 1.8 ■). Mrs. Gamp was portrayed as a drunk, disreputable nurse who neglected, stole from, and physically abused the sick. This literary portrayal of nurses greatly influenced the negative image and attitude toward nurses in the 19th century. In contrast, the guardian angel or angel of mercy image arose in the latter part of the 19th century, largely because of the work of Florence Nightingale during the Crimean War. After Nightingale brought respectability to the nursing profession, nurses were viewed as noble, compassionate, moral, religious, dedicated, and self-sacrificing. Another image arising in the early 19th century that has affected subsequent generations of nurses and the public and other professionals working with nurses is that of the doctor’s handmaiden. This image evolved when women had yet to obtain the right to vote, when family structures were largely paternalistic, and when the medical profession increasingly applied scientific knowledge that, at that time, was viewed as a male domain. Since that time, several images of nursing have been portrayed. The heroine portrayal evolved from nurses’ acts of bravery in World Chapter 1 • Historical and Contemporary Nursing Practice 33 Figure 1.9 ■ Considered the founder of modern nursing, Florence Nightingale (1820–1910) was influential in developing nursing education, practice, and administration. Her publication Notes on Nursing: What It Is, and What It Is Not, first published in England in 1859 and in the United States in 1860, was intended for all women. David Cole/Alamy Stock Photo. Figure 1.8 ■ Sairey Gamp, a character in Dickens’ book Martin Chuzzlewit, represented the negative image of nurses in the 1800s. Historia/Shutterstock. War II and their contributions in fighting poliomyelitis— in particular, the work of the Australian nurse Elizabeth Kenney. Other images in the late 1900s include the nurse as sex object, surrogate mother, and tyrannical mother. The nursing profession has taken steps to improve the image of the nurse. In the early 1990s, the Tri-Council for Nursing (the American Association of Colleges of Nursing, the American Nurses Association [ANA], the American Organization of Nurse Executives, and the National League for Nursing [NLN]) initiated a national effort, titled “Nurses of America,” to improve the image of nursing. Launched in 2002, Johnson & Johnson corporation’s “Campaign for Nursing’s Future” promotes nursing as a positive career choice. Through various outreach programs, this campaign increases exposure to the nursing profession, raises awareness about its challenges, and encourages people of all ages to consider a career in nursing. Nursing Leaders Florence Nightingale, Clara Barton, Linda Richards, Mary Mahoney, Lillian Wald, Lavinia Dock, Margaret Sanger, Mary Breckinridge, Luther Christman, and Ernest Grant are among the leaders who have made notable contributions both to nursing’s history and to American history. These nurses were all politically astute pioneers. Their skills at influencing others and bringing about change remain models for political nurse activists today. Nightingale (1820–1910) The contributions of Florence Nightingale to nursing are well documented. Her achievements in improving the standards for the care of war casualties in the Crimea earned her the title “Lady with the Lamp.” Her efforts in reforming hospitals and in producing and implementing public health policies also made her an accomplished political nurse: She was the first nurse to exert political pressure on government. Through her contributions to nursing education—perhaps her greatest achievement—she is also recognized as nursing’s first scientist-theorist for her work Notes on Nursing: What It Is, and What It Is Not (1860/1969). Nightingale (Figure 1.9 ■) was born to a wealthy and intellectual family. She believed she was “called by God to help others . . . [and] to improve the well-being of mankind” (Schuyler, 1992, p. 4). She was determined to become a nurse in spite of opposition from her family and the restrictive societal code for affluent young English women. As a well-traveled young woman of the day, she visited Kaiserswerth in 1847, where she received 3 months’ training in nursing. In 1853 she studied in Paris with the Sisters of Charity, after which she returned to England to assume the position of superintendent of a charity hospital for ill governesses. When she returned to England from the Crimea, a grateful English public gave Nightingale an honorarium of £4500. She later used this money to develop the Nightingale Training School for Nurses, which opened in 1860. The school served as a model for other training schools. Its graduates traveled to other countries to manage hospitals and institute nurse training programs. These training schools, at the time, accepted only females because Nightingale viewed nursing as being unsuitable for men. It is believed, unfortunately, that this perception has played a role in the invisibility of male nurses (Yi & Keogh, 2016, p. 95). Despite poor health that left her an invalid, Florence Nightingale worked tirelessly until her death at age 90. As a passionate statistician, she conducted extensive research and analysis. Nightingale is often referred to as the first nurse researcher. For example, her record keeping proved 34 Unit 1 • The Nature of Nursing Figure 1.12 ■ Mary Mahoney (1845–1926) was the first African Figure 1.10 ■ Clara Barton (1821–1912) organized the American American trained nurse. Schomberg Center for Research in Black Culture/NYPL/Art Resource. Red Cross, which linked with the International Red Cross when the U.S. Congress ratified the Geneva Convention in 1882. Library of Congress. that her interventions dramatically reduced mortality rates among soldiers during the Crimean War. Nightingale’s vision of nursing changed society’s view of nursing. She believed in personalized and holistic client care. Her vision also included public health and health promotion roles for nurses. Barton (1821–1912) Clara Barton (Figure 1.10 ■) was a schoolteacher who volunteered as a nurse during the American Civil War. Her responsibility was to organize the nursing services. Barton is noted for her role in establishing the American Red Cross, which linked with the International Red Cross when the U.S. Congress ratified the Treaty of Geneva (Geneva Convention). It was Barton who persuaded Congress in 1882 to ratify this treaty so that the Red Cross could perform humanitarian efforts in times of peace. Richards (1841–1930) Women and Children in 1873. Richards is known for introducing nurse’s notes and doctor’s orders. She also initiated the practice of nurses wearing uniforms (ANA, n.d.c). She is credited for her pioneering work in psychiatric and industrial nursing. Mahoney (1845–1926) Mary Mahoney (Figure 1.12 ■) was the first African American professional nurse. She graduated from the New England Hospital for Women and Children in 1879. She constantly worked for the acceptance of African Americans in nursing and for the promotion of equal opportunities (Donahue, 2011, p. 144). The ANA (n.d.e) gives a Mary Mahoney Award biennially in recognition of significant contributions in interracial relationships. Wald (1867–1940) Lillian Wald (Figure 1.13 ■) is considered the founder of public health nursing. Wald and Mary Brewster were Linda Richards (Figure 1.11 ■) was America’s first trained nurse. She graduated from the New England Hospital for Figure 1.11 ■ Linda Richards (1841–1930) was America’s first trained nurse. National League for Nursing. National League for Nursing Records. 1894–1952. Located in: Archives and Modern Manuscripts Collection, History of Medicine Division, National Library of Medicine, Bethesda, MD; MS C 274. Figure 1.13 ■ Lillian Wald (1867–1940) founded the Henry Street Settlement and Visiting Nurse Service (circa 1893), which provided nursing and social services and organized educational and cultural activities. She is considered the founder of public health nursing. National Portrait Gallery, Smithsonian Institution/Art Resources, NY. Chapter 1 • Historical and Contemporary Nursing Practice 35 the first to offer trained nursing services to the poor in the New York slums. Their home among the poor on the upper floor of a tenement, called the Henry Street Settlement and Visiting Nurse Service, provided nursing services and social services, and organized educational and cultural activities. Soon after the founding of the Henry Street Settlement, school nursing was established as an adjunct to visiting nursing. Dock (1858–1956) Lavinia L. Dock was a feminist, prolific writer, political activist, suffragette, and friend of Wald. She participated in protest movements for women’s rights that resulted in the 1920 passage of the 19th Amendment to the U.S. Constitution, which granted women the right to vote. In addition, Dock campaigned for legislation to allow nurses rather than physicians to control their profession. In 1893, Dock, with the assistance of Mary Adelaide Nutting and Isabel Hampton Robb, founded the American Society of Superintendents of Training Schools for Nurses of the United States, a precursor to the current National League for Nursing. Sanger (1879–1966) Margaret Higgins Sanger (Figure 1.14 ■), a public health nurse in New York, has had a lasting impact on women’s healthcare. Imprisoned for opening the first birth control information clinic in America, she is considered the founder of Planned Parenthood. Her experience with the large number of unwanted pregnancies among the working poor was instrumental in addressing this problem. Breckinridge (1881–1965) After World War I, Mary Breckinridge (Figure 1.15 ■), a notable pioneer nurse, established the Frontier Nursing Service (FNS). In 1918, she worked with the American Committee for Devastated France, distributing food, clothing, and supplies to rural villages and taking care of sick children. In 1921, Breckinridge returned to the United Figure 1.15 ■ Mary Breckinridge (1881–1965), a nurse who prac- ticed midwifery in England, Australia, and New Zealand, founded the Frontier Nursing Service in Kentucky in 1925 to provide family-centered primary healthcare to rural populations. T. Tso KRT/Newscom. States with plans to provide healthcare to the people of rural America. In 1925, Breckinridge and two other nurses began the FNS in Leslie County, Kentucky. Within this organization, Breckinridge started one of the first midwifery training schools in the United States. Christman (1915–2011) Luther Christman, one of the founders of the AAMN, graduated from the Pennsylvania Hospital School of Nursing for Men in 1939 and experienced discrimination while in nursing school. For example, he was not allowed a maternity clinical experience, yet he was expected to know the information related to that clinical experience for the licensing exam. After becoming licensed, he wanted to earn a baccalaureate degree in nursing but was denied access to two universities because of his gender. After receiving his doctorate, he accepted the position as dean of nursing at Vanderbilt University, making him the first man to be a dean at a university school of nursing. He accomplished many firsts: (a) the first man nominated for president of the ANA; (b) the first man elected to the American Academy of Nursing (AAN), which presented him with its highest honor by naming him a “Living Legend”; and (c) the first man inducted into ANA’s Hall of Fame for his extraordinary contributions to nursing. The ANA currently bestows the Luther Christman Award, which acknowledges the valuable role of men in nursing (ANA, n.d.d). Grant (1958–) Ernest Grant made professional nursing history when he Figure 1.14 ■ Nurse activist Margaret Sanger (1879–1966), consid- ered the founder of Planned Parenthood, was imprisoned for opening the first birth control information clinic in Baltimore in 1916. became the first male president of the American Nurses Association in January 2019. He is also the first African American man to serve as ANA vice president (Trossman, 36 Unit 1 • The Nature of Nursing 2018). Grant began his distinguished nursing career as a student in a licensed practical nurse (LPN) program and progressed through baccalaureate and graduate nursing programs to earning a PhD in nursing from the University of North Carolina–Greensboro. After working early in his career at a burn center, he made this work his mission and is now recognized as an internationally known expert on burn care and fire safety. In 2002, President George W. Bush gave Grant a Nurse of the Year Award for his work treating burn victims from the 2001 terrorist attack on the World Trade Center in New York. His top priorities include ensuring that nurses have the educational opportunities and tools needed for the best client outcomes, encouraging nurses to become more politically involved, and encouraging young nurses to become involved with their national and state nursing associations (Nelson, 2019, p. 66). Political Nurse Activists Today The nursing profession continues to provide dynamic challenges to all nurses to keep current with the needs of the public and the role of the nurse. Current nursing leaders include presidents of national professional organizations; members of national foundations that contribute to high-quality, safe, client-centered care; and nurses who serve in public office. For example, in 2017 three nurses served in Congress (ANA, n.d.f) and a nurse, Dr. TrentAdams, became the first individual who is not a physician to serve as surgeon general (NLN, 2017b). Nursing leader Linda Burnes Bolton was vice chair of the Institute of Medicine Commission on the Future of Nursing and in 2011 was named one of the top 25 women in healthcare. Dr. Linda Cronenwett led the Quality and Safety Education in Nursing (QSEN) project, which identified the knowledge, skills, and attitudes (KSAs) that nurses must possess to deliver safe, effective care (AACN, n.d.b). In the 2018 midterm elections, Eddie Bernice Johnson (D-Texas), a former psychiatric nurse and the first nurse elected to Congress, was re-elected to a 14th term, and Lauren Underwood (D-Illinois), an RN who specializes in public health nursing and is a health policy expert, won the race for Illinois’ 14th Congressional District. These are just a few examples of contemporary nursing leaders. socioeconomic changes in society, nursing education curricula have been revised to enable nurses to work in more diverse settings and assume more diverse roles. Nursing programs are based on a broad knowledge of biological, social, and physical sciences, as well as the liberal arts and humanities. Current nursing curricula emphasize critical thinking and the application of nursing and supporting knowledge to health promotion, health maintenance, and health restoration as provided in both community and hospital settings (Figure 1.16 ■). There are two types of entry-level generalist nurses: the registered nurse (RN) and the licensed practical or vocational nurse (LPN or LVN). Responsibilities and licensure requirements differ for these two levels. The majority of new RNs are graduates of associate degree or baccalaureate degree nursing programs. In some states, an individual can be eligible to take the licensure exam through other qualifications such as completing a diploma nursing program or challenging the exam as a military corps person or LVN after completing specified coursework. The U.S. Navy and Marine Corps have a pathway to a commission in the Nurse Corps. Qualified enlisted men and women serving on active duty can apply to participate in the Medical Enlisted Commissioning Program (MECP). This program has been successful in increasing the diversity of nursing within the military. There are also “generic” master’s and doctoral programs that lead to eligibility for RN licensure. These latter programs are for students who already have a baccalaureate degree in a discipline other than nursing. On completion of the program, which may be from 1 to 3 years in length, graduates obtain their initial professional degree in nursing. Graduates of these programs are eligible to take the licensure examination to become an RN and may continue into specialty roles such as nurse practitioner or nurse educator. Nursing Education The practice of nursing is controlled from within the profession through state boards of nursing and professional nursing organizations. These groups also determine the content and type of education that is required for different levels or scopes of nursing practice. Originally, the focus of nursing education was to teach the knowledge and skills that would enable a nurse to practice in a hospital setting. However, as nursing roles have evolved in response to new scientific knowledge; advances in technology; and cultural, political, and Figure 1.16 ■ Nursing students learn to care for clients in community settings. Tyler Olson/123RF. Chapter 1 Although educational preparation varies considerably, all RNs in the United States take the same licensure examination, the National Council Licensure Examination (NCLEX-RN). This examination is administered in each state, and the successful candidate becomes licensed in that particular state, even though the examination is of national origin. To practice nursing in another state, the nurse must receive reciprocal licensure by applying to that state’s board of nursing. Some state legislatures have created a regulatory model called mutual recognition that allows for multistate licensure under one license. Nurses who have received their training in other countries may be granted registration after successfully completing the NCLEX. Both licensure and registration must be renewed regularly in order to remain valid. For additional information about licensure and registration, see Chapter 3 . The legal right to practice nursing requires not only passing the licensing examination, but also verification that the candidate has completed a prescribed course of study in nursing. Some states may have additional requirements. All U.S. nursing programs must be approved by their state board of nursing. In addition to state approval, the Accreditation Commission for Education in Nursing (ACEN) provides accreditation for all levels of nursing programs, and the Commission on Collegiate Nursing Education (CCNE) accredits baccalaureate and higher degree programs. Accreditation is a voluntary, peer review process. Accredited programs meet standard requirements that are evaluated periodically through written self-studies and on-site visitation by peer examiners. Types of Education Programs Education programs available for nurses include practical or vocational nursing, registered nursing, graduate nursing, and continuing education. All levels of nursing are needed in healthcare today. Each has a unique scope of practice and by working collaboratively can help meet the often complex needs of clients. Licensed Practical (Vocational) Nursing Programs Practical or vocational nursing programs are housed in community colleges, vocational schools, hospitals, or other independent health agencies. These programs generally last 9 to 12 months and include both classroom and clinical experience. At the end of the program, graduates take the NCLEX-PN to obtain licensure as a practical or vocational nurse. Some LPN and LVN programs articulate with associate degree programs. In these ladder programs, the practical or vocational education component constitutes the first year of an associate degree program for registered nursing, and, if successful in passing the NCLEX-PN, students can work while continuing their registered nurse education. • Historical and Contemporary Nursing Practice 37 Practical nurses work under the supervision of an RN in numerous settings, including hospitals, nursing homes, rehabilitation centers, home health agencies, ambulatory care, and hospice. Although the scope of practice varies by state regulation and agency policy, LPNs usually provide basic direct technical care to clients. Employment of LPNs has shifted away from acute care settings to care of older adults in community-based settings, including long-term care. Registered Nursing Programs Currently, three major routes lead to eligibility for RN licensure: completion of a diploma, associate degree, or baccalaureate program. DIPLOMA PROGRAMS After Florence Nightingale established the Nightingale Training School for Nurses at St. Thomas Hospital in England in 1860, the concept traveled quickly to North America. Hospital administrators welcomed the idea of training schools as a source of nursing staff for free or inexpensive staffing for the hospital. In early years, nursing education largely took the form of apprenticeship programs. With little formal classroom instruction, students learned by doing—that is, by providing direct care to clients. There was no standardization of curriculum and no accreditation. Programs were designed to meet the service needs of the hospital, not the educational needs of the students. Three-year diploma programs were the dominant nursing programs and the major source of nursing graduates from the late 1800s until the mid-1960s. Today’s diploma programs are hospital-based educational programs that provide rich clinical experiences for nursing students. These programs often are associated with colleges or universities. Approximately 12% of RNs obtained their initial nursing education in diploma programs in 2017, which is a decrease of 5.4% since 2013 (Smiley et al., 2018, p. S15). ASSOCIATE DEGREE PROGRAMS Associate degree nursing programs, which originated in the early 1950s, were the first and only educational programs for nursing that were systematically developed from planned research and controlled experimentation. Most of these programs take place in community colleges. The graduating student receives an associate degree in nursing (ADN) or an associate of arts (AA), associate of science (AS), or associate in applied science (AAS) degree with a major in nursing. Several trends and events prompted the development of these programs: (a) the Cadet Nurse Corps, (b) the community college movement, (c) earlier nursing studies, and (d) Dr. Mildred Montag’s proposal for an associate degree. The Cadet Nurse Corps of the United States was legislated and financed during World War II to provide 38 Unit 1 • The Nature of Nursing nurses to meet both military and civilian needs. The corps demonstrated that qualified nurses could be educated in less time than the traditional 3 years of most diploma programs. After World War II, the number of community colleges in the United States increased rapidly. The low tuition and open-door admission policy of these colleges, as well as their location in towns and cities lacking 4-year colleges and universities, made higher education accessible to more individuals by offering the first 2 years of a 4-year college program, as well as vocational programs that addressed community needs. Studies of nursing education, such as the Goldmark Report in 1923, the Committee on the Grading of Nursing Schools in 1934, and the Brown Report in 1948, also had a significant influence on the development of 2-year nursing programs. The recommendations in these reports supported the idea of independent schools of nursing in institutions of higher learning separate from hospitals. In the United States, associate degree nursing programs were started after Mildred Montag published her doctoral dissertation, The Education of Nursing Technicians, in 1951. This study proposed a 2-year education program for RNs in community colleges as a solution to the acute shortage of nurses that came about because of World War II. Dr. Montag conceptualized a “nursing technician” or “bedside nurse” able to perform nursing functions broader than those of a practical nurse, but lesser in scope than those of the professional nurse. At the end of the 2 years, the student was to be awarded an ADN and be eligible to take the state board examination for RN licensure. The first ADN program was established at Columbia University Teachers College in 1952 under the direction of Dr. Montag. Currently, 36.3% of all new RNs each year are initially educated in associate degree programs, which is a decrease of 1.9% since 2013 (Smiley et al., 2018, p. S15). Dr. Montag’s original idea that these graduates be nursing technicians and that the degree become a terminal one did not last. In 1978, the ANA proposed that associate degree programs no longer be considered terminal, but part of a career upward-mobility plan. Today many students enter an associate degree program with the intention of continuing their education to the baccalaureate or higher level. Many community colleges have articulation agreements with college and university bachelor of science in nursing (BSN) programs to facilitate the upward mobility toward the BSN. RN to master of science in nursing (MSN) programs are also available to the associate degree nurse. BACCALAUREATE DEGREE PROGRAMS The first school of nursing in a university setting was established at the University of Minnesota in 1909. This program’s curriculum, however, differed little from that of a 3-year diploma program. It was not until 1919 that the University of Minnesota established its undergraduate baccalaureate degree in nursing. Most of the early baccalaureate programs were 5 years in length. They consisted of the basic 3-year diploma program plus 2 years of liberal arts education. In the 1960s, the number of students enrolled in baccalaureate programs increased markedly. Almost 42% of RNs in the United States are initially educated in baccalaureate programs (Smiley et al., 2018, p. S15). Baccalaureate programs are located in senior colleges and universities and are generally 4 years in length. Programs include courses in the liberal arts, sciences, humanities, and nursing, including nursing leadership, nursing research, and community health nursing. Graduates must complete both the degree requirements of the college or university and the nursing program before being awarded a baccalaureate degree. The usual degree awarded is a BSN. Partially in response to the significant shortage of RNs, some schools have established accelerated BSN programs. These programs may include summer coursework in order to shorten the length of time required to complete the curriculum or may be a modified curriculum designed for students who already have a baccalaureate degree in another field. These “second degree” or “fast track” BSN programs can be completed in as little as 12 to 18 months of study. Many baccalaureate programs also admit RNs who have a diploma or associate degree. These programs typically are referred to as BSN completion, BSN transition, 2 + 2, or RN-BSN programs. Most RN-BSN programs have a special curriculum designed to meet the needs of these students. Many accept transfer credits from other accredited colleges or universities and award academic credit for the nursing coursework completed previously in a diploma or associate degree program. An increasing number of RN-BSN programs are offered online. In the four years between 2007 to 2011, there was an 86% increase in RN to BSN graduates (HRSA, 2013, p. 48). Because of changes in the practice environment, the nurse who holds a baccalaureate degree generally experiences more autonomy, responsibility, participation in institutional decision making, and career advancement than the nurse prepared with a diploma or associate degree. Some employers have different salary scales for nurses with a baccalaureate degree, as opposed to an associate degree or diploma. In addition, the American Nurses Credentialing Center (ANCC) requires a baccalaureate degree for initial basic certification in most nursing specialties, and certification often is rewarded with a salary increase. The Magnet Recognition Program, developed by the ANCC to recognize healthcare organizations that provide nursing excellence, requires that 75% of nurse managers hold at least a baccalaureate degree. Also, the Institute of Medicine’s (IOM) publication The Future of Nursing (2010) recommended that 80% of RNs be baccalaureate prepared by 2020. All of these points provide an incentive for nurses with diplomas and associate degrees to continue their formal preparation in baccalaureate completion programs. This is Chapter 1 • Historical and Contemporary Nursing Practice 39 reflected in the increasing enrollment in RN to BSN programs. across the continuum of care in any healthcare setting (AACN, n.d.a). Graduate Nursing Programs DOCTORAL PROGRAMS Although graduate schools differ, typical requirements for admission to a graduate program in nursing include the following: Doctoral programs in nursing began in the 1960s in the United States. Before 1960, nurses who pursued doctoral degrees chose related fields such as education, psychology, sociology, and physiology. The two primary doctoral degrees in nursing are the PhD and DNP (doctor of nursing practice). Nurses who earn a PhD in nursing generally assume faculty roles in nursing education programs or work in research programs. The DNP, a practice-focused doctorate, has been increasing in popularity and is the highest degree for nurse clinicians. Nurses with a DNP received additional education in evidence-based practice, quality improvement, and systems leadership to promote improved client outcomes. Doctorates in related fields such as education or public health are still highly relevant for nurses depending on their practice role. • • • • • Licensure as an RN or eligibility for licensure. A baccalaureate degree in nursing from an approved college or university. Some graduate programs accept individuals with a diploma or associate degree in nursing and a baccalaureate degree in another field of study. Some accept individuals with an associate degree in nursing as their only postsecondary education. Evidence of scholastic ability (usually a minimum grade point average of 3.0 on a 4.0 scale). Satisfactory achievement on a standard qualifying examination such as the Graduate Record Examination (GRE) or Miller Analogies Test (MAT). Letters of recommendation from supervisors, nursing faculty, or nursing colleagues indicating the applicant’s ability to do graduate study. MASTER’S DEGREE PROGRAMS The growth of baccalaureate nursing programs encouraged the development of graduate study in nursing. Approximately 18.9% of licensed RNs hold a master’s or higher degree in nursing (Smiley et al., 2018, p. S17). Master’s prepared nurses work in a variety of roles, including clinical nurse specialist (CNS), nurse practitioner (NP, also called advanced practice registered nurse [APRN]), nurse midwife (CNM), and nurse anesthetist (CRNA). The emphasis of master’s degree programs is on preparing nurses for advanced leadership roles in administration, clinical practice, or teaching (Figure 1.17 ■). A nursing role developed by the AACN is the clinical nurse leader (CNL). The CNL is a master’s degree– prepared clinician who oversees the integration of care for a specific group of clients. CNLs are prepared for practice Figure 1.17 ■ A nurse practitioner holds a master’s degree and assumes an advanced practice role. Custom Medical Stock Photo/Alamy. Nursing Theories As a profession, nursing is involved in identifying its own unique body of knowledge essential to nursing practice— nursing science. To identify this knowledge base, nurses must develop and recognize concepts and theories specific to nursing. Because theories in some other disciplines were developed and used long before nursing theories, it is helpful to explore briefly how theory has been used by those disciplines before considering theory in nursing. A theory may be defined as a system of ideas that is presumed to explain a given phenomenon. For now, think of a theory as a major, very well-articulated idea about something important. Theories are used to describe, predict, and control phenomena. Most undergraduate students are introduced to the major theories in their disciplines. For example, psychology majors study Freud and Jung’s theories of the unconscious; sociology majors study Marx’s theory of alienation; biology majors are introduced to Darwin’s theory of evolution; and physics majors are introduced to a historical progression of theorists including Copernicus, Newton, Einstein, and newer theorists in quantum mechanics. The extent to which theories build on or modify previous theories varies with the discipline, as does the importance of theory in the discipline. Students in nursing, teaching, and management often take some courses in theory, but these students generally focus on learning their practice. The term practice discipline is used for fields of study in which the central focus is performance of a professional role (e.g., nursing, teaching, management, music). Practice disciplines are differentiated from the disciplines that have research and theory development as their central focus, for example, the natural sciences. In the practice disciplines, the main function of theory (and research) is to provide new possibilities for understanding the discipline’s practice. 40 Unit 1 • The Nature of Nursing Context for Theory Development in American Universities In the 19th century, Florence Nightingale thought that the people of Great Britain needed to know more about how to maintain healthy homes and how to care for sick family members. Nightingale’s Notes on Nursing: What It Is, and What It Is Not (1860/1969) was nursing’s first textbook on home care and community health. However, the audience for that text was the public at large, not a separate discipline or profession. In the 20th century, nursing education in the United States took a different path from nursing education in Great Britain and Europe. The drive to establish nursing departments in colleges and universities exposed American nursing to the dominant ideas and pressures in American higher education at the time. During the latter half of the 20th century, disciplines seeking to establish themselves in universities had to demonstrate something that Nightingale had not envisioned for nursing: a unique body of theoretical knowledge. The Metaparadigm for Nursing In the late 20th century, much of the theoretical work in nursing focused on articulating relationships among four major concepts: person, environment, health, and nursing. Because these four concepts can be superimposed on almost any work in nursing, they are collectively referred to as the metaparadigm for nursing. The term originates from two Greek words: meta, meaning “with,” and paradigm, meaning “pattern.” Many consider the following four concepts to be central to nursing: 1. The individuals or clients are the recipients of nursing care (includes individuals, families, groups, and communities). 2. The environment is the internal and external surroundings that affect the client. 3. Health is the degree of wellness or well-being that the client experiences. 4. Nursing is the attributes, characteristics, and actions of the nurse providing care on behalf of, or in conjunction with, the client. During this time, a number of nurse theorists developed their own theoretical definitions of nursing. Theoretical definitions are important because they go beyond simplistic common definitions. They describe what nursing is and the interrelationship among nurses, nursing, the client, the environment, and the intended client outcome: health. Certain themes are common to many of these definitions: • • • • • Nursing is caring. Nursing is an art. Nursing is a science. Nursing is client centered. Nursing is holistic. • • • Nursing is adaptive. Nursing is concerned with health promotion, health maintenance, and health restoration. Nursing is a helping profession. Role of Nursing Theory Direct links exist among nursing theory, education, research, and clinical practice. In many cases, nursing theory guides knowledge development and directs education, research, and practice, although each influences the others. The interface between nursing experts in each area helps to ensure that work in the other areas remains relevant, current, and useful and ultimately influences health. Some nursing programs and healthcare delivery systems use a theoretical framework. Examples include Orem’s General Theory of Nursing, Leininger’s Cultural Care Diversity and Universality Theory, Neuman’s Systems Model, and Roy’s Adaptation Model. Nursing theory remains an important focus of nurses’ work. Continuing Education The term continuing education (CE) refers to formalized experiences designed to enhance the knowledge or skills of practicing professionals. Compared to advanced educational programs, which result in an academic degree, CE courses tend to be more specific and shorter. Participants may receive certificates of completion or specialization. CE is the responsibility of all practicing nurses. For example, one of ANA’s Standards of Professional Performance is education, which states, “The registered nurse seeks knowledge and competence that reflects current nursing practice and promotes futuristic thinking,” with one of the competencies describing a commitment to lifelong learning through self-reflection and inquiry for learning and personal growth (ANA, 2015b, p. 76). Constant updating and growth are essential to keep abreast of scientific and technologic changes and changes within healthcare and the nursing profession. A variety of educational and healthcare institutions conduct CE programs on site, via home study, and online. CE programs usually are designed to meet one or more of the following needs: (a) to inform nurses of new techniques and knowledge; (b) to help nurses attain expertise in a specialized area of practice, such as critical care nursing; and (c) to provide nurses with information essential to nursing practice, such as knowledge about legal and ethical aspects of nursing. Some states require nurses to obtain a certain number of CE credits to renew their license. Required contact hours typically range from 15 to 30 hours per 2-year license renewal period. A few states also require a certain number of hours of practice, either independently or in lieu of study hours, before licensure renewal. An in-service education program is a specific type of CE program that is offered by an employer. It is designed to upgrade the knowledge or skills of employees, as well Chapter 1 as to validate continuing competence in selected procedures and areas of practice. For example, an employer might offer an in-service program to inform nurses about a new piece of equipment or a new surgical procedure, new documentation procedures, or methods of implementing a nurse theorist’s conceptual framework for nursing. Some in-service programs are mandatory on a regular basis, such as cardiopulmonary resuscitation and fire safety programs. Contemporary Nursing Practice An understanding of contemporary nursing practice includes a look at definitions of nursing, recipients of nursing, scope of nursing, settings for nursing practice, nurse practice acts, and current standards of clinical nursing practice. Definitions of Nursing Professional nursing associations have examined nursing and developed their definitions of it. In 1973, the ANA described nursing practice as “direct, goal oriented, and adaptable to the needs of the individual, the family, and community during health and illness” (ANA, 1973, p. 2). In 1980, the ANA changed this definition of nursing to this: “Nursing is the diagnosis and treatment of human responses to actual or potential health problems” (ANA, 1980, p. 9). In 1995, the ANA recognized the influence and contribution of the science of caring to nursing philosophy and practice. Research to explore the meaning of caring in nursing has been increasing. Details about caring are discussed in Chapter 15 . The current definition of nursing remains unchanged from the 2003 edition of Nursing’s Social Policy Statement: “Nursing is the protection, promotion, and optimization of health and abilities, preventions of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” (ANA, 2010, p. 10; ANA, 2015b, p. 7). Recipients of Nursing The recipients of nursing are sometimes called consumers, sometimes patients, and sometimes clients. A consumer is an individual, a group of people, or a community that uses a service or commodity. People who use healthcare products or services are consumers of healthcare. A patient is an individual who is waiting for or undergoing medical treatment and care. The word patient comes from a Latin word meaning “to suffer” or “to bear.” Traditionally, the individual receiving healthcare has been called a patient. Usually, people become patients when they seek assistance because of illness or for surgery. Some nurses believe that the word patient implies passive acceptance of the decisions and care of • Historical and Contemporary Nursing Practice 41 health professionals. Additionally, with the emphasis on health promotion and prevention of illness, many recipients of nursing care are not ill. Moreover, nurses interact with family members and significant others to provide support, information, and comfort in addition to caring for the patient. For these reasons, nurses increasingly refer to recipients of healthcare as clients. A client is an individual who engages the advice or services of another who is qualified to provide this service. The term client presents the receivers of healthcare as collaborators in the care, that is, as people who are also responsible for