Chapter 1 Nursing Foundations.pdf

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Nursing Foundations

1c h a p t e r

active listeningactivities of daily livingadvanced practiceart

assessment skillscapitationcaring skillsclinical pathwayscomforting skillscounseling skillscross-trained

discharge planningempathymanaged care practicesmulticultural diversity

nursing skillsnursing theory

primary carequality assurance

sciencesympathytheory

Learning Objectives

On completion of this chapter, the reader will:

Name one historical event that led to the demise of nursing in Englandbefore the time of Florence Nightingale.

Identify four reforms for which Florence Nightingale is responsible. Describe at least five ways in which early U.S. training schools deviated

from those established under the direction of Florence Nightingale. Name three ways that nurses used their skills in the early history of

U.S. nursing. Explain how art, science, and nursing theory have been incorporated into

contemporary nursing practice. Discuss the evolution of definitions of nursing. List four types of educational programs that prepare students for begin-

ning levels of nursing practice. Identify at least five factors that influence a persons choice of educational

nursing program. State three reasons that support the need for continuing education in

nursing. List examples of current trends affecting nursing and health care. Discuss the shortage of nurses and methods to reduce the crisis. Describe four skills that all nurses use in clinical practice.

Words to Know

This chapter traces the historical development of nurs-ing from its unorganized beginning to current practice.Nurses in the 21st century owe a debt of gratitude to theirpioneering counterparts who served their clients on battle-fields, in settlement houses in urban slums, in Bostons

harbor on a floating childrens hospital, and on horse-back in the Appalachian frontier of Kentucky. Ironically,nursing is returning to the original community-basedmodel of practice from which it originated.

NURSING ORIGINS

Nursing is one of the youngest professions but one of theoldest arts. It evolved from the familial roles of nurturingand caretaking. Early responsibilities included assistingwomen during childbirth, suckling healthy newborns, and

ministering to the ill, aged, and helpless within householdsand surrounding communities. Its hallmark was caringmore than curing.

During the Middle Ages in Europe, religious groupsassumed many of the roles of nursing. Nuns, priests, and

brothers combined their efforts to save souls with a com-mitment to care for the sick. Despite their zeal, they wereoverworked and overwhelmed as a result of their limitednumbers, especially during periods when plagues andpestilence spread quickly among communities. Conse-quently, some convents and monasteries engaged consci-entious penitent and disadvantaged lay people to assistwith the burden of physical care.

In England, the character and quality of nursing carechanged dramatically when religious groups were exiledto Western Europe during the schism between KingHenry VIII and the Catholic Church. The management of

Unit 1 Exploring Contemporary Nursing


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parochial hospitals and the ill within them in England fellto the state. Hospitals became poorhouses, which somecharacterized more accurately as pesthouses. The Englishstate recruited the hospital labor force from the ranks ofcriminals, widows, and orphans, who repaid the Crownfor their meager food and shelter by tending to the un-fortunate sick. An example of the menial requirements

for employment appears in Box 1-1. Generally, nursingattendants were ignorant, uncouth, and apathetic to theneeds of their charges. Without supervision, they rarelyperformed even their minimal duties. Infections, pressuresores, and malnutrition were a testimony to their neglect.

THE NIGHTINGALE REFORMATION

In the midst of the deplorable health care conditions,Florence Nightingale, an Englishwoman born of wealthyparents, announced that God had called her to become a

nurse. Despite her familys protests, she worked withnursing deaconesses, a Protestant order of women whocared for the sick in Kaiserwerth, Germany. After becom-ing suitably prepared through her nursing apprenticeship,Nightingale embarked on the next phase of her career.

The Crimean War

While Nightingale was providing nursing care for resi-dents at the Institution for the Care of Sick Gentlewomenin Distressed Circumstances, England found itself alliedwith Turkey, France, and Sardinia in defending the

Crimea, a peninsula on the north shore of the Black Sea(18541856). The British military suffered terribly, andwar correspondents at the front lines made public the direcircumstances of the soldiers. Reports of high death ratesand complications among the war casualties caused out-rage among the British people. As a result, the governmentbecame the object of national criticism.

It was then that Florence Nightingale offered a strategicplan to Sidney Herbert, Secretary of War and an old fam-ily friend. She proposed that the sick and injured Britishsoldiers at Scutari, a military barracks in Turkey, would

fare better if a team of women trained in nursing skillscould care for them (Fig. 1-1). With Herberts approval ofthis plan, Nightingale selected women with reputationsbeyond reproach. She realized intuitively that only peoplewith devotion and idealism could accept the discipline andhard work necessary for the task before them.

To the British medical staff at Scutari, the arrival of

this group of women implied that they were incapable ofproviding adequate care. Jealousy and rivalry causedthem to refuse any help from Nightingale and her 38 vol-unteers. When it became clear that the daily death rate,which averaged about 60%, was not subsiding, the med-ical staff allowed Nightingales nurses to work. UnderNightingales supervision, the women cleaned the filth,eliminated the vermin, and improved ventilation, nutri-tion, and sanitation. They helped control infection andgangrene and lowered the death rate to 1%.

Servicemen and their families alike were grateful, andEngland adored Nightingale. To show their appreciation,many donated funds to sustain the great work that she had

begun. Nightingale used this money to start the first train-ing school for nurses at St. Thomas Hospital in England.This school became the model for others in Europe andthe United States.

Nightingales Contributions

Nightingale changed the negative image of nursing to apositive one. She is credited with:

Training people for their future work

Selecting only those with upstanding characters aspotential nurses

2 UNIT 1 Exploring Contemporary Nursing

No dirt, rags, or bones may be thrown from the windows. Nurses are to punctually shift the bed and body linen of patients, viz.,

once in a fortnight (2 weeks), their shirts once in four days, their drawersand stockings once a week or oftener, if found necessary.

All nurses who disobey orders, get drunk, neglect their patients, quarrelwith men, shall be immediately discharged.

From Goodnow, M. (1933). Outlines of nursing history(5th ed., pp. 5758). Philadelphiaand London: W. B. Saunders.

BOX 1-1 Rules of Employment for NursingAttendants1789

FIGURE 1.1 Florence Nightingale (center), her brother-in-law, Sir HarryVerney, and Miss Crossland, the nurse in charge of the NightingaleTraining School at St. Thomas Hospital, with a class of student nurses.(Courtesy of The Florence Nightingale Museum Trust, London, England.)


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Improving sanitary conditions for the sick andinjured

Significantly reducing the death rate of Britishsoldiers

Providing classroom education and clinical teaching Advocating that nursing education should be life-

long

Stop, Think, and Respond BOX 1-1

How did Florence Nightingale convince the Englishand others that formal education of people whocared for the sick and injured was essential?

NURSING IN THE UNITED STATES

The Civil War occurred around the same time as theNightingale reformation. Like England, the United Statesfound itself involved in a war with no organized or sub-stantial staff of trained nurses to care for the sick andwounded. The military had to rely on untrained corps-men and civilian volunteers, often the mothers, wives,and sisters of soldiers.

The Union government appointed Dorothea LyndeDix, a social worker who had proved her worth byreforming health conditions for the mentally ill, to selectand organize women volunteers to care for the troops. In1862, Dix followed Nightingales advice and establishedthe following selection criteria. Applicants were to be:

35 to 50 years of age Matronly and plain-looking

Educated Neat, orderly, sober, and industrious, with a serious

disposition

Applicants also had to submit two letters of recommen-dation attesting to their moral character, integrity, andcapacity to care for the sick. Once selected, a volunteernurse was to dress plainly in brown, gray, or black and hadto agree to serve for at least 6 months (Donahue, 1985).

U.S. Nursing Schools

After the Civil War, training schools for nurses began tobe established in the United States. Unfortunately, how-ever, the standards of U.S. schools deviated substantiallyfrom those of the Nightingale paradigm (Table 1-1).Whereas planned, consistent, formal education was thepriority in the Nightingale schools, the training of U.S.nurses was more an unsubsidized apprenticeship.

Eventually, the curricula and content of U.S. trainingschools became more organized and uniform. Trainingperiods lengthened from 6 months to 3 full years. Gradu-ate nurses received a diploma attesting to their successfulcompletion of training.

Expanding Horizons of Practice

Diplomas in hand, U.S. nurses began the 20th centuryby distinguishing themselves in caring for the sick anddisadvantaged outside hospitals (Fig. 1-2). Some nursesmoved into communities and established settlementhouses where they lived and worked among poor

CHAPTER 1 Nursing Foundations 3

TABLE 1.1 DIFFERENCES IN NIGHTINGALE SCHOOLS AND U.S. TRAINING SCHOOLS

NIGHTINGALE SCHOOLS U.S. TRAINING SCHOOLS

Training schools were affiliated with a few select hospitals.

Training hospitals relied on employees to provide client care.

Education costs were borne by students or endowed from theNightingale Trust Fund.

Training of nurses provided no financial advantages to the

hospital.Class schedules were planned separately from practical

experiences.

Curricular content was uniform.

A previously trained nurse provided formal instruction,focusing on nursing care.

The number of clinical hours during training was restricted.

At the end of training, graduates became paid employees orwere hired to train others.

Any hospital, rural or urban, could establish a training school.

Students staffed the hospital.

Students worked without pay in return for training, whichusually consisted of chores.

Hospitals profited by eliminating the need to pay employees.

No formal classes were held; training was an outcome of work.

Curricular content was unplanned and varied according tocurrent cases.

Instruction was usually informal, at the bedside, and from aphysicians perspective.

Students were expected to work 12 hours a day and to live inor adjacent to the hospital in case they were neededunexpectedly.

At the end of training, students were discharged and newstudents took their places. Most graduates sought private-duty positions.


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immigrants. Other nurses provided midwifery services,especially in the rural hills of Appalachia. The success ofsuch public health efforts in administering prenatal andobstetric care, teaching child care, and immunizing chil-dren is well documented.

Like their counterparts in previous generations, nursescontinued to volunteer during wars. They offered theirservices to fight yellow fever, typhoid, malaria, and dysen-tery during the Spanish-American War. They replenishedthe nursing staff in military hospitals during World WarsI and II (Fig. 1-3). They worked side by side with physi-cians in Mobile Army Service Hospitals (MASH) duringthe Korean War, acquiring knowledge about trauma carethat later would help to reduce the mortality rate of U.S.soldiers in the Vietnam conflict. More recently, nursesanswered the call during Operation Desert Storm. When-ever and wherever there has been a need, nurses have puttheir own lives on the line.


FIGURE 1.2 Community health nurses circa late 1800s to early 1900s. (Courtesy of Visiting Nurse Asso-ciation, Inc., Detroit, MI.)

FIGURE 1.3 A military nurse comforts a soldier during World War II.(Courtesy of the National Archives, Washington, DC.)


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CONTEMPORARY NURSING

Combining Nursing Art With Science

At first, the training of nurses consisted of learning theart (ability to perform an act skillfully) of nursing. Stu-dents learned this art by watching and imitating the tech-

niques performed by other nurses with more experience.In this way, mentors informally passed nursing skills tostudents.

Contemporary nursing practice has added anotherdimension: science. The English word science comesfrom the Latin word scio, which means, I know. A sci-ence (body of knowledge unique to a particular subject)develops from observing and studying the relation of onephenomenon to another. By developing a unique body ofscientific knowledge, it is now possible to predict whichnursing interventions are most likely to produce desiredoutcomes.

Integrating Nursing Theory

The word theory (opinion, belief, or view that explainsa process) comes from a Greek word that means vision.For example, a scientist may study the relation betweensunlight and plants and derive a theory of photosynthe-sis that explains how plants grow. Others who believethe theorists view to be true may then apply the theoryfor their own practical use.

Nursing has undergone a similar scientific review.

People such as Florence Nightingale and others haveexamined the relationships among humans, health, theenvironment, and nursing. The outcome of such analy-sis becomes the basis for nursing theory (proposedideas about what is involved in the process called nurs-ing). Nursing programs then adopt the theory to serve asthe conceptual framework or model for their philosophy,curriculum, and most importantly approach to clients.Similarly, psychologists have adopted Freuds psycho-analytic theory or Skinners behavioral theory and usedit as a model for diagnostic and therapeutic interventionswith clients.

Table 1-2 summarizes some nursing theories and dis-

cusses how each has been applied to nursing practice.These are only a few of the many theories that exist;additional information can be found in current nursingliterature.

Defining Nursing

In an effort to clarify for the public, and nurses them-selves, just what nursing encompasses, various workingdefinitions have been proposed. Nightingale is credited

with the earliest modern definition: she defined nursingas putting individuals in the best possible condition fornature to restore and preserve health.

Other definitions have been offered by nurses whohave come to be recognized as authorities and thereforequalified spokespersons on the practice of nursing. Onesuch authority is Virginia Henderson. Her definition,

adopted by the International Council of Nurses, broad-ened the description of nursing to include health promo-tion, not just illness care. She stated in 1966:

The unique function of the nurse is to assist the individ-ual, sick or well, in the performance of those activitiescontributing to health or its recovery (or to a peacefuldeath) that he could perform unaided if he had the nec-essary strength, will or knowledge. And to do this insuch a way as to help him gain independence as rapidlyas possible.

Henderson proposed that nursing is more than carryingout medical orders. It involves a special relationship and

service between the nurse and the client (and his or herfamily). According to Henderson, the nurse acts as atemporary proxy, meeting the clients health needs withknowledge and skills that neither the client nor familymembers can provide.

The most recent definition of nursing comes from theAmerican Nurses Association (ANA). In its 1980 report

Nursing: A Social Policy Statement, the ANA defines nurs-ing as the diagnosis and treatment of human responsesto actual or potential health problems. The ANAs posi-tion is that in addition to traditional dependent and inter-dependent functions, nursing has an independent area ofpractice. As the role of the nurse continues to change,there will be further revisions to the definition of nursingand the scope of nursing practice.

THE EDUCATIONAL LADDER

Two basic educational options are available to those inter-ested in pursuing a career in nursing: practical (voca-tional) nursing and registered nursing. Several types ofprograms prepare graduates in registered nursing. Eacheducational track provides the knowledge and skills for a

particular entry level of practice. Some factors affectingthe choice of a nursing program include the following:

Career goals Geographic location of schools Costs involved Length of programs Reputation and success of graduates Flexibility in course scheduling Opportunity for part-time versus full-time enroll-

ment Ease of movement into the next level of education



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Practical/Vocational Nursing

During World War II, many registered nurses enlisted inthe military. As a result, civilian hospitals, clinics, schools,and other health care agencies faced an acute shortage oftrained nurses. To fill the void expeditiously, abbreviatedprograms in practical nursing were developed across thecountry to teach essential nursing skills. The goal was toprepare graduates to care for the health needs of infants,

children, and adults who were mildly or chronically ill orconvalescing so that registered nurses could be used moreeffectively to care for acutely ill clients.

After the war, many registered nurses opted for part-time employment or resigned to become full-time house-wives, and thus the need for practical nurses continued. Itbecame obvious that the role practical nurses were fulfill-ing in health care delivery would not be temporary. Con-sequently, leaders in practical nursing programs organized


TABLE 1.2 NURSING THEORIES AND APPLICATIONS

THEORIST THEORY EXPLANATION

Florence Nightingale18201910

Virginia Henderson18971996

Dorothea Orem1914

Sister Callista Roy1939

Environmental TheoryMan

Health

Environment

NursingSynopsis of Theory

Application to Nursing Practice

Basic Needs TheoryManHealth

EnvironmentNursing

Synopsis of Theory


Self-Care TheoryMan

Health

Environment

Nursing

Synopsis of Theory


Adaptation TheoryMan

HealthEnvironmentNursing

Synopsis of Theory


An individual whose natural defenses are influenced by a healthy orunhealthy environment

A state in which the environment is optimal for the natural bodyprocesses to achieve reparative outcomesAll the external conditions capable of preventing, suppressing, or

contributing to disease or deathPutting the client in the best condition for nature to actExternal conditions such as ventilation, light, odor, and cleanliness can

prevent, suppress, or contribute to disease or death.Nurses modify unhealthy aspects of the environment to put the client in

the best condition for nature to act.

An individual with human needs that have unique meaning and valueThe ability to independently satisfy human needs composed of 14 basic

physical, psychological, and social elementsThe setting in which a person learns unique patterns for livingTemporarily assisting a person who lacks the necessary strength, will,

and knowledge to satisfy one or more of 14 basic needsPeople have basic needs that are components of health. The significance

and value of these needs are unique to each person.Nurses assist in performing those activities that the client would perform

if he or she had strength, will, and knowledge.

An individual who uses self-care to sustain life and health, recover fromdisease or injury, or cope with its effects

The result of practices that people have learned to carry out on theirown behalf to maintain life and well-being

External elements with which man interacts in the struggle to maintainself-care

A human service that assists people to progressively maximize their self-care potential

People learn behaviors that they perform on their own behalf to

maintain life, health, and well-being.Nurses assist clients with self-care to improve or to maintain health.

A social, mental, spiritual, and physical being affected by stimuli in theinternal and external environments

A persons ability to adapt to changes in the environmentInternal and external forces in a continuous state of changeA humanitarian art and expanding science that manipulates and

modifies stimuli to promote and to facilitate mans ability to adaptMan is a biopsychosocial being. A change in one component results in

adaptive changes in the others.Nurses assess biologic, psychological, and social factors interfering with

health; alter the stimuli causing the maladaptation; and evaluate theeffectiveness of the action taken.


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to form the National Association for Practical Nurse Edu-cation and Service, Inc. This group worked to standardizepractical nurse education and to facilitate the licensure ofgraduates. By 1945, eight states had approved practicalnurse programs (Mitchell & Grippando, 1997). In 1993,enrollments in LPN/LVN nursing programs reached apeak of 60,749 students. Since then, however, the num-

bers have declined gradually (Fig 1-4).Despite the trend in enrollments, the Bureau of LaborStatistics (2002) predicts that job opportunities in nurs-ing are expected to increase 10% to 20% through 2010.Career centers, vocational schools, hospitals, indepen-dent agencies, and community colleges generally offerpractical nursing programs, arranging clinical experi-ences at local community hospitals, clinics, and nursinghomes. The average length of a practical nursing pro-gram ranges from 12 to 18 months, after which graduatesare qualified to take their licensing examination. Becausethis nursing preparatory program is the shortest, manyconsider it the most economical.

Licensed graduates provide direct health care forclients under the supervision of a registered nurse, physi-cian, or dentist. To provide career mobility, many schoolsof practical nursing have developed articulation agree-ments to help their graduates enroll in another schoolthat offers a path to registered nursing via associate orbaccalaureate degrees.

Registered Nursing

Students can choose one of three paths to become a regis-

tered nurse: a hospital-based diploma program, a programthat awards an associate degree in nursing, or a baccalau-reate nursing program. All three meet the requirementsfor taking the national licensing examination (NCLEX-

RN). A person licensed as a registered nurse may workdirectly at the bedside or supervise others in managing thecare of groups of clients.

Table 1-3 describes how educational programs preparegraduates to assume separate but coordinated responsi-bilities. When hiring new graduates, however, manyemployers do not differentiate between these educational

programs, arguing that a nurse is a nurse.

Hospital-Based Diploma Programs

Diploma programs were the traditional route for nursesthrough the middle of the 20th century. Their declinebecame obvious in the 1970s, and their numbers con-tinue to dwindle (Fig. 1-5). The reason for their declineis twofold: first, there has been a movement to increaseprofessionalism in nursing by encouraging education incolleges and universities; second, hospitals can no longerfinancially subsidize schools of nursing.

Diploma nurses were, and are, well trained. Because

of their vast clinical experience (compared with studentsfrom other types of programs), they often are character-ized as more self-confident and easily socialized into therole requirements of a graduate nurse.

A hospital-based diploma program generally lasts3 years. Many hospital schools of nursing collaborate withnearby colleges to provide basic science and humanitiescourses; graduates can transfer these credits if they chooseto pursue associate or baccalaureate degrees later.

Associate Degree Programs

During World War II, when qualified nurses were being

used for the military effort, hospital-based schools accel-erated the education of some registered nursing studentsthrough the Cadet Nurse Corps. After the war ended,Mildred Montag, a doctoral nursing student, began to


FIGURE 1.4 Trends in LPN/LVN andRN enrollments 19972001. Num-bers are based on U.S. candidatestaking the NCLEX for the first time inrespective years, as reported by theNational Council of State Boards ofNursing.

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question whether it was necessary for students in regis-tered nursing programs to spend 3 years acquiring a basiceducation. She believed that nursing education could beshortened to 2 years and relocated to vocational schoolsor junior or community colleges. The graduate from thistype of program would acquire an associate degree innursing, would be referred to as a technical nurse, andwould not be expected to work in a management position.

This type of nursing preparation has proven extremelypopular and now commands the highest enrollmentamong all registered nurse programs. Despite the con-

densed curriculum, graduates of associate degree pro-grams have demonstrated a high level of competence inpassing the NCLEX-RN.

Baccalaureate Programs

Although collegiate nursing programs were established atthe beginning of the 20th century, until recently they didnot attract large numbers of students. Their popularityhas been increasing, perhaps because of proposals by theANA and the National League for Nursing to establish


TABLE 1.3 LEVELS OF RESPONSIBILITIES FOR THE NURSING PROCESS*

PRACTICAL/VOCATIONAL NURSE ASSOCIATE DEGREE NURSE BACCALAUREATE NURSE

Assessing

Diagnosing

Planning

Implementing

Evaluating

Gathers data by interviewing,observing, and performing a basicphysical examination of people

with common health problemswith predictable outcomes

Contributes to the development ofnursing diagnoses by reportingabnormal assessment data

Assists in setting realistic andmeasurable goals

Suggests nursing actions that canprevent, reduce, or eliminatehealth problems with predictableoutcomes

Assists in developing a written plan

of carePerforms basic nursing care under

the direction of a registered nurse

Shares observations on the progressof the client in reachingestablished goals

Contributes to the revision of theplan of care

Collects data from people withcomplex health problems withunpredictable outcomes, their

family, medical records, andother health team members

Uses a classification list to write anursing diagnostic statement,including the problem, its etiol-ogy, and signs and symptoms

Identifies problems that requirecollaboration with the physician

Sets realistic, measurable goalsDevelops a written individualized

plan of care with specificnursing orders that reflects thestandards for nursing practice

Identifies prioritiesDirects others to carry out nursing

orders

Evaluates the outcomes of nursingcare routinely

Revises the plan of care

Identifies the informationneeded from individuals orgroups to provide an

appropriate nursingdatabase

Conducts clinical testing ofapproved nursing diagnoses

Proposes new diagnosticcategories for considerationand approval

Develops written standards fornursing practice

Plans care for healthy or sickindividuals or groups instructured health careagencies or the community

Applies nursing theory to theapproaches used forresolving actual andpotential health problems ofindividuals or groups

Conducts research on nursingactivities that may beimproved with further study

*Note that each more advanced practitioner can perform the responsibilities of those identified previously.

FIGURE 1.5 Distribution of basic RN programs. Numbers are based oneducational programs of U.S. candidates taking the NCLEX-RN exami-nation in 2001, as reported by the National Council of State Boards ofNursing.

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baccalaureate education as the entry level into nursingpractice. The deadline for implementation of this goal,once set for 1985, has been postponed for three reasons:

The date coincided with a national shortage ofnurses.

There was tremendous opposition from nurseswithout degrees, who believed that their titles and

positions would be jeopardized. Employers feared that paying higher salaries to per-

sonnel with degrees would escalate budgets beyondtheir financial limits.

Consequently, the adoption of a unified entry level intopractice remains in limbo.

Although this preparatory program is the longest andmost expensive, baccalaureate-prepared nurses have thegreatest flexibility in qualifying for nursing positions, bothstaff and managerial. Nurses with a baccalaureate degreeusually are preferred in areas where the need for indepen-dent decision-making is substantial, such as public health.

Currently, many nurses without degrees are returningto school to earn baccalaureate degrees. Articulation hasbeen difficult for many because of problems transferringcredits for courses they took during their diploma or asso-ciate degree programs. To increase enrollment, some col-legiate programs are offering nurses an opportunity toobtain credit by passing challenge examinations. Inaddition, many colleges and universities provide satelliteor outreach programs to accommodate nurses who cannotgo to school full-time or travel long distances.

Graduate Nursing Programs

Graduate nursing programs are available at both the mas-ters and doctoral levels. Masters-prepared nurses fillroles as clinical specialists, nurse practitioners, adminis-trators, and educators. Nurses with doctoral degrees con-duct research and advise, administer, and instruct nursespursuing undergraduate and graduate degrees. Althougha graduate degree in nursing is preferred, some nursespursue advanced education in fields outside nursing, suchas business, leadership, and education, to enhance theirnursing career.

Continuing Education

Continuing education in nursing is defined as any plannedlearning experience that takes place beyond the basicnursing program (ANA, 1974). Nightingale is creditedwith having said, to stand still is to move backwards.The principle that learning is a life-long process stillapplies. Box 1-2 lists reasons why nurses, in particular,pursue continuing education. Many states now requirenurses to show proof of continuing education to renewtheir nursing license.

FUTURE TRENDS

Two major issues dominate nursing today. The first con-

cerns methods of eliminating the shortage of nurses. Thesecond involves strategies for responding to a growingaging population with chronic health problems.

Enrollment in all nursing programs and continuingeducation will contribute to reducing the current and pro-jected shortages of nurses. In 2001, the vacancy rate innursing positions was 13% (Tieman, 2002). The futurelooks even more alarming. The Bureau of Labor Statisticsprojects that one million nursing positions will be open by2010 (http://www.nursingworld.org/gova/federal/news/nrs.htm; American Association of Colleges of Nursing,2002). Many of these positions are likely to remain un-filled, because the number of practicing nurses is fore-

casted to decrease by approximately 20% by that time(ANA, 2001). According to the National Council of StateBoards of Nursing (2001), factors contributing to thenurse shortage include the following:

Retirement rate of nurses that exceeds their re-placement

Declining enrollment in nursing programs Attrition of aging faculty, which restricts numbers

of student applicants Increased aging population requiring health care Job dissatisfaction as a result of stress and the un-

relenting rigor of working in health care

Governmental Responses

In 2002, the federal government attempted to address theshortage of nurses by passing the Nurse ReinvestmentAct. This legislation authorizes the following:

1. Loan repayment programs and scholarships fornursing students

2. Funding for public service announcements toencourage more people to enter nursing programs


No basic program provides all the knowledge and skills needed for a life-time career.

Current advances in technology make previous methods of practice obsolete. Assuming responsibility for self-learning demonstrates personal account-

ability. To ensure the publics confidence, nurses must demonstrate evidence of

current competence. Practicing according to current nursing standards helps to ensure that

care is legally safe. Renewal of state licensure often is contingent on evidence of continuing

education.

BOX 1-2 Rationales for AcquiringContinuing Education


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3. Career ladder programs to facilitate advancementto higher levels of nursing practice

4. Best practice grants modeled after the ANA/Amer-ican Nursing Credentialing Centers magnet pro-gram, which recognizes workplaces with positiveoutcomes for clients (e.g., low mortality rates, shortlengths of stay) combined with increased satis-

faction among employed nurses who demonstratequality care and work productivity

5. Grants to incorporate gerontology into the curric-ula of nursing programs

6. Loan repayment programs for nursing students whoagree to teach following graduation (http://www.nursingworld.org/gova/federal/news/nrs.htm)

Before the provisions are set into motion, Congress mustapprove appropriations to fund them.

Proactive StrategiesRather than taking a wait-and-see position about thenursing shortage and the ramifications of the Nurse Re-investment Act, many nurses are proactively responding

to the trends affecting their role in health care (Table 1-4).Nurses are dealing with the unique challenges of the 21stcentury by:

Pursuing post-licensure education Training for advanced practice roles (nurse prac-

titioner, nurse midwifery) to provide cost-effectivehealth care in areas in which numbers of primary

care physicians are inadequate Becoming cross-trained (able to assume non-

nursing jobs, depending on the census or levels ofclient acuity on any given day). For example, nursesmay be trained to provide respiratory treatmentsand to obtain electrocardiograms, duties that non-nursing health care workers previously performed.

Learning more about multicultural diversity(unique characteristics of ethnic groups) as it affectshealth beliefs and values, food preferences, language,communication, roles, and relationships

Supporting legislative efforts toward national health

insurance that involves nurses in primary care(the first health care worker to assess a person witha health need)

Promoting wellness through home health care andcommunity-based programs


TABLE 1.4 TRENDS IN HEALTH CARE AND NURSING

HEALTH CARE NURSING

The most underserved health care populations include older adults,

ethnic minorities, and the poor, who delay seeking earlytreatment because they cannot afford it.

The number of uninsured has risen from 37 million in 1995 to41.2 million in 2002. This figure could exceed 48 millionby 2009.

Medicare and Medicaid benefits are being modified and reduced.

Chronic illness is the major health problem.

Disease and injury prevention and health promotion are priorities.

Medicine tends to focus on high technology, which improvesoutcomes for a select few.

Hospitals are downsizing and hiring unlicensed personnel toperform procedures once in the exclusive domain of licensednurses for cost containment.

There are fewer primary care physicians in rural areas.

Changes in reimbursement practices have created a shift indecision making from hospitals, nurses, and physicians toinsurance companies.

Health care costs continue to increase despite managed carepractices (cost-containment strategies used to plan andcoordinate a clients care to avoid delays, unnecessary services,or overuse of expensive resources).

Capitation (strategy for controlling health care costs by paying afixed amount per member) encourages health providers to limittests and services to increase profits.

Hospitals, practitioners, and health insurance companies are beingrequired to measure, monitor, and manage quality of care.

Enrollments and numbers of graduates from LPN/LVN and

RN educational programs are currently decreasing.More licensed nurses are earning masters and doctoraldegrees.

There continues to be a shortage of nurses in varioushealth care settings because of decreased enrollments,retirement, attrition, and cost-containment measures.

Hospital employment is decreasing.

Client-to-nurse ratios in employment settings are higher.

More high-acuity clients are in previously nonacutesettings such as long-term and intermediate health carefacilities.

Job opportunities have expanded to outpatient services,home health care, hospice programs, communityhealth, and mental health agencies.


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Helping clients with chronic diseases learn tech-niques for living healthier and, consequently, longerlives

Referring clients with health problems for earlytreatment, a practice that requires the fewest re-sources and thus minimizes expenses

Coordinating nursing services across health care

settingsthat is, discharge planning (managingtransitional needs and ensuring continuity)

Developing and implementing clinical pathways,standardized multidisciplinary plans for a specificdiagnosis or procedure that identify aspects of careto be performed during a designated length of stay(Fig. 1-6)

Participating in quality assurance (process of iden-tifying and evaluating outcomes)

Concentrating on the knowledge and skills to man-age the health needs of older Americans whosenumbers will reach 70 million by 2030, according tothe National Center for Chronic Disease Prevention

and Health Promotion (2002)

UNIQUE NURSING SKILLS

Although employment location and how they carry outnursing skills (activities unique to the practice of nurs-ing) differ according to educational preparation, all nursesshare the same philosophical perspective. In keeping withNightingales traditions, contemporary nursing practicecontinues to include assessment skills, caring skills, coun-seling skills, and comforting skills.

Assessment Skills

Before the nurse can determine what nursing care a per-son requires, he or she must determine the clients needsand problems. This requires the use of assessment skills(acts that involve collecting data), which include inter-viewing, observing, and examining the client and in somecases the clients family (family is used loosely to refer tothe people with whom the client lives and associates).Although the client and the family are the primary

sources of information, the nurse also reviews the clientsmedical record and talks with other health care workersto obtain facts. Assessment skills are discussed in moredetail in Unit IV.

Caring Skills

Caring skills (nursing interventions that restore or main-tain a persons health) may involve actions as simple asassisting with activities of daily living (ADLs), the acts

that people normally do every day. Examples of ADLsinclude bathing, grooming, dressing, toileting, and eating.More and more, however, the nurses role is expandingto include the safe care of clients who require invasive orhighly technical equipment. This textbook introducesbeginning nurses to the concepts and skills needed to pro-vide care for clients whose disorders have fairly predict-

able outcomes. Once this foundation has been established,students may add to their initial knowledge base.Traditionally, nurses always have been providers of

physical care for people unable to meet their own healthneeds independently. But caring also involves the concernand attachment that result from the close relationship ofone human being with another. Despite the close rela-tionship that caring involves, the nurse ultimately wantsclients to become self-reliant. The nurse who assumes toomuch care for clients, like a parent who continues to tie achilds shoes, often delays their independence.

Counseling Skills

A counselor is one who listens to a clients needs, re-sponds with information based on his or her area of exper-tise, and facilitates the outcome that a client desires.Nurses implement counseling skills (interventions thatinclude communicating with clients, actively listeningduring exchanges of information, offering pertinenthealth teaching, and providing emotional support) inrelationships with clients.

To understand the clients perspective, the nurse usestherapeutic communication techniques to encourage ver-

bal expression. Therapeutic and nontherapeutic commu-nication techniques are discussed in Chapter 7. The use ofactive listening (demonstrating full attention to what isbeing said, hearing both the content being communicatedand the unspoken message) facilitates therapeutic inter-actions. Giving clients the opportunity to be heard helpsthem to organize their thoughts and to evaluate their situ-ation more realistically.

Once the clients perspective is clear, the nurse pro-vides pertinent health information without offeringspecific advice. By reserving personal opinions, nursespromote the right of every person to make his or her owndecisions and choices on matters affecting health and ill-ness care. The role of the nurse is to share informationabout potential alternatives, allow clients the freedom tochoose, and support the decision that is made.

While giving care, the nurse finds many opportunitiesto teach clients how to promote healing processes, staywell, prevent illness, and carry out ADLs in the best pos-sible way. People know much more about health andhealth care today, and they expect nurses to share accu-rate information with them.

Because clients do not always communicate their feel-ings to strangers, nurses use empathy (intuitive aware-



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FIGURE 1.6 Example of recovery pathway in managed care. (Courtesy of Elkhart General Hospital, Elkhart, IN.)


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ness of what the client is experiencing) to perceive theclients emotional state and need for support. This skilldiffers from sympathy (feeling as emotionally distraughtas the client). Empathy helps the nurse become effectivein providing for the clients needs while remaining com-passionately detached.

Comforting Skills

Nightingales presence and the light from her lamp com-municated comfort to the frightened British soldiers. Asa result of that heritage, contemporary nurses understandthat illness often causes feelings of insecurity that maythreaten the clients or familys ability to cope; they mayfeel very vulnerable. It is then that the nurse uses com-forting skills (interventions that provide stability andsecurity during a health-related crisis) (Fig. 1-7). Thenurse becomes the clients guide, companion, and inter-preter. This supportive relationship generally increases

trust and reduces fear and worry.As a result of one womans efforts, modern nursing

was born. It has continued to mature and flourish eversince. The skills that Nightingale performed on a verygrand scale are repeated today during each and everynurseclient relationship.

Stop, Think, and Respond BOX 1-2

Identify which of the following nursing actions is anassessment skill, caring skill, counseling skill, andcomforting skill: (a) the nurse discusses with a fam-ily the progress of a client undergoing surgery;

(b) the nurse provides information on advanceddirectives, which allows a client to identify his orher end-of-life decisions; (c) the nurse asks a clientto identify his or her current health problems; (d)the nurse provides medication for a client in pain.

Critical Thinking Exercises

1. Explain the reason for enacting the Nurse Reinvestment Actin 2002.

2. Name four types of skills that all nurses perform when caringfor clients.

References and Selected Readings

Albert, Y. (1998). Profile of a NAPNES member. From trainedpractical nurses to licensed practical/vocational nursescertified in a specialty. Journal of Practical Nursing, 48(4),2223.

American Association of Colleges of Nursing. (2002). Enroll-ment increase insufficient to meet the projected need for newnurses. http://www.aacn.nche.edu/Media/NewsReleases/enrl01.htm. Accessed 9/22/02.

American Nurses Association. (2001).2001 annual stakeholdersreport. Washington, DC: Author.

American Nurses Association. (1980).Nursing: A social policy

statement. Kansas City, MO: Author.American Nurses Association. (1974). Standards for continuing

education in nursing. Kansas City, MO: Author.Barber, J. L., Bland, C., Langdon, M. B., et al. (2000). LPN role

advancement: From blueprints to ribbon cutting.Journal forNurses in Staff Development, 16(3), 112117.

Boden, L., & Smith, M. (2002). Debate. Is it really possible torecruit an extra 35,000 nurses?Nursing Times, 98(18), 16.

Buerhaus, P. I. (1998). Is a nursing shortage on the way?Nurs-ing, 28(8), 3435.

Buerhaus, P., & McCue, P. (2000). This nursing shortage willbe unprecedented.News & Views, Winter(1), 6.

Bureau of Labor Statistics. (2001). Occupational outlook hand-

book. Licensed practical and licensed vocational nurses.Wash-ington, D.C.: U.S. Dept. of Labor (http://www.bls.gov/oco/ocos102.htm). Accessed 9/24/02.

Curtin, L. (2002). Editorial opinion. Why stay in nursing today?Journal of Clinical Systems Management, 4(5), 56, 18.

Davidhizar, R., & Shearer, R. (2000). Your continuing educationtopic #12000. Self-talk for the licensed practical/vocationalnurse.Journal of Practical Nursing, 50(1), 1621.

Donahue, M. P. (1985). The finest art. St. Louis: Mosby.Donley, R., & Flaherty, M. J. (2002). Revisiting the American

Nurses Associations first position on education for nurses.Online Journal of Issues in Nursing, 7(2), 15p.

Duff, S. (2002). Nurses get funds to ease shortage. ModernHealthcare, 32(23), 13.

Gosnell, D. J. (2002). Overview and summary: The 1965 entryinto practice proposalis it relevant today? Online Journal ofIssues in Nursing, 7(2), 3p.

Henderson, V. (1966). The nature of nursing. New York:Macmillan.

James, M. K. (2002). LPNs/LVNs hit comeback trail!Nursing,32(1), LPN Education Directory: 34.

Joel, L. A. (2002). Education for entry into nursing practice:Looking backward into the future. Online Journal of Issues inNursing, 7(2), 8p.

Jolly, A. (2002). Essence of care: Involving nursing students.Nursing Times, 98(18), 3638.


FIGURE 1.7 This nurse offers comfort and emotional support. (Copy-right B. Proud.)


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Kenney, P. A. (2001). Maintaining quality care during a nurs-ing shortage using licensed practical nurses in acute care.Journal of Nursing Care Quality, 15(4), 6068.

Mahaffey, E. H. (2002). The relevance of associate degree nurs-ing: Past, present, future. Online Journal of Issues in Nursing,7(2), 11p.

National Center for Chronic Disease Prevention and Health Pro-motion. (2002). Healthy aging for older adults. United States

Department of Health and Human Services. http://www.cdc.gov/aging

National Council of State Boards of Nursing, Inc. (2001).Licensure and examination statistics. Chicago.

National Council of State Boards of Nursing, Inc. (2001).NCSBN position statement: Nurse shortage. http://www.ncsbn.org/public/news/ncsbn_position_nurse_shortage.htm.Accessed 9/24/02.

Nightingale, F. (1859).Notes on nursing: What it is, and what itis not. London: Harrison.

Palmer, P. (2001). Ever upward: An innovative online collegeoffers an unusual solution to the nursing shortage: Helping

minority medical technicians, LPNs and others move up toRN careers.Minority Nurse, Fall, 3237.

Redmond, G. M. (1997). LPN-BSN: Education for a reformedhealth care system. Journal of Nursing Education, 36(3),121127.

Rosseter, R. (2002). Nursing shortage fact sheet. AmericanAssociation of Colleges of Nursing.http://www.aacn.nche.edu/Media/Bacgrounders/shortagefacts.htm. Accessed 9/22/02.

Sigma Theta Tau International. (2001). Facts about the nursingshortage. http://www.nursesource.org/facts_shortage.html.Accessed 9/22/02.

Tieman, J. (2002). Nursing the nursing shortage: As feds col-laborate, states and localities act on own. Modern Health-care, 32(20), 2021.

Visit the Connection site at http://connection.lww.com/go/timbyFundamentals for links to chapter-related resources onthe Internet.


Documents

Chapter 1 Nursing Foundations.pdf