Fundamentals of Nursing Chapter 1

Nursing Today

Author: Eze-Odikwa Tochukwu Jed

Note: All articles posted here are accurate, up-to-date and drafted from real university curriculums. Proper references will be added at the bottom of this article upon its completion. 

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College Reg Number: MOUAU/CME/14/18475

Nursing is an art and a science. As a professional nurse you will learn to deliver care artfully with compassion, caring, and respect for each patient’s dignity and personhood. As a science nursing practice is based on a body of knowledge that is continually changing with new discoveries and innovations. When you integrate the science and art of nursing into your practice, the quality of care you provide to your patients is at a level of excellence that benefits patients and their families.

Your opportunities for a nursing career are limitless. There are a variety of career paths, including clinical practice, education, research, management, administration, and even entrepreneurship. As a student it is important for you to understand the scope of nursing practice and how nursing influences the lives of your patients.

The patient is the center of your practice. The patient includes the individual, family, and/or community. Patients have a wide variety of health care needs, experiences, vulnerabilities, and expectations; but this is what makes nursing both challenging and rewarding. Making a difference in your patients’ lives is fulfilling (e.g., helping a dying patient find relief from pain, helping a young mother learn parenting skills, and finding ways for older adults to remain independent in their homes). Nursing offers personal and professional rewards every day. This chapter presents a contemporary view of the evolution of nursing and nursing practice and the historical, practical, social, and political influences on the discipline of nursing when giving care, it is essential to provide a specified service according to standards of practice and to follow a code of ethics (American Nurses Association [ANA], 2008, 2010b). Professional practice includes knowledge from social and behavioral sciences, biological and physiological sciences, and nursing theories. In addition, nursing practice incorporates ethical and social values, professional autonomy, and a sense of commitment and community. The American Nurses Association (ANA) defines nursing as the protection, promotion, and optimization of health and abilities; prevention 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, 2010b). The International Council of Nurses (ICN, 2010) has another definition: Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health; prevention of illness; and the care of ill, disabled, and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles. Both of these definitions support the prominence and importance that nursing holds in providing safe, patient-centered health care to the global community.

Expert clinical nursing practice is a commitment to the application of knowledge, ethics, aesthetics, and clinical experience. Your ability to interpret clinical situations and make complex decisions is the foundation for your nursing care and the basis for the advancement of nursing practice and the development of nursing science (Benner, 1984; Benner, Tanner, and Chelsea, 1997; Benner et al., 2010). Critical thinking skills are essential to nursing (see later chapter). When providing nursing care, you need to make clinical judgments and decisions about your patients’ health care needs based on knowledge, experience, and standards of care. Use critical thinking skills and reflections to help you gain and interpret scientific knowledge, integrate knowledge from clinical experiences, and become a lifelong learner (Benner et al., 2010).

Historical Highlights

Nursing has responded and always will respond to the needs of its patients. In times of war the nursing response was to meet the needs of the wounded in combat zones and military hospitals in the United States and abroad. When communities face health care crises such as disease outbreaks or insufficient health care resources, nurses establish community-based immunization and screening programs, treatment clinics, and health promotion activities. Our patients are most vulnerable when they are injured, sick, or dying.

Since the beginning of the profession, nurses have studied and tested new and better ways to help their patients. A classic article described Florence Nightingale’s work during the Crimean War. She studied and implemented methods to improve battlefield sanitation, which ultimately reduced illness, infection, and mortality (Cohen, 1984). Take time to reflect about Nightingale’s actions centuries ago and think about the impact of her actions. She set the stage for using evidence to direct practice.

Today nurses are active in determining the best practices for skin care management, pain control, nutritional management, and care of older adults, to cite just a few examples. Nurse researchers are leaders in expanding knowledge in nursing and other health care disciplines. Their work provides evidence for practice to ensure that nurses have the best available evidence to support their practices.

Nursing is a combination of knowledge from the physical sciences, humanities, and social sciences, along with clinical competencies needed for safe, quality patient-centered care (Gugliemi, 2010). It continuously responds and adapts to new challenges. Nurses are in a unique position to refine and shape the future of health care.

Nurses are active in social policy and political arenas. Nurses and their professional organizations lobby for health care legislation to meet the needs of patients, particularly the medically underserved. For example, nurses in communities provide home visits to newborns of high-risk mothers (e.g., adolescent, poorly educated mothers or medically underserved). These visits result in fewer emergency department visits, fewer newborn infections, and reduced infant mortality (Mason et al., 2012).

Knowledge of the history of our profession increases your ability to understand the social and intellectual origins of the discipline. Although it is not practical to describe all of the historical aspects of professional nursing, some of the more significant milestones are described in the following paragraphs.

Florence Nightingale

In Notes on Nursing: What It Is and What It Is Not, Florence Nightingale established the first nursing philosophy based on health maintenance and restoration (Nightingale, 1860). She saw the role of nursing as having “charge of somebody’s health” based on the knowledge of “how to put the body in such a state to be free of disease or to recover from disease” (Nightingale, 1860). During the same year she developed the first organized program for training nurses, the Nightingale Training School for Nurses at St. Thomas’ Hospital in London.

Nightingale was the first practicing nurse epidemiologist (Cohen, 1984). Her statistical analyses connected poor sanitation with cholera and dysentery. She volunteered during the Crimean War in 1853 and traveled the battlefield hospitals at night carrying her lamp; thus she was known as the “lady with the lamp.” The sanitary, nutrition, and basic facilities in the battlefield hospitals were poor at best. Eventually she was given the task to organize and improve the quality of the sanitation facilities. As a result, the mortality rate at the Barracks Hospital in Scutari, Turkey, was reduced from 42.7% to 2.2% in 6 months (Donahue, 2011).

The Civil War to the Beginning of the Twentieth Century

The Civil War (1860 to 1865) stimulated the growth of nursing in the United States. Clara Barton, founder of the American Red Cross, tended soldiers on the battlefields, cleansing their wounds, meeting their basic needs, and comforting them in death. The U.S. Congress ratified the American Red Cross in 1882 after 10 years of lobbying by Barton. Dorothea Lynde Dix, Mary Ann Ball (Mother Bickerdyke), and Harriet Tubman also influenced nursing during the Civil War (Donahue, 2011). As superintendent of the female nurses of the Union Army, Dix organized hospitals, appointed nurses, and oversaw and regulated supplies to the troops. Mother Bickerdyke organized ambulance services and walked abandoned battlefields at night, looking for wounded soldiers. Harriet Tubman was active in the Underground Railroad movement and assisted in leading over 300 slaves to freedom (Donahue, 2011).

The first professionally trained African American nurse was Mary Mahoney. She was concerned with relationships between cultures and races; and as a noted nursing leader she brought forth an awareness of cultural diversity and respect for the individual, regardless of background, race, color, or religion.

Isabel Hampton Robb helped found the Nurses’ Associated Alumnae of the United States and Canada in 1896. This organization became the ANA in 1911. She authored many nursing text books, including Nursing: It’s Principles and Practice for Hospital and Private Use (1894), Nursing Ethics (1900), and Educational Standards for Nurses (1907) and was one of the original founders of the American Journal of Nursing (AJN) (Donahue, 2011).

Nursing in hospitals expanded in the late nineteenth century. However, nursing in the community did not increase significantly until 1893, when Lillian Wald and Mary Brewster opened the Henry Street Settlement, which focused on the health needs of poor people who lived in tenements in New York City (Donahue, 2011). Nurses working in this settlement were some of the first to demonstrate autonomy in practice because they frequently encountered situations that required quick and innovative problem solving and critical thinking without the supervision or direction of a health care provider.

Twentieth Century

In the early twentieth century a movement toward developing a scientific, research-based defined body of nursing knowledge and practice was evolving. Nurses began to assume expanded and advanced practice roles. Mary Adelaide Nutting was instrumental in the affiliation of nursing education with universities. She became the first professor of nursing at Columbia University Teachers College in 1906 (Donahue, 2011). In addition, the Goldmark Report concluded that nursing education needed increased financial support and suggested that university schools of nursing receive the money.

As nursing education developed, nursing practice also expanded, and the Army and Navy Nurse Corps were established. By the 1920s nursing specialization was developing. Graduate nurse-midwifery programs began; in the last half of the century specialty-nursing organizations were created. Examples of these specialty organizations include the American Association of Critical Care Nurses; Association of Operating Room Nurses (AORN); Emergency Nurses Association (ENA); Infusion Nurses Society (INS); Oncology Nursing Society (ONS); and Wound, Ostomy, Continence Nurses Society (WOCN).

Twenty-First Century

Nursing practice and education continue to evolve to meet the needs of society. In 1990 the ANA established the Center for Ethics and Human Rights (see Chapter 22). The Center provides a forum to address the complex ethical and human rights issues confronting nurses and designs activities and programs to increase ethical competence in nurses (ANA, 2010c).

Today the profession faces multiple challenges. Nurses and nurse educators are revising nursing practice and school curricula to meet the ever-changing needs of society, including bioterrorism, emerging infections, and disaster management. Advances in technology and informatics (see Chapter 26), the high acuity level of care of hospitalized patients, and early discharge from health care institutions require nurses in all settings to have a strong and current knowledge base from which to practice. In addition, nursing and the Robert Wood Johnson Foundation are taking a leadership role in developing standards and policies for end-of-life care through the Last Acts Campaign (see Chapter 36). The End-of-Life Nursing Education Consortium (ELNEC) offered collaboratively by the American Association of Colleges of Nursing (AACN) and the City of Hope Medical Center has brought end-of-life care and practices into nursing curricula and professional continuing-education programs for practicing nurses (Tilden and Thompson, 2009).

Influences on Nursing

Multiple external forces affect nursing, including demographic changes of the population, human rights, increasing numbers of medically underserved, and the threat of bioterrorism.

Health Care Reform

Health care reform not only affects how health care is paid for but how it is delivered. There will be greater emphasis on health promotion, disease prevention, and illness management in the future. This model impacts the delivery of nursing care. More services will be in community-based care settings. As a result, more nurses will be needed to practice in community care centers, schools, and senior centers. This will require nurses to be more adept at assessing for resources, service gaps, and how the patient adapts to returning to the community. Nursing must respond to such changes by exploring new methods to provide care, changing nursing education, and revising practice standards (O’Neil, 2009).

Demographic Changes

The U.S. Census Bureau (2008a) predicts that between 2010 and 2050 there will be a steady rise in the population. This change alone requires expanded health care resources. Add to the population change a steady increase in the population of people 65 years and older (U.S. Census Bureau, 2008b). To effectively meet all the health care needs of the expanding and aging population, changes need to occur as to how care is provided, especially in the area of public health, to address health care reform and meet the needs of the changing population. The population is still shifting from rural areas to urban centers, and more people are living with chronic and long-term illness (Presley, 2010). Not only are there expansions of outpatient settings, but more and more people want to receive outpatient and community-based care and remain in their homes or community.

Medically Underserved

The rising rates of unemployment, underemployment and low[1]paying jobs, mental illness, and homelessness and rising health care costs all contribute to increases in the medically underserved population. Caring for the medically underserved population is a global issue; the social, political, and economic factors of a country affect both access to care and resources to provide and pay for these services (Huicho et al., 2010). In the United States some of the medically underserved population are poor and on Medicaid. Others are part of the working poor (i.e., they cannot afford their own insurance, but they make too much money to qualify for Medicaid and as a result do not receive any health care). In addition, the number of underserved patients who require home-based palliative care services is increasing. This is a group of patients whose physical status does not improve and heath care needs increase. As a result, the cost for home-based care continues to rise, to the point that some patients opt out of all palliative services because of costs (Fernandes et al., 2010). Today nurses and schools of nursing are developing partnerships to improve health outcomes in underserved communities. Nurses work in these community-based settings providing health promotion and disease prevention to the homeless, mentally ill, and others who have limited access to health care or who lack health care insurance (McCann, 2010).

Threat of Bioterrorism

The world is a changing place; the threats of bioterrorism are continuous. Many health care agencies, schools, and communities have educational programs to prepare for nuclear, chemical, or biological attack. Nurses are active in disaster preparedness. The ICN works alongside national nursing associations to determine how to best educate and prepare nurses for future disasters (Robinson, 2010). For example, public health emergency simulation exercises allow nurses and students to work with community disaster[1]preparedness groups and hospitals to determine what specific nursing activities are needed (Morrison and Catanzaro, 2010). These activities sometimes range from participation in vaccine research, decontamination in the event of biological attack, and triage for mass casualty to crisis response units. If a disaster were to occur, nurses would be essential in evaluating the strengths and weaknesses of any disaster plan.

Rising Health Care Costs

Skyrocketing health care costs present challenges to the profession, consumer, and the health care delivery system. As a nurse you are responsible for providing the patient with the best-quality care in an efficient and economically sound manner. The challenge is to use health care and patient resources wisely. Reasons for the rise in health care costs and its implications for nursing are summarized in later chapters.

Nursing Shortage

There is an ongoing global nursing shortage, which results from insufficient qualified registered nurses (RNs) to fill vacant positions and the loss of qualified RNs to other professions (Flinkman et al., 2010). This shortage affects all aspects of nursing such as patient care, administration, and nursing education (Tanner and Bellack, 2010), but it also represents challenges and opportunities for the profession. Many health care dollars are invested in strategies aimed at recruiting a well-educated, critically thinking, motivated, and dedicated nursing workforce (Benner et al., 2010). There is a direct link between registered nurses’ care and positive patient outcomes, reduced complication rates, and a more rapid return of the patient to an optimal functional status (Aiken, 2010; Lucero et al., 2009).

Professional nursing organizations predict that there will continue to be a diminishing pipeline of RNs in the future (AACN, 2008b; Aiken, 2010). Like it or not, the nursing shortage affects the needs of the consumer (Block and Sredl, 2006). With fewer nurses in the workplace, it is important for you to learn to use your patient contact time efficiently and professionally. Time management, therapeutic communication, patient education, and compassionate implementation of psychomotor skills are just a few of the essential skills you need. Most important, your patients leave the health care setting with a positive image of nursing and a feeling that they received quality care. In a rapid-discharge and high-tech health care environment nurses need to relate to their patients on a human, caring level (Manthey, 2008). Your patient should never feel rushed or that he or she was unimportant. If a certain aspect of patient care requires 15 minutes of contact, it will take the same time to deliver the care in an organized manner as it would in a rushed, harried manner.

Nursing as a profession

Nursing is not simply a collection of specific skills, and you are not simply a person trained to perform specific tasks. Nursing is a profession. No one factor absolutely differentiates a job from a profession, but the difference is important in terms of how you practice. To act professionally you administer quality patient-centered care in a safe, conscientious, and knowledgeable manner. You are responsible and accountable to yourself and your patients and peers. A profession has the following primary characteristics:

• It requires a basic liberal foundation and an extended education of its members.
•  It has a theoretical body of knowledge leading to defined skills, abilities, and norms.
• It provides a specific service.
•  Members of a profession have autonomy in decision making and practice.
•  The profession as a whole has a code of ethics for practice

Scope and Standards of Practice

Since 1960 the ANA has engaged in documenting the scope of nursing and developing standards of practice (ANA, 2010b). Within this document are the Standards of Practice and Standards of Professional Performance. It is important that you know and apply these standards in your practice. The document is usually available in most schools of nursing and practice settings. The goal of this document is to improve the health and well-being of all individuals, communities, and populations through the significant and visible contributions of registered nursing using standard based practice (ANA, 2010b).

Standards of Practice: The Standards of Practice describe a competent level of nursing care. The levels of care are demonstrated by the critical thinking model known as the nursing process: assessment, diagnosis, outcomes identification and planning, implementation, and evaluation (ANA, 2010b). The nursing process is the foundation of clinical decision making and includes all significant actions taken by nurses in providing care to patients.

Standards of Professional Performance: The ANA Standards of Professional Performance describe a competent level of behavior in the professional role (ANA, 2010b). These standards provide objective guidelines for nurses to be accountable for their actions, their patients, and their peers. The standards provide a method to assure patients that they are receiving high quality care that the nurses know exactly what is necessary to provide nursing care, and that measures are in place to determine whether care meets the standards.

Code of Ethics: The code of ethics is the philosophical ideals of right and wrong that define the principles you will use to provide care to your patients. It is important for you to also incorporate your own values and ethics into your practice. As you incorporate these values, you explore what type of nurse you will be and how you will function within the discipline (ANA, 2008, 2010c). Ask yourself: how do your ethics, values, and practice compare with established standards? The ANA has a number of publications that address ethics and human rights in nursing. The Code of Ethics for Nurses with Interpretive Statements is a guide for carrying out nursing responsibilities that provide quality nursing care; it also outlines the ethical obligations of the profession (ANA, 2008). The nursing code of ethics and ethical principles for everyday practice is discussed further in later chapters.

Nursing Education

Nursing requires a significant amount of formal education. The issues of standardization of nursing education and entry into practice remain a major controversy. In 1965 the ANA published a position paper on nursing education that emphasizes the role of education for the advancement of the science of the profession (ANA, 1965). Most nurses agree that nursing education is important to practice and that education needs to respond to changes in health care created by scientific and technological advances. There are various education preparations for an individual intending to be an RN. In addition, there is graduate nurse education and continuing and in-service education for practicing nurses.

Professional Registered Nurse Education

Currently in the United States the most frequent way to become a registered nurse (RN) is either through completion of an associate or baccalaureate degree program. Graduates of both programs are eligible to take the National Council Licensure Examination for Registered Nurses (NCLEX-RN®) to become RNs in the state in which they will practice.

The associate degree program in the United States is a 2-year program that is usually offered by a university or community college. This program focuses on the basic sciences and theoretical and clinical courses related to the practice of nursing.

The baccalaureate degree program usually includes 4 years of study in a college or university. The program focuses on the basic sciences; theoretical and clinical courses; and courses in the social sciences, arts, and humanities to support nursing theory. In Canada the degree of Bachelor of Science in Nursing (BScN) or Bachelor in Nursing (BN) is equivalent to the degree of Bachelor of Science in Nursing (BSN) in the United States. The Essentials of Baccalaureate Education for Professional Nursing (AACN, 2008a) delineates essential knowledge, practice and values, attitudes, personal qualities, and professional behavior for the baccalaureate-prepared nurse and guides faculty on the structure and evaluation of the curriculum. The National League for Nursing Accreditation Council (NLNAC) published the NLNAC Standards and Criteria Baccalaureate Programs in Nursing—2008. This document identifies core competencies for the professional nurse and supports the Pew Health Commission and the competencies of the Institute of Medicine (IOM) for health professionals (NLNAC, 2008). In addition, one of the IOM’s recommendations is that 80% of nurses be prepared with a baccalaureate in nursing by 2020 (IOM, 2010).

Graduate Education

After obtaining a baccalaureate degree in nursing, you can pursue graduate education leading to a master’s or doctoral degree in any number of graduate fields, including nursing. A nurse completing a graduate program can receive a master’s degree in nursing. The graduate degree provides the advanced clinician with strong skills in nursing science and theory, with emphasis on the basic sciences and research-based clinical practice. A master’s degree in nursing is important for the roles of nurse educator and nurse administrator, and it is required for an advanced practice registered nurse (APRN).

Doctoral Preparation: Professional doctoral programs in nursing (DSN or DNSc) prepare graduates to apply research findings to clinical nursing. Other doctoral programs emphasize more basic research and theory and award the research-oriented Doctor of Philosophy (PhD) in nursing. Recently the AACN recommended the Doctor of Nursing Practice (DNP) as the terminal practice degree and required preparation for all APRNs by 2015 (Chase and Pruitt, 2006). The DNP is a practice-focused doctorate. It provides skills in obtaining expanded knowledge through the formulation and interpretations of evidence-based practice (Chism, 2010).

The need for nurses with doctoral degrees is increasing. Expanding clinical roles and continuing demand for well-educated nursing faculty, nurse administrators, and APRNs in the clinical settings and new areas of nursing specialties such as nursing informatics are just a few reasons for increasing the number of doctor ally prepared nurses.

Continuing and In-Service Education

Nursing is a knowledge-based profession, and technological expertise and clinical decision making are qualities that our health care consumers demand and expect. Continuing education programs are one way to promote and maintain current nursing skills, gain new knowledge and theory, and obtain new skills reflecting the changes in the health care delivery system (Hale et al., 2010). Continuing education involves formal, organized educational programs offered by universities, hospitals, state nurses associations, professional nursing organizations, and educational and health care institutions. An example is a program on caring for older adults with dementia offered by a university or a program on safe medication practices offered by a hospital. Continuing education updates your knowledge about the latest research and practice developments, helps you to specialize in a particular area of practice, and teaches you new skills and techniques (Hale et al., 2010).

In-service education programs are instruction or training provided by a health care agency or institution. An in-service program is held in the institution and is designed to increase the knowledge, skills, and competencies of nurses and other health care professionals employed by the institution. Often in-service programs are focused on new technologies such as how to correctly use the newest safety syringes. Many in-service programs are designed to fulfill required competencies of an organization. For example, a hospital might offer an in-service program on safe principles for administering chemotherapy or a program on cultural sensitivity.

Nursing Practice

You will have an opportunity to practice in a variety of settings, in many roles within those settings, and with caregivers in other related health professions. Administrators in health care agencies and institutions guide the practice of nursing only in part. State and provincial Nurse Practice Acts (NPAs) establish specific legal regulations for practice, and professional organizations establish standards of practice as criteria for nursing care. The ANA is concerned with legal aspects of nursing practice, public recognition of the significance of nursing practice to health care, and implications for nursing practice regarding trends in health care. The ANA definition of nursing illustrates the consistent orientation of nurses to providing care to promote the well-being of their patients individually or in groups and communities (ANA, 2010a).

Nurse Practice Acts

In the United States the State Boards of Nursing oversee NPAs. NPAs regulate the scope of nursing practice and protect public health, safety, and welfare. This protection includes shielding the public from unqualified and unsafe nurses. Although each state defines for itself the scope of nursing practice, most have similar NPAs. The definition of nursing practice published by the ANA is representative of the scope of nursing practice as defined in most states. However, in the last decade many states have revised their NPAs to reflect the growing autonomy of nursing and the expanded roles of nurses in practice. For example, NPAs expanded their scope to include minimum education requirements, required certifications, and practice guidelines for APRNs such as nurse practitioners and certified RN anesthetists. The expansion of scope of practice includes skills unique to the advanced practice role (e.g., advanced assessment, prescriptive authority for certain medications and diagnostic procedures, and some invasive procedures).

Licensure and Certification

Licensure: In the United States RN candidates must pass the NCLEX-RN® examination administered by the individual State Boards of Nursing. Regardless of educational preparation, the examination for RN licensure is exactly the same in every state in the United States. This provides a standardized minimum knowledge base for nurses.

Certification: Beyond the NCLEX-RN®, the nurse may choose to work toward certification in a specific area of nursing practice. Minimum practice requirements are set, based on the certification the nurse seeks. National nursing organizations such as the ANA have many types of certification to enhance your career such as certification in medical surgical or geriatric nursing. After passing the initial examination, you maintain your certification by ongoing continuing education and clinical or administrative practice.

Science and Art of Nursing Practice

Because nursing is both an art and a science, nursing practice requires a blend of the most current knowledge and practice standards with an insightful and compassionate approach to patient care. Your patients’ health care needs are multidimensional. Thus your care will reflect the needs and values of society and professional standards of care and performance, meet the needs of each patient, and integrate evidence-based findings to provide the highest level of care. Nursing has a specific body of knowledge; however, it is essential that you socialize within the profession and practice to fully understand and apply the nursing knowledge base and develop professional expertise. Clinical expertise takes time and commitment. According to Benner et al. (2010), an expert nurse passes through five levels of proficiency when acquiring and developing generalist or specialized nursing skills.

Use the competencies of critical thinking in your practice. This includes integrating knowledge from basic science and nursing knowledge bases, applying knowledge from past and present experiences, applying critical thinking attitudes to a clinical situation, and implementing intellectual and professional standards (see Chapter 15). When you provide well–thought out care with compassion and caring, you provide each of your patients the best of the science and art of nursing care (see Chapter 7).

Professional Responsibilities and Roles

As a nurse, you are responsible for obtaining and maintaining specific knowledge and skills for a variety of professional roles and responsibilities. Nurses provide care and comfort for patients in all health care settings. Nurses’ concern for meeting the patient’s needs remains the same whether care focuses on health promotion and illness prevention, disease and symptom management, family support, or end-of-life care.

Autonomy and Accountability

Autonomy is an essential element of professional nursing that involves the initiation of independent nursing interventions without medical orders. For example, you independently implement coughing and deep-breathing exercises for a patient who recently had surgery. You actively collaborate with other health professionals to pursue the best treatment plan for a patient. With increased autonomy comes greater responsibility and accountability. Accountability means that you are responsible, professionally and legally, for the type and quality of nursing care provided. You need to keep current and competent in nursing and scientific knowledge and technical skills. The nursing profession also regulates accountability through nursing audits and standards of practice.

Caregiver

As a caregiver, you help patients maintain and regain health, manage disease and symptoms, and attain a maximal level function and independence through the healing process. You provide healing through both physical and interpersonal skills. Healing involves more than achieving improved physical well-being. You need to meet all health care needs of the patient by providing measures that restore a patient’s emotional, spiritual, and social well-being. As a caregiver, you help the patient and family set goals and assist them with meeting these goals with minimal financial cost, time, and energy.

Advocate

As a patient advocate, you protect your patient’s human and legal rights and provide assistance in asserting these rights if the need arises. As an advocate you act on behalf of your patient and secure your patient’s health care rights and stand up for them (Hanks, 2010). For example, you provide additional information to help a patient decide whether or not to accept a treatment, or you find an interpreter to help family members communicate their concerns. You sometimes need to defend patients’ rights in a general way by speaking out against policies or actions that put patients in danger or conflict with their rights.

Educator

As an educator you explain concepts and facts about health, describe the reason for routine care activities, demonstrate procedures such as self-care activities, reinforce learning or patient behavior, and evaluate the patient’s progress in learning. Some of your patient teaching is unplanned and informal. For example, during a casual conversation you respond to questions about the reason for an intravenous infusion, a health issue such as smoking cessation, or necessary lifestyle changes. Other teaching activities are planned and more formal such as when you teach your patient to self-administer insulin injections. Always use teaching methods that match your patient’s capabilities and needs and incorporate other resources such as the family in teaching plans.

Communicator

Your effectiveness as a communicator is central to the nurse-patient relationship. It allows you to know your patients, including their strengths and weaknesses, and their needs. Communication is essential for all nursing roles and activities. You will routinely communicate with patients and families, other nurses and health care professionals, resource persons, and the community. Without clear communication, it is impossible to give comfort and emotional support, give care effectively, make decisions with patients and families, protect patients from threats to well-being, coordinate and manage patient care, assist the patient in rehabilitation, or provide patient education. The quality of communication is a critical factor in meeting the needs of individuals, families, and communities.

Manager

Today’s health care environment is fast paced and complex. Nurse Managers need to establish an environment for collaborative patient-centered care to provide safe, quality care with positive patient outcomes. A manager coordinates the activities of members of the nursing staff in delivering nursing care and has personnel, policy, and budgetary responsibility for a specific nursing unit or agency. The manager uses appropriate leadership styles to create a nursing environment for the patients and staff that reflect the mission and values of the health care organization.

Career Development

Innovations in health care, expanding health care systems and practice settings, and the increasing needs of patients have been stimuli for new nursing roles. Today the majority of nurses practice in hospital settings, followed by community-based care, ambulatory care, and nursing homes/extended care settings.

Nursing provides an opportunity for you to commit to lifelong learning and career development to provide patients the state-of-the-art care they need. Career roles are specific employment positions or paths. Because of increasing educational opportunities for nurses, the growth of nursing as a profession, and a greater concern for job enrichment, the nursing profession offers expanded roles and different kinds of career opportunities. Your career path is limitless. You will probably switch career roles more than once. Take advantage of the different clinical practice and professional opportunities. These career opportunities include APRNs, nurse researchers, nurse risk managers, quality improvement nurses, consultants, and even business owners.

Provider of Care: Most nurses provide direct patient care in an acute care setting. As health care returns to the home care setting, there are increased opportunities for you to provide direct care in the patient’s home or community. Use the nursing process and critical thinking skills to provide care that is both restorative and curative. Educate your patients and families to promote health maintenance and self-care. In collaboration with other health care team members, focus your care on returning the patient to his or her home at an optimal functional status.

In the hospital you may choose to practice in a medical-surgical setting or concentrate on a specific area of specialty practice such as pediatrics, critical care, or emergency care. Most specialty care areas require some experience as a medical-surgical nurse and additional continuing or in-service education. Many intensive care unit and emergency department nurses are required to have certification in advanced cardiac life support and critical care, emergency nursing, or trauma nursing.

Advanced Practice Registered Nurses: The advanced practice registered nurse (APRN) is the most independently functioning nurse. An APRN has a master’s degree in nursing; advanced education in pathophysiology, pharmacology, and physical assessment; and certification and expertise in a specialized area of practice (APRN, 2008). There are four core roles for the APRN:

• Clinical nurse specialist (CNS)
• Certified nurse practitioner (CNP)
• Certified nurse midwife (CNM)
• Certified RN anesthetist (CRNA).

The educational preparation for the four roles is in at least one of the following six populations: adult-gerontology, pediatrics, neonatology, women’s health/gender related, family/individual across life span, and psychiatric mental health (APRN, 2008).

APRNs function as a clinician, educator, case manager, consultant, and researcher within his or her area of practice to plan or improve the quality of nursing care for the patient and family.

Clinical Nurse Specialist: The clinical nurse specialist (CNS) is an APRN who is an expert clinician in a specialized area of practice. The specialty may be identified by a population (e.g., geriatrics), a setting (e.g., critical care), a disease specialty (e.g., diabetes), a type of care (e.g., rehabilitation), or a type of problem (e.g., pain) (National CNS Competency Task Force, 2010). The CNS practice is in all health care settings.

Nurse Practitioner: The nurse practitioner (NP) is an APRN who provides health care to a group of patients, usually in an outpatient, ambulatory care, or community-based setting. NPs provide care for patients with complex problems and a more holistic approach than physicians. The NP provides comprehensive care, directly managing the medical care of patients who are healthy or who have chronic conditions. A significant percentage of primary care visits by patients result from health-related problems that extend beyond the boundaries of medicine and demand the expertise of a nurse. The NP is able to establish a collaborative provider patient relationship, working with a specific group of patients or with patients of all ages and health care needs. The major NP categories are acute care, adult, family, pediatric, women’s, psychiatric mental health, and geriatric. An NP has the knowledge and skills necessary to detect and manage self-limiting acute and chronic stable medical conditions such as asthma, diabetes mellitus, and hypertension.

Certified Nurse-Midwife: A certified nurse-midwife (CNM) is an APRN who is also educated in midwifery and is certified by the American College of Nurse-Midwives. The practice of nurse midwifery involves providing independent care for women during normal pregnancy, labor, and delivery and care for the newborn. It includes some gynecological services such as routine Papanicolaou (Pap) smears, family planning, and treatment for minor vaginal infections. A CNM practices with a health care agency that provides medical consultation, collaborative management, and referral.

Certified Registered Nurse Anesthetist: A certified registered nurse anesthetist (CRNA) is an APRN with advanced education in a nurse anesthesia accredited program. Nurse anesthetists provide surgical anesthesia under the guidance and supervision of an anesthesiologist, who is a physician with advanced knowledge of surgical anesthesia.

Nurse Educator: A nurse educator works primarily in schools of nursing, staff development departments of health care agencies, and patient education departments. Nurse educators need experience in clinical practice to provide them with practical skills and theoretical knowledge. A faculty member in a school of nursing educates students to become professional nurses. Nursing faculty members are responsible for teaching current nursing practice, trends, theory, and necessary skills in laboratories and clinical settings. Nurse educators in schools of nursing usually have graduate degrees in nursing and additional education. Many hold doctorate or advanced degrees in nursing, education, or administration such as a master’s degree in business administration (MBA). Generally they have a specific clinical, administrative, or research specialty and advanced clinical experience. Nurse educators in staff development departments of health care institutions provide educational programs for nurses within their institution. These programs include orientation of new personnel, critical care nursing courses, assisting with clinical skill competency, safety training, and instruction about new equipment or procedures. These nursing educators often participate in the development of nursing policies and procedures. The primary focus of the nurse educator in the patient education department of an agency is to teach patients who are ill or disabled and their families how to self-manage their illness or disability. These nurse educators are usually specialized and certified such as a certified diabetes educator (CDE) or an ostomy care nurse and see only a specific population of patients.

Nurse Administrator: A nurse administrator manages patient care and the delivery of specific nursing services within a health care agency. Nursing administration begins with positions such as the assistant nurse manager. Experience and additional education sometimes lead to a middle-management position such as nurse manager of a specific patient care area or house supervisor or to an upper-management position such as assistant or associate director or director of nursing services. Nurse Manager Positions usually require at least a baccalaureate degree in nursing, and director and nurse executive positions generally require a master’s degree. Chief Nurse Executive and vice president positions in large health care organizations often require preparation at the doctoral level. Nurse administrators often have advanced degrees such as an MBA or a master’s degree in hospital administration (MHA), public health (MPH), or health service administration.

In today’s health care organizations directors may have responsibility for more than nursing units. Often directors manage a particular service or product line such as medicine or cardiology. Management of a service line often includes directing supportive functions and the health care personnel within areas such as medicine clinics, diagnostic departments, or outpatient.

Vice presidents of nursing or chief nurse executives often have responsibilities for all clinical functions within the hospital. This may include all ancillary personnel who provide and support patient care services. The nurse administrator needs to be skilled in business and management and understand all aspects of nursing and patient care. Functions of administrators include budgeting, staffing, strategic planning of programs and services, employee evaluation, and employee development.

Nurse Researcher: The nurse researcher investigates problems to improve nursing care and further define and expand the scope of nursing practice (see Chapter 5). The nurse researcher often works in an academic setting, hospital, or independent professional or community service agency. The preferred educational requirement is a doctoral degree, with at least a master’s degree in nursing.

Professional Nursing Organization

A professional organization deals with issues of concern to those practicing in the profession. In North America the major professional nursing organizations are the National League for Nursing (NLN) and the ANA. The NLN advances excellence in nursing education to prepare nurses to meet the needs of a diverse population in a changing health care environment. The NLN (2008) sets standards for excellence and innovation in nursing education.

The purpose of the ANA is to improve standards of health and the availability of health care, to foster high standards for nursing, and to promote the professional development and general and economic welfare of nurses. The ANA is part of the International Council of Nurses (ICN). The objectives of the ICN parallel those of the ANA: promoting national associations of nurses, improving standards of nursing practice, seeking a higher status for nurses, and providing an international power base for nurses.

The ANA is active in political, professional, and financial issues affecting health care and the nursing profession. It is a strong lobbyist in professional practice issues such as limits of overtime hours. For example, ANA extensively lobbied state legislatures to restrict the length of overtime any one nurse’s shift can be extended. When nurses’ shifts last longer than 12 to 16 hours, both the patient’s and nurse’s safety is at risk. The risk for treatment errors and nurse injury is increased when the nurse’s workday is extended. Nursing students take part in organizations such as the National Student Nurses Association (NSNA) in the United States and the Canadian Student Nurses Association (CSNA) in Canada. These organizations consider issues of importance to nursing students such as career development and preparation for licensing. The NSNA often cooperates in activities and programs with the professional organizations.

Some professional organizations focus on specific areas such as critical care, nursing administration, nursing research, or nurse midwifery. These organizations seek to improve the standards of practice, expand nursing roles, and foster the welfare of nurses within the specialty areas. In addition, professional organizations present educational programs and publish journals.

Trends in Nursing

Nursing is a dynamic profession that grows and evolves as society and lifestyles change, as health care priorities and technologies change, and as nurses themselves change. The current philosophies and definitions of nursing have a holistic focus, which addresses the needs of the whole person in all dimensions, in health and illness, and in interaction with the family and community. In addition, there continues to be an increasing awareness for patient safety in all care settings.

Quality and Safety Education for Nurses

The Robert Wood Johnson Foundation sponsored the Quality and Safety Education for Nurses (QSEN) initiative to respond to reports about safety and quality patient care by the IOM (Barton et al., 2009). QSEN addresses the challenge to prepare nurses with the competencies needed to continuously improve the quality of care in their work environments (Table 1-1). The QSEN initiative encompasses the competencies of: patient-centered care, team work and collaboration, evidence-based practice, quality improvement, safety, and informatics (Cronenwett et al., 2007). For each competency there are targeted knowledge, skills, and attitudes (KSAs). The KSAs are elements that are integrated in a nursing prelicensure program (Jarzemsky et al., 2010). As you gain experience in clinical practice, you will encounter situations in which your education helps you to make a difference in improving patient care. Whether that difference in care is to provide evidence for implementing care at the bedside, identify a safety issue, or study patient data to identify trends in outcomes, each of these situations requires competence in patient-centered care, safety, or informatics. Although it is not within the scope of this textbook to present the QSEN initiative in its entirety, subsequent clinical chapters will provide you an opportunity to address how to build competencies in one or more of these areas.

Genomics

Genetics is the study of inheritance, or the way traits are passed down from one generation to another. Genes carry the instructions for making proteins, which in turn direct the activities of cells and functions of the body that influence traits such as hair and eye color. Genomics is a newer term that describes the study of all the genes in a person and interactions of these genes with one another and with that person’s environment (CDC, 2010). Using genomic information allows health care providers to determine how genomic changes contribute to patient conditions and influence treatment decisions (Badzek et al., 2008). For example, when a family member has colon cancer before the age of 50, it is likely that other family members are at risk for developing this cancer. Knowing this information is important for family members who will need a colonoscopy before the age of 50 and repeat colonoscopies more often than the patient who is not at risk. In this case nurses are key in identifying the patients’ risk factors through assessment and counseling patients about what this genomic finding means to them personally and to their family.

Public Perception of Nursing

Nursing is a pivotal health care profession. As frontline health care providers, nurses practice in all health care settings and constitute the largest number of health care professionals. They are essential to providing skilled, specialized, knowledgeable care; improving the health status of the public; and ensuring safe, effective quality care (ANA, 2010b).

Consumers of health care are more informed than ever, and with the Internet consumers have access to more health care and treatment information. This information affects the perception the public has of nursing. For example, the media frequently highlights incidents of preventable medical errors such as medication and surgical errors. Publications such as To Err Is Human (IOM, 2000) describe strategies for government, health care providers, industry, and consumers to reduce preventable medical errors. When you care for patients, realize how your approach to care influences public opinion. Always act in a competent professional manner.

Impact of Nursing on Politics and Health Policy

Political power or influence is known as the ability to influence or persuade an individual holding a government office to exert the power of that office to affect a desired outcome. Nurses’ involvement in politics is receiving greater emphasis in nursing curricula, professional organizations, and health care settings. Professional nursing organizations have employed lobbyists to urge state legislatures and the U.S. Congress to improve the quality of health care (Mason et al., 2012).

The ANA works for the improvement of health standards and the availability of health care services for all people, fosters high standards of nursing, stimulates and promotes the professional development of nurses, and advances their economic and general welfare. The purposes are unrestricted by considerations of nationality, race, creed, lifestyle, color, gender, or age. The ANA employs RNs as lobbyists at the federal level. State nursing organizations also hire lobbyists and legislative specialists to work on state nursing issues and assist with federal efforts. Finally, lobbyists working on behalf of nursing are employed in Washington, DC, by professional organizations such as the American Federation of Teachers, the NLN, the American College of Nurse-Midwives, the American Public Health Association, and the AACN. These groups aim to remove financial barriers to health care, increase the quality of nursing care available, increase economic rewards to nurses, and expand professional nursing roles.

You can influence policy decisions at all governmental levels. One way to get involved is by participating in local and national efforts (Mason et al., 2012). This effort is critical to exerting nurses’ influence early in the political process. When nurses become serious students of social needs, activists in influencing policy to meet those needs, and generous contributors of time and money to nursing organizations and to candidates working for universal good health care, the future is bright indeed (Mason et al., 2012).

Table 1.1 Quality and Safety Education for Nurses

COMPETENCY	DEFINITION WITH EXAMPLES
Patient-Centered Care	Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs. Examples: Involve family and friends in care. Elicit patient values and preferences. Provide care with respect for diversity of the human experience.
Teamwork and Collaboration	Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care. Examples: Recognize the contributions of other health team members and patient’s family members. Discuss effective strategies for communicating and resolving conflict. Participate in designing methods to support effective teamwork.
Evidence-Based Practice	Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care. Examples: Demonstrate knowledge of basic scientific methods. Appreciate strengths and weaknesses of scientific bases for practice. Appreciate the importance of regularly reading relevant journals.
Quality Improvement	Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems. Examples: Use tools such as flow charts and diagrams to make process of care explicit. Appreciate how unwanted variation in outcomes affects care. Identify gaps between local and best practices.
Safety	Minimize risk of harm to patients and providers through both system effectiveness and individual performance. Examples: Examine human factors and basic safety design principles and commonly used unsafe practices. Value own role in preventing errors.
Informatics	Use information and technology to communicate, manage knowledge, mitigate error, and support decision-making. Examples: Navigate an electronic health record. Protect confidentiality of protected health information in electronic health records.