meet the nguyens

Meet the Nguyens

Throughout this text, you will be applying what you have learned as you care for theNguyen family. In Chapter 1, you will meet Nam Nguyen, a construction work supervisor, who arrives at the Family Medicine Center for his first physical exam in 10 years. It is Mr. Nguyen’s knee pain that causes him to seek help because it affects his work. But as youwill see, Mr. Nguyen will discover he has other serious health problems that require him to be more vigilant about his health. As you read and work through the exercises in Caring forthe Nguyens, you will also get to know Nam’s wife, Yen Nguyen, his grandchild Kim Phan, other members of his extended family, and his friends, as they deal with health issues and life changes.

Your experience in caring for the Nguyens will show you that patients come to you withsymptoms, but each person brings unique values, lifestyle, and relationships to the encounter.From the Nguyens, you will learn what it means to care for the whole person and how to be afull-spectrum nurse.

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Mr. Nam Nguyen is a new patient at the Family Medicine Center. He arrives atthe center for a scheduled physical exam and completes the following admissionquestionnaire.

Please list your current medications and dosages. Also list over-the-counter and herbal products you use regularly.

Ben-Gay Balm on kneesIbuprofenMultiVitamin 1 per day Acetaminophen

Nam Nguyen

YenConstruction supervisor Daycare teacher

30, 27, 22

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The Diagnosis During the visit, the clinic nurse records the followinginformation in Mr. Nguyen’s chart:

Height 5 ft 4 in.Weight 165 lb (75 kg) BP 162/94 mm HgPulse 84 beats/minRR 20 breaths/minTemp 98.2°F oral

Present ing Complaint : Patient states he is here tobecome established as a patient at the center and that he has not had a physical exam in over 10 years.Wife accompanies. He is currently experiencing bilateralknee pain that is affecting his work performance. “I am a building inspector. To check on things, I have to climb up and down ladders, lift things, and crawl around a lot.” Has not missed any work but has been usingincreasing amounts of acetaminophen and ibuprofen “to get through the day.” The medications provide onlylimited relief. States pain occurs daily even if not atwork. Describes the pain as “achy” and “dull.” Feels bestwhen he is off his feet. Desires pain relief and checkup.Explains that both parents had heart disease. Wifeexpressing worry that he may be developing heartproblems “because he’s so tired after work and he gets short of breath easy.”

The nurse explains to Mr. Nguyen that he will be seen by the nurse practitioner shortly. She asks Mr. Nguyen if he would like his wife to be present for the exam. Heanswers yes.

Zach Jackson, MSN, FNP, is on duty at the center today.Zach worked as an RN for more than 10 years in the local emergency department and urgent care clinic. He hasbeen a family nurse practitioner (FNP-BC) for more than 5 years. Zach enters the room and introduces himself to theNguyen couple. To begin the exam, Zach reviews theinformation Nam supplied on the admission form, and then asks him about his family history.

Zach: “Are your parents still living?”Nam: “Yes, they’re both alive. My father is

80 years old and my mother is 76.”Zach: “I’d like to hear a little more about your

family history. Tell me about your father’scancer. How old was he when he was firstdiagnosed? Has he had treatment?”

Nam: “He was probably about 60 when he first found out about it. I know he had somekind of surgery and takes medicines but I don’t know the details. He seems all rightthough.”

Zach: “Your father also has high blood pressure and heart disease. Please tell me a little moreabout that.”

Nam: “My father and mother both have high blood pressure and heart disease. They both take medicines for their blood pressure.My father had a small heart attack about10 years ago. My mother has never had aheart attack that I know of, but shesometimes has chest pain.”

Jordan: “Your mother also has diabetes?”Nam: “She’s had that for a long time. A lot of

people in his family, especially on myfather’s side, have diabetes but nobody inmy mother’s family. Yet my mother is theone with the diabetes!”

Yen: “A lot of people in my family have diabetes too. But so far I’m OK, I think.

Zach: “Have you had a health exam lately, Mrs. Nguyen?”

Yen: “Not in about a year, but I’m going to schedule an appointment here.”

The Nguyen couple and Zach continue to review thehealth information. After reviewing the history anddiscussing current complaints, Zach performs a completephysical exam.

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1 Nursing Past & Present

2 Critical Thinking & the Nursing Process

3 Nursing Process: Assessment

4 Nursing Process: Diagnosis

5 Planning Outcomes

6 Planning Interventions

7 Implementation & Evaluation

8 Theory, Research, & Evidence-Based Practice

unit 1How Nurses Think

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C H A P T E R 1Nursing Past & Present

➤ Describe the role of religion in thedevelopment of nursing.

➤ Identify the factors that led to thechange of nursing from a vocation ofboth men and women to apredominantly female profession.

➤ Explain the role of the military in thedevelopment of the nursing profession.

➤ Define nursing in your own words.➤ Discuss the transitions that nursing

education has undergone in the lastcentury.

➤ Differentiate among the various formsof nursing education.

➤ Explain how nursing practice isregulated.

➤ Give four examples of influential nursingorganizations.

➤ Name and recognize the four purposesof nursing care.

➤ Delineate the forces and trendsaffecting contemporary nursingpractice.

If you were assigned readings in theExpanded Discussion on DavisPlus, youshould also be able to demonstrate thefollowing outcomes:➤ Describe the healthcare delivery system

in the United States, including sites forcare, types of workers, regulation, andfinancing of healthcare.

➤ Name nine expanded roles for nursing.➤ Discuss issues related to healthcare

reform.

Learning OutcomesAfter completing this chapter, you should be able to:

5

Key ConceptsNursingNursing imageContemporary nursing educationContemporary nursing practice

Related Concepts See the Concept Map at the end of thischapter.

Caring for the NguyensThis feature allows you to practice the kind of thinking you will use as a full-spectrum nurse. There is usually more than one correct answer to a critical thinking question, so we do not provide answers for thesefeatures. It is more important to develop your nursing judgment than to“cover content.” Discuss the questions with your peers. If you are stillunsure, consult your instructor.

Review the opening scenario in the front of the book. Onthe preliminary visit of Nam Nguyen at the Family MedicineCenter, he is examined by Zach Jackson, MSN, FNP-BC.

A. How would you respond to Nam’s concern that he wasexamined by someone who is “just a nurse”?

B. What factors might be causing Mr. Nguyen to questioncare by “a male nurse”?

Go to Caring for the Nguyens Response Sheet onDavisPlus.

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ThinkLike a Nurse 1-1 The Quality and Safety Education for Nurses (QSEN) projectand the Institute of Medicine (IOM) have identified quality and safety competencies for nurses: (1) patient-centered care,(2) teamwork and collaboration, (3) evidence-based practice,(4) quality improvement, (5) safety, and (6) informatics(Cronenwett, Sherwood, Barnsteiner, et al., 2007). Which

of these did Florence Nightingale demonstrate? Explain yourthinking.

ABOUT THE KEY CONCEPTSThe overarching concept for this chapter is the definition of nursing. As you come to understand other key concepts(i.e., nursing images, contemporary nursing education, and

6 UNIT 1 How Nurses Think

Nurses Make a Difference . . .Then & NowTime: 1854, Üsküdar (now part of Istanbul, Turkey) in the Crimea

The hospital tent is set up away from the battlefield. The injured and dying soldiers are lying on the bare earth, soiled and covered with crusted blood. The rankodor of disease and death are inescapable in the stiflinghospital tent. Scanning the scene, Florence Nightingaleand her staff of 38 nurses review the environment in the tent, the health problems of the soldiers, and the supplies and equipment they have. First, they open thetent to allow in fresh air. Then they clean the tent, bathethe wounded, and provide clean bedding. They assess and dress the wounds, feed the soldiers a nutritious meal,and comfort those who are dying or are in pain. Theyoffer encouragement and emotional care to the healthiersoldiers and help them to write letters home. Within abrief period of time, the mortality rate drops from 47% to 2% and morale improves immeasurably.

Time: 2014, Your Local Hospital

While standing at the bedside mixing an antibioticsolution, Susan listens to the ventilator cycle. She notesthat her patient has begun to trigger breaths on his own. In the background she hears the cardiac monitorsounds, which have become more irregular over the pasthour. She mentally runs through her patient assessment.“Why is his heart so irritable?” she wonders. She calls the lab for the morning blood work results. When the lab technician e-mails the results, Susan notes that the potassium level is low at 2.9 mEq/L. She notifies the physician of the test results and the cardiac irritability.Susan says, “The patient’s potassium is low from the diarrhea he’s had since we began the antibiotics.”Together they develop a plan to raise the potassium level and check it every 8 hours. Susan administers intravenous (IV) potassium chloride. Several hours latershe documents that the ectopy (irregular heartbeat) hasdecreased to less than 2 beats/min.

Time: 2030, A LocalHome

Yesterday, Mr. Samuels under-went cardiac surgery. He was discharged home thismorning.As a home healthnurse, your role is to assesshis condition; provide skilledcare; teach Mr. Samuels howto care for himself; instructhis family about his care; andcoordinate any required addi-tional services. Mrs. Samuelsgreets you at the front door.She tells you that herhusband is in a lot of pain andthat the chest drainagesystem is full. She looksfrightened as she says, “When my father had cardiacsurgery 25 years ago, hespent 4 days in the hospital. I don’t understand why myhusband got sent home soquickly.” You explain thatchanges in technology andthe healthcare system allowyou to take care of clients in the home who would previously have been in the hospital. As you begin your assess-ments, you tell Mrs. Samuels, “After I’ve gathered moreinformation, we’ll make a plan for his care that will make all of us more comfortable.”

In each of these scenarios, the nurses engaged in full-spectrum nursing; that is, they used their minds and theirhands to improve the client’s comfort and condition. As thescenarios illustrate, nursing roles have changed over time. Yetnursing remains a profession dedicated to care of the client.

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contemporary nursing practice), you will grasp how theimage of nursing and actual nursing practice have changedover time.

NURSING IMAGES THROUGHOUTHISTORYAn understanding of the past can give insight into the present.Throughout history, artwork, television, popular stories, ad-vertisements, and greeting cards have all portrayed nurses inmany ways. Whether the images are flattering or demeaning,accurate or inaccurate, they influence how people view nurs-ing. Some of these images may have, in either a positive ornegative way, influenced your decision to become a nurse.

Common Images of NursesIn the next few pages you will see how nursing has been portrayed in art and popular culture at different periods in history, and relate the truth and fiction of those images to thepractice of contemporary nursing. This will help you appre-ciate the rich traditions of nursing and the forces that haveshaped nursing as it is today. Pay close attention to the rateof change in recent years, and keep in mind that nursing and healthcare are likely to change even more rapidly in the future.

When you think of nursing, what images do you think of?As you reflect on each of the three scenarios at the opening ofthis chapter, what pictures come into your mind? Is this thesame image you get when you imagine yourself as a nurse? Inthe following sections we explore four common nursingstereotypes.

The Angel of MercyImages of the angel-nurse are usually serene and content, witha halo or other religious symbol. This image grew out of the in-fluence of religion and the risks inherent to the practice ofnursing.

Influence of Religion. The strong link between nursingand religious orders can be traced back to ancient cultures.In Egypt, Greece, and Rome, temples were health centers aswell as places of worship. Priests and priestesses treated theill with a combination of physical care, prayer, and magicspells. In Asia, some of the earliest writings about a distinctnursing occupation are included in the Vedas, the ancient sa-cred books of the Hindu faith (circa 1200 BCE). The nursesincluded in these texts were always men who were part of apriestly order and who possessed knowledge of the prepara-tion, compounding, and administration of drugs; wisdom;purity; and devotion to the patient. In later centuries, laydeacons and deaconesses in the early Christian church vis-ited the sick in their homes and functioned as nurses untilthe first hospitals were established in the first century. Theoldest continuously existing hospital, Hôtel Dieu, in France,was founded in 542 (Fig. 1-1). In the United States, all train-ing programs for nurses were affiliated with religious ordersuntil well after the Civil War.

Today, many nursing programs, universities, colleges, andhealthcare institutions are affiliated with religious groups. Ex-amples include the University of Notre Dame, the SeventhDay Adventist hospital system, and the American Baptistnursing home system.

Effect of the Protestant Reformation. Christianitygradually lost influence in general society over the 15th to

the 19th centuries. Catholic religious orders were often per-secuted, and many monasteries were closed during theProtestant Reformation (16th and 17th centuries CE), forcingmany nurses to flee in order to avoid imprisonment ordeath. Medicine in this period moved to the universities,with major advances in theoretical knowledge of anatomy,physiology, and communicable disease. After the 19th cen-tury, religious groups gradually regained influence, andmany modern nursing programs, universities, colleges, andhealthcare institutions are affiliated with religious groups.Although most of these organizations have mission state-ments that incorporate charitable values, such as compas-sion and caring, they no longer require religious dedicationfrom their nursing students.

Risks Involved in Patient Care. Another reason forthe association between nursing and spirituality is the in-herent risks involved in patient care, especially in the recentpast. Before the development of microscopes and tech-niques for culturing microorganisms in the 19th century,people who entered nursing placed themselves at risk forexposure to diseases that were poorly understood and oftencould not be cured. Even as recently as the 1950s, antibioticswere not readily available, and the chief cause of mortality(death) was infectious disease. Providing care in spite ofthese risks was considered self-sacrificing, much like thecall to serve in religious life.

ThinkLike a Nurse 1-2Which aspects of the nurse-as-angel concept appeal to you mostwhen you think about the way you will practice nursing? Why?

The HandmaidenThe validity of this image has changed over time. While thenurse’s role was initially limited, nurses now collaborate withall members of the healthcare team, planning and providingcare not only at the direction of physicians but also along withthem. Many activities that nurses now do independently wereonce performed only by physicians, including taking vitalsigns, performing physical assessments, and administering IVand other injectable medications (Table 1-1). Nevertheless,while nurses perform these and other critical and complex

CHAPTER 1 Nursing Past & Present 7

FIGURE 1-1 Hôtel Dieu in France, the oldest continuouslyexisting hospital.

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tasks, the physician remains the final decision maker for mostpatient care. ■ Physicians derive much of their power from legal and

financial authority. Early physicians from wealthy andeducated classes wrote and lobbied for legislation thatawarded them extensive power and ensured control ofhealthcare. Now it is very difficult to change these laws toaccommodate the expanded role of modern nurses(Quadagno, 2004; Rockwell, 1994; Safriet, 1994).

■ Without physicians, the institution does not generate in-come. Most patients—or their insurers—directly pay thefacility to provide care that is prescribed by the physician.In contrast, nurses, with the exception of advanced carenurses, are often employees of healthcare institutions.Therefore, they are considered an expense because theycannot bill for the services they provide. To learn moreabout circumstances that have made it difficult to expandthe role of nursing,

Go to Chapter 1, Reading More About Nursing Past and Present, on DavisPlus.

■ In the past, not all nurses considered themselves to be subservient to physicians. The letters and writings of Florence Nightingale (Fig. 1-2), the founder of modernnursing, indicate that she considered nurses the colleaguesof physicians rather than their servants. She stated at one time that the standard description of nurses as “devoted and obedient . . . would do well for a porter” and “[i]t might even do well for a horse” (Chambers, 1958, p. 130).

Despite the protests of her wealthy, upper-class family,Nightingale went on to study nursing in Germany at the

age of 24. She became a field nurse during the CrimeanWar, where she became known as “the Lady of the Lamp”because of her nighttime care to the wounded. Upon herreturn to England, she used her experience in the Crimeato immediately lobby politicians and physicians about the importance of nursing and the need for public healthreform. Nightingale’s major contributions include the following:

The establishment of nursing as a distinct professionIntroduction of a broad-based liberal education for nursesMajor reform in the delivery of care in hospitalsThe introduction of standards to control the spread of

disease in hospitalsMajor reforms in healthcare for the military

If you would like more information about other historicalnursing leaders,

Go to Chapter 1, Supplemental Materials: NursingLeaders, on DavisPlus.

■ The employment status of most nurses is another factorthat must be considered when looking at the validity of thehandmaiden image. As we said earlier, most nurses workfor healthcare institutions rather than directly for physicians.If nurses have indeed been handmaidens, perhaps it hasbeen to the institutions that employ them. Nurses are actively working to combat the handmaiden stereotype; forinstance, they have formed unions to improve their workingconditions and benefits and to advocate for patient safety.The increased number of advance practice nurses and nurseentrepreneurs further rebukes the validity of the hand-maiden image. It is interesting that with changes in thehealthcare system, more physicians are becoming employeesof healthcare institutions as well—and some, like nurses, areforming unions. The increasing costs of healthcare, coupledwith decreasing reimbursement for health services, appearto be driving these changes.


Table 1-1 ➤ Examples of Nursing Activities

DEPENDENT INDEPENDENT ACTIVITIES ACTIVITIES

Administering prescribed medication

Assisting with a diagnostic test (e.g., opening trays, handing instruments to the physician)

Administering IV fluids

Ensuring that the patient receives the prescribed diet

Evaluating the patient’sresponse to medicationand withholding the nextdose if the patient has anegative reaction

Teaching the patient whatto expect from thediagnostic test; preparingthe patient for the test(e.g., shaving a site);supporting the patientduring the test

Evaluating the patient’sresponse to treatment;monitoring the flow rate;evaluating the site forredness or leakage

Teaching a pregnantwoman about additionalnutrients needed in herdiet

FIGURE 1-2 Florence Nightingale (1820–1910).

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ThinkLike a Nurse 1-3 What similarities or differences do you see between the angelicand handmaiden images of nursing?

The Battle-AxThe image of the nurse as a battle-ax is in direct opposition tothe image of the angel of mercy, but these opposing images havecoexisted for centuries. Charles Dickens created an early ver-sion of the abusive nurse in his 1844 novel Martin Chuzzlewit, inthe character of Sairey Gamp. Mrs. Gamp personified the viewof nurses that many people held at that time: She was corrupt,harsh, and frequently intoxicated. In the 1975 film One FlewOver the Cuckoo’s Nest, Nurse Ratched personifies the contempo-rary image of the nurse as the battle-ax or torturer, treating her patients with cruelty and disdain. How did these negativeimages come about? And why does this image persist? Again,history may provide insight.

Fading Influence of Christianity. Before the 14th century,religious-affiliated nursing orders provided most of the care forthe sick. However, as science and philosophy grew more so-phisticated and popular, religious orders for nursing becameless common, and much of the devotion and knowledge of car-ing for the sick was lost. Municipal authorities took over hospi-tals and began to sentence criminals to care for the sick in thehospitals—to assume the nursing role. Forced to care for largenumbers of patients without training, supplies, assistance, ortime off, these criminals often managed their workload by treat-ing patients harshly and drinking alcohol while on duty. Mostpatients who entered such hospitals died there. Such practicespersisted until the 1860s in Europe and until after the Civil Warin the United States. It is no wonder, then, that the battle-aximage of nurses endured so long.

Perception of Nursing Activities. Nurses give injec-tions, clean and dress wounds, draw blood, and start intra-venous lines—such activities are performed to improve the patient’s health, but they may cause significant pain, contribut-ing to the persistence of the battle-ax image. Unfortunately, theassociation with pain helps to perpetuate the image of nursesas unfeeling. Aware of the power of this image, nurses on pedi-atric units typically wear colorful uniforms with child-friendlypatterns, such as cartoon characters or cuddly animals, to avoidfrightening children who may associate “nurse” with “pain.”Providers in many pediatric and outpatient facilities delivercare in street clothes without white lab coats in order to reducepatient anxiety.

The Naughty NurseThe image of the sexy, risqué nurse arose in the early part ofthe 20th century with burlesque shows and persists in popularculture today. In many television programs such as Nightin-gales, M*A*S*H, and more recently Grey’s Anatomy, nurses areportrayed as sexy, mindless, irrelevant, or simply potentialdates for bright and talented surgeons. Get-well cards oftenportray nurses in short skirts, fishnet stockings, high heels,and cap, as do paperback novels, comic books, CDs, and otherprint media. An Internet search yields links to legitimate siteswith realistic pictures of nurses, but also a large number of car-toons, greeting cards, and pornographic Web sites featuringwomen who are supposedly nurses. Their role is impliedthrough props—a nursing cap, a stethoscope, or a uniform—inthe background.

Why is this so? What gives this image its power? As trustedhealth professionals, nurses frequently provide care that

involves exposing the patient’s body, contact with bare skin, and discussion of intimate aspects of the client’s life. Inaddition, hospitalized patients are in a weakened, vulnerablestate, and the nurse may seem quite powerful by contrast.Thus, despite the fact that nurse–patient contact is profes-sional and does not involve sexual intimacy, the “naughtynurse” stereotype may express a forbidden desire for intimatecontact with a stranger in a position of power. In addition, thetraditionally female nurse’s collaboration with traditionallymale physicians may reinforce the stereotype of the nurse in asexual role. The “naughty nurse” stereotype may be popular,but it is not founded on truth.

ThinkLike a Nurse 1-4 ■ How do the images of the nurse as a battle-ax or sex object

affect your view of nursing?■ As a nurse, what can you do to counteract these images?

The Military ImageNursing imagery is often military, both in the general publicand within the profession itself. Throughout the past century,nurses were frequently portrayed in uniform providing sup-port at the battlefield, and nurses are still often characterizedas warriors fighting disease. What is the history of these twomilitary images?

Nurses on the BattlefieldNurses’ involvement in the military dates from 27 BCE, as the

Roman Empire began to consolidate its dominion. Becausethe Roman Empire relied on the success of military excursionsto extend its domain, the well-being of its soldiers was critical.Thus, one of the great contributions of the Roman Empire wasthe development of the military hospital and the practice ofproviding first aid on the battlefield.

During the Middle Ages, the two largest influences onnursing were the military and religion. These two threadsfused in the Crusaders, soldiers who went to battle to conquerIslamic lands and spread Christianity throughout the world.Among the Crusaders were hospitalers, specialized soldierswho at the end of battle returned to the outposts to care for the sick and injured (Fig. 1-3). The hospitaler order known as


FIGURE 1-3 A hospitaler at the time of the Crusades.

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the Knights of St. John of Jerusalem established men’s andwomen’s branches throughout Europe—one of which still exists in England as the Order of Malta.

Nursing presence on the battlefield continued during the Civil War. The U.S. government established the ArmyNursing Service in 1861, and its role was to organize nursesand hospitals and coordinate supplies for the soldiers. Manytrained nurses joined the Army Nursing Service from reli-gious orders. Thousands of laypersons also volunteered, in-cluding the following:■ Clara Barton. Among the lay nurses was Clara Barton, who

organized her own nursing efforts. Rather than providingcare in base hospitals, far removed from the battlefield, Barton and her volunteers provided care in tents set up closeto the fighting. Barton did not discriminate when givingcare, nursing soldiers from both the North and South, blackand white. When the war was over, Barton continued thisuniversal care through the establishment of the AmericanRed Cross.

■ Other laypersons. Other notable figures who served asnurses include Harriet Tubman, who helped slaves escape to freedom on the Underground Railroad; the poet WaltWhitman; the author Louisa May Alcott; and Dorothea Dix,the Union’s Superintendent of Female Nurses during theCivil War. Nurses also served in World War I, World War II, the Korean

and Vietnam wars (Fig. 1-4), the Gulf War, and the conflicts inIraq and Afghanistan. In these wars the nurses were all for-mally trained. Formal training for nurses became widespreadin Europe in the 1860s after the widely publicized success ofNightingale in the Crimea. In the United States the first formaltraining program was established in 1873.

Nurses Fighting DiseaseA second military image portrays nurses as warriors in the

fight against disease. This image is common in public aware-ness campaigns against infectious diseases.■ Florence Nightingale. Florence Nightingale’s contribu-

tions in public health and epidemiology (the study of thedistribution and origins of disease) were among the first

nursing efforts to fight disease. In her Notes on Hospitals(1863), Nightingale stated that air, light, nutrition, and ade-quate ventilation and space assist the patient to recuperate.The hospitals she designed to incorporate these ideas wereassociated with decreased mortality, decreased length of hospital stay, and decreased rate of nosocomial infection (aninfection associated with a healthcare facility and now morecommonly called healthcare-associated infection).

■ Lillian Wald and Mary Brewster. Another notable event inthe fight against disease occurred in 1893 when LillianWald and Mary Brewster founded the Henry Street Settle-ment in New York to improve the health and social condi-tions of poor immigrants. This is considered the start of public health nursing in the United States. Since then,nurses have played an important role in improving healthand preventing illness by promoting safe drinking water,adequate sewage facilities, and proper sanitation measuresin communities. In spite of the historical association of nursing with the mil-

itary, currently only a small percentage of licensed U.S. nurseswork in the armed services. Similarly, despite the powerfulimage of the nurse fighting diseases, only approximately 8% of nurses work in community and public health agencies,which includes school and public health departments (HealthResources and Services Administration [HRSA], 2010).

Caucasian WomenHistorically, images of nurses have been of Caucasian women.Rarely are the images of various ethnicity or men of any race.To a degree, this reflects reality. About 83% of RNs in theUnited States are Caucasian, and only about 9% of nurses inthe United States are men (HRSA, 2010). Male nurses make upa higher percentage in other countries (12.5% in Great Britain,for example); nevertheless, men are a minority of the totalnursing population worldwide (Fig. 1-5) (Pullen, 2006). This is ironic considering that many ancient nursing orders wereexclusively male. In early Christianity, deacons provided nurs-ing care to parish men while deaconesses provided care towomen, and even today the majority of medics and hospitalcorpsmen who provide battlefront first aid are men.

The trend in the United States now is toward a slightlymore diverse workforce. In 2008, 16.8% of nurses were otherthan Caucasian—an increase from 12.2% in 2004. The percent-age will likely increase, because RNs from racial and ethnic


FIGURE 1-4 Women’s Memorial for the Vietnam War. (Copyright 1993, Vietnam Women’s Memorial Foundation, Inc. Glenna Goodacre,sculptor.)

FIGURE 1-5 The roles of men in nursing are now as varied asthose for women, and the opportunities for personal andprofessional fulfillment are as great.

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These actions are intertwined with the nursing process stagesof assessing, diagnosing, and evaluating.

Critical thinking is a reflective thinking process that in-volves collecting information, analyzing the adequacy and ac-curacy of the information, and carefully considering optionsfor action. Nurses use critical thinking in every aspect of nurs-ing care. Critical thinking is discussed at length in Chapter 2and applied in every chapter in this text.

Problem-solving is a process by which nurses consider anissue and attempt to find a satisfactory solution to achieve thebest outcomes. You will often use problem-solving in your pro-fessional life. The nursing process (see Chapters 2 through 7) isone type of problem-solving process.

ThinkLike a Nurse 1-6 In the three scenarios of Nurses Make a Difference . . . Then &Now, what image of nursing predominates: thinking or doing?

CONTEMPORARY NURSING: EDUCATION,REGULATION, AND ORGANIZATIONAs a student about to enter your new professional life, youneed a realistic understanding of the nature and demands ofyour chosen career. To help you to better acquaint yourselfwith nursing today, the remainder of this chapter discussesthe current state of nursing, nursing education, and the trendsaffecting nursing.

How Is Nursing Defined?As you have seen, there are many perceptions of nursing. Theseimages are only loosely based on fact and sometimes they con-flict. They make it difficult for the public to know the reality ofnursing—and they are also confusing to nurses and other mem-bers of the healthcare team. In addition, the constantly changingnature of nursing, healthcare, and society further complicatesthe definition of nursing. Therefore, it is important for nurses toarticulate clearly what nursing is and what nurses do. The fol-lowing are the views of three important nursing organizationswith regard to the question, “What is nursing?”

International Council of Nurses DefinitionIn 1973 the International Council of Nurses (ICN), an organi-zation representing nurses throughout the world, definednursing according to the beliefs of respected theorist VirginiaHenderson:

The unique function of the nurse is to assist the individual, sick orwell, in the performance of those activities contributing to health or itsrecovery (or to peaceful death) that he would perform unaided if he hadthe necessary strength, will or knowledge. (Henderson, 1966, p. 15)

In the decades since the adoption of this definition, nursingthroughout the world has changed. Advances in healthcarehave altered the type of care required by clients. To reflectthese changes, the ICN has revised its definition of nursing, asfollows:

Nursing encompasses autonomous and collaborative care of individ-uals of all ages, families, groups and communities, sick or well and inall settings. Nursing includes the promotion of health, prevention ofillness, and the care of ill, disabled and dying people. Advocacy, pro-motion of a safe environment, research, participation in shapinghealth policy and in patient and health systems management, and education are also key nursing roles. (International Council ofNurses [ICN], 2007)

Table 1-2 ➤ Racial and Ethnic DistributionUpon Graduation From InitialNursing Education

WHITE, NON-WHITE GRADUATION YEAR NON-HISPANIC OR HISPANIC

1980 or earlier 87.7% 12.3%

1981–1985 88.0% 12.0%

1986–1990 82.4% 17.6%

1991–1995 80.5% 19.5%

1996–2000 79.4% 20.6%

2001–2004 78.5% 21.5%

2005–2008 77.5% 22.5%

Source: Compiled from the U. S. Dept. of Health and Human Services,Health Resources and Services Administration (HRSA). (September2010). The registered nurse population. Findings from the 2008 NationalSample Survey of Registered Nurses. Retrieved January 6, 2011, fromhttp://bhpr.hrsa.gov/healthworkforce/rnsurvey/2008/nssrn2008.pdf

minority groups represent a larger portion of recent nursingschool graduates than in earlier years (see Table 1-2).

It is encouraging for diversity that more men are being re-cruited into nursing. For example, in 2006, 8.3% of nursing stu-dents in the United States were men (Pullen, 2006). During2008–2009 the proportion of men increased to 13.8% (NationalLeague for Nursing, n. d.). However, it is important that prac-ticing nurses embrace these changes and welcome others intothe field.

ThinkLike a Nurse 1-5In your opinion, what efforts, if any, should nursing organizationstake to recruit a more diverse workforce?

Full-Spectrum NurseNurses have often been shown actively caring for the patient—dressing wounds, bathing, giving medications—but the intellec-tual or thinking side of nursing is rarely portrayed. The angel ofmercy and military stereotypes reinforce the idea that nursing isa duty and that nurses are carrying out orders. The naughtynurse, battle-ax, and handmaiden images suggest a woman whois quick to act but may not carefully consider her actions. In real-ity, a large portion of the nursing role involves thinking.

To be safe providers, nurses must carefully consider their ac-tions and think carefully about the patient, the treatment plan, thehealthcare environment, the patient’s support system, the nurse’ssupport system, resources, and safety.

Full-spectrum nursing involves clinical judgment, criticalthinking, and problem-solving. You will learn more about thisin Chapter 2.

Clinical judgment involves observing, comparing, con-trasting, and evaluating the client’s condition to determinewhether change has occurred. It also involves careful consid-eration of the client’s health status in light of what is expectedbased on the client’s condition, medications, and treatment.

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Profession. Although the term profession is freely used,Starr (1982) said that a group must meet certain criteria to beconsidered a profession (see Table 1-4). Nursing appears tomeet all criteria of a profession as defined by Starr.

Discipline. To be considered a discipline, a professionmust have a domain of knowledge that has both theoreticaland practical boundaries. The theoretical boundaries of aprofession are the questions that arise from clinical practiceand are then investigated through research. The practicalboundaries are the current state of knowledge and researchin the field—the facts that dictate safe practice (Meleis, 1991).A case can be made that nursing is both a profession and adiscipline:■ It is a scientifically based and self-governed profession that

focuses on the ethical care of others. ■ It is a discipline, driven by aspects of theory and practice. It

demands mastery of both theoretical knowledge and clinicalskills. Occupation. In spite of meeting criteria for both designa-

tions (profession and discipline), nursing is often described asan occupation, or job. Unlike physicians, most of whom are incontrol of their practice environment, working conditions, andschedule, most nurses are hourly wage earners. The employer,not the nurse, decides the conditions of practice and the natureof the work. Nurse practice acts do not prevent nurses fromfunctioning more autonomously, however.

Rather than continuing to develop arguments to “prove”that nursing is a profession, the following actions might domore to improve the status of nursing:■ Standardizing the educational requirements for entry into

practice


ThinkLike a Nurse 1-7 Look at the three scenarios of Nurses Make a Difference . . . Then& Now. What nursing actions did the nurses perform that arerepresented in the International Council of Nurses (ICN)definition of nursing?

American Nurses Association DefinitionYou can see similar changes in the approach of the AmericanNurses Association (ANA). In 1980, the ANA defined nursingas “the diagnosis and treatment of human responses to actualand potential health problems” (p. 2). Attempts to refine thisdefinition have been difficult. Nurses are a heterogeneousgroup of people with varying skills who perform activities de-signed to provide care ranging from basic to complex in agrowing number of settings. It is very difficult to describe theboundaries of the profession.

In 2010, the ANA acknowledged five characteristics of reg-istered nursing:1. Nursing practice is individualized.2. Nurses coordinate care by establishing partnerships (with

persons, families, support systems, and other providers).3. Caring is central to the practice of the registered nurse.4. Registered nurses use the nursing process to plan and pro-

vide individualized care to their healthcare consumers.5. A strong link exists between the professional work environ-

ment and the registered nurse’s ability to provide qualityhealth care and achieve optimal outcomes. (pp. 4–5)The ANA now defines professional nursing as the following:

The protection, promotion, and optimization of health and abilities,prevention of illness and injury, alleviation of suffering through thediagnosis and treatment of human response, and advocacy in the careof individuals, families, communities, and populations. (AmericanNurses Association [ANA], 2010)

Importance of a DefinitionYou may wonder why there has been so much emphasis oncreating a definition. Nursing organizations and leaders havepushed for accurate definitions to (1) help the public under-stand the value of nursing, (2) describe what activities androles belong to nursing versus other health professions, and (3) help students and practicing nurses understand what is expected of them within their role as nurses. Undoubtedlynursing will continue to change as nursing knowledge in-creases and society changes. Box 1-1 lists several additionaldefinitions of nursing for you to consider.

As a student entering nursing, you can use definitionsand descriptions to understand what is expected of you. To aid you in this task, Table 1-3 reviews the essential components of the nursing role. While in the clinical setting,you will observe nurses functioning in each of these capaci-ties. Nursing is a flexible career that requires you to move effortlessly among these various roles to meet the needs ofthe patient.

KnowledgeCheck 1-1■ What factors make it difficult to define nursing?■ Based on the ICN definition of nursing, what does a nurse do?

Is Nursing a Profession, a Discipline, or an Occupation?One strategy used to describe a field of work is to categorize itas a profession, a discipline, or an occupation.

■ I use the word nursing, for want of a better. It has beenlimited to signify little more than the administration of medicines and the application of poultices. It ought to signify the proper use of fresh air, light, warmth,cleanliness, quiet, and the proper choosing and giving of diet—all at the least expense of vital power to thepatient (Nightingale, 1876, p. 5).

■ Events that give rise to higher degrees of considerationfor those who are helpless or oppressed, kindliness andsympathy for the unfortunate and for those who suffer,tolerance for those of differing religion, race, color,etc.—all tend to promote activities like nursing whichare primarily humanitarian (Dock & Stewart, 1938, p. 3).

■ Nursing has been called the oldest of the arts and theyoungest of the professions. As such, it has gone throughmany stages and has been an integral part of societalmovements. Nursing has been involved in the existingculture—shaped by it and yet helping to develop it(Donahue, 1985, p. 3).

■ Nurses provide care for people in the midst of health,pain, loss, fear, disfigurement, death, grieving, challenge,growth, birth, and transition on an intimate front-linebasis. Expert nurses call this the privileged place ofnursing (Benner & Wrubel, 1989, p. xi).

■ Nursing: The care and nurturing of healthy and ill people,individually or in groups and communities [Taber’s alsoincludes as a part of the definition the ANA “essentialfeatures” involving holism, use of subjective and objectivedata, application of scientific knowledge, and provision ofa caring relationship.] (Venes, D., 2009).

BOX 1-1 ■ What Is Nursing?

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Table 1-3 ➤ Roles and Functions of the Nurse

ROLE FUNCTION EXAMPLES

Direct care provider

Communicator

Client/family educator

Client advocate

Counselor

Change agent

Leader

Manager

Case manager

Research consumer

Assessing the clientGiving medicationsPatient teaching

Counseling a clientDiscussing unit staffing needs at ameeting

Providing pregnancy preventioneducation at a local school

Preoperative teachingPrenatal education for siblingsCommunity classes on nutrition

Helping a client explain to hisfamily that he does not want tohave further chemotherapy

Counseling a client on weight-loss strategies

Working to improve thenutritional quality of the lunchprogram at a preschool

Florence NightingaleWalt WhitmanHarriet Tubman

Charge nurse on a hospital unit(e.g., assigns patients and workto staff nurses)

Coordinator of services forclients with tuberculosis

Reading journal articlesAttending continuing education;seeking additional education

Addressing the physical, emotional, social, and spiritualneeds of the client

Using interpersonal and therapeutic communicationskills to address the needs of the client, to facilitatecommunication in the healthcare team, and to advisethe community about health promotion and diseaseprevention

Assessing and diagnosing the teaching needs of theclient, group, family, or community. Once the diagnosisis made, nurses plan how to meet these needs,implement the teaching plan, and evaluate itseffectiveness.

Supporting clients’ right to make healthcare decisionswhen they are able to voice their opinions andprotecting clients from harm when they are unable tomake decisions

Using therapeutic communication skills to advise clientsabout health-related issues

Advocating for change on an individual, family, group,community, or societal level that enhances health. Thenurse may use counseling, communication, andeducator skills to accomplish this change.

Inspiring others by setting an example of positivehealth, assertive communication, and willingness toimprove

Coordinating and managing the activities of all membersof the team

Coordinating the care delivered to a client

Applying evidence-based practice to provide the mostappropriate care, to identify clinical problems thatwarrant research, and to protect the rights of researchsubjects

■ Enacting uniform continuing education requirements■ Encouraging the participation of more nurses in professional

organizations■ Educating the public about the true nature of nursing

practice

ThinkLike a Nurse 1-8 Evaluate the status of nursing. Is nursing a respected profession?Give examples to support your opinion.

How Do Nurses’ Educational PathsDiffer?The transition into the nursing profession involves the con-cepts of formal and informal processes. Formal educationconsists of completing the initial and continuing education

required for licensure. Informal education involves a gradualprogression in skill and clinical judgment that allows thenurse to advance in the profession.

Formal EducationWhen the patient calls out “Nurse!” who can respond? Tolegally use the title nurse, a person must be a graduate of an ac-credited nursing education program and have successfullypassed a licensure exam. Students may enter nursing throughtwo paths: as a practical nurse or a registered nurse. Other per-sonnel may respond to the patient’s call, but they cannotlegally be considered nurses.

Practical and Vocational Nursing EducationPractical nursing education prepares nurses to provide

bedside care to clients. Practical nurses are known as licensedpractical nurses (LPNs) or licensed vocational nurses (LVNs).

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In the United States a student who wishes to become anLPN/LVN may attend one of approximately 1,200 approvedprograms given at technical schools and community colleges.Educational programs for LPN/LVNs offer both classroomand clinical teaching and usually last 1 year. After complet-ing the practical nursing education program, the studentmust pass the NCLEX-PN® exam. Practical nurses workunder the direction of the registered nurse (RN) or the pri-mary care provider.

Registered Nursing Entry EducationCurrently, five educational pathways lead to licensure as a

registered nurse (RN). Graduates of all these programs must suc-cessfully complete the NCLEX-RN® exam to practice as RNs.■ Diploma. Until the 1960s, diploma programs were the main-

stay of nursing education. These programs are usually associ-ated with a hospital. The typical program lasts 3 years and focuses on clinical experience in direct patient care. Since the1960s the number of diploma programs has steadily decreased.In 2004, only about 4% of nursing schools were diploma pro-grams; in 2008, about 20% of U.S. RNs reported their initial education was in a diploma program (HRSA, 2010).

■ Associate degree. Most associate degree (AD) programsare offered in community colleges. Although the nursingcomponent typically lasts 2 years, students are required totake numerous other courses in liberal arts and the sci-ences. In 2008, 45% of U.S. RNs reported their initial educa-tion was in an AD program (HRSA, 2010). ADN studentsare prepared to provide direct patient care.

■ Baccalaureate degree. Students in baccalaureate programspursue a course of study like that of other undergraduate students. The course of study lasts at least eight semesters.Students are prepared to provide direct patient care, to work


Table 1-4 ➤ Nursing: Is It a Profession?

STARR CRITERION EXAMPLES IN NURSING

The knowledge of thegroup must be basedon technical andscientific knowledge.

The knowledge andcompetence ofmembers of the groupmust be evaluated by acommunity of peers.

The group must have aservice orientation anda code of ethics.

■ Entry-level nursing educationrequires coursework in basicand social sciences as well ashumanities, arts, and generaleducation.

■ Nursing education andpractice are increasinglybased on research fromnursing and related fields.

■ State or provincial regulatorybodies have defined thecriteria that nurses mustmeet to practice, and theymonitor members foradherence to standards.

■ Nursing is clearly focused on providing service toothers.

■ The major professionalorganizations have developedethical guidelines to guidethe practice of nursing.

in community care, to use research, and to enter graduate education (Bureau of Labor Statistics, 2009). In 2008, BSNgraduates accounted for 34% of U.S. RNs (HRSA, 2010).Many AD graduates enter RN-to-BSN (or RN “completion”)programs to obtain a baccalaureate degree in nursing. Thelength of time required to complete the BSN varies accordingto the program and the number of credits each student cantransfer.

■ Master’s entry. The typical student in these programs has abaccalaureate degree in another field and has entered nurs-ing as a second career. Programs usually are completed in 3 years of full-time study. At the completion, the student iseligible to take the licensing exam and is awarded a master’sdegree in nursing.

■ Doctoral entry. This is the most unusual entry pathway intonursing. The nursing doctorate (ND) path parallels the path-way through which physicians enter the healthcare field.This entry path has very limited enrollment.For several decades, nursing leaders have debated about

the most appropriate educational pathway for entry into theprofession. For an overview of this debate,

Go to Chapter 1, Supplemental Materials: Entry-into-Practice Debate, on DavisPlus.

Graduate Nursing EducationGraduate education prepares the RN for advanced practice,

expanded roles, or research. Master’s degree programs pre-pare RNs to function in a more independent role, for example,as advanced practice nurses (APNs) or educators. Programstypically last 2 years or longer. Doctoral programs in nursingoffer professional degrees. Typically the student has com-pleted a baccalaureate and master’s degree before entry into adoctoral program. Degrees awarded are usually the DNS (doc-tor of nursing science) or PhD (doctor of philosophy). TheDNS program prepares the nurse for advanced clinical prac-tice. The PhD is a research degree. For additional discussionon expanded nurse roles,

Go to Chapter 1, Supplemental Materials: ExpandedCareer Roles, on DavisPlus.

Other Forms of Formal EducationTo stay current with advances in healthcare after graduat-

ing, you must participate in ongoing education. ■ Continuing education programs are intended to ensure

that nurses keep up with current clinical knowledge.These programs are available at work sites, at colleges and universities, through privately operated educationalgroups, on the Internet, and in professional journals. In 23 states, renewal of the nursing license requires success-ful completion of a specified number of continuing educa-tion courses. When you receive your initial nursing license, your state board of nursing (SBN) will notify you about continuing education requirements, if any.Thereafter, the SBN will notify you of any changes in the requirements—regulations change frequently. For anoverview of the continuing education requirements for license renewal in the United States,

Go to Chapter 1, Supplemental Materials: ContinuingEducation Requirements for Nurses, on DavisPlus.

■ Inservice education is another form of ongoing education. Itis offered at the work site, and usually does not count

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toward meeting the continuing education requirement for license renewal. For instance, inservice education mightfocus on the use of new equipment or the introduction ofnew policies in an institution, or it may resemble traditionalcontinuing education programs.

Informal EducationIn addition to formal programs of study, education also re-quires socialization into the profession. Socialization is theinformal education that occurs as you move into your newprofession. It is the knowledge gained from direct experience,observation in the real world, and informal discussion withpeers and colleagues. Professional socialization begins whenyou enter the educational program and continues as you gainexpertise throughout your career. Informal education comple-ments formal education to create clinical competence.

Benner’s ModelPatricia Benner (1984) described the process by which a

nurse acquires clinical skills and judgment. Expertise is notmerely demonstration of skilled application of knowledge,but rather a personal integration of knowledge that requirestechnical skill, thoughtful application, and insight. That iswhat we mean in this text when we use the term full-spectrumnursing. Expertise requires thinking, doing, and caring. Ben-ner’s process occurs in stages:

Stage 1: Novice. This phase begins with the onset of educa-tion. The novice is typically receptive to education and is“learning the rules” of the profession.

Stage 2: Advanced beginner. After considerable exposure toclinical situations, nurses improve in performance and,through repeated experiences or mentoring, begin torecognize the elements of a situation. The nurse func-tioning at this level begins to use more facts and is moresophisticated with use of the rules. A new graduate usu-ally functions at this level.

Stage 3: Competence. Nurses achieve competence after afew years of practice. Competent performers havegained additional experience and wrestle with morecomplex concerns. They are able to handle their pa-tient load and prioritize situations. They are also moreinvolved in their caregiving role and may be emotion-ally involved in the clinical choices made. Althoughcompetent nurses manage clinical care with mastery,they often do not fully grasp the overall scope andmost important aspects.

Stage 4: Proficient. Proficient nurses are a resource for lessexperienced nurses. They are able to see the “big picture”and can coordinate services and forecast needs. They aremuch more flexible and fluent with their role and able toadapt to nuances of various patient situations. Proficientnurses plan intuitively as well as consciously.

Stage 5: Expert. Expert nurses are able to see what needs tobe achieved and how to do it. They trust in and use theirintuition while operating with a deep understanding ofa situation. They have expert skills and are often con-sulted when others need advice or assistance.

Benner’s model deals with the development of clinical wis-dom and competence. Nurses do not automatically movethrough the stages as they gain experience. Instead, this modelassumes that, to improve in skill and judgment, you must alsobe attuned to each clinical situation. This requires an ability to take in information from a variety of sources and to noticesubtle variations. Although expertise (stage 5) is a goal, noteveryone can achieve this level of skill.

Nursing Organization GuidelinesThe ANA and other organizations also help nurses to con-

tinue to improve their practice (e.g., by setting standards andarticulating nursing values). For example, in the Code forNurses, the ANA provides guidelines for nurses to conductthemselves in their day-to-day practice. These guidelines de-scribe behaviors and values that help improve practice andparticipation in the profession. Box 1-2 presents some valuesand behaviors associated with nursing. See Chapter 42 for fur-ther discussion of nursing values and the ANA Code forNurses.

KnowledgeCheck 1-2■ Compare and contrast formal and informal education.■ Name and describe five educational pathways leading to

licensure as an RN.

How Is Nursing Practice Regulated?Nurse Practice Acts. Nurse practice acts are laws that

regulate nursing practice. In the United States, each state en-acts its own nurse practice act. The state board of nursing is theagency responsible for regulating nursing practice. Althoughthere are minor variations, each board of nursing is responsi-ble for the following:■ Defining the practice of nursing■ Establishing criteria that allow a person to be considered a

registered nurse (RN) or licensed practical or vocationalnurse (LPN/LVN)

■ Determining activities that are in the scope of practice ofnursing: that nurses may perform (and by implication, thosethey may not); and those that may be performed only by li-censed nurses

■ Enforcing the rules that govern nursingTo practice nursing, an individual must be licensed as a

nurse. Licenses are issued by the state. All states require gradu-ation from an approved nursing program and successful com-pletion of the National Council Licensure Exam (NCLEX®). To receive licensure in another state, the nurse simply appliesfor reciprocity. For further details about licensing and the regu-lation of nursing practice, see Chapter 43.

Standards of Practice. Nursing is also guided by stan-dards of practice, which “describe a competent level of nurs-ing practice and professional performance common to allregistered nurses. . . . They are authoritative statements of theduties that all registered nurses, regardless of role, popula-tion, or specialty, are expected to perform competently”(ANA, 2010, p. 2). Standards are used by individual nurses,employers of nurses, professional organizations, and otherprofessions.

As a student of nursing, you may use the ANA standards ofnursing practice to get a better understanding of nursing(Table 1-5). Practicing nurses use the standards to judge their


■ The nurse’s primary concern is the good of the patient.■ Nurses ought to be competent.■ Nurses demonstrate a strong commitment to service.■ Nurses believe in the dignity and worth of each person.■ Nurses constantly strive to improve their profession.■ Nurses work collaboratively within the profession.

BOX 1-2 ■ Nursing Values and Behaviors

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Table 1-5 ➤ American Nurses Association: Scope and Standards of Clinical Nursing Practice Standards of Care

Standard 1

Standard 2

Standard 3

Standard 4

Standard 5

Standard 5A

Standard 5B

Standard 5C

Standard 5D

Standard 6

Standards of Professional Performance

Standard 7

Standard 8

Standard 9

Standard 10

Standard 11

Standard 12

Standard 13

Standard 14

Standard 15

Standard 16

Source: American Nurses Association (2010). Nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Nursebooks.org.

The registered nurse collects comprehensive data pertinent to thehealthcare consumer’s health and/or the situation.

The registered nurse analyzes the assessment data to determine thediagnoses or the issues.

The registered nurse identifies expected outcomes for a planindividualized to the healthcare consumer or situation.

The registered nurse develops a plan that prescribes strategies andalternatives to attain expected outcomes.

The registered nurse implements the identified plan.

The registered nurse coordinates care delivery.

The registered nurse employs strategies to promote health and a safeenvironment.

The graduate-level prepared specialty nurse or advanced practiceregistered nurse provides consultation to influence the identified plan,enhance the abilities of others, and effect change.

The advanced practice registered nurse uses prescriptive authority,procedures, referrals, treatments, and therapies in accordance withstate and federal laws and regulations.

The registered nurse evaluates progress toward attainment ofoutcomes.

The registered nurse practices ethically.

The registered nurse attains knowledge and competence that reflectscurrent nursing practice.

The registered nurse integrates evidence and research findings intopractice.

The registered nurse contributes to quality nursing practice.

The registered nurse communicates effectively in all areas ofpractice.

The registered nurse demonstrates leadership in the professionalpractice setting and the profession.

The registered nurse collaborates with healthcare consumer, family, andothers in the conduct of nursing practice.

The registered nurse evaluates her or his own nursing practice inrelation to professional practice standards and guidelines, relevantstatutes, rules, and regulations.

The registered nurse utilizes appropriate resources to plan andprovide nursing services that are safe, effective, and financiallyresponsible.

The registered nurse practices in an environmentally safe and healthymanner.

Assessment

Diagnosis

Outcome Identification

Planning

Implementation

Coordination of Care

Health Teaching andHealth Promotion

Consultation

Prescriptive Authorityand Treatment

Evaluation

Ethics

Education

Evidence-Based Practiceand Research

Quality of Practice

Communication

Leadership

Collaboration

Professional PracticeEvaluation

Resource Utilization

Environmental Health

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own performance, develop an improvement plan, and under-stand what employers expect of them. Employers incorporatethe standards into annual evaluation tools at hospitals andhealth facilities. Professional organizations use the standardsto educate the public about nursing, to plan for continuing education programs for nurses, and to guide their efforts atlobbying and other activities that advocate for nurses. Finally,other professions read the standards of practice to examine theboundaries between nursing and other health professions.

ThinkLike a Nurse 1-9 What additional information have you learned about nursingfrom your review of the American Nurses Association (ANA)and Canadian Nurses Association (CNA) standards of practice?

What Are Some Important NursingOrganizations?Numerous organizations are involved in the profession ofnursing. Some of the most influential are discussed here.

American and Canadian Nurses AssociationsThe ANA and the CNA are the official professional organiza-tions for nurses in their respective countries. Both of theseorganizations were formed in 1911 from an organization pre-viously known as the Nurses’ Associated Alumnae of theUnited States and Canada.

Originally, these organizations focused on establishing stan-dards of nursing to promote high-quality care and work towardlicensure as a means of ensuring adherence to the standards.Representatives are elected from the local branches of the stateorganizations to bring their concerns to the national level. Assuch, they track healthcare legislation, serve as liaisons with national government representatives to inform them of howcurrent and proposed legislation will affect nursing, and de-velop and sponsor legislation that will have a positive effect onnursing and on patient care. The ANA publishes educationalmaterials on nursing news, issues, and standards.

National League for NursingOriginally founded as the American Society of Superintend-ents of Training Schools for Nurses in 1893, the NationalLeague for Nursing (NLN) was the first nursing organizationwith a goal to establish and maintain a universal standard ofeducation. The NLN sets standards for and evaluates all typesof nursing education programs, studies the nursing work-force, lobbies and participates with other major healthcare organizations to set policy for the nursing workforce, aids fac-ulty development, funds research on nursing education, andpublishes the journal Nursing Education Perspectives.

International Council of NursingThe International Council of Nursing (ICN) represents nurs-ing on a global level. It is composed of a federation of nationalnursing organizations from more than 120 nations. The ICNaims to ensure quality nursing care for all, supports globalhealth policies that advance nursing and improve worldwidehealth, and strives to improve working conditions for nursesthroughout the world.

National Student Nurses AssociationThe National Student Nurses Association (NSNA) representsnursing students in the United States. It is the student coun-terpart of the ANA. Like the ANA, this association is made up

of elected volunteers who advocate on behalf of studentnurses. The NSNA sponsors yearly conventions to addressstudent concerns. Local chapters are usually organized at in-dividual schools. The NSNA also publishes Image, a journaldedicated to nursing student issues. In Canada, the CanadianUniversity Student Nurses Association serves in the same ca-pacity as the NSNA.

Sigma Theta Tau InternationalSigma Theta Tau International (STTI) is the national honor society for nursing. Members are sought from the clinical, educator, and researcher nursing communities as well as fromsenior-level baccalaureate and graduate programs. The goal ofthis organization is to foster nursing scholarship, leadership,and research.

Specialty OrganizationsNumerous specialty organizations have developed aroundclinical specialties, group identification, or similarly held values.The following are some examples:■ Clinical specialty. Association of Operating Room Nurses

(AORN); Association of Nurses in AIDS Care (ANAC);Emergency Nurses Association (ENA)

■ Group identification. National Organization for AssociateDegree Nursing (NOADN), National Association of HispanicNurses (NAHN), American Assembly for Men in Nursing(AMN)

■ Similar values. Nurses Christian Fellowship (NCF), Nurs-ing Ethics Network (NEN) Web sites of a variety of nursing organizations are identi-

fied on DavisPlus.

Go to Chapter 1, Resources for Caregivers and HealthProfessionals, on DavisPlus.

CONTEMPORARY NURSING: CARING FOR CLIENTSLook again at the definitions of nursing you have read in thischapter (e.g., Box 1-1). Notice that they all agree that nursingis about caring for clients. Recent studies show that when thepercentage of RNs increases in an agency, quality of carerises, death and infection rates drop (Potera, 2007), andlength of stay is shorter by at least 30% (Kane, Shamliyan,Mueller, et al., 2007).

Who Are the Recipients of NursingCare?The recipients of nursing care may be individuals, groups,families, or communities. They can be referred to as patients,clients, or persons. Direct care involves personal interactionbetween the nurse and clients (e.g., giving medications orteaching a client about a treatment). Nurses deliver indirectcare when they work on behalf of clients to improve theirhealth status (e.g., restocking a resuscitation cart or arrang-ing unit staffing). A nurse may use independent judgment todetermine the care needed or may work under the directorder of a primary care provider.

As a nurse, you should not view patients as passive recipi-ents of care. On the contrary, nurses should actively encouragepatients’ involvement in decisions about their care, and facili-tate their participation as collaborative members of the health-care team (e.g., by being informed and speaking up about theirconcerns).


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What Are the Purposes of NursingCare?Nurses provide care to achieve the goals of health promotion,illness prevention, health restoration, and end-of-life care. To-gether these aspects of care represent a range of services thatcover the health spectrum from complete well-being to death.

Health PromotionThe World Health Organization, in 1948, defined health as“a state of complete physical, mental, and social well-beingand not merely the absence of disease or infirmity.” The definition has not been changed since that time (WHO,2007). This inclusive definition can be applied to individu-als, groups, families, or communities. Health promotionactivities foster the recipient’s highest state of well-being.For example, at the individual level you might counsel apregnant client about the importance of adequate prenatalnutrition to promote health. Group and family-level healthpromotion activities might include teaching about nutritionduring pregnancy in family education programs. On a com-munity level your activities would be focused on reaching alarger number of people. For example, you could post signsin grocery stores recommending food sources for pregnantwomen and lobby for the labeling of substances that shouldbe avoided in pregnancy.

Illness PreventionIllness prevention focuses on avoidance of disease, infection,and other comorbidities. Activities are targeted to decrease therisk of developing an illness or to minimize the risk of exposureto disease. For example, pneumonia affects society’s most vul-nerable: the very young, the very old, and the very ill. Somenursing activities to decrease the risk of pneumonia include:■ Teaching the importance of hand hygiene to decrease the

transmission of infection■ Advocating for and administering pneumonia immuniza-

tions to those at high risk

Health RestorationHealth restoration activities foster a return to health for thosealready ill. To restore health, the nurse provides direct care toill individuals, groups, families, or communities. Direct care iswhat most people think of when they envision the nursingrole. Recall that health has physical, mental, and social dimen-sions. When you engage in health-restoration activities, yourcare should address each of these dimensions, for example:■ Providing hygiene care■ Providing client teaching■ Lobbying for health policy changes to improve access to care

End-of-Life CareDeath is the inevitable destination on the journey of life.Nurses have been active in promoting the respectful care ofthose who are terminally ill or dying. Nursing activities for thedying are designed to promote comfort, maintain quality oflife, provide culturally relevant spiritual care, and ease theemotional burden of death. Nurses work with dying individu-als, their family members and support persons, and organiza-tions that focus on the needs of the terminally ill. You willlearn more about this in Chapter 17.

KnowledgeCheck 1-3Recall the last time you had a cold. Identify health-promotion,illness-prevention, and health-restoration activities for

individuals, families, groups, and communities in relation to thecommon cold.

Where Do Nurses Work?As a nurse you will have the opportunity to work in a varietyof settings. During your education you will have assignmentsin many settings and clinical units that will allow you to see some of the options available to you upon graduation. Approximately 62% of nurses work in hospitals. The remain-ing 40% work in extended care facilities, ambulatory care,home health settings, public health, or nursing education(HRSA, 2010).

Hospitals. Hospitals provide services to patients whorequire around-the-clock nursing care. This type of care is frequently referred to as acute care. Length of stay is lim-ited to the amount of time that the client requires 24-hourobservation.

Extended Care Facilities. These facilities provide carefor clients for an extended period of time—usually longer than1 month. They include nursing homes, skilled nursing facili-ties (also known as convalescent hospitals), and rehabilitationfacilities. The distinction among them is based primarily onwhether they provide skilled or custodial care. Skilled careincludes services of trained professionals that are needed for alimited period of time after an injury or illness. Custodial careconsists of help with activities of daily living: bathing, dress-ing, eating, grooming, ambulation, toileting, and other carethat people typically do for themselves (e.g., taking medica-tions, monitoring blood glucose levels).■ A nursing home provides custodial care for people who

cannot live on their own but are not sick enough to requirehospitalization. It provides a room, custodial care, andrecreation. In the United States approximately 16,000 nurs-ing homes provide care for approximately 1.7 million residents (Centers for Disease Control and Prevention[CDC], n.d.).

■ A skilled nursing facility primarily provides skilled nurs-ing care for patients who can be expected to improve withtreatment. For example, a patient who no longer needshospitalization may transfer to a skilled nursing facilityuntil she is able to return home.Ambulatory Care. Ambulatory care is also referred to as

outpatient care. Clients live at home or in nonhospital settingsand come to the site for care. Ambulatory care sites includeprivate health and medical offices; clinics; outpatient therapycenters; and walk-in clinics in shopping centers, pharmacies,and other retail sites. Typically they treat only common ail-ments and refer complex or serious illnesses to specializedphysicians or emergency rooms (Darcé, 2007).

Home Care. Home healthcare is provided to clients whoare homebound or unable to get to ambulatory care centers forservices. Home care services may also be used when the clientor family prefers to receive care in the home—particularlywhen the client is terminally ill. Home care is also appropriatewhen a client still requires skilled care but is discharged fromthe hospital because his reimbursable length-of-stay has ex-pired. Services are usually coordinated by a home health orvisiting nurse service and include nursing care as well as vari-ous therapies and home assistance programs.

Community Health. Community health deals with carefor the community at large. Community health nurses provideservices to at-risk populations and devise strategies to im-prove the health status of the surrounding community. Exam-ples of community health programs include healthcare for the


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homeless and school-based programs designed to decrease theincidence of teen pregnancies. Community, public health, andhome care are discussed in Chapter 41.

The Healthcare Delivery SystemFor an expanded discussion of the preceding workplaces andservices, as well as the organization and regulation of thehealthcare delivery system in the United States,

Go to Chapter 1, Healthcare Delivery Systems—Expanded Discussion, on DavisPlus.

QSEN Commission and QualityImprovementRecall that the Quality and Safety Education for Nurses(QSEN) project and the Institute of Medicine (IOM) have identified quality and safety competencies for nurses.You will find those in the accompanying QSEN box. Yournursing education should enable you to achieve these competencies.

To see the KSAs for the QSEN competencies,

Go to the QSEN web site, athttp://www.qsen.org/ksas_prelicensure.php

One important QSEN competency is quality improve-ment (QI). QSEN defines that competence as the ability to“use data to monitor the outcomes of care processes and useimprovement methods to design and test changes to continu-ously improve the quality and safety of healthcare systems”(Cronenwett, Sherwood, Barnsteiner, et al., 2007). For moredetailed information about quality improvement programsand processes,

Go to Chapter 1, Supplemental Materials: How DoProviders and Facilities Ensure Quality Care, on DavisPlus.

WHAT FACTORS INFLUENCECONTEMPORARY NURSING PRACTICE?Contemporary nursing practice is influenced by factors out-side the profession in society at large, and factors within nurs-ing and healthcare.

Trends in SocietyAs you have seen, our historical roots strongly influence cur-rent nursing practice and will undoubtedly continue to do so.In addition, nursing is influenced by trends in the economy,the growing number of older adults, increased consumerknowledge, legislation, the women’s movement, and collec-tive bargaining.

The National Economy. The economy has a tremen-dous impact on nursing. In the United States, health insur-ance coverage is linked to full-time employment with healthinsurance benefits (although that is changing with recent federal legislation). Thus, when unemployment is high orbusinesses reduce their employee healthcare benefits, fewerpeople have insurance. Fearing the high cost of healthcare,many uninsured people delay seeking treatment. The effect isthat they are often sicker when they enter the healthcare system. This taxes the system’s resources and raises the levelof nursing care required.

Another consideration is that the healthcare industry—evenin a strong economy—is very expensive to operate. Downturnsin the economy affect institutional investments and profits, andthe amount of taxes the government can collect; these in turnlimit the medications and services that are available in public-supported healthcare programs. Similarly, the salaries of health-care providers are influenced by national economic trends.

The Growing Proportion of Older Adults in theUnited States. A larger older adult population creates aneed for more medical and nursing care; at the same time,there are fewer younger people to provide care. The growthrate for adults 65 years and older has greatly outpaced thegrowth of the population of the country as a whole. In 2007,13% of the total U.S. population was 65 and older. By theyear 2030, about one in five people will be age 65 and older,and the oldest old (those 85 years and older) will continue tobe the fastest growing part of the population into the nextcentury (Hobbs, 2001; U.S. Census Bureau, 2007). As peopleage, they tend to need more assistance with activities of daily living, and they experience more acute and chronicillnesses.

Changes in Healthcare Consumers. Historically, pa-tients relied on the knowledge and decision making of the


QSE

N

What are QSEN Competencies?

Competencies

Patient-Centered Care, Teamwork and Collaboration,Evidence-Based Practice, Quality Improvement, Safety,Informatics

The QSEN (pronounced cue-zen) competencies are sixareas of expertise nursing students are expected toacquire before graduation. Each competency includes alist of associated knowledge, skills, and attitudes (KSAs)that operationalize the concepts. The six competenciesand their definitions are as follow:➤ Patient-Centered Care: Recognize the patient or

designee as the source of control and [a] full partner[when] providing compassionate and coordinated carebased on respect for patient’s preferences, values, andneeds.

➤ Teamwork and Collaboration: Function effectivelywithin nursing and inter-professional teams, fosteringopen communication, mutual respect, and shareddecision making to achieve quality patient care.

➤ Evidence-Based Practice: Integrate best currentevidence with clinical expertise and patient/familypreferences and values for delivery of optimal HC[healthcare].

➤ Quality Improvement (QI): Use data to monitorthe outcomes of care processes and use improvementmethods to design and test changes to continuouslyimprove the quality and safety of HC systems.

➤ Safety: Minimize risk of harm to patients andproviders through both system effectiveness andindividual performance.

➤ Informatics: Use information and technology tocommunicate, manage knowledge, mitigate error, andsupport decision-making.

Source: Cronenwett, L, et al (2007). See Appendix A for specificKnowledge, Skills and Attitudes.

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physician or the healthcare team. Now, however, consumersare demanding greater choice in the decisions that affecttheir health, including legislation. Patients have access tovast amounts of health and medical information, particu-larly through the Internet (e.g., through Web sites such asWebMD). Informed consumers tend to be active participantsin discussions about their health problems and therapy options. Clients may request their healthcare providers toprescribe specific trade name therapies they have heardabout in the media, so nurses need to be prepared to addressthe truthfulness of the advertisements, present balanced information to clients, and address the appropriateness ofthe advertised products and services for the individual person’s needs.

The Women’s Movement. Historically, only unmarriedwomen were allowed to practice nursing. As the women’smovement gained momentum, women were no longer forcedout of nursing if they chose to have a family. However, thewomen’s movement also opened up more career choices forwomen, and nursing has become just one of many options asopposed to a preferred career pathway. Also, as you have seen,societal views of nursing as a women’s profession influencethe decisions of men to enter nursing.

Collective Bargaining. Collective bargaining is a form ofnegotiating that allows nurses to seek better wages and work-ing conditions as a group rather than individually. A union or organization that represents the nurses usually conductscollective bargaining. Collective bargaining has resulted insignificant improvements in wages, benefits, and workingconditions for nurses, as well as safer conditions for patients.Not all states have collective bargaining groups for nurses.

ThinkLike a Nurse 1-10What effect do you think the women’s movement has had onthe number of women in the nursing workforce? Speculate alsoon the ways in which women entering nursing might have beendifferent before and after the women’s movement.

Trends in Nursing and HealthcareIn addition to societal factors, trends in nursing and healthcarealso affect contemporary practice. We discuss the most signifi-cant trends here.

Increased Use of Complementary and Alternative MedicineComplementary and alternative medicine (CAM) consists ofhealthcare treatments or services outside the traditionalhealthcare system. CAM includes homeopathy, naturopathy,chiropractic, and traditional Chinese medicine, as well as spe-cific treatments, such as herbal medications, dietary changes,massage therapy, yoga, aromatherapy, prayer, and hypnotism.The following factors have contributed to this interest in CAM. Many people have turned to CAM as a result of the rising costs of traditional care, concern about the safety of tra-ditional healthcare, distrust of the role of insurance and man-aged care organizations in determining treatment options, andconfusion over changing recommendations (e.g., how often tohave a screening exam for breast cancer). In addition, as thepopulation becomes more culturally diverse, there is an ac-companying exchange of information about therapies fromdifferent cultural traditions. If you want to know more aboutCAM, see Chapter 46.

Go to Chapter 46, Holistic Healing, on DavisPlus.

Expanded Variety of Settings for CareNearly 40% of RNs now work outside the hospital setting, ascompared to 20% in 1980 (ANA, 2010; HRSA, 2010; Jonas &Kovner, 2005). As the site of employment shifts away fromthe hospital, nurses must be prepared to function in these alternative settings. This change requires entry-level edu -cation programs to prepare nurses for this type of work(Wilkinson, 1996). In the hospital, nurses have access to sup-port personnel, consultation with other nurses and health-care providers, ready access to equipment and diagnostictesting services, and increased access to the patient. In outpa-tient, community, or home settings, nurses must be preparedto function more autonomously and creatively, adapting careto the equipment available at the site.

ThinkLike a Nurse 1-11What is your nursing program doing to prepare you to workoutside the hospital setting?

Interest in Interprofessional CollaborationThe growing role of nursing outside the hospital, the increasingcomplexity of care, the limited supply of nurses, and the in-creased use of technology are changing nursing from a largelysupportive role to one of increasing responsibility. More andmore, leaders in healthcare are finding interprofessional team-work to be essential to providing safe, high-quality patient out-comes.

Collaboration is the process of joint decision making amongindependent parties, involving joint ownership of decisionsand collective responsibility for outcomes (Disch, Bellman, &Ingbar, as cited in Sterchi, 2001). However, in a relationship in which there is a power imbalance, true collaboration canoccur only if the more powerful parties are willing. Physiciansand nurses tend to have different values and to place differentemphases on patient care. This may contribute to strained rela-tionships and disagreements about a patient’s plan of care,which may lead to undesired outcomes for patients. True collaboration occurs when institutions state it as a goal andgive recognition to those who practice it.

Increased Use of Advanced Practice NursesThe increased use of advanced practice nurses (APNs) has resulted in greater public exposure for nurses. Professionaland public reports (e.g., Tourangeau, Doran, Hall, et al., 2007)demonstrate high patient satisfaction with APNs; compara-ble, and at times superior, patient outcomes over physician-provided care; better understanding of and compliance withtreatment regimen; fewer hospitalizations; and greater costeffectiveness when compared with physician providers. Thispositive exposure has resulted in increased acceptance andsupport for all nurses.

Increased Use of Nursing Assistive PersonnelNursing assistive personnel (NAP) are healthcare providerswho help nurses and physicians provide patient care. Com-mon NAP roles include nurse aide, assistant, orderly, and tech-nician. NAPs may perform simple nursing tasks (e.g., bathing,taking temperatures, or making beds) under the direction ofthe licensed nurse. Some institutions even train NAPs formore complex tasks traditionally reserved for licensed nurses


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(e.g., inserting urinary catheters, giving certain medications).This redistribution of workload has prompted controversyabout safety and quality of care.

Although it may seem appropriate to allow the NAP to as-sume the simple tasks, this distances the licensed nurse frommany aspects of direct patient care. The nurse retains ultimateresponsibility for the patient, yet may have to base importantpatient care decisions on information obtained by the NAP.Unfortunately many nurses now in practice were never taughtin their formal nursing programs about delegation and super-vision, so they are uncertain about what they can safely andlegally delegate and how much responsibility they retain. Toremedy this problem, nursing schools are now adding course-work on delegation; and textbooks, such as this one, includeinformation about delegation.

Influence of Nurses on Healthcare PolicyProfessional nursing organizations are actively involved inlocal, state, and national politics. Each of the major profes-sional organizations actively lobbies and educates elected andappointed officials about the role of nursing in healthcare.Nursing organizations sponsor legislation that promotes theinterest of the profession and supports changes that positivelyinfluence health outcomes. Nurse-sponsored legislation hasaddressed safe staffing in hospitals, needle-exchange pro-grams to decrease the transmission of HIV and other infec-tious diseases, and funding to increase nursing enrollmentduring times of nursing shortages.

As individuals, nurses should vote, lobby their elected representatives, and run for political office. Together, nursesrepresent the largest health professional group; as a votingblock, they have strong political power. Many nurses organizelocal nursing groups to support candidates or legislation, orspeak out in the community on health and nursing issues.Nurses are typically trusted and respected political candidates,

running successful campaigns at the local, state, and nationallevel. You should consider all of these political activities as youmove into the profession.

Divergence Between High-Tech and High-TouchAdvances in clinical knowledge and technology have con-tributed to improved care for many patients who are criticallyill (e.g., premature newborns and patients with advanced car-diovascular, pulmonary, or renal disease). However, in pro-longing life, technology has created numerous legal and ethicaldilemmas, particularly about end-of-life care. This trend is incontrast to the concurrent trend toward holism and high-touchtherapies, which often avoid technology. One of the challengesin healthcare is integrating these two divergent trends. For anexcellent discussion on these colliding values, read HolisticHealth and Healing by Mary Anne Bright (2002).


Toward Evidence-Based PracticeCapezuti, E., Wagner, L., Brush, B., et al. (2007). Consequencesof an intervention to reduce restrictive siderail use in nursing homes. Journal of the American Geriatrics Society,55(3), 334–341.

This study of more than 700 nursing home residents at foursites found that routine use of side rails does not reduce therisk of bed-related falls.

Brush, B. L., & Capezuti, E. (2001). Historical analysis ofsiderail use in American hospitals. Journal of NursingScholarship, 33(4), 381–385.

This study used social historical research methods toexamine the pattern of siderail use, the value attached toside rails, and attitudes about raising side rails over time.Initially siderails were used for temporary protection ofconfused patients. Siderails on adult beds were rare until the 1930s; nurses used continual watchfulness to ensurepatient safety. During the 1930s, recurrent nurse shortages,litigation against hospitals and nurses for fall-related injuries,

and the move away from ward structure towardsemiprivate and private rooms all promoted the use ofsiderails instead of nursing observation. They now havebecome a permanent fixture of the hospital bed. However,recent research has demonstrated that side rail-inducedinjuries may occur. In spite of these recent research-basedfindings, side rail use remains the norm in promoting patientsafety.

1. What trends and factors currently affecting nursing mightinfluence whether siderail use will change in the near future?

2. What additional information would you like to know beforeadvocating for a change in siderail use?

Go to Chapter 1, Toward Evidence-Based PracticeSuggested Responses, on DavisPlus.

To explore learning resources for this chapter,

Go to DavisPlus at http://www.Davisplus.fadavis.com,keyword Treas.

Chapter Resources for Chapter 1:Knowledge Check and Think Like a Nurse Response

Sheets Knowledge Check AnswersResources for Caregivers and Health ProfessionalsReading More About Nursing Past & Present

(Suggested Readings)What Are the Main Points in This Chapter?

NCLEX-Style Review QuestionsChapter Overview Podcasts

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Educational pathways

Internalfactors

Externalfactors

Include ANA and CNANLNICN

NSNASpecialty organizations

InfluenceInfluenceInfluence Influence

Guides Guides

Nursing values Nursing organizations

Nursing Practice

Contemporary Nursing

CaringHealth promotionIllness preventionHealth restoration

End-of-life care

Full-SpectrumNursing

Clinical judgmentCritical thinkingProblem-solving

FunctionsDirect care provider

CommunicatorEducator, Advocate

Counselor, Change agentLeader, ManagerCase manager

Include

Patientis primary concernCompetent practice

Commitment to serviceDignity and worth of patientProfessional improvement

Collaboration withinprofession

Evolution of Nursing

History Stereotypes Societal/healthcare trends

Concept Map

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meet the nguyens

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