Forum: Discussion 1


The Pedagogy

Role Development in Professional Nursing Practice, Fifth Edition drives comprehension through various strategies that meet the learning needs of students while also generating enthusiasm about the topic. This interactive approach addresses different learning styles, making this the ideal text to ensure mastery of key concepts. The pedagogical aids that appear in most chapters include the following:

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Library of Congress Cataloging-in-Publication Data

Names: Masters, Kathleen, editor. Title: Role development in professional nursing practice / [edited by]

Kathleen Masters. Description: Fifth edition. | Burlington, Massachusetts : Jones & Bartlett

Learning, 2018. | Includes bibliographical references and index. Identifiers: LCCN 2018023086 | eISBN 9781284152920 Subjects: | MESH: Nursing--trends | Nursing--standards | Professional

Practice | Nurse’s Role | Philosophy, Nursing Classification: LCC RT82 | NLM WY 16.1 | DDC 610.73--dc23 LC record available at


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This book is dedicated to my Heavenly Father and to my loving family: my husband, Eddie, and my two daughters, Rebecca and Rachel. Words cannot express my appreciation for their ongoing encouragement and

support throughout my career.


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Preface Contributors


A History of Health Care and Nursing Karen Saucier Lundy and Kathleen Masters

Classical Era Middle Ages The Renaissance The Dark Period of Nursing The Industrial Revolution And Then There Was Nightingale . . . Continued Development of Professional Nursing in the United Kingdom The Development of Professional Nursing in Canada The Development of Professional Nursing in Australia Early Nursing Education and Organization in the United States





The Evolution of Nursing in the United States: The First Century of Professional Nursing The New Century International Council of Nurses Conclusion References

Frameworks for Professional Nursing Practice Kathleen Masters

Overview of Selected Nursing Theories Overview of Selected Nonnursing Theories Relationship of Theory to Professional Nursing Practice Conclusion References

Philosophy of Nursing Mary W. Stewart

Philosophy Early Philosophy Paradigms Beliefs Values Developing a Personal Philosophy of Nursing Conclusion References

Competencies for Professional Nursing Practice Jill Rushing and Kathleen Masters

Overview Nurse of the Future: Nursing Core Competencies Critical Thinking, Clinical Judgment, and Clinical Reasoning in Nursing Practice Conclusion References

Education and Socialization to the Professional Nursing Role Kathleen Masters and Melanie Gilmore




Professional Nursing Roles and Values The Socialization (or Formation) Process Facilitating the Transition to Professional Practice Conclusion References

Advancing and Managing Your Professional Nursing Career Mary Louise Coyne and Cynthia Chatham

Nursing: A Job or a Career? Trends That Affect Nursing Career Decisions Showcasing Your Professional Self Mentoring Education and Lifelong Learning Professional Engagement Expectations for Your Performance Taking Care of Self Conclusion References

Social Context and the Future of Professional Nursing Mary W. Stewart, Katherine E. Nugent, and Kathleen Masters

Nursing’s Social Contract with Society Public Image of Nursing The Gender Gap Changing Demographics and Cultural Competence Access to Health Care Societal Trends Trends in Nursing Conclusion References


Safety and Quality Improvement in Professional Nursing Practice Kathleen Masters




Patient Safety Quality Improvement in Health Care Quality Improvement Measurement and Process The Role of the Nurse in Quality Improvement Conclusion References

Evidence-Based Professional Nursing Practice Kathleen Masters

Evidence-Based Practice: What Is It? Barriers to Evidence-Based Practice Promoting Evidence-Based Practice Searching for Evidence Evaluating the Evidence Implementation Models for Evidence-Based Practice Conclusion References

Patient Education and Patient-Centered Care in Professional Nursing Practice Kathleen Masters

Dimensions of Patient-Centered Care Communication as a Strategy to Support Patient-Centered Care Patient Education as a Strategy to Support Patient-Centered Care Evaluation of Patient-Centered Care Conclusion References

Informatics in Professional Nursing Practice Kathleen Masters and Cathy K. Hughes

Informatics: What Is It? The Effect of Legislation on Health Informatics Nursing Informatics Competencies Basic Computer Competencies Information Literacy Information Management Current and Future Trends





Conclusion References

Leadership and Systems-Based Professional Nursing Practice Kathleen Masters and Sharon Vincent

Healthcare Delivery System Nursing Leadership in a Complex Healthcare System Nursing Models of Patient Care Roles of the Professional Nurse Conclusion References

Teamwork, Collaboration, and Communication in Professional Nursing Practice Kathleen Masters

Interprofessional Teams and Healthcare Quality and Safety Interprofessional Collaborative Practice Domains Interprofessional Team Performance and Communication Conclusion References

Ethics in Professional Nursing Practice Janie B. Butts and Karen L. Rich

Ethics Ethical Theories and Approaches Professional Ethics and Codes Ethical Analysis and Decision Making in Nursing Relationships in Professional Practice Moral Rights and Autonomy Social Justice Death and End-of-Life Care Conclusion References

Law and Professional Nursing Practice Kathleen Driscoll and Kathleen Masters

The Sources of Law

Classification and Enforcement of the Law Nursing Scope and Standards Malpractice and Negligence Nursing Licensure Professional Accountability Conclusion References

Appendix A Provisions of Code of Ethics for Nurses Appendix B The ICN Code of Ethics for Nurses Glossary Index

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Although the process of professional development is a lifelong journey, it is a journey that begins in earnest during the time of initial academic preparation. The goal of this book is to provide nursing students with a road map to help guide them along their journey as professional nurses.

This book is organized into two units. The chapters in the first unit focus on the foundational concepts that are essential to the development of the individual professional nurse. The chapters in Unit II address issues related to professional nursing practice and the management of patient care, specifically in the context of quality and safety. In the Fifth Edition, the chapter content is conceptualized, when applicable, around nursing competencies, professional standards, and recommendations from national groups, such as Institute of Medicine reports. All chapters have been updated, several chapters have been expanded, and two new chapters have been added in this edition. The chapters included in Unit I provide the student nurse with a basic foundation in such areas as nursing history, theory, philosophy, socialization into the nursing role, professional development, the social context of nursing, and professional nursing competencies. The social context of nursing chapter has been

expanded to incorporate not only societal trends but also trends in nursing practice and education that are changing the future landscape of the profession. The chapters in Unit II are more directly related to patient care management and, as stated previously, are presented in the context of quality and safety. Chapter topics include the role of the nurse in patient safety and quality improvement, evidence-based nursing practice, the role of the nurse in patient education and patient-centered care, informatics in nursing practice, the role of the nurse related to teamwork and collaboration, systems-based practice and leadership, ethics in nursing practice, and the law as it relates to patient care and nursing. Unit II chapters have undergone revision, with a refocus of the content on recommended nursing and healthcare competencies as well as recommendations from faculty using the text in the classroom.

The Fifth Edition incorporates the revised Nurse of the Future: Nursing Core Competencies: Registered Nurse throughout each chapter. The 10 essential competencies that are intended to guide nursing curricula and practice emanate from the central core of the model that represents nursing knowledge (Massachusetts Department of Higher Education, 2016) and are based on the American Association of Colleges of Nursing (AACN) Essentials of Baccalaureate Education for Professional Nursing Practice, National League for Nursing Council of Associate Degree Nursing competencies, Institute of Medicine recommendations, Quality and Safety Education for Nurses (QSEN) competencies, and American Nurses Association standards, as well as other professional organization standards and recommendations. The 10 competencies included in the model are patient-centered care, professionalism, informatics and technology, evidence-based practice, leadership, systems-based practice, safety, communication, teamwork and collaboration, and quality improvement. Essential knowledge, skills, and attitudes (KSAs) reflecting cognitive, psychomotor, and affective learning domains are specified for each competency. The KSAs identified in the model reflect the expectations for initial nursing practice following the completion of a prelicensure professional nursing education program (Massachusetts Department of Higher Education, 2016).

This new edition has competency boxes throughout the chapters that link examples of the KSAs appropriate to the chapter content to Nurse of the Future: Nursing Core Competencies required of entry-level

professional nurses. The competency model is explained in detail in Chapter 4 and is available in its entirety online at

The Fifth Edition also includes applicable AACN essentials incorporated as key outcomes throughout each chapter to assist faculty with the alignment of curricular content with criteria required by accreditors. The key outcomes also demonstrate for students the link between expectations included in the competency model, the expectations embodied in the essentials document, and the chapter content. A discussion of the AACN (2008) Essentials of Baccalaureate Education for Professional Nursing Practice is also included in Chapter 4.

This new edition continues to use case studies, congruent with Benner, Sutphen, Leonard, and Day’s (2010) Carnegie Report recommendations that nursing educators teach for “situated cognition” using narrative strategies to lead to “situated action,” thus increasing the clinical connection in our teaching or that we teach for “clinical salience.” In addition, critical thinking questions are included throughout each chapter to promote student reflection on the chapter concepts. Classroom activities are also provided based on chapter content. Additional resources not connected to this text, but applicable to the content herein, include a toolkit focused on the nursing core competencies available at March2016.pdf and teaching activities related to nursing competencies available on the QSEN website at

Although the topics included in this textbook are not inclusive of all that could be discussed in relationship to the broad theme of role development in professional nursing practice, it is my prayer that the subjects herein make a contribution to the profession of nursing by providing the student with a solid foundation and a desire to grow as a professional nurse throughout the journey that we call a professional nursing career. Let the journey begin.

—Kathleen Masters

References American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved

from Essentials

Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.

Massachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. Retrieved from

Editor Kathleen Masters, DNS, RN Professor and Dean University of Southern Mississippi College of Nursing Hattiesburg, Mississippi

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Janie B. Butts, PhD, RN Professor University of Southern Mississippi College of Nursing Hattiesburg, Mississippi

Cynthia Chatham, DSN, RN Associate Professor University of Southern Mississippi College of Nursing Long Beach, Mississippi

Mary Louise Coyne, DNSc, RN Professor University of Southern Mississippi College of Nursing Long Beach, Mississippi

Kathleen Driscoll, JD, MS, RN University of Cincinnati College of Nursing Cincinnati, Ohio

Melanie Gilmore, PhD, RN Associate Professor (Retired) University of Southern Mississippi

College of Nursing Hattiesburg, Mississippi

Cathy K. Hughes, DNP, RN Teaching Assistant Professor University of Southern Mississippi College of Nursing Hattiesburg, Mississippi

Karen Saucier Lundy, PhD, RN, FAAN Professor Emeritus University of Southern Mississippi College of Nursing Hattiesburg, Mississippi

Katherine E. Nugent, PhD, RN Professor and Dean (Retired) University of Southern Mississippi College of Nursing Hattiesburg, Mississippi

Karen L. Rich, PhD, RN Associate Professor University of Southern Mississippi College of Nursing Long Beach, Mississippi

Jill Rushing, MSN, RN Director of BSN Program University of Southern Mississippi College of Nursing Hattiesburg, Mississippi

Mary W. Stewart, PhD, RN Director of PhD Program University of Mississippi Medical Center School of Nursing Jackson, Mississippi

Sharon Vincent, DNP, RN, CNOR University of North Carolina College of Nursing Charlotte, North Carolina

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Foundations of Professional Nursing Practice

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A History of Health Care and Nursing1 Karen Saucier Lundy and Kathleen Masters

Learning Objectives

After completing this chapter, the student should be able to:

1. Identify social, political, and economic influences on the development of professional nursing practice.

2. Identify important leaders and events that have significantly affected the development of professional nursing practice.

Key Terms and Concepts

Greek era Roman era Deaconesses Florence Nightingale Reformation Chadwick Report Shattuck Report William Rathbone Ethel Fenwick Jeanne Mance Mary Agnes Snively Goldmark Report Brown Report Isabel Hampton Robb American Nurses Association (ANA) Lavinia Lloyd Dock American Journal of Nursing (AJN) Margaret Sanger Lillian Wald Jane A. Delano Annie Goodrich Mary Brewster Henry Street Settlement Elizabeth Tyler Jessie Sleet Scales

Dorothea Lynde Dix Clara Barton Frontier Nursing Service Mary Breckinridge Mary D. Osborne Frances Payne Bolton International Council of Nurses (ICN)

Although no specialized nurse role per se developed in early civilizations, human cultures recognized the need for nursing care. The truly sick person was weak and helpless and could not fulfill the duties that were normally expected of a member of the community. In such cases, someone had to watch over the patient, nurse him or her, and provide care. In most societies, this nurse role was filled by a family member, usually female. As in most cultures, the childbearing woman had special needs that often resulted in a specialized role for the caregiver. Every society since the dawn of time had someone to nurse and take care of the mother and infant around the childbearing events. In whatever form the nurse took, the role was associated with compassion, health promotion, and kindness (Bullough & Bullough, 1978).

Classical Era More than 4,000 years ago, Egyptian physicians and nurses used an abundant pharmacologic repertoire to cure the ill and injured. The Ebers Papyrus lists more than 700 remedies for ailments ranging from snakebites to puerperal fever (Kalisch & Kalisch, 1986). Healing appeared in the Egyptian culture as the successful result of a contest between invisible beings of good and evil (Shryock, 1959). Around 1000 B.C., the Egyptians constructed elaborate drainage systems, developed pharmaceutical herbs and preparations, and embalmed the dead. The Hebrews formulated an elaborate hygiene code that dealt with laws governing both personal and community hygiene, such as contagion, disinfection, and sanitation through the preparation of food and water. The Jewish contribution to health is greater in sanitation than in their concept of disease. Garbage and excreta were disposed of outside the city or camp, infectious diseases were quarantined, spitting was outlawed as unhygienic, and bodily cleanliness became a prerequisite for moral purity. Although many of the Hebrew ideas about hygiene were Egyptian in origin, the Hebrews were the first to codify them and link them with spiritual godliness (Bullough & Bullough, 1978).

Disease and disability in the Mesopotamian area were considered a great curse, a divine punishment for grievous acts against the gods. Experiencing illness as punishment for a sin linked the sick person to anything even remotely deviant. Not only was the person suffering from the illness but also he or she also was branded by society as having deserved it. Those who obeyed God’s law lived in health and happiness, and those who transgressed the law were punished with illness and suffering. The sick person then had to make atonement for the sins, enlist

a priest or other spiritual healer to lift the curse, or live with the illness to its ultimate outcome (Bullough & Bullough, 1978). Nursing care by a family member or relative would be needed, regardless of the outcome of the sin, curse, disease-atonement-recovery, or death cycle. This logic became the basis for explanation of why some people “get sick and some don’t” for many centuries and still persists to some degree in most cultures today.

The Greeks and Health In Greek mythology, the god of medicine, Asclepias, cured disease. One of his daughters, Hygieia, from whom we derive the word hygiene, was the goddess of preventive health and protected humans from disease. Panacea, Asclepias’ other daughter, was known as the all-healing “universal remedy,” and today her name is used to describe any ultimate cure-all in medicine. She was known as the “light” of the day, and her name was invoked and shrines built to her during times of epidemics (Brooke, 1997).

During the Greek era, Hippocrates of Cos emphasized the rational treatment of sickness as a natural rather than a god-inflicted phenomenon. Hippocrates (460–370 B.C.) is considered the father of medicine because of his arrangements of the oral and written remedies and diseases, which had long been secrets held by priests and religious healers, into a textbook of medicine that was used for centuries (Bullough & Bullough, 1978).

In Greek society, health was considered to result from a balance between mind and body. Hippocrates wrote a most important book, Air, Water, and Places, which detailed the relationship between humans and the environment. This is considered a milestone in the eventual development of the science of epidemiology as the first such treatise on

the connectedness of the web of life. This topic of the relationship between humans and their environment did not recur until the development of bacteriology in the late 1800s (Rosen, 1958).

Perhaps the idea that most damaged the practice and scientific theory of medicine and health for centuries was the doctrine of the four humors, first spoken of by Empedocles of Acragas (493–433 B.C.). Empedocles was a philosopher and a physician, and as a result, he synthesized his cosmologic ideas with his medical theory. He believed that the same four elements that made up the universe were found in humans and in all animate beings (Bullough & Bullough, 1978). Empedocles believed that man [sic] was a microcosm, a small world within the macrocosm, or external environment. The four humors of the body (blood, bile, phlegm, and black bile) corresponded to the four elements of the larger world (fire, air, water, and earth) (Kalisch & Kalisch, 1986). Depending on the prevailing humor, a person was sanguine, choleric, phlegmatic, or melancholic. Because of this strongly held and persistent belief in the connection between the balance of the four humors and health status, treatment was aimed at restoring the appropriate balance of the four humors through the control of their corresponding elements. Through manipulating the two sets of opposite qualities—hot and cold, wet and dry—balance was the goal of the intervention. Fire was hot and dry, air was hot and wet, water was cold and wet, and earth was cold and dry. For example, if a person had a fever, cold compresses would be prescribed; for a chill the person would be warmed. Such doctrine gave rise to faulty and ineffective treatment of disease that influenced medical education for many years (Taylor, 1922).

Plato, in The Republic, details the importance of recreation, a balanced mind and body, nutrition, and exercise. A distinction was made among gender, class, and health as early as the Greek era; only males of

the aristocracy could afford the luxury of maintaining a healthful lifestyle (Rosen, 1958).

In The Iliad, a poem about the attempts to capture Troy and rescue Helen from her lover, Paris, 140 different wounds are described. The mortality rate averaged 77.6%, the highest as a result of sword and spear thrusts and the lowest from superficial arrow wounds. There was considerable need for nursing care, and Achilles, Patroclus, and other princes often acted as nurses to the injured. The early stages of Greek medicine reflected the influences of Egyptian, Babylonian, and Hebrew medicine. Therefore, good medical and nursing techniques were used to treat these war wounds: The arrow was drawn or cut out, the wound washed, soothing herbs applied, and the wound bandaged. However, in sickness in which no wound occurred, an evil spirit was considered the cause. The Greeks applied rational causes and cures to external injuries, whereas internal ailments continued to be linked to spiritual maladies (Bullough & Bullough, 1978).

Roman Era During the rise and the fall of the Roman era (31 B.C.–A.D. 476), Greek culture continued to be a strong influence. The Romans easily adopted Greek culture and expanded the Greeks’ accomplishments, especially in the fields of engineering, law, and government. For Romans, the government had an obligation to protect its citizens not only from outside aggression, such as warring neighbors, but also from inside the civilization, in the form of health laws. According to Bullough and Bullough (1978), Rome was essentially a “Greek cultural colony” (p. 20).

Galen of Pergamum (A.D. 129–199), often known as the greatest Greek physician after Hippocrates, left for Rome after studying medicine in Greece and Egypt and gained great fame as a medical practitioner,

lecturer, and experimenter. In his lifetime, medicine evolved into a science; he submitted traditional healing practices to experimentation and was possibly the greatest medical researcher before the 1600s (Bullough & Bullough, 1978). He was considered the last of the great physicians of antiquity (Kalisch & Kalisch, 1986).

The Greek physicians and healers certainly made the most contributions to medicine, but the Romans surpassed the Greeks in promoting the evolution of nursing. Roman armies developed the notion of a mobile war nursing unit because their battles took them far from home where they could be cared for by wives and family. This portable hospital was a series of tents arranged in corridors; as battles wore on, these tents gave way to buildings that became permanent convalescent camps at the battle sites (Rosen, 1958). Many of these early military hospitals have been excavated by archaeologists along the banks of the Rhine and Danube rivers. They had wards, recreation areas, baths, pharmacies, and even rooms for officers who needed a “rest cure” (Bullough & Bullough, 1978). Coexisting were the Greek dispensary forms of temples, or the iatreia, which started out as a type of physician waiting room. These eventually developed into a primitive type of hospital, places for surgical clients to stay until they could be taken home by their families. Although nurses during the Roman era were usually family members, servants, or slaves, nursing had strengthened its position in medical care and emerged during the Roman era as a separate and distinct specialty.

The Romans developed massive aqueducts, bathhouses, and sewer systems during this era. At the height of the Roman Empire, Rome provided 40 gallons of water per person per day to its 1 million inhabitants, which is comparable to our rates of consumption today (Rosen, 1958).

Middle Ages Many of the advancements of the Greco-Roman era were reversed during the Middle Ages (A.D. 476–1453) after the decline of the Roman Empire. The Middle Ages, or the medieval era, served as a transition between ancient and modern civilizations. Once again, myth, magic, and religion were explanations and cures for illness and health problems. The medieval world was the result of a fusion of three streams of thought, actions, and ways of life—Greco-Roman, Germanic, and Christian (Donahue, 1985). Nursing was most influenced by Christianity with the beginning of deaconesses, or female servants, doing the work of God by ministering to the needs of others. Deacons in the early Christian churches were apparently available only to care for men, whereas deaconesses cared for the needs of women. The role of deaconesses in the church was considered a forward step in the development of nursing and in the 1800s would strongly influence the young Florence Nightingale. During this era, Roman military hospitals were replaced by civilian ones. In early Christianity, the Diakonia, a kind of combination outpatient and welfare office, was managed by deacons and deaconesses and served as the equivalent of a hospital. Jesus served as the example of charity and compassion for the poor and marginal of society.

Communicable diseases were rampant during the Middle Ages, primarily because of the walled cities that emerged in response to the paranoia and isolation of the populations. Infection was next to impossible to control. Physicians had little to offer, deferring to the church for management of disease. Nursing roles were carried out primarily by religious orders. The oldest hospital (other than military hospitals in the

Roman era) in Europe was most likely the Hôtel-Dieu in Lyon, France, founded about 542 by Childebert I, king of Paris. The Hôtel-Dieu in Paris was founded around 652 by Saint Landry, bishop of Paris. During the Middle Ages, charitable institutions, hospitals, and medical schools increased in number, with the religious leaders as caregivers. The word hospital, which is derived from the Latin word hospitalis, meaning service of guests, was most likely more of a shelter for travelers and other pilgrims as well as the occasional person who needed extra care (Kalisch & Kalisch, 1986). Early European hospitals were more like hospices or homes for the aged, sick pilgrims, or orphans. Nurses in these early hospitals were religious deaconesses who chose to care for others in a life of servitude and spiritual sacrifice.

Black Death During the Middle Ages, a series of horrible epidemics, including the Black Death or bubonic plague, ravaged the civilized world (Diamond, 1997). In the 1300s, Europe, Asia, and Africa saw nearly half their populations lost to the bubonic plague. Worldwide, more than 60 million deaths were attributed to this horrible plague. In some parts of Europe, only one-fourth of the population survived, with some places having too few survivors alive to bury the dead. Families abandoned sick children, and the sick were often left to die alone (Cartwright, 1972).

Nurses and physicians were powerless to avert the disease. Black spots and tumors on the skin appeared, and petechiae and hemorrhages gave the skin a darkened appearance. There was also acute inflammation of the lungs, burning sensations, unquenchable thirst, and inflammation of the entire body. Hardly anyone afflicted survived the third day of the attack. So great was the fear of contagion that ships carrying bodies of infected persons were set to sail without a crew to drift from

port to port through the North, Black, and Mediterranean seas with their dead passengers (Cohen, 1989).

Medieval people knew that this disease was in some way communicable, but they were unsure of the mode of transmission (Diamond, 1997); hence the avoidance of victims and a reliance on isolation techniques. During this time, the practice of quarantine in city ports was developed as a preventive measure that is still used today (Bullough & Bullough, 1978; Kalisch & Kalisch, 1986).

The Renaissance During the rebirth of Europe, political, social, and economic advances occurred along with a tremendous revival of learning. Donahue (1985) contends that the Renaissance has been “viewed as both a blessing and a curse” (p. 188). There was a renewed interest in the arts and sciences, which helped advance medical science (Boorstin, 1985; Bullough & Bullough, 1978). Columbus and other explorers discovered new worlds, and belief in a sun-centered rather than an Earth-centered universe was promoted by Copernicus (1473–1543). Sir Isaac Newton’s (1642–1727) theory of gravity changed the world forever. Gunpowder was introduced, and social and religious upheavals resulted in the American and French revolutions at the end of the 1700s. In the arts and sciences, Leonardo da Vinci, known as one of the greatest geniuses of all time, made a number of anatomic drawings based on dissection experiences. These drawings have become classics in the progression of knowledge about the human anatomy. Many artists of this time left an indelible mark and continue to exert influence today, including Michelangelo, Raphael, and Titian (Donahue, 1985).

The Reformation Religious changes during the Renaissance influenced nursing perhaps more than any other aspect of society. Particularly important was the rise of Protestantism as a result of the reform movements of Martin Luther (1483–1546) in Germany and John Calvin (1509–1564) in France and Switzerland. Although the various sects were numerous in the Protestant movement, the agreement among the leaders was almost unanimous on the abolition of the monastic or cloistered career. The effects on nursing

were drastic: Monastic-affiliated institutions, including hospitals and schools, were closed, and orders of nuns, including nurses, were dissolved. Even in countries where Catholicism flourished, royal leaders seized monasteries frequently.

Religious leaders, such as Martin Luther, who led the Reformation in 1517, were well aware of the lack of adequate nursing care as a result of these sweeping changes. Luther advocated that each town establish something akin to a “community chest” to raise funds for hospitals and nurse visitors for the poor (Dietz & Lehozky, 1963). Thus, the closures of the monasteries eventually resulted in the creation of public hospitals where laywomen performed nursing care. It was difficult to find laywomen who were willing to work in these hospitals to care for the sick, so judges began giving prostitutes, publically intoxicated women, and poverty- stricken women the option of going to jail, going to the poorhouse, or working in the public hospital. Unlike the sick wards in monasteries, which were generally considered to be clean and well managed, the public hospitals were filthy, disorganized buildings where people went to die while being cared for by laywomen who were not trained, motivated, or qualified to care for the sick (Sitzman & Judd, 2014a).

In England, where there had been at least 450 charitable foundations before the Reformation, only a few survived the reign of Henry VIII, who closed most of the monastic hospitals (Donahue, 1985). Eventually, Henry VIII’s son, Edward VI, who reigned from 1547 to 1553, endowed some hospitals, namely, St. Bartholomew’s Hospital and St. Thomas’ Hospital, which would eventually house the Nightingale School of Nursing later in the 1800s (Bullough & Bullough, 1978).

The Dark Period of Nursing The last half of the period between 1500 and 1860 is widely regarded as the “dark period of nursing” because nursing conditions were at their worst (Donahue, 1985). Education for girls, which had been provided by the nuns in religious schools, was lost. Because of the elimination of hospitals and schools, there was no one to pass on knowledge about caring for the sick. As a result, the hospitals were managed and staffed by municipal authorities; women entering nursing service often came from illiterate classes, and even then, there were too few to serve (Dietz & Lehozky, 1963). The lay attendants who filled the nursing role were illiterate, rough, inconsiderate, and often immoral and alcoholic. Intelligent women and men could not be persuaded to accept such a degraded and low-status position in the offensive municipal hospitals of London. Nursing slipped back into a role of servitude as menial, low- status work. According to Donahue (1985), when a woman could no longer make it as a gambler, prostitute, or thief, she might become a nurse. Eventually, women serving jail sentences for such crimes as prostitution and stealing were ordered to care for the sick in the hospitals instead of serving their sentences in the city jail (Dietz & Lehozky, 1963). The nurses of this era took bribes from clients, became inappropriately involved with them, and survived the best way they could, often at the expense of their assigned clients.

Nursing had, during this era, virtually no social standing or organization. Even Catholic sisters of the religious orders throughout Europe “came to a complete standstill” professionally because of the intolerance of society (Donahue, 1985, p. 231). Charles Dickens, in Martin Chuzzlewit (1844), created the enduring characters of Sairey

Gamp and Betsy Prig. Sairey Gamp was a visiting nurse based on an actual hired attendant whom Dickens had met in a friend’s home. Sairey Gamp was hired to care for sick family members but was instead cruel to her clients, stole from them, and ate their rations; she was an alcoholic and has been immortalized forever as a reminder of the world in which Florence Nightingale came of age (Donahue, 1985). The first hospital in the Americas, the Hospital de la Purísima Concepción, was founded some time before 1524 by Hernando Cortez, the conqueror of Mexico. The first hospital in the continental United States was erected in Manhattan in 1658 for the care of sick soldiers and slaves. In 1717, a hospital for infectious diseases was built in Boston; the first hospital established by a private gift was the Charity Hospital in New Orleans. A sailor, Jean Louis, donated the endowment for the hospital’s founding (Bullough & Bullough, 1978).

During the 1600s and 1700s, colonial hospitals with little resemblance to modern hospitals were often used to house the poor and downtrodden. Hospitals called “pesthouses” were created to care for clients with contagious diseases; their primary purpose was to protect the public at large rather than to treat and care for the clients. Contagious diseases were rampant during the early years of the American colonies, often being spread by the large number of immigrants who brought these diseases with them on their long journey to America. Medicine was not as developed as in Europe, and nursing remained in the hands of the uneducated. By 1720, average life expectancy at birth was only around 35 years. Plagues were a constant nightmare, with outbreaks of smallpox and yellow fever. In 1751, the first true hospital in the new colonies, Pennsylvania Hospital, was erected in Philadelphia on the recommendation of Benjamin Franklin (Kalisch & Kalisch, 1986).

By today’s standards, hospitals in the 1800s were disgraceful, dirty, unventilated, and contaminated by infections; to be a client in a hospital

actually increased one’s risk of dying. As in England, nursing was considered an inferior occupation. After the sweeping changes of the Reformation, educated religious health workers were replaced with lay people who were “down and outers,” in prison or had no option left but to work with the sick (Kalisch & Kalisch, 1986).

The Industrial Revolution During the mid-1700s in England, capitalism emerged as an economic system based on profit. This emerging system resulted in mass production, as contrasted with the previous system of individual workers and craftsmen. In the simplest terms, the Industrial Revolution was the application of machine power to processes formerly done by hand. Machinery was invented during this era and ultimately standardized quality; individual craftsmen were forced to give up their crafts and lands and become factory laborers for the capitalist owners. All types of industries were affected; this new-found efficiency produced profit for owners of the means of production. Because of this, the era of invention flourished, factories grew, and people moved in record numbers to work in the cities. Urban areas grew, tenement housing projects emerged, and overcrowding in cities seriously threatened individuals’ well-being (Donahue, 1985).

Workers were forced to go to the machines, not the other way around. Such relocations meant giving up not only farming but also a way of life that had existed for centuries. The emphasis on profit over people led to child labor, frequent layoffs, and long workdays filled with stressful, tedious, unfamiliar work. Labor unions did not exist, and neither was there any legal protection against exploitation of workers, including children (Donahue, 1985). All these rapid changes and often threatening conditions created the world of Charles Dickens, where, as in his book Oliver Twist, children worked as adults without question.

According to Donahue (1985), urban life, trade, and industrialization contributed to these overwhelming health hazards, and the situation was confounded by the lack of an adequate means of social control. Reforms

were desperately needed, and the social reform movement emerged in response to the unhealthy by-products of the Industrial Revolution. It was in this world of the 1800s that such reformers as John Stuart Mill (1806– 1873) emerged. Although the Industrial Revolution began in England, it quickly spread to the rest of Europe and to the United States (Bullough & Bullough, 1978). The reform movement is critical to understanding the emerging health concerns that were later addressed by Florence Nightingale. Mill championed popular education, the emancipation of women, trade unions, and religious toleration. Other reform issues of the era included the abolition of slavery and, most important for nursing, more humane care of the sick, the poor, and the wounded (Bullough & Bullough, 1978). There was a renewed energy in the religious community with the reemergence of new religious orders in the Catholic Church that provided service to the sick and disenfranchised.

Epidemics had ravaged Europe for centuries, but they became even more serious with urbanization. Industrialization brought people to cities, where they worked in close quarters (as compared with the isolation of the farm) and contributed to the social decay of the second half of the 1800s. Sanitation was poor or nonexistent, sewage disposal from the growing population was lacking, cities were filthy, public laws were weak or nonexistent, and congestion of the cities inevitably brought pests in the form of rats, lice, and bedbugs, which transmitted many pathogens. Communicable diseases continued to plague the population, especially those who lived in these unsanitary environments. For example, during the mid-1700s, typhus and typhoid fever claimed twice as many lives each year as did the Battle of Waterloo (Hanlon & Pickett, 1984). Through foreign trade and immigration, infectious diseases were spread to all of Europe and eventually to the growing United States.

The Chadwick Report Edwin Chadwick became a major figure in the development of the field of public health in Great Britain by drawing attention to the cost of the unsanitary conditions that shortened the life span of the laboring class and threatened the wealth of Britain. Although the first sanitation legislation, which established a National Vaccination Board, was passed in 1837, Chadwick found in his classic study, Report on an Inquiry into the Sanitary Conditions of the Labouring Population of Great Britain, that death rates were high in large industrial cities, such as Liverpool. A more startling finding, from what is often referred to simply as the Chadwick Report, was that more than half the children of labor-class workers died by age 5, indicating poor living conditions that affected the health of the most vulnerable. Laborers lived only half as long as the upper classes.

One consequence of the report was the establishment in 1848 of the first board of health, the General Board of Health for England (Richardson, 1887). More legislation followed that initiated social reform in the areas of child welfare, elder care, the sick, mentally ill persons, factory health, and education. Soon sewers and fireplugs, based on an available water supply, appeared as indicators that the public health linkages from the Chadwick Report had an effect.

The Shattuck Report In the United States during the 1800s, waves of epidemics of yellow fever, smallpox, cholera, typhoid fever, and typhus continued to plague the population as in England and the rest of the world. As cities continued to grow in the industrialized young nation, poor workers crowded into larger cities and suffered from illnesses caused by the unsanitary living conditions (Hanlon & Pickett, 1984). Similar to Chadwick’s classic study in England, Lemuel Shattuck, a Boston bookseller and publisher who had

an interest in public health, organized the American Statistical Society in 1839 and issued a census of Boston in 1845. Shattuck’s census revealed high infant mortality rates and high overall population mortality rates. In 1850, in his Report of the Massachusetts Sanitary Commission, Shattuck not only outlined his findings on the unsanitary conditions but also made recommendations for public health reform that included the bookkeeping of population statistics and development of a monitoring system that would provide information to the public about environmental, food, and drug safety and infectious disease control (Rosen, 1958). He also called for services for well-child care, school-age children’s health, immunizations, mental health, health education for all, and health planning. The Shattuck Report was revolutionary in its scope and vision for public health, but it was virtually ignored during Shattuck’s lifetime. Nineteen years later, in 1869, the first state board of health was formed (Kalisch & Kalisch, 1986).

And Then There Was Nightingale . . . Florence Nightingale (Figure 1-1) was named one of the 100 most influential persons of the last millennium by Life magazine (“The 100 People Who Made the Millennium,” 1997). She was one of only eight women identified as such. Of those eight women, including Joan of Arc, Helen Keller, and Elizabeth I, Nightingale was identified as a true “angel of mercy,” having reformed military health care in the Crimean War and used her political savvy to forever change the way society views the health of the vulnerable, the poor, and the forgotten. She is probably one of the most written about women in history (Bullough & Bullough, 1978). Florence Nightingale has become synonymous with modern nursing.

Figure 1-1 Engraving From 1873 featuring the English reformer and founder of modern nursing, Florence Nightingale.

© traveler1116/E+/Getty Images

Born on May 12, 1820, in her namesake city, Florence, Italy, Florence Nightingale was the second child in the wealthy English family of William

and Frances Nightingale. As a young child, Florence displayed incredible curiosity and intellectual abilities not common to female children of the Victorian age. She mastered the fundamentals of Greek and Latin, and she studied history, art, mathematics, and philosophy. To her family’s dismay, she believed that God had called her to be a nurse. Nightingale was keenly aware of the suffering that industrialization created; she became obsessed with the plight of the miserable and suffering people. Conditions of general starvation accompanied the Industrial Revolution, prisons and workhouses overflowed, and persons in all sections of British life were displaced. She wrote in the spring of 1842, “My mind is absorbed with the sufferings of man; it besets me behind and before. . . . All that the poets sing of the glories of this world seem to me untrue. All the people that I see are eaten up with care or poverty or disease” (Woodham-Smith, 1951, p. 31).

Nightingale’s entire life would be haunted by this conflict between the opulent life of gaiety that she enjoyed and the misery of the world, which she was unable to alleviate. She was, in essence, an “alien spirit in the rich and aristocratic social sphere of Victorian England” (Palmer, 1977, p. 14). Nightingale remained unmarried, and at the age of 25, she expressed a desire to be trained as a nurse in an English hospital. Her parents emphatically denied her request, and for the next 7 years, she made repeated attempts to change their minds and allow her to enter nurse training. She wrote, “I crave for some regular occupation, for something worth doing instead of frittering my time away on useless trifles” (Woodham-Smith, 1951, p. 162). During this time, she continued her education through the study of math and science and spent 5 years collecting data about public health and hospitals (Dietz & Lehozky, 1963). During a tour of Egypt in 1849 with family and friends, Nightingale spent her 30th year in Alexandria with the Sisters of Charity of St. Vincent de Paul, where her conviction to study nursing was only reinforced (Tooley,

1910). While in Egypt, Nightingale studied Egyptian, Platonic, and Hermetic philosophy; Christian scripture; and the works of poets, mystics, and missionaries in her efforts to understand the nature of God and her “calling” as it fit into the divine plan (Calabria, 1996; Dossey, 2000).

The next spring, Nightingale traveled unaccompanied to the Kaiserwerth Institute in Germany and stayed there for 2 weeks, vowing to return to train as a nurse. In June 1851, Nightingale took her future into her own hands and announced to her family that she planned to return to Kaiserwerth and study nursing. According to Dietz and Lehozky (1963, p. 42), her mother had “hysterics” and scene followed scene. Her father “retreated into the shadows,” and her sister, Parthe, expressed that the family name was forever disgraced (Cook, 1913). In 1851, at the age of 31, Nightingale was finally permitted to go to Kaiserwerth, and she studied there for 3 months with Pastor Fliedner. Her family insisted that she tell no one outside the family of her whereabouts, and her mother forbade her to write any letters from Kaiserwerth. While there, Nightingale learned about the care of the sick and the importance of discipline and commitment of oneself to God (Donahue, 1985). She returned to England and cared for her then ailing father, from whom she finally gained some support for her intent to become a nurse—her lifelong dream.

In 1852, Nightingale wrote the essay “Cassandra,” which stands today as a classic feminist treatise against the idleness of Victorian women. Through her voluminous journal writings, Nightingale reveals her inner struggle throughout her adulthood with what was expected of a woman and what she could accomplish with her life. The life expected of an aristocratic woman in her day was one she grew to loathe, and she expressed this detestation throughout her writings (Nightingale, 1979). In “Cassandra,” Nightingale put her thoughts to paper, and many scholars believe that her eventual intent was to extend the essay to a novel. She wrote in “Cassandra,” “Why have women passion, intellect, moral activity

—these three—in a place in society where no one of the three can be exercised?” (Nightingale, 1979, p. 37). Although uncertain about the meaning of the name Cassandra, many scholars believe that it came from the Greek goddess Cassandra, who was cursed by Apollo and doomed to see and speak the truth but never to be believed. Nightingale saw the conventional life of women as a waste of time and abilities. After receiving a generous yearly endowment from her father, Nightingale moved to London and worked briefly as the superintendent of the Establishment for Gentlewomen During Illness hospital, finally realizing her dream of working as a nurse (Cook, 1913).

The Crimean Experience: “I Can Stand Out the War with Any Man” Nightingale’s opportunity for greatness came when she was offered the position of superintendent of the female nursing establishment of the English General Hospitals in Turkey by the secretary of war, Sir Sidney Herbert. Soon after the outbreak of the Crimean War, stories of the inadequate care and lack of medical resources for the soldiers became widely known throughout England (Woodham-Smith, 1951). The country was appalled at the conditions so vividly portrayed in the London Times. Pressure increased on Sir Sidney to react. He knew of one woman who was capable of bringing order out of the chaos and wrote a letter to Nightingale on October 15, 1854, as a plea for her service. Nightingale accepted the challenge and set sail with 38 self-proclaimed nurses with varied training and experiences, of whom 24 were Catholic and Anglican nuns. Their journey to the Crimea took a month, and on November 4, 1854, the brave nurses arrived at Istanbul and were taken to Scutari the same day. Faced with 3,000 to 4,000 wounded men in a hospital designed to accommodate 1,700, the nurses went to work (Kalisch &

Kalisch, 1986). They found 4 miles of beds 18 inches apart. Most soldiers were lying naked with no bedding or blanket. There were no kitchen or laundry facilities. The little light present took the form of candles in beer bottles. The hospital was literally floating on an open sewage lagoon filled with rats and other vermin (Donahue, 1985).

By taking the newly arrived medical equipment and setting up kitchens, laundries, recreation rooms, reading rooms, and a canteen, Nightingale and her team of nurses proceeded to clean the barracks of lice and filth. Nightingale was in her element. She set out not only to provide humane health care for the soldiers but also to essentially overhaul the administrative structure of the military health services (Williams, 1961).

Florence Nightingale and Sanitation Although Nightingale never accepted the germ theory, she demanded clean dressings; clean bedding; well-cooked, edible, and appealing food; proper sanitation; and fresh air. After the other nurses were asleep, Nightingale made her famous solitary rounds with a lamp or lantern to check on the soldiers. Nightingale had a lifelong pattern of sleeping few hours, spending many nights writing, developing elaborate plans, and evaluating implemented changes. She seldom believed in the “hopeless” soldier, only one who needed extra attention. Nightingale was convinced that most of the maladies that the soldiers suffered and died from were preventable (Williams, 1961).

Before Nightingale’s arrival and her radical and well-documented interventions based on sound public health principles, the mortality rate from the Crimean War was estimated to be from 42% to 73%. Nightingale is credited with reducing that rate to 2% within 6 months of her arrival at Scutari. She did this through careful, scientific epidemiologic research

(Dietz & Lehozky, 1963). Upon arriving at Scutari, Nightingale’s first act was to order 200 scrubbing brushes. The death rate fell dramatically once Nightingale discovered that the hospital was built literally over an open sewage lagoon (Andrews, 2003).

According to Palmer (1982), Nightingale possessed the qualities of a good researcher: insatiable curiosity, command of her subject, familiarity with methods of inquiry, a good background of statistics, and the ability to discriminate and abstract. She used these skills to maintain detailed and copious notes and to codify observations. Nightingale relied on statistics and attention to detail to back up her conclusions about sanitation, management of care, and disease causation. Her now-famous “cox combs” are a hallmark of military health services management by which she diagrammed deaths in the army from wounds and from other diseases and compared them with deaths that occurred in similar populations in England (Palmer, 1977).

Nightingale was first and foremost an administrator: She believed in a hierarchical administrative structure with ultimate control lodged in one person to whom all subordinates and offices reported. Within a matter of weeks of her arrival in the Crimea, Nightingale was the acknowledged administrator and organizer of a mammoth humanitarian effort. From her Crimean experience on, Nightingale involved herself primarily in organizational activities and health planning administration. Palmer contends that Nightingale “perceived the Crimean venture, which was set up as an experiment, as a golden opportunity to demonstrate the efficacy of female nursing” (Palmer, 1982, p. 4). Although Nightingale faced initial resistance from the unconvinced and oppositional medical officers and surgeons, she boldly defied convention and remained steadfastly focused on her mission to create a sanitary and highly structured environment for her “children”—the British soldiers who dedicated their lives to the defense of Great Britain. Because of her insistence on absolute authority

regarding nursing and the hospital environment, Nightingale was known to send nurses home to England from the Crimea for suspicious alcohol use and character weakness.

It was through this success at Scutari that she began a long career of influence on the public’s health through social activism and reform, health policy, and the reformation of career nursing. Using her well-publicized successful “experiment” and supportive evidence from the Crimea, Nightingale effectively argued the case for the reform and creation of military health care that would serve as the model for people in uniform to the present (D’Antonio, 2002). Nightingale’s ideas about proper hospital architecture and administration influenced a generation of medical doctors and the entire world, in both military and civilian service. Her work in Notes on Hospitals, published in 1860, provided the template for the organization of military health care in the Union Army when the U.S. Civil War erupted in 1861. Her vision for health care of soldiers and the responsibility of the governments that send them to war continues today; her influence can be seen throughout the previous century and into this century as health care for the women and men who serve their country is a vital part of the well-being not only of the soldiers but also of society in general (D’Antonio, 2002).

Returning Home a Heroine: The Political Reformer When Nightingale returned to London, she found that her efforts to provide comfort and health to the British soldier succeeded in making heroes of both herself and the soldiers (Woodham-Smith, 1951). Both had suffered from negative stereotypes: The soldier was often portrayed as a drunken oaf with little ambition or honor, and the nurse as a tipsy, self-serving, illiterate, promiscuous loser. After the Crimean War and the

efforts of Nightingale and her nurses, both returned with honor and dignity, never again downtrodden and disrespected.

After her return from the Crimea, Florence Nightingale never made a public appearance, never attended a public function, and never issued a public statement (Bullough & Bullough, 1978). She single-handedly raised nursing from, as she put it, “the sink it was” into a respected and noble profession (Palmer, 1977). As an avid scholar and student of the Greek writer Plato, Nightingale believed that she had a moral obligation to work primarily for the good of the community. Because she believed that education formed character, she insisted that nursing must go beyond care for the sick; the mission of the trained nurse must include social reform to promote the good. This dual mission of nursing— caregiver and political reformer—has shaped the profession as we know it today. LeVasseur (1998) contends that Nightingale’s insistence on nursing’s involvement in a larger political ideal is the historic foundation of the field and distinguishes us from other scientific disciplines, such as medicine.

How did Nightingale accomplish this? She effected change through her wide command of acquaintances: Queen Victoria was a significant admirer of her intellect and ability to effect change, and Nightingale used her position as national heroine to get the attention of elected officials in Parliament. She was tireless and had an amazing capacity for work. She used people. Her brother-in-law, Sir Harry Verney, was a member of Parliament and often delivered her “messages” in the form of legislation. When she wanted the public incited, she turned to the press, writing letters to the London Times and having others of influence write articles. She was not above threats to “go public” by certain dates if an elected official refused to establish a commission or appoint a committee. And when those commissions were formed, Nightingale was ready with her list of selected people for appointment (Palmer, 1982).

Nightingale and Military Reforms The first real test of Nightingale’s military reforms came in the United States during the Civil War. Nightingale was asked by the Union to advise on the organization of hospitals and care of the sick and wounded. She sent recommendations back to the United States based on her experiences and analysis in the Crimea, and her advisement and influence gained wide publicity. Following her recommendations, the Union set up a sanitary commission and provided for regular inspection of camps. She expressed a desire to help with the Confederate military also but, unfortunately, had no channel of communication with them (Bullough & Bullough, 1978).

The Nightingale School of Nursing at St. Thomas: The Birth of Professional Nursing The British public honored Nightingale by endowing 50,000 pounds sterling in her name upon her return to England from the Crimea. The money had been raised from the soldiers under her care and donations from the public. This Nightingale Fund eventually was used to create the Nightingale School of Nursing at St. Thomas, which was to be the beginning of professional nursing (Donahue, 1985). Nightingale, at the age of 40, decided that St. Thomas’ Hospital was the place for her training school for nurses. While the negotiations for the school went forward, she spent her time writing Notes on Nursing: What It Is and What It Is Not (Nightingale, 1860). The small book of 77 pages, written for the British mother, was an instant success. An expanded library edition was written for nurses and used as the textbook for the students at St. Thomas. The book has since been translated into many languages, although it is believed that Nightingale refused all royalties earned from

the publication of the book (Cook, 1913; Tooley, 1910). The nursing students chosen for the new training school were handpicked; they had to be of good moral character, sober, and honest. Nightingale believed that the strong emphasis on morals was critical to gaining respect for the new “Nightingale nurse,” with no possible ties to the disgraceful association of past nurses. Nursing students were monitored throughout their 1-year program both on and off the hospital grounds; their activities were carefully watched for character weaknesses, and discipline was severe and swift for violators. Accounts from Nightingale’s journals and notes reveal instant dismissal of nursing students for such behaviors as “flirtation, using the eyes unpleasantly, and being in the company of unsavory persons.” Nightingale contended that “the future of nursing depends on how these young women behave themselves” (Smith, 1934, p. 234). She knew that the experiment at St. Thomas to educate nurses and raise nursing to a moral and professional calling was a drastic departure from the past images of nurses and would take extraordinary women of high moral character and intelligence. Nightingale knew every nursing student, or probationer, personally, often having the students at her house for weekend visits. She devised a system of daily journal keeping for the probationers; Nightingale herself read the journals monthly to evaluate their character and work habits. Every nursing student admitted to St. Thomas had to submit an acceptable “letter of good character,” and Nightingale herself placed graduate nurses in approved nursing positions.

One of the most important features of the Nightingale School was its relative autonomy. Both the school and the hospital nursing service were organized under the head matron. This was especially significant because it meant that nursing service began independently of the medical staff in selecting, retaining, and disciplining students and nurses (Bullough & Bullough, 1978). Nightingale was opposed to the use of a

standardized government examination and the movement for licensure of trained nurses. She believed that schools of nursing would lose control of educational standards with the advent of national licensure, most notably those related to moral character. Nightingale led a staunch opposition to the movement by the British Nurses’ Association (BNA) for licensure of trained nurses, one the BNA believed critical to protecting the public’s safety by ensuring the qualification of nurses by licensure exam. Nightingale was convinced that qualifying a nurse by examination tested only the acquisition of technical skills, not the equally important evaluation of character (Nutting & Dock, 1907; Woodham-Smith, 1951).

Taking Health Care to the Community: Nightingale and Wellness Early efforts to distinguish hospital from community health nursing are evidence of Nightingale’s views on “health nursing,” which she distinguished from “sick nursing.” She wrote two influential papers, one in 1893, “Sick-Nursing and Health-Nursing” (Nightingale, 1893), which was read in the United States at the Chicago Exposition, and the second, “Health Teaching in Towns and Villages” in 1894 (Monteiro, 1985). Both papers praised the success of prevention-based nursing practice. Winslow (1946) acknowledged Nightingale’s influence in the United States by being one of the first in the field of public health to recognize the importance of taking responsibility for one’s health. According to Palmer (1982), Nightingale was a leader in the wellness movement long before the concept was identified. Nightingale saw the nurse as the key figure in establishing a healthy society. She saw a logical extension of nursing in acute hospital settings to the community. Clearly, through her Notes on Nursing, she visualized the nurse as “the nation’s first bulwark in health maintenance, the promotion of wellness, and the prevention of

disease” (Palmer, 1982, p. 6). William Rathbone, a wealthy ship owner and philanthropist, is

credited with the establishment of the first visiting nurse service, which eventually evolved into district nursing in the community. He was so impressed with the private duty nursing care that his sick wife had received at home that he set out to develop a “district nursing service” in Liverpool, England. At his own expense, in 1859, he developed a corps of nurses trained to care for the sick poor in their homes (Bullough & Bullough, 1978). He divided the community into 16 districts; each was assigned a nurse and a social worker that provided nursing and health education. His experiment in district nursing was so successful that he was unable to find enough nurses to work in the districts. Rathbone contacted Nightingale for assistance. Her recommendation was to train more nurses, and she advised Rathbone to approach the Royal Liverpool Infirmary with a proposal for opening another training school for nurses (Rathbone, 1890; Tooley, 1910). The infirmary agreed to Rathbone’s proposal, and district nursing soon spread throughout England as successful health nursing in the community for the sick poor through voluntary agencies (Rosen, 1958). Ever the visionary, Nightingale contended that the goal is to care for the sick in their own homes (Attewell, 1996). A similar service, health visiting, began in Manchester, England, in 1862 by the Manchester and Salford Sanitary Association. The purpose of placing health visitors in the home was to provide health information and instruction to families. Eventually, health visitors evolved to provide preventive health education and district nurses to care for the sick at home (Bullough & Bullough, 1978).

Although Nightingale is best known for her reform of hospitals and the military, she was a great believer in the future of health care, which she anticipated should be preventive in nature and would more than likely take place in the home and community. Her accomplishments in the field

of “sanitary nursing” extended beyond the walls of the hospital to include workhouse reform and community sanitation reform. In 1864, Nightingale and William Rathbone once again worked together to lead the reform of the Liverpool Workhouse Infirmary, where more than 1,200 sick paupers were crowded into unsanitary and unsafe conditions. Under the British Poor Laws, the most desperately poor of the large cities were gathered into large workhouses. When sick, they were sent to the workhouse infirmary. Trained nursing care was all but nonexistent. Through legislative pressure and a well-designed public campaign describing the horrors of the workhouse infirmary, reform of the workhouse system was accomplished by 1867. Although not as complete as Nightingale had wanted, nurses were in place and being paid a salary (Seymer, 1954).

The Legacy of Nightingale A great deal has been written about Nightingale—an almost mythic figure in history. She truly was a beloved legend throughout Great Britain by the time she left the Crimea in July 1856, 4 months after the war. Longfellow immortalized this “Lady with the Lamp” in his poem “Santa Filomena” (Longfellow, 1857). However, when Nightingale returned to London after the Crimean War, she remained haunted by her experiences related to the soldiers dying of preventable diseases. She was troubled by nightmares and had difficulty sleeping in the years that followed (Woodham-Smith, 1983). Nightingale became a prolific writer and a staunch defender of the causes of the British soldier, sanitation in England and India, and trained nursing.

As a woman, she was not able to hold an official government post, nor could she vote. Historians have had varied opinions about the exact nature of the disability that kept her homebound for the remainder of her life. Recent scholars have speculated that she experienced posttraumatic

stress disorder (PTSD) from her experiences in the Crimea; there is also considerable evidence that she suffered from the painful disease brucellosis (Barker, 1989; Young, 1995). She exerted incredible influence through friends and acquaintances, directing from her sick room sanitation and poor law reform. Her mission to “cleanse” spread from the military to the British Empire; her fight for improved sanitation both at home and in India consumed her energies for the remainder of her life (Vicinus & Nergaard, 1990).

According to Monteiro (1985), two recurrent themes are found throughout Nightingale’s writings about disease prevention and wellness outside the hospital. The most persistent theme is that nurses must be trained differently and instructed specifically in district and instructive nursing. She consistently wrote that the “health nurse” must be trained in the nature of poverty and its influence on health, something she referred to as the “pauperization” of the poor. She also believed that above all, health nurses must be good teachers about hygiene and helping families learn to better care for themselves (Nightingale, 1893). She insisted that untrained, “good intended women” could not substitute for nursing care in the home. Nightingale pushed for an extensive orientation and additional training, including prior hospital experience, before one was hired as a district nurse. She outlined the qualifications in her paper “On Trained Nursing for the Sick Poor,” in which she called for a month’s “trial” in district nursing, a year’s training in hospital nursing, and 3 to 6 months training in district nursing (Monteiro, 1985).

The second theme that emerged from her writings was the focus on the role of the nurse. She clearly distinguished the role of the health nurse in promoting what we today call self-care. In the past, philanthropic visitors in the form of Christian charity would visit the homes of the poor and offer them relief (Monteiro, 1985). Nightingale believed that such activities did little to teach the poor to care for themselves and further

“pauperized” them—dependent and vulnerable—keeping them unhealthy, prone to disease, and reliant on others to keep them healthy. The nurse then must help the families at home manage a healthy environment for themselves, and Nightingale saw a trained nurse as being the only person who could pull off such a feat.

By 1901, Nightingale lived in a world without sight or sound, leaving her unable to write. Over the next 5 years, Nightingale lost her ability to communicate and most days existed in a state of unconsciousness. In November 1907, Nightingale was honored with the Order of Merit by King Edward VII, the first time it was ever given to a woman. After 50 years, in May 1910, the Nightingale Training School of Nursing at St. Thomas celebrated its jubilee. There were now more than a thousand training schools for nurses in the United States alone (Cook, 1913; Tooley, 1910).

Nightingale died in her sleep around noon on August 13, 1910 and was buried quietly and without pomp near the family’s home at Embley, her coffin carried by six sergeants of the British Army. Only a small cross marks her grave at her request: “FN. Born 1820. Died 1910.” (Brown, 1988). The family refused a national funeral and burial at Westminster Abbey out of respect for Nightingale’s last wishes. She had lived for 90 years and 3 months.

Continued Development of Professional Nursing in the United Kingdom Although Florence Nightingale opposed registration, based on the belief that the essential qualities of a nurse could not be taught, examined, or regulated, registration in the United Kingdom began in the 1880s. The Hospitals Association maintained a voluntary registry that was an administrative list. In an effort to protect the public led by Ethel Fenwick, the BNA was formed in 1887 with its charter granted in 1893 to unite British nurses and to provide registration as evidence of systematic training. Finally, in 1919, nurse registration became law. It took 30 years and the tireless efforts of Ethel Fenwick, who was supported by other nursing leaders, such as Isla Stewart, Lucy Osbourne, and Mary Cochrane, to achieve mandated registration (Royal British Nurses’ Association, n.d.).

Another milestone in British nursing history was the founding in 1916 of the College of Nursing as the professional organization for trained nurses. For a century, the organization has focused on professional standards for nurses in their education, practice, and working conditions. Although the principles of a professional organization and those of a trade union have not always fit together easily, the Royal College of Nursing has pursued its role as both the professional organization for nurses and the trade union for nurses (McGann, Crowther, & Dougall, 2009). Today the Royal College of Nursing is recognized as the voice of nursing by the government and the public in the United Kingdom (Royal College of Nursing, n.d.).

The Development of Professional Nursing in Canada Marie Rollet Hebert, the wife of a surgeon–apothecary, is credited by many with being the first person in present-day Canada to provide nursing care to the sick as she assisted her husband after arriving in Quebec in 1617; however, the first trained nurses arrived in Quebec to care for the sick in 1639. These nurses were Augustine nuns who traveled to Canada to establish a medical mission to care for the physical and spiritual needs of their patients, and they established the first hospital in North America, the Hôtel-Dieu de Québec. These nuns also established the first apprenticeship program for nursing in North America. Jeanne Mance came from France to the French colony of Montreal in 1642 and founded the Hôtel Dieu de Montréal in 1645 (Canadian Museum of History, n.d.).

The hospital of the early 19th century did not appeal to the Canadian public. They were primarily homes for the poor and were staffed by those of a similar class rather than by nurses (Mansell, 2004). The decades of the 1830s and 1840s in Canada were characterized by an influx of immigrants and outbreaks of diseases, such as cholera. There is evidence that it was difficult, especially in times of outbreak, to find sufficient people to care for the sick. Little is known of the hospital “nurses” of this era, but the descriptions are unflattering and working in the hospital environment was difficult. Early midwives did have some standing in the community and were employed by individuals, although there is record of charitable organizations also employing midwives (Young, 2010).

During the Crimean War and American Civil War, nurses were

extremely effective in providing treatment and comfort not only to battlefield casualties but also to individuals who fell victim to accidents and infectious disease; however, it was in the North-West Rebellion of 1885 that Canadian nurses performed military service for the first time. At first, the nursing needs identified were for such duties as making bandages and preparing supplies. It soon became apparent that more direct participation by nurses was needed if the military was to provide effective medical field treatment. Seven nurses, under the direction of Reverend Mother Hannah Grier Coome, served in Moose Jaw and Saskatoon, Saskatchewan. Although their tour of duty lasted only 4 weeks, these women proved that nursing could, and should in the future, play a vital role in providing treatment to wounded soldiers. In 1899, the Canadian Army Medical Department was formed, followed by the creation of the Canadian Army Nursing Service. Nurses received the relative rank, pay, and allowances of an army lieutenant. Nursing sisters served thereafter in every military force sent out from Canada, from the South African War to the Korean War (Veterans Affairs Canada, n.d.). In 1896, Lady Ishbel Aberdeen, wife of the governor-general of Canada, visited Vancouver. During this visit, she heard vivid accounts of the hardship and illness affecting women and children in rural areas. Later that same year at the National Council of Women, amid similar stories, a resolution was passed asking Lady Aberdeen to found an order of visiting nurses in Canada. The order was to be a memorial to the 60th anniversary of Queen Victoria’s ascent to the throne of the British Empire; it received a royal charter in 1897. The first Victorian Order of Nurses (VON) sites were organized in the cities of Ottawa, Montreal, Toronto, Halifax, Vancouver, and Kingston. Today the VON delivers over 75 different programs and services, such as prenatal education, mental health services, palliative care services, and visiting nursing, through 52 local sites staffed by 4,500 healthcare workers and over 9,016 volunteers

(VON, n.d.). By the mid- to late 19th century, despite previous negativity, nursing

came to be viewed as necessary to progressive medical interventions. To make the work of the nurse acceptable, changes had to be made to the prevailing view of nursing. In the 1870s, the ideas of Florence Nightingale were introduced in Canada. Dr. Theophilus Mack imported nurses who had worked with Nightingale and founded the first training school for nurses in Canada at St. Catharine’s General Hospital in 1873. Many hospitals appeared across Canada from 1890 to 1910, and many of them developed training schools for nurses. By 1909, there were 70 hospital- based training schools in Canada (Mansell, 2004).

In 1908, Mary Agnes Snively, along with 16 representatives from organized nursing bodies, met in Ottawa to form the Canadian National Association of Trained Nurses (CNATN). By 1924, each of the nine provinces had a provincial nursing organization with membership in the CNATN. In 1924, the name of the CNATN was changed to the Canadian Nurses Association (CNA). CNA is currently a federation of 11 provincial and territorial nursing associations and colleges representing nearly 150,000 registered nurses (CNA, n.d.).

In 1944, the CNA approved the principle of collective bargaining. In 1946, the Registered Nurses Association of British Columbia became the first provincial nursing association to be certified as a bargaining agent. By the 1970s, other provincial nursing organizations gained this right. Between 1973 and 1987, nursing unions were created. Today each of the 10 provinces has a nursing union in addition to a professional association (Ontario Nurses’ Association, n.d.). One of the best known of these professional associations is the Registered Nurses’ Association of Ontario (RNAO). Established in 1925 to advocate for health public policy, promote excellence in nursing practice, increase nursing’s contribution to shaping the healthcare system, and influence decisions that affect nurses

and the public they serve, the RNAO is the professional association representing registered nurses, nurse practitioners (NPs), and nursing students in Ontario (RNAO, n.d.). Through the RNAO, nurses in Canada have led the world in systematic implementation of evidence-based practice and have made their best practice guidelines available to all nurses to promote safe and effective care of patients.

As Canadians entered the decade of the 1960s, there was serious concern about the healthcare system. In 1961, all Canadian provinces signed on to the Hospital Insurance and Diagnostic Services Act. This legislation created a national, universal health insurance system. The same year, the Royal Commission on Health Services was established and presented four recommendations. One of the recommendations was to examine nursing education. Prior to this, the CNA had requested a survey of nursing schools across Canada with the goal of assessing how prepared the schools were for a national system of accreditation. The findings of this survey, paired with the commission’s recommendation, led to the establishment of the Canadian Nurses Foundation (CNF) in 1962. The CNF (2014) provides funding for nurses to further their education and for research related to nursing care. The Canadian Association of Schools of Nursing (n.d.) is the organization that promotes national nursing education standards and is the national accrediting agency for university nursing programs in Canada.

Nursing in Canada transformed itself to meet the needs of a changing Canadian society and in doing so was responsible for a shift from nursing as a spiritual vocation to a secular but indispensable profession. Nurses’ willingness to respond in times of need, whether economic crisis, epidemic, or war, contributed to their importance in the healthcare system (Mansell, 2004). Canadian nursing associations agreed that starting in the year 2000, the basic educational preparation for the registered nurse would be the baccalaureate degree, and all provinces and territories

launched a campaign known as EP 2000, which later became EP 2005. Currently, the baccalaureate degree earned from a university is the accepted entry level into nursing practice in Canada (Mansell, 2004).

The Development of Professional Nursing in Australia In the earliest days of the colony, the care of the sick was performed by untrained convicts. Male attendants undertook the supervision of male patients and female attendants undertook duties with the female patients. Attention to hygiene standards was almost nonexistent. In 1885, the poor health and living conditions of disadvantaged sick persons in Melbourne prompted a group of concerned citizens to meet and form the Melbourne District Nursing Society. This society was formed to look after sick poor persons at home to prevent unnecessary hospitalization. Home visiting services also have a long history in Australia, with Victoria being the first state to introduce a district nursing service in 1885, followed by South Australia in 1894, Tasmania in 1896, New South Wales in 1900, Queensland in 1904, and Western Australia in 1905 (Australian Bureau of Statistics, 1985).

Australian nurses were involved in military nursing as civilian volunteers as early as the 1880s (University of Melbourne, 2015); however, involvement of Australian women as nurses in war began in 1898 with the formation of the Australian Nursing Service of New South Wales, which was composed of 1 superintendent and 24 nurses. Based on the performance of the nurses, the Australian Army Nursing Service was formed in 1903 under the control of the federal government. The Royal Australian Army Nursing Corps (RAANC) had its beginnings in the Australian Army Nursing Service (RAANC, n.d.). Since that time, Australian nurses have dealt with war, the sick, the wounded, and the dead. They have served in Australia, in war zones around the world, in field hospitals, on hospital ships anchored off shore near battlefields, and

on transports (Australian War Memorial, n.d.; Biedermann, Usher, Williams, & Hayes, 2001). Other military opportunities for nurses include the Royal Australian Navy and the Royal Australian Air Force.

Nursing registration in Australia began in 1920 as a state-based system. Prior to 1920, nurses received certificates from the hospitals where they trained, the Australian Trained Nurses Association (ATNA), or the Royal British Nurses’ Association in order to practice. Today nurses and midwives are registered through the Nursing and Midwifery Board of Australia (NMBA), which is made up of member state and territorial boards of nursing and supported by the Australian Health Practitioner Regulation Agency. State and territorial boards are responsible for making registration and notification decisions related to individual nurses or midwives (NMBA, n.d.).

Around the turn of the 20th century, in order to create a formal means of supporting their role and improve nursing standards and education, the nurses of South Australia formed the South Australian branch of ATNA. From this organization the Australian Nursing and Midwifery Federation in South Australia (ANMFSA) evolved (ANMFSA, 2012). The Australian Nursing and Midwifery Accreditation Council (ANMAC) is now the independent accrediting authority for nursing and midwifery under Australia’s National Registration and Accreditation Scheme. The ANMAC is responsible for protecting and promoting the safety of the Australian community by promoting high standards of nursing and midwifery education through the development of accreditation standards, accreditation of programs, and assessment of internationally qualified nurses and midwives for migration (ANMAC, 2016).

In the late 1920s, two nurses, Evelyn Nowland and a Miss Clancy, began working separately on the idea of a union for nurses and were brought together by Jessie Street, who saw the improvement of nurses’ wages and conditions as a feminist cause. What is now the New South

Wales Nurses and Midwives’ Association (NSWNMA) was registered as a trade union in 1931 (NSWNMA, 2014). Through the amalgamation of various organizations, there is now one national organization to represent registered nurses, enrolled nurses, midwives, and assistants doing nursing work in every state and territory throughout Australia: the Australian Nursing and Midwifery Federation (ANMF). The organization was established in 1924 and serves as a union for nurses with an ultimate goal of improving patient care. The ANMF is now composed of eight branches: the Australian Nursing and Midwifery Federation (South Australia branch), the NSWNMA, the Australian Nursing and Midwifery Federation Victorian Branch, the Queensland Nurses Union, the Australian Nursing and Midwifery Federation Tasmanian Branch, the Australian Nursing and Midwifery Federation Australian Capital Territory, the Australian Nursing and Midwifery Federation Northern Territory, and the Australian Nursing and Midwifery Federation Western Australia Branch (ANMF, 2015).

Early Nursing Education and Organization in the United States Formal nursing education in the United States did not begin until 1862, when Dr. Marie Zakrzewska opened the New England Hospital for Women and Children, which had its own nurse training program (Sitzman & Judd, 2014b). Many of the first training schools for nursing were modeled after the Nightingale School of Nursing at St. Thomas in London. They included the Bellevue Training School for Nurses in New York City; the Connecticut Training School for Nurses in New Haven, Connecticut; and the Boston Training School for Nurses at Massachusetts General Hospital (Christy, 1975; Nutting & Dock, 1907). Based on the Victorian belief in the natural abilities of women to be sensitive, possess high morals, and be caregivers, early nursing training required that applicants be female. Sensitivity, high moral character, purity of character, subservience, and “ladylike” behavior became the associated traits of a “good nurse,” thus setting the “feminization of nursing” as the ideal standard for a good nurse. These historical roots of gender- and race-based caregiving continued to exclude males and minorities from the nursing profession for many years and still influence career choices for men and women today. These early training schools provided a stable, subservient, white female workforce because student nurses served as the primary nursing staff for these early hospitals. Minority nurses found limited educational opportunities in this climate. The first African American nursing school graduate in the United States was Mary P. Mahoney. She graduated from the New England Hospital for Women and Children in 1879 (Sitzman & Judd, 2014b).


Some nurses believe that Florence Nightingale holds nursing back and represents the negative and backward elements of nursing. This view cites as evidence that Nightingale supported the subordination of nurses to physicians, opposed registration of nurses, and did not see mental health nurses as part of the profession. After reading this chapter, what do you think? Is Nightingale relevant in the 21st century to the nursing profession? Why or why not?

Nursing education in the newly formed schools was based on accepted practices that had not been validated by research. During this time, nurses primarily relied on tradition to guide practice rather than engaging in research to test interventions; however, scientific advances did help to improve nursing practice as nurses altered interventions based on knowledge generated by scientists and physicians. During this time, a nurse, Clara Maass, gave her life as a volunteer subject in the research of yellow fever (Sitzman & Judd, 2014b).

A significant report, known simply as the Goldmark Report, Nursing and Nursing Education in the United States, was released in 1922 and advocated for the establishment of university schools of nursing to train nursing leaders. The report, initiated by Nutting in 1918, was an exhaustive and comprehensive investigation into the state of nursing education and training resulting in a 500-page document. Josephine Goldmark, social worker and author of the pioneering research of nursing preparation in the United States, stated,

From our field study of the nurse in public health nursing, in private duty, and as instructor and supervisor in hospitals, it is clear that there is need of a basic undergraduate training for all nurses alike, which should lead to a nursing diploma. (Goldmark, 1923, p. 35)

The first university school of nursing was developed at the University of Minnesota in 1909. Although the new nurse training school was under the college of medicine and offered only a 3-year diploma, the Minnesota program was nevertheless a significant leap forward in nursing education. Nursing for the Future, or the Brown Report, authored by Esther Lucille Brown in 1948 and sponsored by the Russell Sage Foundation, was critical of the quality and structure of nursing schools in the United States. The Brown Report became the catalyst for the implementation of educational nursing program accreditation through the National League for Nursing (Brown, 1936, 1948). As a result of the post–World War II nursing shortage, an associate degree in nursing was established by Dr. Mildred Montag in 1952 as a 2-year program for registered nurses (Montag, 1959). In 1950, nursing became the first profession for which the same licensure exam, the State Board Test Pool, was used throughout the nation to license registered nurses. This increased mobility for the registered nurse resulted in a significant advantage for the relatively new profession of nursing (“State Board Test Pool Examination,” 1952).

The Evolution of Nursing in the United States: The First Century of Professional Nursing The Profession of Nursing Is Born in the United States Early nurse leaders of the 20th century included Isabel Hampton Robb, who in 1896 founded the Nurses’ Associated Alumnae, which in 1911 officially became known as the American Nurses Association (ANA); and Lavinia Lloyd Dock, who became a militant suffragist linking women’s roles as nurses to the emerging women’s movement in the United States. Mary Adelaide Nutting, Lavinia L. Dock, Sophia Palmer, and Mary E. Davis were instrumental in developing the first nursing journal, the American Journal of Nursing (AJN) in October 1900. Through the ANA and the AJN, nurses then had a professional organization and a national journal with which to communicate with one another (Kalisch & Kalisch, 1986).

State licensure of trained nurses began in 1903 with the enactment of North Carolina’s licensure law for nursing. Shortly thereafter, New Jersey, New York, and Virginia passed similar licensure laws for nursing. Over the next several years, professional nursing was well on its way to public recognition of practice and educational standards as state after state passed similar legislation.

Margaret Sanger worked as a nurse on the Lower East Side of New York City in 1912 with immigrant families. She was astonished to find widespread ignorance among these families about conception, pregnancy, and childbirth. After a horrifying experience with the death of

a woman from a failed self-induced abortion, Sanger devoted her life to teaching women about birth control. A staunch activist in the early family planning movement, Sanger is credited with founding Planned Parenthood of America (Sanger, 1928).

By 1917, the emerging new profession saw two significant events that propelled the need for additional trained nurses in the United States: World War I and the influenza epidemic. Nightingale and the devastation of the Civil War had well established the need for nursing care in wartime. Mary Adelaide Nutting, now professor of nursing and health at Columbia University, chaired the newly established Committee on Nursing in response to the need for nurses as the United States entered the war in Europe. Nurses in the United States realized early that World War I was unlike previous wars. It was a global conflict that involved coalitions of nations against nations and vast amounts of supplies and demanded the organization of all the nations’ resources for military purposes (Kalisch & Kalisch, 1986). Along with Lillian Wald and Jane A. Delano, director of nursing in the American Red Cross, Nutting initiated a national publicity campaign to recruit young women to enter nurses’ training. The Army School of Nursing, headed by Annie Goodrich as dean, and the Vassar Training Camp for Nurses prepared nurses for the war as well as home nursing and hygiene nursing through the Red Cross (Dock & Stewart, 1931). The committee estimated that there were at most about 200,000 active “nurses” in the United States, both trained and untrained, which was inadequate for the military effort abroad (Kalisch & Kalisch, 1986).

At home, the influenza epidemic of 1917 to 1919 led to increased public awareness of the need for public health nursing and public education about hygiene and disease prevention. The successful campaign to attract nursing students focused heavily on patriotism, which ushered in the new era for nursing as a profession. By 1918, nursing school enrollments were up by 25%. In 1920, Congress passed a bill that

provided nurses with military rank (Dock & Stewart, 1931). Following close behind, the passage of the Nineteenth Amendment to the U.S. Constitution granted women the right to vote.

Lillian Wald, Public Health Nursing, and Community Activism The pattern for health visiting and district nursing practice outside the hospital was similar in the United States to that in England (Roberts, 1954). American cities were besieged by overcrowding and epidemics after the Civil War. The need for trained nurses evolved as in England, and schools throughout the United States developed along the Nightingale model. Visiting nurses were first sent to philanthropic organizations in New York City (1877), Boston (1886), Buffalo (1885), and Philadelphia (1886) to care for the sick at home. By the end of the century, most large cities had some form of visiting nursing program, and some headway was being made even in smaller towns (Heinrich, 1983). Industrial or occupational health nursing was first started in Vermont in 1895 by a marble company interested in the health and welfare of its workers and their families. Tuberculosis (TB) was a leading cause of death in the 1800s; nurses visited patients bedridden from TB and instructed persons in all settings about prevention of the disease (Abel, 1997).

Lillian Wald (Figure 1-2), a wealthy young woman with a great social conscience, graduated from the New York Hospital School of Nursing in 1891 and is credited with creating the title “public health nurse.” After a year working in a mental institution, Wald entered medical school at Women’s Medical College in New York. While in medical school, she was asked to visit immigrant mothers on New York’s Lower East Side and instruct them on health matters. Wald was appalled by the conditions

BOX 1-1

there. During one now famous home visit, a small child asked Wald to visit her sick mother. And the rest, as they say, is history (Box 1-1). What Wald found changed her life forever and secured a place for her in American nursing history. Wald (1915) said, “All the maladjustments of our social and economic relations seemed epitomized in this brief journey” (p. 6). Wald was profoundly affected by her observations; she and her colleague, Mary Brewster, quickly established the Henry Street Settlement in this same neighborhood in 1893. She quit medical school and devoted the remainder of her life to “visions of a better world” for the public’s health. According to Wald, “Nursing is love in action, and there is no finer manifestation of it than the care of the poor and disabled in their own homes” (Wald, 1915, p. 14).

Figure 1-2 A photo of Lillian Wald, taken by Harris and Ewing during the first half of the 20th- century.

Courtesy of Library of Congress, Prints & Photographs Division, photograph by Harris & Ewing, LC-DIG-hec-19537.


From the schoolroom where I had been giving a lesson in bed-making,

a little girl led me one drizzling March morning. She had told me of her sick mother and gathering from her incoherent account that a child had been born, I caught up the paraphernalia of the bed-making lesson and carried it with me.

The child led me over broken roadways . . . between tall, reeking houses whose laden fire-escapes, useless for their appointed purpose, bulged with household goods of every description. The rain added to the dismal appearance of the streets and to the discomfort of the crowds which thronged them, intensifying the odors, which assailed me from every side. Through Hester and Division Streets we went to the end of Ludlow; past odorous fish-stands, for the streets were a market- place, unregulated, unsupervised, unclean; past evil-smelling, uncovered garbage cans. . . .

All the maladjustments of our social and economic relations seemed epitomized in this brief journey and what was found at the end of it. The family to which the child led me was neither criminal nor vicious. Although the husband was a cripple, one of those who stand on street corners exhibiting deformities to enlist compassion, and masking the begging of alms by a pretense of selling; although the family of seven shared their two rooms with boarders—who were literally boarders, since a piece of timber was placed over the floor for them to sleep on—and although the sick woman lay on a wretched, unclean bed, soiled with a hemorrhage two days old, they were not degraded human beings, judged by any measure of moral values.

In fact, it was very plain that they were sensitive to their condition, and when, at the end of my ministrations, they kissed my hands (those who have undergone similar experiences will, I am sure, understand), it would have been some solace if by any conviction of the moral unworthiness of the family I could have defended myself as a part of a society which permitted such conditions to exist. Indeed, my

subsequent acquaintance with them revealed the fact that miserable as their state was, they were not without ideals for the family life, and for society, of which they were so unloved and unlovely a part.

That morning’s experience was a baptism of fire. Deserted were the laboratory and the academic work of the college. I never returned to them. On my way from the sick-room to my comfortable student quarters, my mind was intent on my own responsibility. To my inexperience it seemed certain that conditions such as these were allowed because people did not know, and for me there was a challenge to know and to tell. When early morning found me still awake, my naive conviction remained that, if people knew things—and “things” meant everything implied in the condition of this family—such horrors would cease to exist, and I rejoiced that I had a training in the care of the sick that in itself would give me an organic relationship to the neighborhood in which this awakening had come.

Reproduced from Wald, L. D. (1915). The House on Henry Street. New York, NY: Henry Holt.

The Henry Street Settlement was an independent nursing service where Wald lived and worked. This later became the Visiting Nurse Association of New York City, which laid the foundation for the establishment of public health nursing in the United States. The health needs of the population were met through addressing social, economic, and environmental determinants of health, in a pattern after Nightingale. These nurses helped educate families about disease transmission and emphasized the importance of good hygiene. They provided preventive, acute, and long-term care. As such, Henry Street went far beyond the care of the sick and the prevention of illness. It aimed at rectifying those causes that led to the poverty and misery. Wald was a tireless social activist for legislative reforms that would provide a more just distribution

of services for the marginal and disadvantaged in the United States (Donahue, 1985). Wald began with 10 nurses in 1893, which grew to 250 nurses serving 1,300 clients a day by 1916. During this same period, the budget grew from nothing to more than $600,000 a year, all from private donations.

Wald hired African American nurse Elizabeth Tyler in 1906 as evidence of her commitment to cultural diversity. Although unable to visit white clients, Tyler made her own way by “finding” African American families who needed her service. In 3 months, Tyler had so many African American families within her caseload that Wald hired a second African American nurse, Edith Carter. Carter remained at Henry Street for 28 years until her retirement (Carnegie, 1991). During her tenure at Henry Street, Wald demonstrated her commitment to racial and cultural diversity by employing 25 African American nurses over the years, and she paid them salaries equal to white nurses and provided identical benefits and recognition to minority nurses (Carnegie, 1991). This was exceptional during the early part of the 1900s, a time when African American nurses were often denied admission to white schools of nursing and membership in professional organizations and were denied opportunities for employment in most settings. Because hospitals of this era often set quotas for African American clients, those nurses who managed to graduate from nursing schools found themselves with few clients who needed or could afford their services. African American nurses struggled for the right to take the registration examination available for white nurses.

Wald submitted a proposal to the city of New York after learning of a child’s dismissal from a New York City school for a skin condition. Her proposal was for one of the Henry Street Settlement nurses to serve free for 1 month in a New York school. The results of her experiment were so convincing that salaries were approved for 12 school nurses. From this,

school nursing was born in the United States and became one of many community specialties credited to Wald (Dietz & Lehozky, 1963). In 1909, Wald proposed a program to the Metropolitan Life Insurance Company to provide nursing visits to their industrial policyholders. Statistics kept by the company documented the lowered mortality rates of policyholders attributed to the nurses’ public health practice and clinical expertise. The program demonstrated savings for the company and was so successful that it lasted until 1953 (Hamilton, 1988).

Wald’s other significant accomplishments include the establishment of the Children’s Bureau, set up in 1912 as part of the U.S. Department of Labor. She also was an enthusiastic supporter of and participant in women’s suffrage, lobbied for inspections of the workplace, and supported her employee, Margaret Sanger, in her efforts to give women the right to birth control. She was active in the American Red Cross and International Red Cross and helped form the Women’s Trade Union League to protect women from sweatshop conditions.

Wald first coined the phrase “public health nursing” (Figure 1-3) and transformed the field of community health nursing from the narrow role of home visiting to the population focus of today’s community health nurse (Robinson, 1946). According to Dock and Stewart (1931), the title of public health nurse was purposeful: The role designation was designed to link the public’s health to governmental responsibility, not private funding. As state departments of health and local governments began to employ more and more public health nurses, their role increasingly focused on prevention of illness in the entire community. Discrimination developed between the visiting nurse, who was employed by the voluntary agencies primarily to provide home care to the sick, and the public health nurse, who concentrated on preventive measures (Figure 1-3) (Brainard, 1922).

Figure 1-3 Photo of Town & Country Rural Public Health Nurse carrying the black bag typical of public health nurses in the early 20th-century.

Early public health nurses came closer than hospital-based nurses to the autonomy and professionalism that Nightingale advocated. Their work was conducted in the unconfined setting of the home and community, they were independent, and they enjoyed recognition as specialists in preventive health (Buhler-Wilkerson, 1985). Public health nurses from the beginning were much more holistic in their practice than their hospital counterparts. They were involved with the health of industrial workers, immigrants, and their families and were concerned about exploitation of women and children. These nurses also played a part in prison reform and care of the mentally ill (Heinrich, 1983).

Considered the first African American public health nurse, Jessie Sleet Scales was hired in 1902 by the Charity Organization Society, a philanthropic organization, to visit African American families infected by TB. Scales provided district nursing care to New York City’s African American families and is credited with paving the way for African

American nurses in the practice of community health (Mosley, 1996).

Dorothea Lynde Dix Dorothea Lynde Dix, a Boston schoolteacher, became aware of the horrendous conditions in prisons and mental institutions when asked to do a Sunday school class at the House of Correction in Cambridge, Massachusetts. She was appalled at what she saw and went about studying whether the conditions were isolated or widespread; she took 2 years off to visit every jail and almshouse from Cape Cod to Berkshire (Tiffany, 1890). Her report was devastating. Boston was scandalized by the reality that the most progressive state in the Union was now associated with such appalling conditions. The shocked legislature voted to allocate funds to build hospitals. For the rest of her life, Dorothea Dix stood out as a tireless zealot for the humane treatment of the insane and imprisoned. She had exceptional savvy in dealing with legislators. She acquainted herself with the legislators and their records and displayed the “spirit of a crusader.” For her contributions, Dix is recognized as one of the pioneers of the reform movement for mental health in the United States, and her efforts are felt worldwide to the present day (Dietz & Lehozky, 1963).

Dix was also known for her work in the Civil War, having been appointed superintendent of the female nurses of the army by the secretary of war in 1861. Her tireless efforts led to the recruitment of more than 2,000 women to serve in the army during the Civil War. Officials had consulted with Nightingale concerning military hospitals and were determined not to make the same mistakes. Dix enjoyed far more sweeping powers than Nightingale in that she had the authority to organize hospitals, to appoint nurses, and to manage supplies for the wounded (Brockett & Vaughan, 1867). Among her most well-known

nurses during the Civil War were the poet Walt Whitman and the author Louisa May Alcott (Donahue, 1985).

Clara Barton The idea for the International Red Cross was the brainchild of a Swiss banker, J. Henri Dunant, who proposed the formation of a neutral international relief society that could be activated in time of war. The International Red Cross was ratified by the Geneva Convention on August 22, 1864. Clara Barton, through her work in the Civil War, had come to believe that such an organization was desperately needed in the United States. However, it was not until 1882 that Barton was able to convince Congress to ratify the Treaty of Geneva, thus becoming the founder of the American Red Cross (Kalisch & Kalisch, 1986). Barton also played a leadership role in the Spanish-American War in Cuba, where she led a group of nurses to provide care for both U.S. and Cuban soldiers and Cuban civilians. At the age of 76, Barton went to President McKinley and offered the help of the Red Cross in Cuba. The president agreed to allow Barton to go with Red Cross nurses but only to care for the Cuban citizens. Once in Cuba, the U.S. military saw what Barton and her nurses were able to accomplish with the Cuban military, and American soldiers pressured military officials to allow Barton’s help. Along with battling yellow fever, Barton was able to provide care to both Cuban and U.S. military personnel and eventually expanded that care to Cuban citizens in Santiago. One of Barton’s most famous clients was young Colonel Teddy Roosevelt, who led his Rough Riders and who later became the president of the United States. Barton became an instant heroine both in Cuba and in the United States for her bravery and tenaciousness and for organizing services for the military and civilians torn apart by war. On August 13, 1898, the Spanish-American War came

to an end. The grateful people of Santiago, Cuba, built a statue to honor Clara Barton in the town square, where it stands to this day. The work of Barton and her Red Cross nurses spread through the newspapers of the United States and in the schools of nursing. A congressional committee investigating the work of Barton’s Red Cross staff applauded these nurses and recommended that the U.S. Army Medical Department create a permanent reserve corps of trained nurses. These reserve nurses became the Army Nurse Corps in 1901. Clara Barton will always be remembered both as the founder of the American Red Cross and as the driving force behind the creation of the Army Nurse Corps (Frantz, 1998).

Birth of the Midwife in the United States Women have always assisted other women in the birth of babies. These “lay midwives” were considered by communities to possess special skills and somewhat of a “calling.” With the advent of professional nursing in England, registered nurses became associated with safer and more predictable childbirth practices. In England and in other countries where Nightingale nurses were prevalent, most registered nurses were also trained as midwives with a 6-month specialized training period. In the United States, the training of registered nurses in the practice of midwifery was prevented primarily by physicians. U.S. physicians saw midwives as a threat and intrusion into medical practice. Such resistance indirectly led to the proliferation of “granny wives” who were ignorant of modern practices, were untrained, and were associated with high maternal morbidity (Donahue, 1985).

The first organized midwifery service in the United States was the Frontier Nursing Service founded in 1925 by Mary Breckinridge. Breckinridge graduated from the St. Luke’s Hospital Training School in New York in 1910 and received her midwifery certificate from the British

Hospital for Mothers and Babies in London in 1925. She had extensive experience in the delivery of babies and midwifery systems in New Zealand and Australia. In rural Appalachia, babies had been delivered for decades by granny midwives, who relied mainly on tradition, myths, and superstition as the bases of their practice. For example, they might use ashes for medication and place a sharp axe, blade up, under the bed of a laboring woman to “cut” the pain. The people of Appalachia were isolated because of the terrain of the hollows and mountains, and roads were limited to most families. They had one of the highest birth rates in the United States. Breckinridge believed that if a midwifery service could work under these conditions, it could work anywhere (Donahue, 1985).

Breckinridge had to use English midwives for many years and began training her own midwives only in 1939 when she started the Frontier Graduate School of Nurse Midwifery in Hyden, Kentucky, with the advent of World War II. The nurse midwives accessed many of their families on horseback. In 1935, a small 12-bed hospital was built at Hyden and provided delivery services. Under the direction of Breckinridge, the nurse midwives were successful in lowering the highest maternal mortality rate in the United States (in Leslie County, Kentucky) to substantially below the national average. These nurses, as at Henry Street Settlement, provided health care for everyone in the district for a small annual fee. A delivery had an additional small fee. Nurse midwives provided primary care, prenatal care, and postnatal care, with an emphasis on prevention (Wertz & Wertz, 1977).

Armed with the right to vote, in the Roaring Twenties American women found the new freedom of the “flapper era”—shrinking dress hemlines, shortened hairstyles, and the increased use of cosmetics. Hospitals were used by greater numbers of people, and the scientific basis of medicine became well established because most surgical procedures were done in hospitals. Penicillin was discovered in 1928,

creating a revolution in the prevention of infectious disease deaths (Donahue, 1985; Kalisch & Kalisch, 1986). The previously mentioned Goldmark Report recommended the establishment of college- and university-based nursing programs.

Mary D. Osborne, who functioned as supervisor of public health nursing for the state of Mississippi from 1921 to 1946, had a vision for a collaboration with community nurses and granny midwives, who delivered 80% of the African American babies in Mississippi. The infant and maternal mortality rates were both exceptionally high among African American families, and these granny midwives, who were also African American, were untrained and had little education.

Osborne took a creative approach to improving maternal and infant health among African American women. She developed a collaborative network of public health nurses and granny midwives; the nurses implemented training programs for the midwives, and the midwives in turn assisted the nurses in providing a higher standard of safe maternal and infant health care. The public health nurses used Osborne’s book, Manual for Midwives, which contained guidelines for care and was used in the state until the 1970s. They taught good hygiene, infection prevention, and compliance with state regulations. Osborne’s innovative program is credited with reducing the maternal and infant mortality rates in Mississippi and in other states where her program structure was adopted (Sabin, 1998).

The Nursing Profession Responds to the Great Depression and World War II With the stock market crash of 1929 came the Great Depression, resulting in widespread unemployment of private-duty nurses and the closing of nursing schools with a simultaneous increase in the need for

charity health services for the population. Nursing students who had previously been the primary source to staff hospitals declined in number. Unemployed graduate nurses were hired to replace them for minimal wages, a trend that was to influence the profession for years to come (MacEachern, 1932).

Other nurses found themselves accompanying troops to Europe when the United States entered World War II. Military nurses provided care aboard hospital ships and were a critical presence at the invasion of Normandy in 1944 as well as in military operations in North Africa, Italy, France, and the Philippines. More than 100,000 nurses volunteered and were certified for military service in the Army and Navy Nurse Corps. The resulting severe shortage of nurses on the home front resulted in the development of the Cadet Nurse Corps. Frances Payne Bolton, congressional representative from Ohio, is credited with the founding of the Cadet Nurse Corps through the Bolton Act of 1945. By the end of the war, more than 180,000 nursing students had been trained through this act, and advanced practice graduate nurses in psychiatry and public health nursing had received graduate education to increase the numbers of nurse educators (Donahue, 1985; Kalisch & Kalisch, 1986).

Amid the Depression, many nurses found the expansion and advances in aviation as a new field for nurses. In efforts to increase the public’s confidence in the safety of transcontinental air travel, nurses were hired in the promising new role of “nurse-stewardess” (Kalisch & Kalisch, 1986). Congress created an additional relief program, the Civil Works Administration, in 1933 that provided jobs to the unemployed, including placing nurses in schools, public hospitals and clinics, public health departments, and public health education community surveys and campaigns. The Social Security Act of 1935 was passed by Congress to provide old-age benefits, rehabilitation services, unemployment compensation administration, aid to dependent and/or disabled children

and adults, and monies to state and local health services. The Social Security Act included Title VI, which authorized the use of federal funds for the training of public health personnel. This led to the placement of public health nurses in state health departments and to the expansion of public health nursing as a viable career path.

While nursing was forging new paths for itself in various fields, during the 1930s Hollywood began featuring nurses in films. The only feature- length films to ever focus entirely on the nursing profession were released during this decade. War Nurse (1930), Night Nurse (1931), Once to Every Woman (1934), The White Parade (1934 Academy Award nominee for Best Picture), Four Girls in White (1939), The White Angel (1936), and Doctor and Nurse (1937) all used nurses as major characters. During the bleak years of the economic depression, young women found these nurse heroines who promoted idealism, self- sacrifice, and the profession of nursing over personal desires particularly appealing. No longer were nurses depicted as subservient handmaidens who worked as nurses only as a temporary pastime before marriage (Kalisch & Kalisch, 1986).

During the 1930s, the Association of Collegiate Schools of Nursing was formed to advance nursing education and to promote research related to educational criteria in nursing. Goals were aimed at changing the professional level of the nurse with a focus on preparing nurses in the academic setting and thus preparing nurses for specialized roles, such as faculty, administrators of schools of nursing, and supervisors (Judd, 2014).

Science and Health Care, 1945–1960: Decades of Change Dramatic technologic and scientific changes characterized the decades

following World War II, including the discovery of sulfa drugs, new cardiac drugs, surgeries, and treatment for ventricular fibrillation (Howell, 1996). The Hill-Burton Act, passed in 1946, provided funds to increase the construction of new hospitals. A significant change in the healthcare system was the expansion of private health insurance coverage and the dramatic increase in the birth rate, called the “baby boom” generation. Clinical research, both in medicine and in nursing, became an expectation of health providers, and more nurses sought advanced degrees. The first ANA Code of Ethics for Nurses was adopted in 1950, and in 1953 the International Council of Nurses (ICN) adopted an international Code of Ethics for Nurses. In 1952, the first scholarly journal, Journal of Nursing Research, was first published in the United States (Kalisch & Kalisch, 2004).

As a result of increased numbers of hospital beds, additional financial resources for health care, and the post–World War II economic resurgence, nursing faced an acute shortage and nurses confronted increasingly stressful working conditions. Nurses began showing signs of the strain through debates about strikes and collective bargaining demands.

The ANA accepted African American nurses for membership, consequently ending racial discrimination in the dominant nursing organizations. The National Association of Colored Graduate Nurses was disbanded in 1951. Males entered nursing schools in record number, often as a result of previous military experience as medics. Prior to the 1950s and 1960s, male nurses also suffered minority status and were discouraged from nursing as a career. A fact seemingly forgotten by modern society, including Florence Nightingale and early U.S. nursing leaders, is that during medieval times more than one-half of the nurses were male. The Knights Hospitallers, Teutonic Knights, Franciscans, and many other male nursing orders had provided excellent nursing care for

their societies. Saint Vincent de Paul had first conceived of the idea of social service. Pastor Theodor Fliedner, teacher and mentor of Florence Nightingale at Kaiserwerth in Germany; Ben Franklin; and Walt Whitman during the Civil War all either served as nurses or were strong advocates for male nurses (Kalisch & Kalisch, 1986).

Years of Revolution, Protest, and the New Order, 1961–2000 During the social upheaval of the 1960s, nursing was influenced by many changes in society, such as the women’s movement, organized protest against the Vietnam conflict, civil rights movement, President Lyndon Johnson’s “Great Society” social reforms, and increased consumer involvement in health care. Specialization in nursing, such as cardiac intensive care unit, nurse anesthetist training, and the clinical specialist role for nursing, became trends that affected both education and practice in the healthcare system. Medicare and Medicaid, enacted in 1965 under Title XVIII of the Social Security Act, provided access to health care for older adults, poor persons, and people with disabilities. The ANA took a courageous and controversial stand in that same year (1965) by approving its first position paper on nursing education, advocating for all nursing education for professional practice to take place in colleges and universities (ANA, 1965). Nurses returning from Vietnam faced emotional challenges in the form of PTSD that affected their postwar lives.

With increased specialization in medicine, the demand for primary care healthcare providers exceeded the supply (Christman, 1971). As a response to this need for general practitioners, Dr. Henry Silver, MD, and Dr. Loretta Ford, RN, collaborated to develop the first NP program in the United States at the University of Colorado (Ford & Silver, 1967). NPs were initially prepared in pediatrics, with advanced role preparation in

common childhood illness management and well-child care (Figure 1-4). Ford and Silver (1967) found that NPs could manage as much as 75% of the pediatric patients in community clinics, leading to the widespread use of and educational programs for NPs. The first state in 1971 to recognize diagnosis and treatment as part of the legal scope of practice for NPs was Idaho. Alaska and North Carolina were among the first states to expand the NP role to include prescriptive authority (Ford, 1979). By the turn of the century, NP programs were offered at the master of science in nursing level in family nursing; gerontology; and adult, neonatal, mental health, and maternal–child areas and have expanded to include the acute care practitioner as well (Huch, 2001). Currently, the preferred educational preparation for advanced practice nurse is the doctor of nursing practice. Certification of NPs now occurs at the national level through the ANA and several specialty organizations. NPs are licensed throughout the United States by state boards of nursing.

Figure 1-4 The nurse with advanced preparation and certification as a nurse practitioner is able to diagnose and treat patients.

© KidStock/Getty Images


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential VIII: Professionalism and Professional Values

8.5 Demonstrate an appreciation of the history of and contemporary issues in nursing and their impact on current nursing practice (p. 28).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

In the late 1980s, escalating healthcare costs resulting from the explosion of advanced technology and the increased life span of Americans led to the demand for healthcare reform. The nursing profession heralded healthcare reform with an unprecedented collaboration of more than 75 nursing associations, led by the ANA and the National League for Nursing, in the publication of Nursing’s Agenda for Health Care Reform. In this document, the challenge of managed care was addressed in the context of cost containment and quality assurance of healthcare service for the nursing profession (ANA, 1991).

The New Century The new century began with a renewed focus on quality and safety in patient care. The landmark publication from the Institute of Medicine (IOM) published in November 1999, To Err Is Human, was the launching pad from which this movement began in earnest. This report is best known for drawing attention to the scope of errors in health care; for the conclusion that most errors are related to faulty systems, processes, and conditions that allow error rather than to individual recklessness; and for the recommendation to design healthcare systems at all levels to make it more difficult to make errors. Subsequent reports followed focusing on quality through healthcare redesign and health professions education redesign (IOM, 2001, 2003).

With the roles of nurses in the healthcare system expected to continue to expand in the future, the focus is placed on raising the educational levels and competencies of nurses and fostering interdisciplinary collaboration to increase access, safety, and quality of patient care. For example, the latest IOM report, The Future of Nursing: Leading Change, Advancing Health (2011), specifically calls for interdisciplinary education, decreasing barriers to nurses’ scope of practice, and increasing the educational levels of nurses. The Robert Wood Johnson Foundation sponsored the Quality and Safety Education for Nurses (QSEN) initiative with the overall goal of “preparing future nurses who will have the knowledge, skills and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work” (QSEN, 2018). The focus of QSEN is to develop the competencies of future nursing graduates in six key areas: patient-centered care, evidence-based practice, quality

improvement, teamwork and collaboration, safety, and informatics.


Examples of applicable Nurse of the Future: Nursing Core Competencies


Knowledge (K8a) Understands the responsibilities inherent in being a member of the nursing profession

Skills (S8a) Understands the history and philosophy of the nursing profession

Attitudes/Behaviors (A8a) Recognizes the need for personal and professional behaviors that promote the profession of nursing

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

In 2006, the Massachusetts Department of Higher Education (MDHE) and the Massachusetts Organization of Nurse Executives convened a working session of stakeholders titled Creativity and Connections: Building the Framework for the Future of Nursing Education and Practice. From this beginning, the Nurse of the Future: Nursing Core Competencies (MDHE, 2010) was developed in response to the goals of creating a seamless progression through all levels of nursing education and development of consensus on the minimum competency expectations for all nurses upon completion of prelicensure nursing education. In 2016, the Nurse of the Future: Nursing Core Competencies was revised to ensure that the competencies reflect the changes that have occurred in health care and nursing practice since the previous

edition (MDHE, 2016). This movement to facilitate creation of a core set of entry-level nursing competencies and seamless transition in nursing education is not singular and reflects the current focus in the profession to increase the access, safety, and quality of health care.

U.S. healthcare system reform continues to be the topic of political debate, with the primary focus on federal coverage, access, and control of healthcare costs. Healthcare organizations in a managed care environment see economic and quality outcome benefits of caring for patients and managing their care over a continuum of settings and needs. Patients are followed more closely within the system, during both illness and wellness. Hospital stays are shorter, and more healthcare services are provided in outpatient facilities and through community- based settings.


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential V: Healthcare Policy, Finance, and Regulatory Environments

5.6 Explore the impact of sociocultural, economic, legal, and political factors influencing healthcare delivery and practice (p. 21).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

The Patient Protection and Affordable Care Act (PPACA) was signed into law on March 23, 2010 and was upheld as constitutional by the U.S. Supreme Court on June 28, 2012. The purpose of the PPACA is to provide affordable health care for all Americans, and overall, access to

health care increased under the PPACA. The law included provisions for preventive care, such as cancer screenings and flu shots without cost sharing, and protections for consumers that included ending preexisting exclusions for children, ending lifetime limits, and preventing companies from arbitrarily dropping coverage (Shi & Singh, 2019). It was predicted that this legislation would have results through 2029 and its implementation would increase insurance coverage to 32 million additional uninsured people. In December 2017, a tax bill was passed with an effective date of 2019 that repeals the individual insurance mandate, one of the key elements of the PPACA, but leaves most of the other components of what has become known as Obamacare intact (Qiu, 2017).

As advocates for the public and in response to presidential campaign promises to repeal the PPACA, in December 2016, ANA delivered a letter to then President-elect Trump outlining ANA’s Principles for Health System Transformation. The principles outline system requirements, including that the system must (1) ensure universal access to a standard package of essential healthcare services for all citizens and residents; (2) optimize primary, community-based, and preventive services while supporting the cost-effective use of innovative, technology-driven, acute, hospital-based services; (3) encourage mechanisms to stimulate the economical use of healthcare services while supporting those who do not have the means to share costs; and (4) ensure a sufficient supply of a skilled workforce dedicated to providing high-quality healthcare services (ANA, 2016).


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential VII: Clinical Prevention and Population Health

7.12 Advocate for social justice, including a commitment to the health of vulnerable populations and health disparities (p. 25).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

International Council of Nurses A review of nursing history would not be complete without some discussion of the contributions of the International Council of Nurses (ICN). The ICN was founded in 1899 by women whose names are familiar to the student of nursing history—such names as Ethel Fenwick of Great Britain, Lavinia Dock of the United States, Mary Agnes Snively of Canada, and Agnes Karll of Germany—who believed in the link between women’s rights and professional nursing. They advocated for the creation of national nursing organizations that would allow women to self-govern the profession, and these early leaders from the United Kingdom, Canada, the United States, Germany, the Netherlands, and Scandinavia banded together in the ICN to encourage one another as they continued to build stronger national associations in their respective nations (Brush & Lynaugh, 1999).


Examples of applicable Nurse of the Future: Nursing Core Competencies:


Knowledge (K8) Understands how healthcare issues are identified, how healthcare policy is both developed and changed

Skills (S8) Participates as a nursing professional in political processes and grassroots legislative efforts to influence healthcare policy

Attitudes/Behaviors (A8) Recognizes how the healthcare process can be influenced through the efforts of nurses and other healthcare professionals, as well as lay and special advocacy groups.

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

World War I and World War II presented threats to the organization, but the ICN emerged with greater participation from nurses in nations that had not previously participated in the organization. New members after World War I included China, Palestine, Brazil, and the Philippines. After World War II, there was again an influx of new membership that included nations from Africa, Asia, and South America. With an increasingly diverse membership, the ICN implemented a more global agenda. During the time of the Cold War when Russia, China, and nations in Eastern Europe did not participate, the ICN still defined the work of nurses worldwide and claimed the right to speak for nursing. During the decades that followed, the ICN forged closer links with the World Health Organization, added to its agenda the delivery of primary health care to people around the world, and actively supported the rights of nurses to fair employment and freedom from exploitation (Brush & Lynaugh, 1999).

Currently located in Geneva, Switzerland, the ICN has grown into a federation of more than 130 national nurses associations, representing the more than 16 million nurses worldwide. ICN is the world’s first and widest reaching international organization for health professionals, working to ensure high-quality nursing care for all, sound health policies globally, the advancement of nursing knowledge, and the presence worldwide of a respected nursing profession and a competent and satisfied nursing workforce (ICN, n.d.).

Conclusion Contemplating the progression of nursing as a profession, it becomes evident from the preceding pages that similar issues, barriers, challenges, and opportunities were simultaneously present in locations around the globe. In each circumstance, nursing leaders arose to initiate change; whether related to nurse registration, standards for nursing education, or safe work environments, their ultimate goal was the provision of high-quality patient care. The history of professional nursing began with efforts to reach that goal, and we continue in this quest as our nursing organizations endeavor to develop and revise accreditation standards for programs of nursing, examine practice competencies, and review criteria for licensure.

Consensus regarding basic education and the entry level of registered nurses has not occurred in the United States, although progress has been made in neighboring Canada. Changes in the advanced practice role continue to challenge the nurse education and healthcare systems around the world as the primary healthcare needs of populations compete with acute care for scarce resources. A global community demands that nurses remain committed to cultural sensitivity in care delivery. The history of health care and nursing provides ample examples of the wisdom of our forebears in the advocacy of nursing in challenging settings in an unknown future. By considering the lessons of our past, the nursing profession is positioned to lead the way in the provision of a full range of high-quality, cost-effective services required to care for patients in this century.


What do you think would be the response of such historical nursing leaders as Florence Nightingale, Lillian Wald, and Mary Breckinridge if they could see what the profession of nursing looks like today?

Classroom Activity 1-1

There are many theories about Nightingale’s chronic illness, which caused her to be an invalid for most of her adult life. Many people have interpreted this as hypochondriacal, something of a melodrama of the Victorian times. Nightingale was rich and could take to her bed. She became ill during the Crimean War in May 1855 and was diagnosed with a severe case of Crimean fever. Today Crimean fever is recognized as Mediterranean fever and is categorized as brucellosis. She developed spondylitis, or inflammation of the spine. For the next 34 years, she managed to continue her writing and advocacy, often predicting her imminent death. Others have claimed that Nightingale suffered from bipolar disorder, causing her to experience long periods of depression alternating with remarkable bursts of productivity. Read about the various theories of her chronic disabling condition and reflect on your own conclusions about her mysterious illness. With supporting evidence, what are your conclusions about Nightingale’s health condition?

Data from Dossey, B. (2000). Florence Nightingale: Mystic, visionary, healer. Philadelphia, PA:

Lippincott Williams & Wilkins; Australian Nursing Federation. (2004). Nightingale suffered

bipolar disorder. Australian Nursing Journal, 12(2), 33.

Classroom Activity 1-2

What would Florence Nightingale’s résumé or curriculum vitae look like? Check out Nightingale’s curriculum vitae at

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© James Kang/EyeEm/Getty Images


Frameworks for Professional Nursing Practice1 Kathleen Masters

Learning Objectives

After completing this chapter, the student should be able to:

1. Identify the four metaparadigm concepts of nursing. 2. Explain several theoretical works in nursing. 3. Discuss the Nurse of the Future concepts and core


4. Describe several nonnursing theories important to the discipline of nursing.

5. Begin the process of identifying theoretical frameworks of nursing that are consistent with a personal belief system.

Key Terms and Concepts

Concept Conceptual model Propositions Assumptions Theory Metaparadigm Person Environment Health Nursing Philosophies

Although the beginning of nursing theory development can be traced to Florence Nightingale, it was not until the second half of the 1900s that nursing theory caught the attention of nursing as a discipline. During the decades of the 1960s and 1970s, theory development was a major topic of discussion and publication. During the 1970s, much of the discussion was related to the development of one global theory for nursing. However, in the 1980s, attention turned from the development of a global theory for nursing as scholars began to recognize multiple approaches to theory development in nursing.

Because of the plurality in nursing theory, this information must be organized to be meaningful for practice, research, and further knowledge development. The goal of this chapter is to present an organized and practical overview of the major concepts, models, philosophies, and theories that are essential in professional nursing practice.

It can be helpful to define some terms that might be unfamiliar. A concept is a term or label that describes a phenomenon (Meleis, 2004). The phenomenon described by a concept can be either empirical or abstract. An empirical concept is one that can be either observed or experienced through the senses. An abstract concept is one that is not observable, such as hope or caring (Hickman, 2002).

A conceptual model is defined as a set of concepts and statements that integrate the concepts into a meaningful configuration (Lippitt, 1973; as cited in Fawcett, 1994). Propositions are statements that describe relationships among events, situations, or actions (Meleis, 2004). Assumptions also describe concepts or connect two concepts and represent values, beliefs, or goals. When assumptions are challenged, they become propositions (Meleis, 2004). Conceptual models are composed of abstract and general concepts and propositions that provide a frame of reference for members of a discipline. This frame of reference determines how the world is viewed by members of a discipline and guides the members as they propose questions and make observations relevant to the discipline (Fawcett, 1994).

A theory “is an organized, coherent, and systematic articulation of a set of statements related to significant questions in a discipline that are communicated in a meaningful whole” (Meleis, 2007, p. 37). The primary distinction between a conceptual model and a theory is the level of abstraction and specificity. A conceptual model is a highly abstract system of global concepts and linking statements. A theory, in contrast, deals with one or more specific, concrete concepts and propositions

(Fawcett, 1994). A metaparadigm is the most global perspective of a discipline and

“acts as an encapsulating unit, or framework, within which the more restricted . . . structures develop” (Eckberg & Hill, 1979, p. 927). Each discipline singles out phenomena of interest that it will deal with in a unique manner. The concepts and propositions that identify and interrelate these phenomena are even more abstract than those in the conceptual models. These are the concepts that comprise the metaparadigm of the discipline (Fawcett, 1994).

The conceptual models and theories of nursing represent various paradigms derived from the metaparadigm of the discipline of nursing. Therefore, although each of the conceptual models might link and define the four metaparadigm concepts differently, the four metaparadigm concepts are present in each of the models.

The central concepts of the discipline of nursing are person, environment, health, and nursing. These four concepts of the metaparadigm of nursing are more specifically “the person receiving the nursing, the environment within which the person exits, the health–illness continuum within which the person falls at the time of the interaction with the nurse, and, finally, nursing actions themselves” (Flaskerud & Holloran, 1980, cited in Fawcett, 1994, p. 5).

Because concepts are so abstract at the metaparadigm level, many conceptual models have been developed from the metaparadigm of nursing. Subsequently, multiple theories have been derived from conceptual models in an effort to describe, explain, interpret, and predict the experiences, observations, and relationships observed in nursing practice.

Overview of Selected Nursing Theories To apply nursing theory in practice, the nurse must have some knowledge of the theoretical works of the nursing profession. This chapter is not intended to provide an in-depth analysis of each of the theoretical works in nursing but rather to provide an introductory overview of selected theoretical works to give you a launching point for further reflection and study as you begin your journey into professional nursing practice.


What are the specific competencies for nurses in relation to theoretical knowledge?

Theoretical works in nursing are generally categorized as either philosophies, conceptual models or grand theories, middle-range theories, or practice theories (which may also be referred to as situation- specific theories) depending on the level of abstraction. We begin with the most abstract of these theoretical works, the philosophies of nursing.

Selected Philosophies of Nursing Philosophies set forth the general meaning of nursing and nursing phenomena through reasoning and the logical presentation of ideas. Philosophies are broad and address general ideas about nursing. Because of their breadth, nursing philosophies contribute to the discipline by providing direction, clarifying values, and forming a foundation for theory development (Alligood, 2006).

Nightingale’s Environmental Theory Nightingale’s philosophy includes the four metaparadigm concepts of nursing (Table 2-1), but the focus is primarily on the patient and the environment, with the nurse manipulating the environment to enhance patient recovery. Nursing interventions using Nightingale’s philosophy are centered on the 13 canons, which follow (Nightingale, 1860/1969):

TABLE 2-1 Metaparadigm Concepts as Defined in Nightingale’s Model

Person Recipient of nursing care.

Environment External (temperature, bedding, ventilation) and internal (food, water, and medications).

Health Health is “not only to be well, but to be able to use well every power we have to use” (Nightingale, 1860/1969, p. 24).

Nursing Alter or manage the environment to implement the natural laws of health.

Ventilation and warming: The interventions subsumed in this canon include keeping the patient and the patient’s room warm and keeping the patient’s room well ventilated and free of odors. Specific instructions included “keep the air within as pure as the air without” (Nightingale, 1860/1969, p. 10). Health of houses: This canon includes the five essentials of pure air, pure water, efficient drainage, cleanliness, and light. Petty management: Continuity of care for the patient when the nurse is absent is the essence of this canon. Noise: Instructions include the avoidance of sudden noises that startle or awaken patients and keeping noise in general to a minimum. Variety: This canon refers to an attempt at variety in the patient’s

room to avoid boredom and depression. Taking food: Interventions include the documentation of the amount of food and liquids that the patient ingests. What food? Instructions include trying to include patient food preferences. Bed and bedding: The interventions in this canon include comfort measures related to keeping the bed dry and wrinkle-free. Light: The instructions contained in this canon relate to adequate light in the patient’s room. Cleanliness of rooms and walls: This canon focuses on keeping the environment clean. Personal cleanliness: This canon includes such measures as keeping the patient clean and dry. Chattering hopes and advices: Instructions in this canon include the avoidance of talking without reason or giving advice that is without fact. Observation of the sick: This canon includes instructions related to making observations and documenting observations.

The 13 canons are central to Nightingale’s theory but are not all inclusive. Nightingale believed that nursing was a calling and that the recipients of nursing care were holistic individuals with a spiritual dimension; thus, the nurse was expected to care for the spiritual needs of the patients in spiritual distress. Nightingale also believed that nurses should be involved in health promotion and health teaching with the sick and with those who were well (Bolton, 2006).

Although Nightingale’s theory was developed long ago in response to a need for environmental reform, the nursing principles are still relevant today. Even as some of Nightingale’s rationales have been modified or disproved by advances in medicine and science, many of the concepts in

her theory not only have endured but also have been used to provide general guidelines for nurses for more than 150 years (Pfettscher, 2006).

Virginia Henderson: Definition of Nursing and 14 Components of Basic Nursing Care Henderson made such significant contributions to the discipline of nursing during her more-than-60-year career as a nurse, teacher, author, and researcher that some refer to her as the Florence Nightingale of the 20th century (Tomey, 2006). She is perhaps best known for her definition of nursing, which was first published in 1955 (Harmer & Henderson, 1955) and then published in 1966 with minor revisions. According to Henderson (1966), the role of the nurse involves assisting the patient to perform activities that contribute to health, recovery, or a peaceful death, which the patient would perform without assistance if he or she possessed “the necessary strength, will, or knowledge” and to do so in a way that helps the patient gain independence rather than remain dependent on the nurse (p. 15). In her work, Henderson emphasized the art of nursing as well as empathetic understanding, stating that the nurse must “get inside the skin of each of her patients in order to know what he needs” (Henderson, 1964, p. 63). She believed that “the beauty of medicine and nursing is the combination of your heart, your head and your hands and where you separate them, you diminish them” (McBride, 1997).

Henderson identified 14 basic needs on which nursing care is based. These 14 needs are also referred to as the 14 components of basic nursing care. These needs include the following:

Breathe normally. Eat and drink adequately. Eliminate bodily wastes.

Move and maintain desirable postures. Sleep and rest. Select suitable clothes; dress and undress. Maintain body temperature within normal range by adjusting clothing and modifying the environment. Keep the body clean and well groomed and protect the integument. Avoid dangers in the environment and avoid injuring others. Communicate with others in expressing emotions, needs, fears, or opinions. Worship according to one’s faith. Work in such a way that there is a sense of accomplishment. Play or participate in various forms of recreation. Learn, discover, or satisfy the curiosity that leads to normal development and health and use the available health facilities (Henderson, 1966, 1991).

Although Henderson did not consider her work a theory of nursing and did not explicitly state assumptions or define each of the domains of nursing, her work includes the metaparadigm concepts of nursing (Table 2-2) (Furukawa & Howe, 2002). In recent years many have begun to refer to the 14 components of basic nursing care as Virginia Henderson’s Need Theory (Ahtisham & Jacoline, 2015).

TABLE 2-2 Metaparadigm Concepts as Defined in Henderson’s Philosophy and Art of


Person Recipient of nursing care who is composed of biological, psychological, sociological, and spiritual components.

Environment External environment (temperature, dangers in environment); some discussion of impact of community on the individual and family.

Health Based upon the patient’s ability to function independently (as outlined in 14 components of basic nursing care).

Nursing Assist the person, sick or well, in performance of activities (14 components of basic nursing care) and help the person gain independence as rapidly as possible (Henderson, 1966, p. 15).

Jean Watson: Philosophy and Science of Caring According to Watson’s theory (1996), the goal of nursing is to help persons attain a higher level of harmony within the mind–body–spirit. Attainment of that goal can potentiate healing and health (Table 2-3). This goal is pursued through transpersonal caring guided by carative factors and corresponding caritas processes.

TABLE 2-3 Metaparadigm Concepts as Defined in Watson’s Philosophy and Science

of Caring

Person (human) A “unity of mind–body–spirit/nature” (Watson, 1996, p. 147); embodied spirit (Watson, 1989).

Healing space and environment

A nonphysical energetic environment; a vibrational field integral with the person where the nurse is not only in the environment but also “the nurse IS the environment” (Watson, 2008, p. 26).

Health (healing) Harmony, wholeness, and comfort.

Nursing Reciprocal transpersonal relationship in caring moments guided by carative factors and caritas processes.

Watson’s theory for nursing practice is based on 10 carative factors

(Watson, 1979). As Watson’s work evolved, she renamed these carative factors into what she termed clinical caritas processes (Fawcett, 2005). Caritas means to cherish, to appreciate, and to give special attention. It conveys the concept of love (Watson, 2001). The 10 caritas processes are summarized here:

Practice of loving kindness and equanimity for oneself and other Being authentically present and enabling and sustaining the deep belief system and subjective life world of self and the one being cared for Cultivating one’s own spiritual practices; going beyond the ego self; deepening of self-awareness Developing and sustaining a helping–trusting, authentic caring relationship Being present to, and supportive of, the expression of positive and negative feelings as a connection with a deeper spirit of oneself and the one being cared for Creatively using oneself and all ways of knowing as part of the caring process and engagement in artistry of caring–healing practices Engaging in a genuine teaching–learning experience within the context of a caring relationship while attending to the whole person and subjective meaning; attempting to stay within the other’s frame of reference Creating a healing environment at all levels, subtle environment of energy and consciousness whereby wholeness, beauty, comfort, dignity, and peace are potentiated Assisting with basic needs, with an intentional caring consciousness; administering human care essentials, which potentiate alignment of the mind–body–spirit, wholeness, and unity of being in all aspects of care; attending to both embodied spirit and evolving emergence

Opening and attending to spiritual, mysterious, and unknown existential dimensions of life, death, suffering; “allowing for a miracle” (Watson, 2008)

Watson (2001) refers to the clinical caritas processes as the “core” of nursing, which is grounded in the philosophy, science, and the art of caring. She contrasts the core of nursing with what she terms the “trim,” a term she uses to refer to the practice setting, procedures, functional tasks, clinical disease focus, technology, and techniques of nursing. The trim, Watson explains, is not expendable, but it cannot be the center of professional nursing practice (Watson, 1997).

Regarding the value system that is blended with the 10 carative factors, Watson (1985) states,

Human care requires high regard and reverence for a person and human life. . . . There is high value on the subjective– internal world of the experiencing person and how the person (both patient and nurse) is perceiving and experiencing health– illness conditions. An emphasis is placed upon helping a person gain more self-knowledge, self-control, and readiness for self- healing. (pp. 34, 35)

The carative factors described by Watson provide guidelines for nurse–patient interactions; however, the theory does not furnish instructions about what to do to achieve authentic caring–healing relationships. Watson’s theory is more about being than doing, but it provides a useful framework for the delivery of patient-centered nursing care (Neil & Tomey, 2006).

Patricia Benner’s Clinical Wisdom in Nursing Practice Benner’s work has focused on the understanding of perceptual acuity,

clinical judgment, skilled know-how, ethical comportment, and ongoing experiential learning (Brykczynski, 2010). Also important in Benner’s philosophy is an understanding of ethical comportment. According to Day and Benner (2002), good conduct is a product of an individual relationship with the patient that involves engagement in a situation combined with a sense of membership in a profession where professional conduct is socially embedded, lived, and embodied in the practices, ways of being, and responses to clinical situations and where clinical and ethical judgments are inseparable.

Benner’s original domains and competencies of nursing practice were derived inductively from clinical situation interviews and observations of nurses in actual practice. From these interviews and observations, 31 competencies and 7 domains were identified and described. The seven domains are the helping role, the teaching-coaching function, the diagnostic and patient monitoring function, effective management of rapidly changing situations, administering and monitoring therapeutic interventions and regimens, monitoring and ensuring the quality of healthcare practices, and organizational work role competencies (Benner, 1984/2001). Along with the identification of the competencies and domains of nursing, Benner identified five stages of skill acquisition based on the Dreyfus model of skill acquisition as applied to nursing along with characteristics of each stage. The stages identified included novice, advanced beginner, competent, proficient, and expert (Benner, 1984/2001).

Later, in an extension of her original work, Benner and her colleagues identified nine domains of critical care nursing. These domains are diagnosing and managing life-sustaining physiologic functions in unstable patients, using skilled know-how to manage a crisis, providing comfort measures for the critically ill, caring for patients’ families, preventing hazards in a technologic environment, and facing death: end-of-life care

and decision making, communicating and negotiating multiple perspectives, monitoring quality and managing breakdown, using the skilled know-how of clinical leadership, and coaching and mentoring others (Benner, Hooper-Kyriakidis, & Stannard, 1999). In addition, the nine domains of critical care nursing practice are used as broad themes in data interpretation for the identification and description of six aspects of clinical judgment and skilled comportment. These six aspects are as follows:

Reasoning-in-transition: Practical reasoning in an ongoing clinical situation Skilled know-how: Also known as embodied intelligent performance; knowing what to do, when to do it, and how to do it Response-based practice: Adapting interventions to meet the changing needs and expectations of patients Agency: One’s sense of and ability to act on or influence a situation Perceptual acuity and the skill of involvement: The ability to tune into a situation and hone in on the salient issues by engaging with the problem and the person Links between clinical and ethical reasoning: The understanding that good clinical practice cannot be separated from ethical notions of good outcomes for patients and families (Benner et al., 1999)

Benner identifies and defines the four metaparadigm concepts of nursing in addition to the concepts previously discussed. The concepts of person, environment, health, and nursing as defined by Benner are summarized in Table 2-4.

TABLE 2-4 Metaparadigm Concepts as Defined in Benner’s Philosophy

Person Embodied person living in the world who is a “self-interpreting being, that is, the person

does not come into the world pre-defined but gets defined in the course of living a life” (Benner & Wrubel, 1989, p. 41).

Environment (situation)

A social environment with social definition and meaningfulness.

Health The human experience of health or wholeness.

Nursing A caring relationship that includes the care and study of the lived experience of health, illness, and disease.

Selected Conceptual Models and Grand Theories of Nursing Conceptual models provide a comprehensive view and guide for nursing practice. They are organizing frameworks that guide the reasoning process in professional nursing practice (Alligood, 2006). At the level of the conceptual model, each metaparadigm concept is defined and described in a manner unique to the model, with the model providing an alternative way to view the concepts considered important to the discipline (Fawcett, 2005).

Martha Rogers’s Science of Unitary Human Beings According to Rogers (1994), nursing is a learned profession, both a science and an art. The art of nursing is the creative use of the science of nursing for human betterment.

Rogers’s theory asserts that human beings are dynamic energy fields that are integrated with environmental energy fields so that the person and his or her environment form a single unit. Both human energy fields and environmental fields are open systems, pandimensional in nature and in a constant state of change. Pattern is the identifying characteristic

of energy fields (Table 2-5).

TABLE 2-5 Metaparadigm Concepts as Defined in Rogers’s Theory

Person An irreducible, irreversible, pandimensional, negentropic energy field identified by pattern; a unitary human being develops through three principles: helicy, resonancy, and integrality (Rogers, 1992).

Environment An irreducible, pandimensional, negentropic energy field, identified by pattern and manifesting characteristics different from those of the parts and encompassing all that is other than any given human field (Rogers, 1992).

Health Health and illness as part of a continuum (Rogers, 1970).

Nursing Seeks to promote symphonic interaction between human and environmental fields, to strengthen the integrity of the human field, and to direct and redirect patterning of the human and environmental fields for realization of maximum health potential (Rogers, 1970).

Rogers identified the principles of helicy, resonancy, and integrality to describe the nature of change within human and environmental energy fields. Together, these principles are known as the principle of homeodynamics. The helicy principle describes the unpredictable but continuous, nonlinear evolution of energy fields, as evidenced by a spiral development that is a continuous, nonrepeating, and innovative patterning that reflects the nature of change. Resonancy is depicted as a wave frequency and an energy field pattern evolution from lower to higher frequency wave patterns and is reflective of the continuous variability of the human energy field as it changes. The principle of

integrality emphasizes the continuous mutual process of person and environment (Rogers, 1970, 1992).

Rogers used two widely recognized toys to illustrate her theory and constant interaction of the human–environment process. The Slinky illustrates the openness, rhythm, motion, balance, and expanding nature of the human life process, which is continuously evolving (Rogers, 1970). The kaleidoscope illustrates the changing patterns that appear to be infinitely different (Johnson & Webber, 2010).

Rogers (1970) identified five assumptions that support and connect the concepts in her conceptual model:

Man is a unified whole possessing his own integrity and manifesting characteristics more than and different from the sum of his parts (p. 47). Man and environment are continuously exchanging matter and energy with one another (p. 54). The life process evolves irreversibly and unidirectionally along the space–time continuum (p. 59). Pattern and organization identify man and reflect his innovative wholeness (p. 65). Man is characterized by the capacity for abstraction and imagery, language and thought, sensation, and emotion (p. 73).

Rogers’s model is an abstract system of ideas but is applicable to practice, with nursing care focused on pattern appraisal and patterning activities. Pattern appraisal involves a comprehensive assessment of environmental field patterns and human field patterns of communication, exchange, rhythms, dissonance, and harmony through the use of cognitive input, sensory input, intuition, and language. Patterning activities can include such interventions as meditation, imagery, journaling, or modifying surroundings. Evaluation is ongoing and requires

a repetition of the appraisal process (Gunther, 2006). This process of pattern appraisal continues as long as the nurse–patient relationship continues (Gunther, 2010).

Dorothea Orem’s Self-Care Deficit Theory of Nursing Orem describes her theory as a general theory that is made up of three related theories, the Theory of Self-Care, the Theory of Self-Care Deficit, and the Theory of Nursing Systems. The Theory of Self-Care describes why and how people care for themselves. The Theory of Self-Care Deficit describes and explains why people can be helped through nursing. The Theory of Nursing Systems describes and explains relationships that must exist and be maintained for nursing to occur. These three theories in relationship constitute Orem’s general theory of nursing known as the Self-Care Deficit Theory of Nursing (Berbiglia, 2010; Orem, 1990; Taylor, 2006).

Theory of Self-Care The Theory of Self-Care describes why and how people care for themselves and suggests that nursing is required in case of inability to perform self-care as a result of limitations. This theory includes the concepts of self-care agency, therapeutic self-care demand, and basic conditioning factors.

Self-care agency is an acquired ability of mature and maturing persons to know and meet their requirements for deliberate and purposive action to regulate their own human functioning and development (Orem, 2001). The concept of self-care agency has three dimensions: development, operability, and adequacy. According to Orem (2001), therapeutic self-care demand consists of the summation of care measures necessary to meet all of an individual’s known self-care requisites. Basic conditioning factors refer to those factors that affect the

value of the therapeutic self-care demand or self-care agency of an individual. Ten factors are identified: age, gender, developmental state, health state, pattern of living, healthcare system factors, family system factors, sociocultural factors, availability of resources, and external environmental factors (Orem, 2001).

Orem identifies three types of self-care requisites that are integrated into the Theory of Self-Care and that provide the basis for self-care. These include universal self-care requisites, developmental self-care requisites, and health deviation self-care requisites.

Universal self-care requisites are those found in all human beings and are associated with life processes. These requisites include the following needs:

Maintenance of sufficient intake of air Maintenance of sufficient intake of water Maintenance of sufficient intake of food Provision of care associated with elimination processes and excrements Maintenance of a balance of activity and rest Maintenance of a balance between solitude and social interaction Prevention of hazards to human life, human functioning, and human well-being Promotion of human functioning and development within social groups in accordance with human potential, known limitations, and the human desire to be normal (Orem, 1985, pp. 90–91)

Developmental self-care requisites are related to different stages in the human life cycle and might include such events as attending college, marriage, and retirement. Broadly speaking, the development self-care requisites include the following needs:

Bringing about and maintenance of living conditions that support life

processes and promote the processes of development—that is, human progress toward higher levels of organization of human structures and toward maturation Provision of care either to prevent the occurrence of deleterious effects of conditions that can affect human development or to mitigate or overcome these effects from various conditions (Orem, 1985, p. 96)

Health-deviation self-care requisites are related to deviations in structure or function of a human being. There are six categories of health-deviation requisites:

Seeking and securing appropriate medical assistance Being aware of and attending to the effects and results of illness states Effectively carrying out medically prescribed treatments Being aware of and attending to side effects of treatment Modifying self-concept in accepting oneself in a particular state of health Learning to live with the effects of illness and medical treatment (Orem, 1985, pp. 99–100)

Theory of Self-Care Deficit The Theory of Self-Care Deficit explains that maturing or mature adults deliberately learn and perform actions to direct their survival, quality of life, and well-being; put more simply, it explains why people can be helped through nursing. According to Orem, nurses use five methods to help meet the self-care needs of patients:

Acting for or doing for another Guiding and directing Providing physical or psychological support

Providing and maintaining an environment that supports personal development Teaching (Johnson & Webber, 2010; Orem, 1995, 2001)

Theory of Nursing Systems The Theory of Nursing Systems describes and explains relationships that must exist and be maintained for the product (nursing) to occur (Berbiglia, 2010; Taylor, 2006). Three systems can be used to meet the self-requisites of the patient: the wholly compensatory system, the partially compensatory system, and the supportive-educative system.

In the wholly compensatory system, the patient is unable to perform any self-care activities and relies on the nurse to perform care. In the partially compensatory system, both the patient and the nurse participate in the patient’s self-care activities, with the responsibility for care shifting from the nurse to the patient as the self-care demand changes. In the supportive-educative system, the patient has the ability for self- care but requires assistance from the nurse in decision making, knowledge, or skill acquisition. The nurse’s role is to promote the patient as a self-care agent.

The system selected depends on the nurse’s assessment of the patient’s ability to perform self-care activities and self-care demands (Johnson & Webber, 2010; Orem, 1995, 2001). There are eight general propositions for the Self-Care Deficit Theory of Nursing (although each of the three individual theories also has its own set of propositions) (Meleis, 2004):

Human beings have capabilities to provide their own self-care or care for dependents to meet universal, developmental, and health- deviation self-care requisites. These capabilities are learned and recalled.

Self-care abilities are influenced by age, developmental state, experiences, and sociocultural background. Self-care deficits should balance between self-care demands and self-care capabilities. Self-care or dependent care is mediated by age, developmental stage, life experience, sociocultural orientation, health, and resources. Therapeutic self-care includes the actions of nurses, patients, and others that regulate self-care capabilities and meet self-care needs. Nurses assess the abilities of patients to meet their self-care needs and their potential of not performing their self-care. Nurses engage in selecting valid and reliable processes, technologies, or actions for meeting self-care needs. Components of therapeutic self-care are wholly compensatory, partly compensatory, and supportive-educative.

In addition to these other concepts, the four metaparadigm concepts of nursing are identified in Orem’s theory (Table 2-6). Orem’s theory clearly differentiates the focus of nursing and is one of the nursing theories that is most commonly used in practice.

TABLE 2-6 Metaparadigm Concepts as Defined in Orem’s Theory

Person (patient) A person under the care of a nurse; a total being with universal, developmental needs and capable of self-care.

Environment Physical, chemical, biologic, and social contexts within which human beings exist; environmental components include environmental factors, environmental elements, environmental conditions, and developmental environment (Orem, 1985).

Health “A state characterized by soundness or wholeness of developed human structures and of bodily and mental functioning” (Orem, 1995, p. 101).

Nursing Therapeutic self-care designed to supplement self-care requisites. Nursing actions fall into one of three categories: wholly compensatory, partly compensatory, or supportive–educative system (Orem, 1985).

Callista Roy’s Adaptation Model The Roy Adaptation Model presents the person as an adaptive system in constant interaction with the internal and external environments. The main task of the human system is to maintain integrity in the face of environmental stimuli (Phillips, 2006). The goal of nursing is to foster successful adaptation (Table 2-7).

TABLE 2-7 Metaparadigm Concepts as Defined in Roy’s Model

Person “An adaptive system with cognator and regulator subsystems acting to maintain adaptation in the four adaptive modes” (Roy, 2009, p. 12).

Environment “All conditions, circumstances, and influences surrounding and affecting the development and behavior of persons and groups, with particular consideration of mutuality of person and earth resources” (Roy, 2009, p. 12).

Health “A state and process of being and becoming an integrated and whole that reflects person and environment mutuality” (Roy, 2009, p. 12).

Nursing The goal of nursing is “to promote adaptation for individuals and groups in the four adaptive

modes, thus contributing to health, quality of life, and dying with dignity by assessing behavior and factors that influence adaptive abilities and to enhance environmental factors” (Roy, 2009, p. 12).

According to Roy and Andrews (1999), adaptation refers to “the process and outcome whereby thinking and feeling persons, as individuals or in groups, use conscious awareness and choice to create human and environmental integration” (p. 54). Adaptation leads to optimum health and well-being, to quality of life, and to death with dignity (Andrews & Roy, 1991). The adaptation level represents the condition of the life processes. Roy describes three levels: integrated, compensatory, and compromised life processes. An integrated life process can change to a compensatory process, which attempts to reestablish adaptation. If the compensatory processes are not adequate, compromised processes result (Roy, 2009).

The processes for coping in the Roy Adaptation Model are categorized as “the regulator and cognator subsystems as they apply to individuals, and the stabilizer and innovator subsystems as applied to groups” (Roy, 2009, p. 33). A basic type of adaptive process, the regulator subsystem responds through neural, chemical, and endocrine coping channels. Stimuli from the internal and external environments act as inputs through the senses to the nervous system, thereby affecting the fluid, electrolyte, and acid–base balance as well as the endocrine system. This information is all channeled automatically, with the body producing an automatic, unconscious response to it.

The second adaptive process, the cognator subsystem, responds through four cognitive-emotional channels: perceptual and information processing, learning, judgment, and emotion. Perceptual and information

processing includes activities of selective attention, coding, and memory. Learning involves imitation, reinforcement, and insight. Judgment includes problem solving and decision making. Defenses are used to seek relief from anxiety and to make affective appraisal and attachments through the emotions (Roy, 2009).

The cognator–regulator and stabilizer–innovator subsystems function to maintain integrated life processes. These life processes—whether integrated, compensatory, or compromised—are manifested in behaviors of the individual or group. Behavior is viewed as an output of the human system and takes the form of either adaptive responses or ineffective responses. These responses serve as feedback to the system, with the human system using this information to decide whether to increase or decrease its efforts to cope with the stimuli (Roy, 2009).

Behaviors can be observed in four categories, or adaptive modes: physiologic-physical mode, self-concept–group identity mode, role function mode, and interdependence mode. Behavior in the physiologic- physical mode is the manifestation of the physiologic activities of all cells, tissues, organs, and systems making up the body. The self-concept– group identity mode includes the components of the physical self, including body sensation and body image, and the personal self, including self-consistency, self-ideal, and moral-ethical-spiritual self. The role function mode focuses on the roles of the person in society and the roles within a group, and the interdependence mode is a category of behavior related to interdependent relationships. This mode focuses on interactions related to the giving and receiving of love, respect, and value (Roy, 2009).

In the Roy Adaptation Model, three classes of stimuli form the environment: the focal stimulus (internal or external stimulus most immediately in the awareness of the individual or group), contextual stimuli (all other stimuli present in the situation that contribute to the

effect of the focal stimulus), and residual stimuli (environmental factors within or outside human systems, the effects of which are unclear in the situation) (Roy, 2009).

The propositions of Roy’s theory include the following:

Nursing actions promote a person’s adaptive responses. Nursing actions can decrease a person’s ineffective adaptive responses. People interact with the changing environment in an attempt to achieve adaptation and health. Nursing actions enhance the interaction of persons with the environment. Enhanced interactions of persons with the environment promote adaptation (Meleis, 2004).

The Roy Adaptation Model is commonly used in nursing practice. To use the model in practice, the nurse follows Roy’s six-step nursing process, which is as follows (Phillips, 2006):

Assessing the behaviors manifested from the four adaptive modes (physiologic-physical mode, self-concept–group identity mode, role function mode, and interdependence mode) Assessing and categorizing the stimuli for those behaviors Making a nursing diagnosis based on the person’s adaptive state Setting goals to promote adaptation Implementing interventions aimed at managing stimuli to promote adaptation Evaluating achievement of adaptive goals

Andrews and Roy (1986) point out that by manipulating the stimuli rather than the patient, the nurse enhances “the interaction of the person with their environment, thereby promoting health” (p. 51).

Betty Neuman’s Systems Model The Neuman Systems Model is a wellness model based on general systems theory in which the client system is exposed to stressors from within and without the system. The focus of the model is on the client system in relationship to stressors. The client system is a composite of interacting variables that include the physiologic variable, the psychological variable, the sociocultural variable, the developmental variable, and the spiritual variable (Neuman, 2002). Stressors are classified as intrapersonal, interpersonal, or extrapersonal depending on their relationship to the client system.

The client system is represented structurally in the model as a series of concentric rings or circles surrounding a basic structure. These flexible concentric circles represent normal lines of defense and lines of resistance that function to preserve client system integrity by acting as protective mechanisms for the basic structure. The basic structure or central core consists of basic survival factors common to the species, innate or genetic features, and strengths and weaknesses of the system. The flexible line of defense forms the outer boundary of the defined client system; it protects the normal line of defense. The normal line of defense represents what the client has become or the usual wellness state. Adjustment of the five client system variables to environmental stressors determines its level of stability. The concentric broken circles surrounding the basic structure are known as lines of resistance. They become activated following invasion of the normal line of defense by environmental stressors (Neuman, 2002). The greater the quality of the client system’s health, the greater protection is provided by the various lines of defense (Geib, 2006). In addition to these concepts, the four metaparadigm concepts of nursing are identified in Neuman’s theory (Table 2-8).

TABLE 2-8 Metaparadigm Concepts as Defined in Neuman’s Model

Person (client system)

A composite of physiological, psychological, sociocultural, developmental, and spiritual variables in interaction with the internal and external environment; represented by central structure, lines of defense, and lines of resistance (Neuman, 2002).

Environment All internal and external factors of influences surrounding the client system; three relevant environments identified are the internal environment, the external environment, and the created environment (Neuman, 2002, p. 18).

Health A continuum of wellness to illness; equated with optimal system stability (Neuman, 2002, p. 23).

Nursing Prevention as intervention; concerned with all potential stressors.

Basic assumptions of the Neuman Systems Model include the following (Meleis, 2004; Neuman, 1995):

Nursing clients have both unique and universal characteristics and are constantly exchanging energy with the environment. The relationships among client variables influence a client’s protective mechanisms and determine the client’s response. Clients present a normal range of responses to the environment that represent wellness and stability. Stressors attack flexible lines of defense and then normal lines of defense. Nurses’ actions are focused on primary, secondary, and tertiary prevention.

The Neuman Systems Model is health oriented, with an emphasis on prevention as intervention, and has been used in a wide variety of settings. Perhaps one of the greatest attractions to this model is the ease with which it can be used for families, groups, and communities as well as the individual client. The use of the model in practice requires only moderate adaptation of the nursing process with a focus on assessment of stressors and client system perceptions.

Imogene King’s Interacting Systems Framework and Theory of Goal Attainment King, in her Interacting Systems Framework, conceptualizes three levels of dynamic interacting systems that include personal systems (individuals), interpersonal systems (groups), and social systems (society). Individuals exist within personal systems, and concepts relevant to this system include body image, growth and development, perception, self, space, and time. Interpersonal systems are formed when two or more individuals interact. The concepts important to understanding this system include communication, interaction, role, stress, and transaction. Examples of social systems include religious systems, educational systems, and healthcare systems. Concepts important to understanding the social system include authority, decision making, organization, power, and status (King, 1981; Sieloff, 2006).

King’s Theory of Goal Attainment was derived from her Interacting Systems Framework (Sieloff, 2006) and addresses nursing as a process of human interaction (Norris & Frey, 2006). The theory focuses on the interpersonal system interactions in the nurse–client relationship (Table 2-9). During the nursing process, the nurse and the client perceive each other, make judgments, and take action that results in reaction. Interaction results, and if perceptual congruence exists, transactions occur (Sieloff, 2006). Outcomes are defined in terms of goals obtained. If

the goals are related to patient behaviors, they become the criteria by which the effectiveness of nursing care can be measured (King, 1989).

TABLE 2-9 Metaparadigm Concepts as Defined in King’s Theory

Person (human being)

A personal system that interacts with interpersonal and social systems.

Environment Can be both external and internal. The external environment is the context “within which human beings grow, develop, and perform daily activities” (King, 1981, p. 18); the internal environment of human beings transforms energy to enable them to adjust to continuous external environmental changes (King, 1981, p. 5).

Health “Dynamic life experiences of a human being, which implies continuous adjustment to stressors in the internal and external environment through optimum use of one’s resources to achieve maximum potential for daily living” (King, 1981, p. 5).

Nursing A process of human interaction, the goal of nursing is to help patients achieve their goals.

The propositions of King’s Theory of Goal Attainment are as follows (King, 1981):

If perceptual accuracy is present in nurse–client interactions, transactions will occur. If the nurse and client make transactions, goals will be attained. If goals are attained, satisfactions will occur. If goals are attained, effective nursing care will occur. If transactions are made in the nurse–client interactions, growth and development will be enhanced.

If role expectations and role performance as perceived by the nurse and client are congruent, transactions will occur. If role conflict is experienced by the nurse or client or both, stress in nurse–client interactions will occur. If nurses with special knowledge and skills communicate appropriate information to clients, mutual goal setting and goal attainment will occur.

King’s theory can be implemented in practice using the nursing process where assessment focuses on the perceptions of the nurse and client, communication of the nurse and client, and interaction of the nurse and client. Planning involves deciding on goals and agreeing on how to attain goals. Implementation focuses on transactions made, and evaluation focuses on goals attained using King’s theory (King, 1992).

Johnson’s Behavioral System Model Dorothy Johnson’s model for nursing presents the client as a living open system that is a collection of behavioral subsystems that interrelate to form a behavioral system (Table 2-10). The seven subsystems of behavior proposed by Johnson include achievement, affiliative, aggressive, dependence, sexual, eliminative, and ingestive. Motivational drives direct the activities of the subsystems that are constantly changing because of maturation, experience, and learning (Johnson, 1980).

TABLE 2-10 Metaparadigm Concepts as Defined in Johnson’s Model

Person (human being)

A biopsychosocial being who is a behavioral system with seven subsystems of behavior.

Environment Includes internal and external environment.

Health Efficient and effective functioning of system; behavioral system balance and stability.

Nursing An external regulatory force that acts to preserve the organization and integrity of the patient’s behavior at an optimal level under those conditions in which the behavior constitutes a threat to physical or social health or in which illness is found (Johnson, 1980, p. 214).

The achievement subsystem functions to control or master an aspect of self or environment to achieve a standard. This subsystem encompasses intellectual, physical, creative, mechanical, and social skills. The affiliative or attachment subsystem forms the basis for social organization. Its consequences are social inclusion, intimacy, and the formation and maintenance of strong social bonds. The aggressive or protective subsystem functions to protect and preserve the system. The dependency subsystem promotes helping or nurturing behaviors.

The consequences include approval, recognition, and physical assistance. The sexual subsystem has the function of procreation and gratification and includes development of gender role identity and gender role behaviors. The eliminative subsystem addresses “when, how, and under what conditions we eliminate,” whereas the ingestive subsystem “has to do with when, how, what, how much, and under what conditions we eat” (Johnson, 1980, p. 213).

The nursing process for the Behavioral System Model is known as Johnson’s nursing diagnostic and treatment process. The components of the process include the determination of the existence of a problem, diagnosis and classification of problems, management of problems, and evaluation of behavioral system balance and stability. When using Johnson’s model in practice, the focus of the assessment process is obtaining information to evaluate current behavior in terms of past patterns, determining the effect of the current illness on behavioral

patterns, and establishing the maximum level of health. The assessment is specifically related to gathering information pertaining to the structure and function of the seven behavioral subsystems as well as the environmental factors that affect the behavioral subsystems (Holaday, 2006). The ultimate goals of nursing using the model are to maintain or restore behavioral system balance (Johnson, 1980).

Selected Theories and Middle-Range Theories of Nursing Middle-range theory may be derived from a grand theory or a conceptual model or may originate from practice perspectives. Middle-range theories are narrower in scope than grand theories and include concepts that are less abstract and therefore more amenable to testing in research and use in nursing practice.

Rosemarie Parse’s Humanbecoming Theory Parse’s theory was originally called man-living-health (Parse, 1981). In 1992, Parse changed the name to human becoming and then in 2007 again changed the name to humanbecoming (Mitchell & Bournes, 2010) to coincide with Parse’s evolution of thought. The Humanbecoming Theory consists of three major themes: meaning, rhythmicity, and transcendence (Parse, 1998). Meaning is the linguistic and imagined content of something and the interpretation that one gives to something. Rhythmicity is the cadent, paradoxical patterning of the human–universe mutual process. Transcendence is defined as reaching beyond with possibles or the “hopes and dreams envisioned in multidimensional experiences powering the originating of transforming” (Parse, 1998, p. 29). The three major principles of the Humanbecoming Theory flow from these themes.

The first principle of the Humanbecoming Theory states, “Structuring meaning multidimensionally is cocreating reality through the languaging of valuing and imaging” (Parse, 1998, p. 35). This principle proposes that persons structure or choose the meaning of their realities and that the choosing occurs at levels that are not always known explicitly (Mitchell, 2006). This means that one person cannot decide the significance of something for another person and does not even understand the meaning of the event unless that person shares the meaning through the expression of his or her views, concerns, and dreams.

The second principle states, “Cocreating rhythmical patterns of relating is living the paradoxical unity of revealing—concealing and enabling—limiting while connecting—separating” (Parse, 1998, p. 42). This principle means that persons create patterns in life, and these patterns tell about personal meanings and values. The patterns of relating that persons create involve complex engagements and disengagements with other persons, ideas, and preferences (Mitchell, 2006). According to Parse (1998), persons change their patterns when they integrate new priorities, ideas, hopes, and dreams.

The third principle of the Humanbecoming Theory states, “Cotranscending with the possibles is powering unique ways of originating in the process of transforming” (Parse, 1998, p. 46). This principle means that persons are always engaging with and choosing from infinite possibilities. The choices reflect the person’s ways of moving and changing in the process of becoming (Mitchell, 2006).

Three processes for practice have been developed from the concepts and principles in the Humanbecoming Theory, including the following (Parse, 1998, pp. 69, 70):

Illuminating meaning is explicating what was, is, and will be. Explicating is making clear what is appearing now through language.

Synchronizing rhythms is dwelling with the pitch, yaw, and roll of the human–universe process. Dwelling with is immersing with the flow of connecting–separating. Mobilizing transcendence is moving beyond the meaning moment with what is not yet. Moving beyond is propelling with envisioned possibles of transforming.

In practice, nurses guided by the Humanbecoming Theory prepare to be truly present (Table 2-11) with others through focused attentiveness on the moment at hand through immersion (Parse, 1998).

TABLE 2-11 Metaparadigm Concepts as Defined in Parse’s Theory

Person An open being, more than and different from the sum of parts in mutual simultaneous interchange with the environment who chooses from options and bears responsibility for choices (Parse, 1987, p. 160).

Environment Coexists in mutual process with the person.

Health Continuously changing process of becoming.

Nursing A learned discipline, the nurse uses true presence to facilitate the becoming of the participant.

Madeleine Leininger’s Cultural Diversity and Universality Theory Leininger (1995) defined transcultural nursing as both an area of study and an area of nursing practice. The main features of the Cultural Diversity and Universality Theory focus on “comparative cultural care (caring) values, beliefs, and practices” (p. 58) for either individuals or groups of people with similar or different cultures. The goal of transcultural nursing is the provision of nursing care that is culture

specific in order to either promote health or to assist individuals facing sickness or death “in culturally meaningful ways” (p. 58). Consistent with the focus of her theory, Leininger defined the metaparadigm concepts of nursing in a manner that causes the nurse to specifically consider culture in the delivery of competent nursing care (Table 2-12).

TABLE 2-12 Metaparadigm Concepts as Defined in Leininger’s Theory

Person Human being, family, group, community, or institution.

Environment Totality of an event, situation, or experience that gives meaning to human expressions, interpretations, and social interactions in physical, ecological, sociopolitical, and/or cultural settings (Leininger, 1991).

Health A state of well-being that is culturally defined, valued, and practiced (Leininger, 1991, p. 46).

Nursing Activities directed toward assisting, supporting, or enabling with needs in ways that are congruent with the cultural values, beliefs, and lifeways of the recipient of care (Leininger, 1995).

According to Leininger (2001), three modalities guide nursing judgments, decisions, and actions to provide culturally congruent care that is beneficial, satisfying, and meaningful to the persons the nurse serves. These three modes include cultural care preservation or maintenance, cultural care accommodation or negotiation, and cultural care repatterning or restructuring. Cultural care preservation or maintenance refers to those assistive, supportive, facilitative, or enabling professional actions and decisions that help people of a specific culture to maintain meaningful care values for their well-being, recover from

illness, or deal with a handicap or dying. Cultural care accommodation or negotiation refers to those assistive, supportive, facilitative, or enabling professional actions and decisions that help people of a specific culture or subculture adapt to or negotiate with others for meaningful, beneficial, and congruent health outcomes. Cultural care repatterning or restructuring refers to the assistive, supportive, facilitative, or enabling professional actions and decisions that help patients reorder, change, or modify their lifeways for new, different, and beneficial health outcomes (Leininger & McFarland, 2006).

The nurse using Leininger’s theory plans and makes decisions with clients with respect to these three modes of action. All three care modalities require coparticipation of the nurse and client working together to identify, plan, implement, and evaluate nursing care with respect to the cultural congruence of the care (Leininger, 2001).

Leininger developed the Sunrise Model, which she revised in 2004. She labeled this model as “an enabler,” to clarify that although it depicts the essential components of the Cultural Diversity and Universality Theory, it is a visual guide for exploration of cultures.

Hildegard Peplau’s Theory of Interpersonal Relations In her theory, Peplau addresses all of nursing’s metaparadigm concepts (Table 2-13), but she is primarily concerned with one aspect of nursing: how persons relate to one another. According to Peplau, the nurse– patient relationship is the center of nursing (Young, Taylor, & McLaughlin- Renpenning, 2001).

TABLE 2-13 Metaparadigm Concepts as Defined in Peplau’s Theory

Person Encompasses the patient (one who has problems for which expert nursing services are needed or sought) and the nurse (a

professional with particular expertise) (Peplau, 1992, p. 14).

Environment Forces outside the organism within the context of culture (Peplau, 1952, p. 163).

Health “Implies forward movement of personality and other ongoing human processes in the direction of creative, constructive, productive, personal, and community living” (Peplau, 1992, p. 12).

Nursing The therapeutic, interpersonal process between the nurse and the patient.

Peplau (1952) originally described four phases in nurse–patient relationships that overlap and occur over the time of the relationship: orientation, identification, exploitation, and resolution. In 1997, Peplau combined the phase of identification and exploitation, resulting in three phases: orientation, working, and termination. Nevertheless, most other theorists still consider the phases of identification and exploitation to be subphases of the working phase. During the orientation phase, a health problem has emerged that results in a “felt need,” and professional assistance is sought (p. 18).

In the working phase, the patient identifies those who can help, and the nurse permits exploration of feelings by the patient. During this phase, the nurse can begin to focus the patient on the achievement of new goals. The resolution (termination) phase is the time when the patient gradually adopts new goals and frees himself or herself from identification with the nurse (Peplau, 1952, 1997).

Peplau (1952) also describes six nursing roles that emerge during the phases of the nurse–patient relationship: the role of the stranger, the role of the resource person, the teaching role, the leadership role, the surrogate role, and the counseling role. Over the course of Peplau’s

career, the nursing roles were refined to include teacher, resource, counselor, leader, technical expert, and surrogate. As a teacher, the nurse provides knowledge about a need or problem. In the role of resource, the nurse provides information to understand a problem. In the role of counselor, the nurse helps recognize, face, accept, and resolve problems. As a leader, the nurse initiates and maintains group goals through interaction. As a technical expert, the nurse provides physical care using clinical skills. As a surrogate, the nurse may take the place of another (Johnson & Webber, 2010, p. 125).

Peplau (1952) also described four psychobiologic experiences: needs, frustration, conflict, and anxiety. According to Peplau, these experiences “all provide energy that is transformed into some form of action” (p. 71) as well as a basis for goal formation and nursing interventions (Howk, 2002).

Peplau, as one of the first theorists since Nightingale to present a theory for nursing, is considered a pioneer in the area of theory development in nursing. Prior to Peplau’s work, nursing practice involved acting on, to, or for the patient such that the patient was considered an object of nursing actions. Peplau’s work was the force behind the conceptualization of the patient as a partner in the nursing process (Howk, 2002). Although Peplau’s book was first published in 1952, her model continues to be used extensively by clinicians and to provide direction to educators and researchers (Howk, 2002).

Nola Pender’s Health Promotion Model The Health Promotion Model is an attempt to portray the multidimensionality of persons interacting with their interpersonal and physical environments as they pursue health while integrating constructs from expectancy-value theory and social cognitive theory with a nursing perspective of holistic human functioning (Pender, 1996). A summary of

the metaparadigm concepts of nursing as defined by Pender is presented in Table 2-14.

TABLE 2-14 Metaparadigm Concepts as Defined in Pender’s Model

Person The individual, who is the primary focus of the model.

Environment The physical, interpersonal, and economic circumstances in which persons live.

Health A positive high-level state.

Nursing The role of the nurse includes raising consciousness related to health-promoting behaviors, promoting self-efficacy, enhancing the benefits of change, controlling the environment to support behavior change, and managing barriers to change.

There are three major categories to consider in Pender’s Health Promotion Model: (1) individual characteristics and experiences, (2) behavior-specific cognitions and affect, and (3) behavioral outcome. Personal factors include personal biological factors, such as age, body mass index, pubertal status, menopausal status, aerobic capacity, strength, agility, or balance. Personal psychological factors include such factors as self-esteem, self-motivation, and perceived health status; personal sociocultural factors include such factors as race, ethnicity, acculturation, education, and socioeconomic status. Some personal factors are amenable to change, whereas others cannot be changed (Pender, Murdaugh, & Parsons, 2006, 2011).

Behavior-specific cognitions and affect are behavior-specific variables within the Health Promotion Model. Such variables are considered to have motivational significance. In the Health Promotion Model, these variables are the target of nursing intervention because

they are amenable to change. The behavior-specific cognitions and affect identified in the Health Promotion Model include (1) perceived benefits of action, (2) perceived barriers to action, (3) perceived self-efficacy, and (4) activity-related affect. Perceived benefits of action are the anticipated positive outcomes resulting from health behavior. Perceived barriers to action are the anticipated, imagined, or real blocks or personal costs of a behavior. Perceived self-efficacy refers to the judgment of personal capability to organize and execute a health-promoting behavior. It influences the perceived barriers to actions such that higher efficacy results in lower perceptions of barriers. Activity-related affect refers to the subjective positive or negative feelings that occur before, during, and following behavior based on the stimulus properties of the behavior. Activity-related affect influences perceived self-efficacy such that the more positive the subjective feeling, the greater the perceived efficacy (Pender et al., 2006, 2011; Sakraida, 2010, 2014).

Commitment to a plan of action marks the beginning of a behavioral event. Interventions in the Health Promotion Model focus on raising consciousness related to health-promoting behaviors, promoting self- efficacy, enhancing the benefits of change, controlling the environment to support behavior change, and managing the barriers to change. Health- promoting behavior, which is ultimately directed toward attaining positive health outcomes, is the product of the Health Promotion Model (Pender et al., 2006, 2011; 2015).

Afaf Ibrahim Meleis’s Transitions Theory Transitions are a central concept of interest to nursing (Meleis, 2007). Nurses interact with individuals experiencing transitions if those transitions relate to health, well-being, or self-care ability. Nurses also interact with individuals within environments that support or hamper personal, communal, familial, or population transitions (Meleis, 2010).

Transition is a process triggered by a change that represents a passage from a fairly stable state to another fairly stable state (Meleis, 2010). Transitions can be described in terms of types and patterns of transitions, properties of transition experiences, transition conditions, process indicators, outcome indicators, and nursing therapeutics Meleis et al., 2000).

Types of transitions include developmental, health and illness, situational, and organizational. Developmental transitions may include such events as the transition from childhood to adolescence or from adulthood to old age. Health and illness transitions may include such events as diagnosis of chronic illness. Birth and death are examples of events that may lead to situational transitions. Patterns of transitions reflect the experience of multiple simultaneous transitions in the lives of individuals rather than single, sequential transition events (Meleis et al., 2000).

Essential and interrelated properties of transition experiences have been identified that include awareness, engagement, change and difference, time span, and critical points and events (Meleis et al., 2000). Awareness is related to perception, knowledge, and recognition of the transition experience; it is often reflected in the congruency between what is known about the process and responses and what the expected perceptions and responses of individuals in similar transitions are. Engagement is related to the involvement of the individual in the transition process, which may be manifested by such activities as seeking information. Change and difference are properties of transitions that are similar but not interchangeable. Either change may be the result of transition or the transition may result in change. All transitions involve change, but not all change is related to transition (Meleis et al., 2000). Confronting difference in the context of transitions refers to “unmet or divergent expectations, feeling different, being perceived as different, or

seeing the work and others in different ways” (Meleis et al., 2000, p. 20). Time span refers to the flow and movement over time that occurs with all transitions. Individuals experiencing long-term transitions do not necessarily constantly experience a state of flux; however, such a state “may periodically surface, reactivating a latent transition experience” (Meleis et al., 2000, pp. 20–21). Thus, it is important to consider the possibility of variability over time and to reassess outcomes.

Most transitions include critical points or marker events, such as birth, death, or diagnosis with an illness. Critical points are often associated with awareness of change or difference or increased engagement in the transition experience and may represent periods of heightened vulnerability. During the period of uncertainty, a number of critical points may occur depending on the nature of the transition. Final critical points are characterized by a sense of stabilization (Meleis et al., 2000).

Transition conditions include facilitators and inhibitors or the perceptions of and meanings attached to health and illness situations that facilitate or hinder progress toward achieving a healthy transition (Schumacher & Meleis, 1994). Perceptions and meanings are influenced by and in turn influence the conditions in which transitions occur. These facilitators and inhibitors include personal, community, or societal conditions. Personal conditions include meanings, cultural beliefs and attitudes, socioeconomic status, and preparation and knowledge. Community conditions may include community resources, support from family, and role models. Societal conditions may include stigmatization, marginalization, and cultural attitudes (Meleis et al., 2000).

Patterns of response include process indicators and outcome indicators. Because transitions occur over time, process indicators that direct individuals toward health or toward vulnerability and risk may be identified through early assessment to promote health outcomes. Assessment of outcome indicators may be used to ascertain whether a

transition process is healthy and may include efforts to determine whether the individual is feeling connected, interacting, being situated, and developing confidence and coping (Meleis et al., 2000). Outcome indicators include mastery and development of identity. Mastery of new skills required to manage a transition and the development of a new fluid and integrative identity reflect a healthy outcome of the transition process.

Nursing therapeutics are conceptualized as measures applicable to therapeutic intervention during transitions. The first nursing therapeutic is an assessment of readiness; it includes an assessment of each transition condition to determine readiness and allows clinicians to determine patterns of the transition experience. Preparation for transition is the second nursing therapeutic. It includes education to generate the best condition for transition. The third nursing therapeutic is role supplementation (Schumacher & Meleis, 1994), a deliberative process that is applied when role insufficiency or potential role insufficiency is identified. In this process, the conditions and strategies of role clarification and role taking are used to develop preventive or therapeutic measures to decrease, improve, or prevent role insufficiency (Meleis, 2010). The metaparadigm concepts of nursing as defined by Meleis are summarized in Table 2-15.

TABLE 2-15 Metaparadigm Concepts as Defined in Meleis’s Transitions Theory

Person Active beings who experience fundamental life patterns and who have perceptions of and attach meaning to transition experiences (Meleis et al., 2000, p. 21).

Environment Environmental conditions expose persons to potential damage, problematic recovery, or delayed or unhealthy coping, contributing to

vulnerability related to transitions.

Health Consists of complex and multidimensional transitions that are characterized by flow and movement over time; healthy outcomes are defined in terms of the transition process.

Nursing Being the primary caregiver for individuals and their families during the transition process and applying nursing therapeutics during transitions to promote healthy outcomes.

Kristen Swanson’s Theory of Caring Swanson’s Theory of Caring (1991, 1993, 1999a, 1999b) offers an explanation of what it means to practice nursing in a caring manner. In this theory, caring is defined as a “nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility” (Swanson, 1991, p. 162). Swanson (1993) posits that caring for a person’s biopsychosocial and spiritual well-being is a fundamental and universal component of good nursing care.

Five additional concepts are integral to Swanson’s Theory of Caring and represent the five basic processes of caring: maintaining belief, knowing, being with, doing for, and enabling.

The concept of maintaining belief is sustaining faith in the other’s capacity to get through an event or transition and to face a future with meaning. This includes believing in the other’s capacity and holding him or her in high esteem, maintaining a hope-filled attitude, offering realistic optimism, helping to find meaning, and standing by the one cared for, no matter what the situation. The concept of knowing refers to striving to understand the meaning of an event in the life of the other, avoiding assumptions, focusing on the person cared for, seeking cues, assessing meticulously, and

engaging both the one caring and the one cared for in the process of knowing. The concept of being with refers to being emotionally present to the other. It includes being present in person, conveying availability, and sharing feelings without burdening the one cared for. The concept of doing for refers to doing for others what one would do for oneself, including anticipating needs, comforting, performing skillfully and competently, and protecting the one cared for while preserving his or her dignity. The concept of enabling refers to facilitating the other’s passage through life transitions and unfamiliar events by focusing on the event, informing, explaining, supporting, validating feelings, generating alternatives, thinking things through, and giving feedback (Swanson, 1991, p. 162).

These caring processes are sequential and overlapping. In fact, they might not exist separate from one another because each is an integral component of the overarching structure of caring (Wojnar, 2010). According to Swanson (1999b), knowing, being with, doing for, enabling, and maintaining belief are essential components of the nurse–client relationship, regardless of the context. A summary of the metaparadigm concepts of nursing as defined by Swanson is included in Table 2-16.

TABLE 2-16 Metaparadigm Concepts as Defined in Swanson’s Theory of Caring

Person “Unique beings who are in the midst of becoming and whose wholeness is made manifest in thoughts, feelings, and behaviors” (Swanson, 1993, p. 352).

Environment “Any context that influences or is influenced by the designated client” (Swanson, 1993, p. 353).

Health Health and well-being is “to live the subjective, meaning-filled experience of wholeness. Wholeness involves a sense of integration and becoming wherein all facets of being are free to be expressed” (Swanson, 1993, p. 353).

Nursing Informed caring for the well-being of others (Swanson, 1991, 1993).

Katharine Kolcaba’s Theory of Comfort Comfort, as described by Kolcaba (2004) in the Theory of Comfort, is the immediate experience of being strengthened by having needs for relief, ease, and transcendence addressed in four contexts—physical, psychospiritual, sociocultural, and environmental; it is much more than simply the absence of pain or other physical discomfort. Physical comfort pertains to bodily sensations and homeostatic mechanisms. Psychospiritual comfort pertains to the internal awareness of self, including esteem, sexuality, meaning in one’s life, and one’s relationship to a higher order or being. Sociocultural comfort pertains to interpersonal, family, societal relationships, and cultural traditions. Environmental comfort pertains to the external background of the human experience, which includes light, noise, color, temperature, ambience, and natural versus synthetic elements (Kolcaba, 2004).

According to Kolcaba, comfort care encompasses three components: an appropriate and timely intervention to meet the comfort needs of patients, a mode of delivery that projects caring and empathy, and the intent to comfort. Comfort needs include patients’ or families’ desire for or deficit in relief, ease, or transcendence in the physical, psychospiritual, sociocultural, or environmental contexts of human experience. Comfort measures refer to interventions that are intentionally designed to enhance patients’ or families’ comfort (Kolcaba, 2004).

The Theory of Comfort also addresses intervening variables— negative or positive factors over which nurses and institutions have little control but that affect the direction and success of comfort care plans. Examples of intervening variables are the presence or absence of social support, poverty, prognosis, concurrent medical or psychological conditions, and health habits (Kolcaba, 2004).

An additional concept within the theory comprises the health-seeking behaviors of patients and families. Health-seeking behaviors are those behaviors that patients and families engage in either consciously or unconsciously while moving toward well-being. Health-seeking behaviors can be either internal or external and can include dying peacefully. It is posited that enhanced comfort results in engagement in health-seeking behaviors (Kolcaba, 2004). The metaparadigm concepts of nursing as defined by Kolcaba are summarized in Table 2-17.

TABLE 2-17 Metaparadigm Concepts as Defined in Kolcaba’s Theory of Comfort

Person Recipients of care may be individuals, families, institutions, or communities in need of health care (Kolcaba, Tilton, & Drouin, 2006).

Environment The environment includes any aspect of the patient, family, or institutional setting that can be manipulated by the nurse, a loved one, or the institution to enhance comfort (Dowd, 2010, p. 711).

Health Health is considered optimal functioning of the patient, the family, the healthcare provider, or the community (Dowd, 2010, p. 711).

Nursing Nursing is the intentional assessment of comfort needs, design of comfort interventions to address those needs, and reassessment of

comfort levels after implementation compared to baseline (Dowd, 2010, p. 711).

Pamela Reed’s Self-Transcendence Theory Three major concepts are central to the Theory of Self-Transcendence: self-transcendence, well-being, and vulnerability. Self-transcendence is the capacity to expand self-boundaries intrapersonally, interpersonally, temporally, and transpersonally (Reed, 2008, 2014). The capacity to expand self-boundaries intrapersonally refers to a greater awareness of one’s philosophy, values, and dreams. The capacity to expand interpersonally relates to others and one’s environment. The capacity to expand temporally refers to integration of one’s past and future in a way that has meaning for the present. Finally, the capacity to expand transpersonally refers to the capacity to connect with dimensions beyond the typically discernible world. Self-transcendence is a characteristic of developmental maturity that is congruent with enhanced awareness of the environment and a broadened perspective on life. Self-transcendence is expressed through behaviors, such as sharing wisdom with others, integrating physical changes of aging, accepting death as a part of life, and finding spiritual meaning in life (Reed, 2008).

Well-being is the second major concept of Reed’s theory. Well-being is a sense of feeling whole and healthy, according to one’s own criteria for wholeness and health. The definition of well-being depends on the individual or population. Indeed, indicators of well-being are as diverse as human perceptions of health and wellness. Examples of indicators of well-being are life satisfaction, positive self-concept, hopefulness, happiness, and having meaning in life. Well-being is viewed as a correlate and an outcome of self-transcendence (Reed, 2008, 2014).

The third major concept, vulnerability, is the awareness of personal mortality and the likelihood of experiencing difficult life situations. Self-

transcendence emerges naturally in health experiences when a person is confronted with mortality and immortality. Life events, such as illness, disability, aging, childbirth, or parenting—all of which heighten a person’s sense of mortality, inadequacy, or vulnerability—can trigger developmental progress toward a renewed sense of identity and expanded self-boundaries (Reed, 2014). According to Reed (2008), self- transcendence is evoked through life events and can enhance well-being by transforming losses and difficulties into healing experiences.

Additional concepts in Reed’s theory include moderating-mediating factors and points of intervention. Moderating-mediating factors are personal and contextual variables, such as age, gender, life experiences, and social environment, that can influence the relationships between vulnerability and self-transcendence and between self-transcendence and well-being. Nursing activities that facilitate self-transcendence are referred to as points of intervention (Coward, 2010). Two points of intervention are intertwined with the process of self-transcendence: Nursing actions can focus either directly on a person’s inner resource for self-transcendence or indirectly on the personal and contextual factors that affect the relationship between vulnerability and self-transcendence and the relationship between self-transcendence and well-being. The metaparadigm concepts of nursing as defined by Reed are summarized in Table 2-18.

TABLE 2-18 Metaparadigm Concepts as Defined in Reed’s Self-Transcendence


Person Persons are human beings who develop over the life span through interactions with other persons and within an environment (Coward, 2010, p. 622).

Environment The environment is composed of family, social

networks, physical surroundings, and community resources (Coward, 2010, p. 622).

Health Well-being is a sense of feeling whole and healthy, according to one’s own criteria for wholeness and health (Reed, 2008).

Nursing The role of nursing activity is to assist persons through interpersonal processes and therapeutic management of their environment to promote health and well-being (Coward, 2010, p. 622).

Merle Mishel’s Uncertainty in Illness Theory The purpose of the Uncertainty in Illness Theory is to “describe and explain uncertainty as a basis for practice and research” (Mishel, 2014, p. 54). Uncertainty, the central concept of the theory, is defined as “the inability to determine the meaning of illness-related events inclusive of inability to assign definite value and/or to accurately predict outcomes” (p. 56). The second central concept in the theory, cognitive schema, is defined by Mishel as a “person’s subjective interpretation of illness- related events” (p. 56).

The Uncertainty in Illness Theory is organized around three themes: antecedents of uncertainty, appraisal of uncertainty, and coping with uncertainty. Antecedents of uncertainty include the stimuli frame, cognitive capacities, and structure providers. According to the model, uncertainty is a result of these antecedents, with the major path to uncertainty being through the stimuli frame variables (Mishel, 2014). The stimuli frame encompasses the form, composition, and structure of the stimuli that the person perceives. It has three components: symptom pattern, event familiarity, and event congruence. The symptom pattern refers to the degree to which symptoms occur with enough consistency to be perceived as following a pattern. Event familiarity refers to the degree

to which a situation is repetitive or contains recognized cues. Event congruence refers to the consistency between what is expected and what is experienced (Mishel, 1988). The stimuli frame is the foundation for cognitive schema or the person’s interpretation of the events (Bailey & Stewart, 2014). Cognitive capacities refer to the information-processing ability of the person, and structure providers refer to the resources, such as education, social support, and credible authority, available to assist the person as he or she interprets the stimuli frame. Thus, cognitive capacities and structure providers influence the components of the stimuli frame (Mishel, 2014).

The second theme, appraisal of uncertainty, refers to the process of placing a value on the uncertain event or situation. Appraisal of uncertainty has two components: inference and illusion. Inference refers to the evaluation of uncertainty by using examples; it is predicated on personality disposition, experience, knowledge, and contextual cues. Illusion comprises the construction of beliefs to create a positive outlook (Mishel, 2014).

The third theme, coping with uncertainty, includes the concepts of danger, opportunity, coping, and adaptation. Danger refers to the possibility of a harmful outcome, whereas opportunity is the possibility of a positive outcome. Coping in the context of a danger appraisal encompasses activities directed toward reducing uncertainty and managing emotions; coping in the context of an opportunity appraisal comprises activities directed toward maintaining uncertainty (Mishel, 2014). Adaptation in the context of the uncertainty theory is defined as biopsychosocial behavior occurring within a person’s range of usual behavior and is the outcome of coping.

The reconceptualized Uncertainty in Illness Theory presents the process of moving from uncertainty appraised as danger to uncertainty appraised as an opportunity and resource for a new view of life. The

revised theory incorporates two new concepts: self-organization and probabilistic thinking. Self-organization refers to the reformulation of a new sense of order resulting from the integration of continuous uncertainty into self-structure, where uncertainty is accepted as the natural rhythm of life. Probabilistic thinking refers to the belief in a conditional world in which the expectation of certainty is abandoned (Bailey & Stewart, 2014; Mishel, 2014).

The metaparadigm concepts of nursing as defined by Mishel are summarized in Table 2-19.

TABLE 2-19 Metaparadigm Concepts as Defined in Mishel’s Uncertainty in Illness


Person The concept of person is the central focus of the theory and may be an individual or the family of an ill individual (Mishel, 2014, p. 54); the individual is viewed as a biopsychosocial being who is an open system, exchanging energy with the environment.

Environment Not explicitly defined but is acknowledged to exchange energy with the person system.

Health Defined in terms of uncertainty in the context of the illness experience, with the concept of health or well-being congruent with the formulation of a new life view and probabilistic thinking.

Nursing Nurses are viewed as a part of the antecedent variable of structure providers (Mishel, 2014, p. 71).

Cheryl Tatano Beck’s Postpartum Depression Theory Two major concepts are included in the Postpartum Depression Theory:

postpartum mood disorders and loss of control. Postpartum mood disorders include postpartum depression, maternity blues, postpartum psychosis, postpartum obsessive–compulsive disorder, and postpartum- onset panic disorder (Beck, 2002). The second major concept in Beck’s theory describes the experience of loss of control in all areas of women’s lives. Loss of control is a basic psychosocial problem with which women attempt to cope through a four-stage process labeled by Beck as “teetering on the edge,” referring to what women describe as walking a fine line between sanity and insanity. The four stages of the coping process consist of (1) encountering terror in the form of symptoms, such as anxiety attacks, fogginess, and obsessive thinking, that hit unexpectedly and suddenly; (2) dying of self, as mothers who no longer know who they have become isolate themselves and contemplate and sometimes attempt self-destruction; (3) struggling to survive, as they battle the healthcare system and seek help from support groups and prayer; and (4) regaining control of their lives during transition and guarded recovery while mourning lost time with their infant (Beck, 1993).

Additional concepts in Beck’s theory include predictors or risk factors for postpartum depression. These concepts include prenatal depression, childcare stress, life stress, social support, prenatal anxiety, marital satisfaction, history of depression, infant temperament, maternity blues, self-esteem, socioeconomic status, marital status, and unplanned or unwanted pregnancy (Beck, 2003). Concepts that are used for screening in the Postpartum Depression Screening Scale include sleeping and eating disturbances, anxiety and insecurity, emotional lability, mental confusion, loss of self, guilt and shame, and suicidal thoughts (Beck & Gable, 2000). Modifications to the Postpartum Depression Theory have occurred as research reveals new information. In addition to these concepts, the four metaparadigm concepts of nursing are presented in the context of Beck’s Postpartum Depression Theory. These concepts

are summarized in Table 2-20.

TABLE 2-20 Metaparadigm Concepts as Defined in Beck’s Postpartum Depression


Person Described in terms of wholeness with biological, sociological, and psychological aspects, with personhood understood in the context of family and community (Maeve, 2014, p. 678).

Environment Viewed broadly in terms of individual factors and external factors (Maeve, 2014, p. 678).

Health Not defined explicitly; traditional ideas of physical and mental health are viewed as a consequence of women’s responses to the contexts of their lives and environments (Maeve, 2014, p. 678).

Nursing A caring profession with caring obligations; the nurse accomplishes the goals of health and wholeness through interpersonal interactions (Maeve, 2014, p. 678).

The American Association of Critical-Care Nurses’ Synergy Model for Patient Care The Synergy Model is a conceptual framework for designing practice competencies to care for critically ill patients with a goal of optimizing outcomes for patients and families. Optimal outcomes are realized when the competencies of the nurse match the patient and family needs.

The Synergy Model for Patient Care is the result of the American Association of Critical-Care Nurses (AACN) envisioning a new paradigm for clinical practice. In 1993, the AACN Certification Corporation convened a think tank that included nationally recognized experts to

develop a conceptual framework for certified practice. The initial work resulted in the description of 13 patient characteristics based on universal needs of patients and 9 characteristics required of nurses to meet patient needs. The patient characteristics identified were compensation, resiliency, margin of error, predictability, complexity, vulnerability, physiologic stability, risk of death, independence, self-determination, involvement in care decisions, engagement, and resource availability. The characteristics of nurses were engagement, skilled clinical practice, agency, caring practices, system management, teamwork, diversity responsiveness, experiential learning, and being an innovator–evaluator. The think tank suggested that the synergy emerging from the interaction between the patient needs and the nurse characteristics should result in optimal outcomes for the patient and that these characteristics of the nurse would determine competencies for certified practice (Hardin, 2005).

In 1995, the AACN Certification Corporation decided to refine this model, to conduct a study of practice and job analysis of critical care nurses, and to test the validity of the concepts in critical care nurses. The group refined the patient characteristics into eight concepts, merged the nurse characteristics into eight concepts, and delineated a continuum for the characteristics. The eight patient characteristics identified in the current model are resiliency, vulnerability, stability, complexity, resource availability, participation in care, participation in decision making, and predictability. The eight nurse characteristics are clinical judgment, advocacy, caring practices, collaboration, systems thinking, response to diversity, clinical inquiry, and facilitation of learning (Hardin, 2005, 2013). Each patient characteristic is placed on a scale from one to five, with the level of each patient characteristic being critical in terms of the competency required of the nurse (Hardin, 2005). The eight nurse characteristics can be considered essential competencies for providing care for critically ill patients. All eight competencies reflect an integration

of knowledge, skills, and experience of the nurse. Each nurse characteristic can be understood on a continuum from one to five (Hardin, 2005).

The Synergy Model delineates three levels of outcomes: outcomes derived from the patient, outcomes derived from the nurse, and outcomes derived from the healthcare system. Outcomes data derived from the patient include functional changes, behavioral changes, trust, satisfaction, comfort, and quality of life. Outcomes data derived from nursing competencies include physiologic changes, the presence or absence of complications, and the extent to which treatment objectives are attained (Curley, 1998). Outcomes data derived from the healthcare system include readmission rates, length of stay, and cost utilization (Hardin, 2005). The metaparadigm concepts of nursing as defined in the Synergy Model for Patient Care are summarized in Table 2-21.

TABLE 2-21 Metaparadigm Concepts as Defined in the Synergy Model for Patient


Person Persons are viewed in the context of patients who are biological, social, and spiritual entities who are present at a particular developmental stage.

Environment The concept of environment is not explicitly defined; however, included in the assumptions is the idea that environment is created by the nurses for the care of the patient.

Health The concept of health is not explicitly defined; an optimal level of wellness as defined by the patient is mentioned as a goal of nursing care.

Nursing The purpose of nursing is to meet the needs of patients and families and to provide safe passage through the healthcare system during

a time of crisis (Hardin, 2005, p. 8).

Overview of Selected Nonnursing Theories Nursing as a discipline with a distinct body of theoretical knowledge has developed over time, but nonnursing theories have influenced and still do influence nursing theory, research, and practice. Brief overviews of nonnursing theories that are commonly used in nursing follow.

General System Theory Von Bertalanffy (1968) emphasized that systems are open to and interact with their environments and that they can evolve as they acquire new properties. Rather than reducing an entity to the properties of its parts or elements, system theory focuses on the arrangement of and relations between the parts that connect them into a whole. This particular organization defines a system. Major concepts of general system theory include a system–environment boundary, input and output processes, and the organizational state of the system. General System Theory is founded on the premise that the world is composed of systems that are interconnected and influenced by one another. The two primary assumptions of the theory are that energy is needed to maintain an organizational state and that dysfunction in one system has an effect on other systems (Boulding, 1956). Roy’s Adaptation Model, King’s Interacting Systems Framework and Theory of Goal Attainment, and Neuman’s System Model are all nursing theories that have foundations in general system theory.

Social Cognitive Theory

Social Cognitive Theory explains human behaviors in terms of dynamic reciprocal interactions among cognitive, behavioral, and environmental influences. According to Albert Bandura (1986), human behavior is learned observationally through modeling or observing others. Once a behavior is observed, the person forms an idea of how the new behavior is performed; on a later occasion, this coded information serves as a guide for action. Principles derived from Social Cognitive Theory are often used to promote behavior change.

Bandura incorporated the concept of self-efficacy into Social Learning Theory (now called Social Cognitive Theory) in 1977. The concept of self- efficacy refers to a person’s confidence in his or her ability to take action and to persist in that action to reach goals. The concept of self-efficacy can be important in influencing health behavior change (Bandura, 1997) and is frequently used by nurses engaged in health education and behavior modification. Nola Pender is a nurse theorist who identifies Social Learning Theory as central to her Health Promotion Model, with the concept of self-efficacy being included as a central construct of the model (Sakraida, 2014).

Stress and Coping Process Theory Richard Lazarus suggested that stress might be an organizing concept for understanding a wide range of phenomena rather than a variable. Stress as conceptualized by Lazarus emphasizes the relationship of the person to the environment, with the judgment of whether a specific person–environment relationship is stressful dependent on cognitive appraisal (Lazarus & Folkman, 1984). He identified three types of cognitive appraisal: primary, secondary, and reappraisal. Vulnerability is related to the concept of cognitive appraisal because the vulnerable individual is one whose coping resources are deficient (Lazarus &

Folkman, 1984). Patricia Benner credits Richard Lazarus with mentoring her in the area of stress and coping.


Examples of applicable outcomes expected of the graduate from a baccalaureate program

Essential I: Liberal Education for Baccalaureate Generalist Nursing Practice

1.1 Integrate theories and concepts from liberal education into nursing practice (p. 12).

1.2 Synthesize theories and concepts from liberal education to build an understanding of the human experience (p. 12).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

General Adaptation Syndrome Hans Selye introduced the notion of a general adaptation syndrome in 1950 (Selye, 1950). In 1974, Selye defined stress as the nonspecific response of the body to any demand for change. General adaptation syndrome is based on physiologic and psychobiologic responses to stress. According to Selye, a stressor results in a three-stage response that includes alarm, resistance, and exhaustion, also known as coping with stress. The goals of coping with stress are adaptation and homeostasis (Selye, 1950, 1974).

Betty Neuman used Selye’s definition of stress in her Systems Model (Lawson, 2014). Sister Callista Roy also used concepts from Selye in the

refinement of her Adaptation Model (Phillips & Harris, 2014).

Relationship of Theory to Professional Nursing Practice How will theory affect your nursing practice? Using a theoretical framework to guide your nursing practice assists you as you organize patient data, understand and analyze patient data, make decisions related to nursing interventions, plan patient care, predict outcomes of care, and evaluate patient outcomes (Alligood & Tomey, 2002). Why? The use of a theoretical framework provides a systematic and knowledgeable approach to nursing practice. The framework also becomes a tool that assists you to think critically as you plan and provide nursing care.

How do you begin? Now that you know why nursing theory is important to your nursing practice, it is time to identify a theoretical framework that fits you and your practice. Alligood (2006) presented guidelines for selecting a framework for theory-based nursing practice. Following are the steps:

1. Consider the values and beliefs in nursing that you truly hold. 2. Write a philosophy of nursing that clarifies your beliefs related to

person, environment, health, and nursing. 3. Survey definitions of person, environment, health, and nursing in

nursing models. 4. Select two or three frameworks that best fit with your beliefs related

to the concepts of person, environment, health, and nursing. 5. Review the assumptions of the frameworks that you have selected. 6. Apply those frameworks in a selected area of nursing practice. 7. Compare the frameworks on client focus, nursing action, and client


8. Review the nursing literature written by persons who have used the frameworks.

9. Select a framework and develop its use in your nursing practice.


Think about the definitions of the metaparadigm concepts and the assumptions or propositions of each of the theories presented. Which of the theories most closely matches your beliefs?

Conclusion As demonstrated by the descriptions of the philosophies, conceptual models, and theories presented in this chapter, there is a wide variety of perspectives and frameworks from which to practice nursing. There is no one right or wrong answer. Various nursing theories represent different realities and address different aspects of nursing (Meleis, 2007). For this reason, the multiplicity of nursing theories presented in this chapter should not be viewed as competing theories but rather as complementary theories that can provide insight into different ways to describe, explain, and predict nursing concepts and/or prescribe nursing care. Curley (2007) describes this understanding in an interesting way by comparing the multiplicity of nursing theories to a collection of maps of the same region. Each map might display a different characteristic of the region, such as rainfall, topography, or air currents. Although all the maps are accurate, the best map for use depends on the information needed or the question being asked. This is precisely the case with the nurse’s choice of nursing theories for practice.

Begin with whichever theoretical framework seems to “fit,” and then practice using it as you provide nursing care. “The full realization of nursing theory–guided practice is perhaps the greatest challenge that nursing as a scholarly discipline has ever faced” (Cody, 2006, p. 119 ). Be patient; developing your nursing practice guided by nursing theory takes time and practice. All nursing theories require in-depth study over time to master them fully (this chapter provides only a brief introduction), but the incorporation of theory into your practice can transform your nursing practice. The end result of this process will be seen in the excellent nursing care that you can provide to patients over the course of



your professional nursing career.


Mr. M. is a 34-year-old Caucasian male who presents to the mental health clinic with depression and complaints of fatigue. An interview reveals that his wife and both of his children were killed in a traffic accident 6 months ago. The nurse knows that Mr. M. is vulnerable as a result of the loss of his family but that self-transcendence is evoked through life events and that well-being can be enhanced by transforming losses and difficulties into healing experiences.

Case Study Questions

The nurse uses Reed’s Self-Transcendence Theory to focus nursing activity for Mr. M. on facilitating self-transcendence. Based on the assessment, what intrapersonal strategies might be appropriate?

Which interpersonal strategies might be appropriate during follow- up visits to facilitate connecting to others?

Classroom Activity 2-1

Divide into small groups and give each group a copy of the same case study. Assign a different nursing theory to each group and ask the groups to develop a plan of care using the assigned nursing theory as the basis for practice. Each group should share its plan of care with the class. Discuss the differences and similarities in the foci of care based on each of the selected theories.

Classroom Activity 2-2

Think about the metaparadigm concepts of nursing. Draw each of the concepts in relation to the other concepts to show your ideas of how each of the concepts interfaces with the others. Present your “conceptual model” to the class and discuss your ideas about each of the concepts represented. This activity works best if you use colored pencils, crayons, or markers and a large piece of paper or newsprint. Actual student examples are presented in Figure 2-1 and Figure 2-2.

Figure 2-1 Student conceptual model.

Used with permission of Heather Grush.

Figure 2-2 Student conceptual model. Used with permission of Linzee McGinnis.

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1Note: Excerpts adapted from Masters, K. (2015). Nursing theories: A framework for professional

practice (2nd ed.). Burlington, MA: Jones & Bartlett Learning appear in this chapter.

© James Kang/EyeEm/Getty Images


Philosophy of Nursing Mary W. Stewart

Learning Objectives

After completing this chapter, the student should be able to:

1. Identify various philosophical views of truth. 2. Differentiate between values and beliefs. 3. Discuss the process of value clarification. 4. Explain the major components of nursing philosophy. 5. Articulate the purpose for having a personal philosophy of


6. Begin the development of a personal philosophy of nursing.

Key Terms and Concepts

Paradigm Realism Idealism Values Values clarification

What is truth? Where do our ideas about truth originate? Why does truth matter? The four principal domains of nursing—person, environment, health, and nursing—are the building blocks for all philosophies of nursing. As you are learning about these ideas, you are also learning that many nurses develop nursing theories or models. Think about it . . . nurses creating theory! Yet who better to describe our profession than professional nurses? All right, so maybe you are not that excited about this reality. Still, you have to admit that the ability to articulate nursing values and beliefs to guide us in our understanding of professional nursing is impressive. More than impressive, nursing theory is necessary.

In this chapter, we look more closely at nursing philosophy and its significance to professional nursing. We study the difference between beliefs and values and investigate the importance of values clarification. Finally, we examine guidelines for creating a personal philosophy of nursing.

Philosophy Although no single definition of philosophy is uncontroversial, philosophy is defined in the following ways by the American Heritage Dictionary of the English Language (2000):

Love and pursuit of wisdom by intellectual means and moral self- discipline Investigation of the nature, causes, or principles of reality, knowledge, or values, based on logical reasoning rather than empirical methods A system of thought based on or involving such inquiry; for example, the philosophy of Hume The critical analysis of fundamental assumptions or beliefs The disciplines presented in university curricula of science and the liberal arts, except medicine, law, and theology The discipline composed of logic, ethics, aesthetics, metaphysics, and epistemology A set of ideas or beliefs relating to a particular field or activity; an underlying theory; for example, an original philosophy of advertising A system of values by which one lives; for example, has an unusual philosophy of life

Examples of philosophies can be found in university catalogs, clinical agency manuals, and nursing school handbooks—and they are prolific on the Internet. Needless to say, people have strong values and beliefs about many topics. A written statement of philosophy is a good way to communicate to others what you see as truth.

Some people are anxious to prescribe their own system of values to others by implying what “should be.” However, each person or group of

persons is responsible for delineating their particular philosophy. At the same time, how the insider’s philosophy fits with the outsider’s view is also important, particularly in such situations as nursing. Because nursing is inextricably linked to society, those of us within the profession must consider how society defines the values and beliefs within nursing.

How do we please everyone all the time? The answer is simple: We don’t. We do, however, consider our own values and beliefs, which are interdependent of society, as we convey our professional philosophy of nursing. Does the philosophy ever change? Absolutely. As society and individuals change, our philosophy of nursing changes to be congruent with new and renewed understanding. How did we get started on this journey? A brief look at the beginnings of philosophy can help answer that question.

Early Philosophy As society and individuals change, our philosophy of nursing changes to be congruent with new and renewed understanding. In the beginning, the Greeks moved from seeking supernatural to natural explanations. One assumption by the early Greek philosophers was that “something” had always existed. They did not question how something could come from nothing. Rather, they wanted to know what the “something” was. The pre- Socratics took the first step toward science in that they abandoned mythological thought and sought reason to answer their questions.

Heraclitus, a pre-Socratic philosopher, is well known for his thesis “everything is in flux.” He moved from simply looking at “being” to “becoming.” A popular analogy he used was that of a river, saying, “You cannot step into the same river twice, for different and again different waters flow.” More emphasis was placed on the senses versus reasoning.

On the other hand, Parmenides, who followed Heraclitus, said these two things: (1) nothing can change, and (2) our sensory perceptions are unreliable. He is called the first metaphysician, a “hard-core philosopher.” Metaphysics is the study of reality as a whole, including beyond the natural senses. What is the nature of reality? The universe? He starts with what it means and then moves to how the world must ultimately be. He does not go with his sense or experience. Parmenides thought that everything in the world had always been and that there was no such thing as change. He did, of course, sense that things changed, but his reason told him otherwise. He believed that our senses give us incorrect information and that we can rely only on our reason for acquiring knowledge about the world. This is called rationalism.

Probably a name more familiar to us is Socrates (469–399 B.C.), famous for philosophy that focused on man, not nature. There is no evidence that Socrates wrote down his ideas; however, his student Plato wrote about the teachings of Socrates, indicating that Socrates believed in the immortal soul and that natural phenomena are merely shadows of eternal forms or ideas. Plato himself was a rationalist, meaning that we know with our reason.

Aristotle (384–322 B.C.) followed Socrates and Plato. His father was a physician, apparently framing Aristotle’s interest in the natural world. He is known for his contribution to logic. Aristotle believed that the highest degree of reality is what we perceive with our senses. Unlike Plato, Aristotle did not believe in forms as separate from the real objects. When an object has both form and matter, it is called a substance. Aristotle said happiness was man’s goal and came through balance of the following: life of pleasure and enjoyment, life as a free and responsible citizen, and life as a thinker and philosopher.

During the Neoplatonism age in the third century, philosophy became known as the soul’s vehicle to return to its intelligible roots. There was an extrarational approach to reach union with the One. Thinking was that truth, and certainty was not found in this world. This was a revival of the “other worldliness” thinking of Plato.

The birth of Christianity and Western philosophy came at the death of classicism. Augustine of Hippo (A.D. 354–430) became a Christian and was attracted to Neoplatonism, where existence is divine. In that period, evil was defined as an absence or incompleteness. Saint Thomas Aquinas (A.D. 1225–1274) is credited with bringing theology and philosophy together.

Throughout the centuries, from the Greeks to the present day, people have debated the same questions: What is man [sic]? What is God? How

do God and man relate? How does man relate to man? One can become dizzy thinking about the possibilities. Humans have been asking questions for a very long time, and thankfully, that practice is not about to change. People have searched for truth and will continue to do so. Therefore, we should not strive to find absolute answers; rather, we should endeavor to be comfortable with the questioning. Table 3-1 provides an overview of the perspectives of truth through the ages (see also Figures 3-1–4). From the pre-Socratics to the poststructuralists and postmodern thinkers, ways of knowing and finding truth have changed.

Figure 3-1 A portrait of British 17th-century empiricist philosopher John Locke, who believed that truth is based on experience and relating to our experiences.

© Georgios Kollidas/Shutterstock, Inc.

Figure 3-2 Rene Descartes, a 17th-century French rationalist philosopher, mathematician, and scientist who believed that all things are knowable by deductive reasoning.

Figure 3-3 Immanuel Kant, an 18th-century Germany idealist philosopher, believed that truth exists only in the mind.

Figure 3-4 John Stuart Mill was a 19th-century British empiricist and positivist philosopher who believed that truth is based on experience and relating to our experiences and that truth is science

and the facts that science discovers.


TABLE 3-1 Overview of the Perspectives of Truth Through the Ages

School of Thought Meaning of Truth (Philosophers)

Classical philosophers Truth corresponds with reality, and reality is achieved through our perceptions of the world in which we live.

Truth could be found in the natural world—through our sensory experiences. (Heraclitus, Aristotle) Truth can be found in the natural world—through our rational intellect. (Parmenides, Plato) Truth is found when one knows self. (Socrates) Truth is not of this world. (Plotinus)

Theocratics Truth comes through an understanding of God.

Truth can be found through both the senses and the intellect. (St. Thomas Aquinas)

Empiricists Truth is based on experience and relating to our experiences. (Bacon, Locke, Hume, Mill)

Rationalists All things are knowable by deductive reasoning. (Descartes, Spinoza)

Idealists Truth exists only in the mind. (Berkeley, Hegel, Kant)

Positivists Truth is science and the facts that science discovers. (Comte, Mill, Spencer)

Early existentialists Truth is found through faith in existence as it relates to God. (Kierkegaard)

Pragmatists Truth is relative and practical —if it works, then it is truth. (James, Peirce, Dewey)

Relativists Truth is always dependent on the knower and the knower’s context. (Kuhn, Laudan)

Phenomenologists Truth is in human consciousness. (Husserl, Heidegger)

Existentialists If truth can be found, it can be found only through the search for self. (Sartre, Merleau-Ponty, Gadamer)

Poststructuralists/Postmodernists Truth (if there is truth) is not singular and is always historical.

Truth can be found in the deconstruction of language. (Derrida) Truth is (evolves from) the outcomes of events. (Foucault) Truth is created through dialogue with a purpose of emancipatory action. (Habermas, Freire) Truth is unique to gender. (Feminists)

Now, back to the real world: What is the purpose for this dialogue in a text on professional nursing? One of the critical theorists, Habermas, would say, “Communication is the way to truth.” We have this discussion because it leads us to truth. In this case, the dialogue leads us to truth about nursing. What we hold as truth does not come through mere reading, studying, or debating. The truth comes through dialogue. Let’s continue.

BOX 3-1

• • • • •

• • • • •

Paradigms How do you see the world? Whether you know it or not, you have an established worldview or paradigm. A paradigm is the lens through which you see the world. Paradigms are also philosophical foundations that support our approaches to research (Weaver & Olson, 2006). The continuum of realism and idealism explains bipolar paradigms (Box 3- 1). Most people today would agree that “somewhere in the middle” of these dichotomies lies truth.


Realism The world is static. Seeing is believing. The social world is a given. Reality is physical and independent. Logical thinking is superior.

Idealism The world is evolving. There is more than meets the eye. The social world is created. Reality is a conception perceived in the mind. Thinking is dynamic and constructive.

Our philosophies are established from a lifelong process of learning and show us how we find truth. In other words, a philosophy is our method of knowing. The experiences we have with ourselves, others, and

the environment provide structure to our thinking. Ultimately, our philosophies are demonstrated in the outcomes of our day-to-day living. Nurses’ values and beliefs about the profession come from observation and experience (Buresh & Gordon, 2000).

Your worldview of nursing began long before you enrolled in nursing school. As far as you can remember, think back on your understanding of nursing. What did you think you would do as a nurse? Did you know a nurse? Did you have an experience with a nurse? What images of the nurse did you see on television or in the movies? Since that time, your worldview of nursing has changed. What experiences in school have changed your perspective of nursing? Undoubtedly, how you see nursing now will differ from your worldview in a few years—or even a few months.


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential VIII: Professionalism and Professional Values

8.6 Reflect on one’s own beliefs and values as they relate to professional practice (p. 28).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

Beliefs A chief goal of this chapter is to provide a starting point for writing a personal philosophy of nursing. To do that, we must have a discussion of beliefs and values. Beliefs indicate what we value, and according to Steele (1979), beliefs have a faith component. Rokeach (1973) identifies three categories of beliefs: existential, evaluative, and prescriptive/proscriptive beliefs. Existential beliefs can be shown to be true or false. An example is the belief that the sun will come up each morning. Evaluative beliefs describe beliefs that make a judgment about whether something is good or bad. The belief that social drinking is immoral is an evaluative belief. Prescriptive and proscriptive beliefs refer to what people should (prescriptive) or should not (proscriptive) do. An example of a prescriptive or desirable belief is that everyone should vote. An example of an undesirable or proscriptive belief is that people should not be dishonest. Beliefs demonstrate a personal confidence in the validity of a person, object, or idea.


Where do you see yourself and your understanding of truth on the continuum of realism and idealism?

Consider the second concept in nursing: environment. How do you define the internal (within the person) and external (outside the person) environments? Is it important that nurses look beyond the individual toward the surroundings and structures that influence quality of human life? If yes, then how do you see the relationship between the internal and external environments? Is one dimension more important than the other? How do they interact with each other? Martha Rogers, a grand

theorist in nursing, described the environment as continuous with the person, no boundaries, in constant exchange of energy. Would you agree?


How would you define person? Look at the following attributes given to a person: (1) the ability to think and conceptualize, (2) the capacity to interact with others, (3) the need for boundaries, and (4) the use of language (Doheny, Cook, & Stopper, 1997). Would you agree? What about Maslow’s description of humanness in terms of a hierarchy of needs with self-actualization at the top? Another possibility is that persons are the major focus of nursing. Do you see humans as good or evil?

Health is the third domain of nursing to ponder. Is health the same as the absence of illness? Is health perception? A person who is living and surviving may be described as “healthy.” Would you support that as a comprehensive definition of health? Doheny et al. (1997) referred to health in the following way:

Health is dynamic and ever changing, not a stagnant state. Health can be measured only in relative terms. No one is absolutely healthy or ill. In addition, health applies to the total person, including progression toward the realization and fulfillment of one’s potential as well as maintaining physical, psychosocial health. (p. 19)

Maybe that definition is sufficient, but probably not. All definitions— including yours—have limitations. Definitions merely give us a way to express our beliefs and may, as our beliefs do, evolve over time.

Finally, consider common beliefs about nursing. Clarke (2006) posed that question in “So What Exactly Is a Nurse?”—an article addressing the

problematic nature of defining nursing. The American Nurses Association (ANA) provided a much-used definition of nursing in 1980: “Nursing is the diagnosis and treatment of human responses to actual and potential health problems” (p. 9). Fifteen years later, the ANA (1995) expanded its basic definition of nursing to acknowledge four fundamental aspects. According to this definition, professional nursing includes attention to the full range of human experiences and responses to health and illness without restriction to a problem-focused orientation, integration of objective data with an understanding of the subjective experience of the patient, application of scientific knowledge to the processes of diagnosis and treatment, and provision of a caring relationship that facilitates health and healing. In 2003, the ANA added two essential features to this list that reflect nursing’s commitment to meeting the needs of society amid constant changes in the healthcare environment. These additional features are the advancement of nursing knowledge through scholarly inquiry and the influence on social and public policy for the promotion of social justice.


Where do you see yourself and your understanding of truth on the continuum of realism and idealism?

The definition of nursing has been only slightly modified since the 2003 revision: “Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” (ANA, 2010, p. 10), with the newest revision (2015) specifically including the concept of facilitation of healing and adding groups to the list of recipients of nursing care. Four essential characteristics of nursing identified from

the definition are “human responses or phenomena, theory application, nursing actions or interventions, and outcomes” (ANA, 2010, p. 10).


What are your beliefs about the major concepts in nursing—person, environment, health, nursing?

How would you define nursing? Understanding our beliefs and articulating them in definitions are beginning steps for developing a personal philosophy. Definitions tell us what things are. Our philosophy tells us how things are. One other piece must be addressed before we begin writing our personal philosophy: the topic of values.

Values Values refer to what the normative standard should be, not necessarily to how things actually are. Values are the principles and ideals that give meaning and direction to our social, personal, and professional lives. Steele (1979) defines value as “an affective disposition towards a person, object, or idea” (p. 1). The values of nursing have been articulated by such groups as the ANA in the Code of Ethics (2001), the National League for Nursing in the NLN Education Competencies Model (2010), and the American Association of Colleges of Nursing’s (AACN) (2008) essentials for baccalaureate nursing education. The NLN identifies seven core values as foundational for all nursing practice that include caring, diversity, ethics, excellence, holism, integrity, and patient-centeredness. The AACN essentials document calls for integration of professional nursing values in baccalaureate education; they are altruism, autonomy, human dignity, integrity, and social justice. Ways of teaching these values have been addressed in the literature (Fahrenwald, 2003).

Nursing values have been identified as the fundamentals that guide our standards, influence practice decisions, and provide the framework used for evaluation (Kenny, 2002). Nevertheless, nursing has been criticized as not clearly articulating what our values are (Kenny, 2002). If nursing is to engage in the move to “interprofessional working,” which is beyond uniprofessional and multiprofessional relationships, we have to define our values clearly. Interprofessional working validates what others provide in health care, and the relationships depend on mutual input and collaboration. Values in nursing need to be clearly articulated so that they can be discussed in the context of interprofessional partnership. We can then work together across traditional boundaries for the good of patients.

Nursing offers something to health care that no other profession does, but that something must first be clear to those of us in nursing. “It is not enough just to argue that caring is never value-free, and that values are a fundamental aspect of nursing. What is required is greater precision and clarity so that values can be identified by those within the profession and articulated beyond it” (Kenny, 2002, p. 66).

Statements such as those by the ANA, the NLN, and the AACN mentioned earlier are a step in the right direction. Others have identified nursing values using different language. Antrobus (1997) sees nursing values as humanistic and include (1) a nurturing response to someone in need, (2) a view of the whole individual, (3) an emphasis on the individual’s perspective, (4) concentration on developing human potential, (5) an aim of well-being, and (6) maintenance of the nurse–patient relationship at the heart of the helping situation. Nursing values have also been listed as caregiving, accountability, integrity, trust, freedom, safety, and knowledge (Weis & Schank, 2000).

Rokeach (1973) makes the following assertions about values:

Each person has a few. All humans possess the same values. People organize values into systems. Values are developed in response to culture, society, and personality. Behaviors are manifestations or consequences of values.

The process of valuing involves three steps: (1) choosing values, (2) prizing values, and (3) acting on values (Chitty, 2001). To choose a value is an intellectual stage in which a person selects a value from identified alternatives. Second, prizing values involves the emotional or affective dimension of valuing. When we “feel” a certain way about our values, it is because we have reached this second step. Finally, we have to act on our intellectual choice and emotion. This third step includes behavior or

action that demonstrates our value. Ideally, a genuine value is evidenced by consistent behavior.

Steele (1979) distinguished between intrinsic and extrinsic values. An intrinsic value is required for living (e.g., food and water), whereas an extrinsic value is not required for living and is originated external to the person. According to Simon and Clark (1975), the following criteria must be met in acquiring values:

Must be freely chosen Must be selected from a list of alternatives Must have thoughtful consideration of each of the outcomes of the alternatives Must be prized and cherished Must involve a willingness to make values known to others Must precipitate action Must be integrated into lifestyle

Value acquisition refers to when a new value is assumed, and value abandonment is when a value is relinquished. Value redistribution occurs when society changes views about a particular value. Values are more dynamic than attitudes because values include motivation as well as cognitive, affective, and behavioral components. Therefore, people have fewer values than attitudes (feelings or dispositions toward a person, object, or idea). In the end, values determine our choices.

According to Steele (1979), values can compete with one another on our “hierarchy of values.” We typically have values that we hold about education, politics, gender, society, occupations, culture, religion, and so on. The values that are higher in the hierarchy receive more time, energy, resources, and attention. For change to occur there must be conflict among the value system. For example, if a patient values both freedom from pain and long life but is diagnosed with bone cancer, a conflict in

values will occur. If professional responsibilities and religious beliefs conflict, the solution is not as simple as “right versus wrong.” Rather, it is the choice between two goods. For example, suppose you have strong religious views about abortion. During your rotation, you are assigned to care for someone who elects to have an abortion. As a nurse, you must balance the value of the patient’s choice with your personal value about elective abortions. These decisions are not easy.

Dowds and Marcel (1998) conducted a study involving 40 female nursing students who were taking a psychology class. The students completed the World Hypothesis Scale, which provided 12 items, each with four possible explanations of an event. Each of the four explanations represented a distinct way of thinking. A list of definitions and descriptions of the different ways of thinking includes the following:

Contextualism: Understanding is embedded in context; meaning is subjective and open to change and dependent on the moment in time and the person’s perspective. Formism: Understanding events in relationship to their similarity to an ideal or objective standard comes from categorization (e.g., the classification of plants and animals in biology). Mechanism: Understanding is in terms of cause-and-effect relationships, the common approach used by modern medicine. Organicism: Understanding comes from patterns and relationships; must understand the whole to understand the parts (e.g., cannot look at a child’s language development without looking at his or her overall development history).

The students ranked the explanations in terms of their preferences for understanding the event. Nursing students chose mechanistic thinking significantly more than all other ways of thinking and chose contextualistic thinking significantly less than the other worldviews. No

other comparisons were significant among or between the four worldviews. In other words, the nursing students did not choose options that allowed for more than one right answer. They resisted the options that allowed for ambiguity. What this tells us in relationship to values is that we can say that we value human response and the whole individual, but do we really? Human situations are dynamic, fluid, and open to multiple options. Nursing claims to respond to these contextual needs, but do we?

Values Clarification Clarifying our values is an eye-opening experience (Figure 3-5). The process of values clarification can occur in a group or individually and helps us understand who we are and what is most important to us. The outcome of values clarification is positive because the outcome is growth. If the process occurs in a group, there must be trust within the group. No one should be embarrassed or intimidated. Everyone is respected.

Figure 3-5 Nursing students engaged in a classroom values clarification exercise to help discern both personal and professional values.

© Iakov Filimonov/Shutterstock.

Values clarification exercises help people discern their individual values. A simple approach to begin the process is considering your responses to such statements as “Patients have a right to know

everything that is in the medical record.” What is your immediate reaction? How do you feel about the options available in this situation? Have you acted on these beliefs in the past? Another statement to consider is this: “Everyone should have equal access to health care— regardless of income.” Ask yourself the same questions. Other exercises involve real or hypothetical clinical situations. For example, a 19-year-old male with human immunodeficiency virus is totally dependent. His parents remain at his bedside but do not say a word. Another example is a single mom who has recently been diagnosed with multiple sclerosis. What about a 70-year-old man who loses his wife of 42 years, only to remarry a woman who is soon diagnosed with dementia? Reflect. What questions do you have? Why are these people in these situations? Does that matter? What in the patient’s life choices conflicts with your choices? Share this with your peers, your friends, and your teachers.

In values clarification, one should consider the steps identified earlier as necessary for value acquisition: (1) choosing freely from among alternatives, (2) experiencing an emotional connection, and (3) demonstrating actions consistent with a stated value. We act on values as the climax of the values clarification process. We are more aware, more empathetic to others, and have greater insight into ourselves and those around us for having gone through this process. Our words and actions are not so different, and we become more content with the individuals we are (i.e., self-actualization). Values clarification also allows us to be more open to accepting others’ choice of values.

We must keep in mind that values vary from person to person. Returning to the concept of health, if we asked several people “What is health?,” we would get different responses because it means different things to different people. Most likely, we would find that others do not place health as high in their hierarchy of values as we do. This helps explain why some people go to the physician for every little ailment,

whereas others wait until the situation is critical. Maintaining a nonjudgmental attitude about the values of others is crucial to the nurse– patient relationship.


Do you believe there is more than one right answer to situations? How do you value the whole individual? What barriers prevent us from responding to the contextual needs of our patients?

In health care, we need to clarify values for both the consumer and the provider in society. Referring once again to health, we recognize that although the majority of our society states that health is a right, not a privilege, not everyone has health care. Is health positioned at the top of society’s hierarchy of values? We also have to assess the individual’s values for congruency with the societal values. As research gives us new options to consider, continual reassessment of values is essential. A questioning attitude is healthy and necessary.


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential IX: Baccalaureate Generalist Nursing Practice

9.18 Develop an awareness of patients’ as well as healthcare professionals’ spiritual beliefs and values and how those beliefs and values impact health care (p. 32).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

As a profession, nursing is responsible for clarifying our values on a regular basis. Just as society places a value on health, society also determines the value of nursing in the provision of health. In addition, nurses need to be involved in all levels where decisions based on values are made, particularly with ethical decisions. The values that nursing supports need to be communicated clearly to those making the policies that affect the health of our society.

Values clarification is done for the purpose of understanding self—to discover what is important and meaningful (Steele, 1979). Throughout life, the process continues as it gives direction to life. As you work through the course of values clarification, keep in mind that personal and professional values are not necessarily the same.

Developing a Personal Philosophy of Nursing Before we begin writing our individual nursing philosophies, consider the following comments about philosophy. According to Doheny et al. (1997), philosophy is defined as “beliefs of a person or group of persons” and “reveals underlying values and attitudes regarding an area” (p. 259). In this concise definition, these authors mentioned the building blocks of philosophy that we have discussed thus far: attitudes, beliefs, and values. Another definition that is not as concise reads, “Nursing philosophy is a statement of foundational and universal assumptions, beliefs, and principles about the nature of knowledge and truth (epistemology) and about the nature of the entities—nursing practice and human healing processes—represented in the metaparadigm (ontology)” (Reed, 1999, p. 483). Finally, philosophy “looks at the nature of things and aims to provide the meaning of nursing phenomena” (Blais, Hayes, Kozier, & Erb, 2002, p. 90).

In Nursing’s Agenda for the Future, the ANA (2002) identified the need for nurses to “believe, articulate, and demonstrate the value of nursing” (p. 15). To do that, each professional nurse is responsible for clearly articulating a personal philosophy of nursing. Suggestions for developing personal professional philosophies have been presented in the literature (Brown & Gillis, 1999). The overall purpose of personal philosophy is to define how one finds truth. Because there are different ways of knowing, each person has a unique way of finding truth—in other words, identifying our individual philosophy. Therefore, your philosophy of nursing will be unique.

How do you start writing? A suggested guide for writing your personal

BOX 3-2

1. a. b.

2. a. b. c.

3. a. b. c. d.

4. a. b. c.

5. a. b. c.

philosophy of nursing is in Box 3-2. When defining nursing, you may refer to definitions by professional individuals or groups. You may also choose to write an original definition, which is certainly acceptable. A final challenge would be this: Once you have used words to describe your personal philosophy, try drawing it. This exercise can enlighten you to gaps in your understanding and further clarify the picture for you.


Introduction Who are you? Where do you practice nursing?

Define nursing. What is nursing? Why does nursing exist? Why do you practice nursing?

What are your assumptions or underlying beliefs about: Nurses? Patients? Other healthcare providers? Communities?

Define the major domains of nursing and provide examples: Person Health Environment

Summary How are the domains connected? What is your vision of nursing for the future? What are the challenges that you will face as a nurse?

d. What are your goals for professional development?


Examples of applicable Nurse of the Future: Nursing Core Competencies


Knowledge (K7) Understands ethical principles, values, concepts, and decision making that apply to nursing and patient care

Skills (S7c) Identifies and responds to ethical concerns, issues, and dilemmas that affect nursing practice

Attitudes/Behaviors (A7c) Clarifies personal and professional values and recognizes their impact on decision making and professional behavior

Attitudes/Behaviors (A7d) Values acting with honesty and integrity in relationships with patients, families, and other team members across the continuum of care

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Writing a philosophy does not have to be a difficult exercise. In fact, you have one already—you just need to practice putting it on paper. Keep in mind that your philosophy will change over time. In addition, composing a nursing philosophy will help you see yourself as an active participant in the profession.

Consider the scene if no one in nursing had a philosophy. What would happen? Unfortunately, we would find ourselves doing tasks

without considering the rationale and performing routines in the absence of purpose. Most likely, we would find ourselves devalued by our patients and fellow care providers.

Although our individual philosophies vary, there are similarities that link us in our universal philosophy as a profession. As a whole, we are kept on track by continually evaluating our attitudes, beliefs, and values. We can evaluate our efforts by reflecting on our philosophies. In the process of personal and professional reflection, we are challenged to reach global relevancy and to begin the development of a global nursing philosophy (Henry, 1998).


Do I believe in health care for everyone? Does health care for everyone have value to me as a person? Does it have value to me as a nurse? What value does universal health care have to my patients?


How does my personal philosophy fit with the context of nursing? Does it fit? What areas, if any, need assessing?

Conclusion In this chapter, we have discussed one of the most ambiguous concepts in professional disciplines—nursing philosophy. The history of philosophy helps us to see that asking questions about humans, environment, health, and nursing is a continual process that leads to a better understanding of truth in our profession. Our own values and beliefs must be clarified so that we can authentically respond to the healthcare needs of our patients and to society as a whole. All along the way, our philosophies are changing. Therefore, we must constantly question the values of our profession, our society, and ourselves—aiming to better the health of all people worldwide.


Examples of applicable Nurse of the Future: Nursing Core Competencies


Knowledge (K8a) Understands responsibilities inherent in being a member of the nursing profession

Skills (S8a) Understands the history and philosophy of the nursing profession

Attitudes/Behaviors (A8b) Values and upholds altruistic and humanistic principles

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Hegel, an early philosopher, said, “History is the spirit seeking freedom.” On this path of searching for truth, we ask the same question but in different contexts and with distinct experiences. The answers for one person do not provide the same satisfaction for another person. Through our individual and collective searching, we become truth knowers. Habermas, the supporter of dialogue, would suggest that the journey does not end with communication and questioning alone. When truth is revealed, oppressive forces are acknowledged, and the truth knowers are then responsible to move to action. Through that action comes a change in the social structure and the hope of rightness in the world.

Classroom Activity 3-1

Take about 15 minutes after the discussion related to developing a philosophy of nursing to begin answering the questions in Box 3-2. Jot down answers to the questions in Box 3-2. Ask questions as necessary while still in the classroom. This simple activity will make it easier when writing a personal philosophy of nursing.

Classroom Activity 3-2

After thinking about your answers to the questions in Box 3-2 related to the metaparadigm concepts (person, health, environment, and nursing), draw each of these concepts as you define them on a separate piece of paper. Save your drawings and think about them and refine them as you develop your philosophy of nursing. This activity works best if you use colored pencils, crayons, or markers. An example is presented in Figure 3-6.

Figure 3-6 Drawing of the concept of person.

Reproduced from Masters, K. (2006). Drawing of concept of person. Unpublished classroom exercise, as adapted from Nee, W. (1968). The spiritual man. New York, NY: Christian Fellowship


References American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from

American Heritage Dictionary of the English Language (4th ed.). (2000). Boston, MA: Houghton Mifflin.

American Nurses Association. (1980). Nursing: A social policy statement. Washington, DC: Author.

American Nurses Association. (1995). Nursing’s social policy statement. Washington, DC: Author.

American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Washington, DC: Author.

American Nurses Association. (2002). Nursing’s agenda for the future: A call to the nation. Washington, DC: Author.

American Nurses Association. (2003). Nursing’s social policy statement: The essence of the profession. Washington, DC: Author.

American Nurses Association. (2010). Nursing’s social policy statement: The essence of the profession. Silver Spring, MD: Author.

American Nurses Association. (2015). Nursing: Scope and standards of practice (3rd ed.). Silver Spring, MD: Author.

Antrobus, S. (1997). An analysis of nursing in context: The effects of current health policy. Journal of Advanced Nursing, 45, 447–453.

Blais, K. K., Hayes, J. S., Kozier, B., & Erb, G. (2002). Professional nursing practice: Concepts and perspectives (4th ed.). Upper Saddle River, NJ: Prentice Hall.

Brown, S. C., & Gillis, M. A. (1999). Using reflective thinking to develop

personal professional philosophies. Journal of Nursing Education, 38, 171–176.

Buresh, B., & Gordon, S. (2000). From silence to voice: What nurses know and must communicate to the public. New York, NY: Cornell University Press.

Chitty, K. K. (2001). Philosophies of nursing. In K. K. Chitty (Ed.), Professional nursing: Concepts and challenges (pp. 199–217). Philadelphia, PA: Saunders.

Clarke, L. (2006). So what exactly is a nurse? Journal of Psychiatric and Mental Health Nursing, 13, 388–394.

Doheny, M. O., Cook, C. B., & Stopper, M. C. (1997). The discipline of nursing: An introduction (4th ed.). Stamford, CT: Appleton & Lange.

Dowds, B. N., & Marcel, B. B. (1998). Students’ philosophical assumptions and psychology in the classroom. Journal of Nursing Education, 37, 219–222.

Fahrenwald, N. L. (2003). Teaching social justice. Nurse Educator, 28, 222–226.

Henry, B. (1998). Globalization, nursing philosophy, and nursing science. Image: Journal of Nursing Scholarship, 30, 302.

Kenny, G. (2002). The importance of nursing values in interprofessional collaboration. British Journal of Nursing, 11(1), 65–68.

Massachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. Retrieved from

Masters, K. (2006). Drawing of concept of person. Unpublished classroom exercise.

National League for Nursing. (2010). Outcomes and competencies for graduates of practical/vocational, diploma, associate degree, baccalaureate, master’s, practice doctorate, and research doctorate programs in nursing. New York, NY: Author.

Nee, W. (1968). The spiritual man. New York, NY: Christian Fellowship. Reed, P. G. (1999). A treatise on nursing knowledge development for the 21st century: Beyond postmodernism. In E. C. Polifroni & M. Welch (Eds.), Perspectives on philosophy of science in nursing (pp. 478– 490). Philadelphia, PA: Lippincott.

Rokeach, M. (1973). The nature of human values. New York, NY: Free Press.

Simon, S. B., & Clark, J. (1975). Beginning values clarification: A guidebook for the use of values clarification in the classroom. San Diego, CA: Pennant Press.

Steele, S. (1979). Values clarification in nursing. New York, NY: Appleton- Century-Crofts.

Weaver, K., & Olson, J. K. (2006). Understanding paradigms used for nursing research. Journal of Advanced Nursing, 53, 459–469.

Weis, D., & Schank, M. J. (2000). An instrument to measure professional nursing values. Journal of Nursing Scholarship, 32, 201–204.

© James Kang/EyeEm/Getty Images


Competencies for Professional Nursing Practice Jill Rushing and Kathleen Masters

Learning Objectives

After completing this chapter, the student should be able to:

1. Describe core competencies for graduates of prelicensure nursing programs.

2. Describe the relationships among critical thinking, clinical judgment, clinical reasoning, decision making, and mindfulness.

3. Explore the characteristics of critical thinking and the critical thinker.

4. Explore the process involved in critical thinking. 5. Explore strategies to develop critical thinking skills.

Key Terms and Concepts

Competence Clinical judgment Clinical reasoning Mindfulness Critical thinking Reflective thinking Nursing process Concept mapping Journaling

Overview The art and science of nursing are based on a framework of caring and respect for human dignity. A compassionate approach to patient care mandates that nurses provide care in a competent manner (Massachusetts Department of Higher Education [MDHE], 2010). Competence has been defined as the ability to demonstrate an integration of knowledge, attitudes, and skills necessary to function in a specific role and work setting. As applied to nursing, competence is an expected and measurable level of nursing performance that integrates knowledge, skills, abilities, and judgment, based on established scientific knowledge and expectations for nursing practice (American Nurses Association [ANA], 2015, p. 86).

In response to calls from the Institute of Medicine (IOM) for increases in safety and quality near the turn of the century, renewed interest in competency in nursing practice emerged, with organizations publishing documents delineating expectations for nursing education and practice. For example, the American Association of Colleges of Nursing (AACN, 2008) essentials document outlines outcomes expected for the baccalaureate-prepared nurse, and the Technology Informatics Guiding Education Reform (TIGER), or what is known as the TIGER Initiative, has become the standard for informatics competencies for practicing nurses (TIGER, 2009).

The best-known initiative that emerged during this era was the Quality and Safety Education for Nurses (QSEN) project, funded by the Robert Wood Johnson Foundation, that began in 2005. Six competences were identified during the QSEN project: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement,

informatics, and safety. In addition to the identification and definition of the competencies, sets of knowledge, skills, and attitudes for each competency were developed (QSEN, 2018). The sets of knowledge, skills, and attitudes for each QSEN competency provided a framework to assess or measure the attainment of each competency as relevant to nursing practice.

Nurse of the Future: Nursing Core Competencies The Nurse of the Future: Nursing Core Competencies also provides a framework for the provision of competent nursing care (MDHE, 2010). What makes this model different is that it builds on many documents in nursing that include the AACN’s (2008) Essentials of Baccalaureate Education for Professional Nursing Practice, National League for Nursing Council of Associate Degree Nursing competencies, IOM recommendations, QSEN competencies, and ANA standards as well as other professional organization standards and recommendations.

The 10 essential competencies included in the Nurse of the Future: Nursing Core Competencies that are intended to guide nursing curricula and practice emanate from the central core of the model that represents nursing knowledge (MDHE, 2016). The 10 competencies included in the model are patient-centered care, professionalism, informatics and technology, evidence-based practice, leadership, systems-based practice, safety, communication, teamwork and collaboration, and quality improvement. Essential knowledge, skills, and attitudes (KSAs) reflecting cognitive, psychomotor, and affective learning domains are specified for each competency. The KSAs identified in the model reflect the expectations for initial nursing practice following the completion of a prelicensure professional nursing education program (MDHE, 2016). Nurse of the Future: Nursing Core Competencies are included throughout each chapter through the use of competency boxes that link examples of the KSAs appropriate to the chapter content to Nurse of the Future: Nursing Core Competencies required of entry-level professional nurses. The competency model in its entirety is available online at The Nurse of the Future: Nursing Core Competencies graphic

illustrates through the use of broken lines the reciprocal and continuous relationship between each of the competencies and nursing knowledge, that the competencies can overlap and are not mutually exclusive, and that all competencies are of equal importance. In addition, nursing knowledge is placed as the core in the graphic to illustrate that nursing knowledge reflects the overarching art and science of professional nursing practice (MDHE, 2016). Figure 4-1 depicts the Nurse of the Future: Nursing Core Competencies.

Figure 4-1 The Nurse of the Future: Nursing Core Competencies graphic. Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

The Nurse of the Future: Nursing Core Competencies (MDHE, 2016) document addresses the knowledge base and relationships among concepts important to the practice of nursing. In the context of nursing knowledge, the concepts of patient, environment, health, and nursing are defined in Table 4-1.

TABLE 4-1 Metaparadigm Concepts as Defined in the Nurse of the Future: Nursing

Core Competencies

Human being/patients

“The recipient of nursing care or services . . . Patients may be individuals, families, groups, communities, or populations” (AACN, 1998, p. 2, as cited in MDHE, 2016, p. 9).

Environment “The atmosphere, milieu, or conditions in which an individual lives, works or plays” (ANA, 2004, p. 47, as cited in MDHE, 2016, p. 9).

Health “An experience that is often expressed in terms of wellness and illness, and may occur in the presence or absence of disease or injury” (ANA, 2004, p. 5, as cited in MDHE, 2016, p. 9).

Nursing “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations” (ANA, 2001, p. 5, as cited in MDHE, 2016, p. 9).

The Nurse of the Future: Nursing Core Competencies for the registered nurse includes the following 10 core competencies, each with a corresponding definition:

Patient-centered care: “The Nurse of the Future will provide holistic care that recognizes an individual’s preferences, values, and needs and respects the patient or designee as a full partner in providing compassionate, coordinated, age and culturally appropriate, safe and effective care” (MDHE, 2016, p. 10). Professionalism: “The Nurse of the Future will demonstrate accountability for the delivery of standard-based nursing care that is consistent with moral, altruistic, legal, ethical, regulatory, and humanistic principles” (MDHE, 2016, p. 14). Leadership: “The Nurse of the Future will influence the behavior of individuals or groups of individuals within their environment in a way that will facilitate the establishment and acquisition/achievement of shared goals” (MDHE, 2016, p. 18). Systems-based practice: “The Nurse of the Future will demonstrate an awareness of and responsiveness to the larger context of the health care system and will demonstrate the ability to effectively call on work unit resources to provide care that is of optimal quality and value” (MDHE, 2016, p. 22). Informatics and technology: “The Nurse of the Future will be able to use advanced technology and to analyze as well as synthesize information and collaborate in order to make critical decisions that optimize patient outcomes” (National Academies of Sciences, Engineering, and Medicine, 2015, as cited in MDHE, 2016, p. 26). Communication: “The Nurse of the Future will interact effectively with patients, families, and colleagues, fostering mutual respect and shared decision making, to enhance patient satisfaction and health outcomes” (MDHE, 2016, p. 32). Teamwork and collaboration: “The Nurse of the Future will function effectively within nursing and interdisciplinary teams, fostering open

communication, mutual respect, shared decision making, team learning, and development” (adapted from QSEN, 2007, as cited in MDHE, 2016, p. 37). Safety: “The Nurse of the Future will minimize risk of harm to patients and providers through both system effectiveness and individual performance” (QSEN, 2007, as cited in MDHE, 2016, p. 42). Quality improvement: “The Nurse of the Future uses data to monitor the outcomes of care processes, and uses improvement methods to design and test changes to continuously improve the quality and safety of health care systems” (QSEN, 2007, as cited in MDHE, 2016, p. 45). Evidence-based practice: “The Nurse of the Future will identify, evaluate, and use the best current evidence coupled with clinical expertise and consideration of patients’ preferences, experience and values to make practice decisions” (adapted from QSEN, 2007, as cited in MDHE, 2016, p. 47).

The committee that designed the Nurse of the Future: Nursing Core Competencies also identified several assumptions and principles to serve as a framework. The assumptions include:

1. Education and practice partnerships are key in developing an effective model.

2. It is imperative that leaders in nursing education and practice develop collaborative curriculum models to facilitate the achievement of a minimum of a baccalaureate degree in nursing for all nurses.

3. A more effective education system must be developed, one capable of incorporating shifting demographics and preparing the nursing workforce to respond to current and future healthcare needs and population health issues.

4. The nurse of the future will be proficient in a core set of

competencies. 5. Nurse educators in education and practice settings will need to use a

different set of knowledge and teaching strategies to effectively integrate the Nurse of the Future core competencies into curriculum.

6. The nurses’ role is integral in recognizing the social and cultural determinants of health that are essential to disease prevention and health promotion efforts needed to improve health and health care and to build a culture of health across the Commonwealth and the nation.

7. With societal shifts, information-related innovations and a focus on teamwork and collaboration, health professions education will be interprofessional and focused on collaborative practice.

8. To create competencies for the future, there must be an ongoing process of evaluation and updating of the competencies to ensure that they are reflective of contemporary health care practice. (MDHE, 2016, p. 4)


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential II: Basic Organizational and Systems Leadership for Quality Care and Patient Safety

2.1 Apply leadership concepts, skills, and decision making in the provision of high-quality nursing care, healthcare team coordination, and the oversight and accountability for care delivery in a variety of settings (p. 14).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

Just as the Nurse of the Future: Nursing Core Competencies have changed between the first publication in 2010 and the current revision (MDHE, 2010, 2016), expectations for the profession of nursing will continue to change with increases in knowledge and changes in technology that affect both nursing practice and patient outcomes. These changes promise to be constant, requiring professional nurses who are vigilant in their practice when it comes to maintaining competency through continuous, lifelong education and workplace training.

Critical Thinking, Clinical Judgment, and Clinical Reasoning in Nursing Practice Nursing competence plays a large role in ensuring patient safety. In addition to such initiatives as QSEN (2018) and Nurse of the Future: Nursing Core Competencies (MDHE, 2016), in 2008, the Robert Wood Johnson Foundation and the IOM launched a 2-year initiative to respond to the need to assess and transform the nursing profession. The IOM report points out that nurses are going to have a critical role in the future, especially in producing safe, high-quality care and coverage for all patients in our healthcare system (IOM, 2011). The Agency for Healthcare Research and Quality (2008), in collaboration with the Robert Wood Johnson Foundation, developed a handbook for nurses on patient safety and quality. The handbook provides a wealth of information for nursing, including background research and tools for improving the quality of care. In 2008, the AACN revised The Essentials of Baccalaureate Education for Professional Nursing Practice based on early discussion of IOM reports and the necessity of building a safer healthcare system (AACN, 2008). As one can see, many initiatives in nursing during the past decade focused on patient safety.

A majority of sentinel events occur in acute care settings, where new graduate nurses traditionally begin their professional nursing careers. The inability of a nurse to set priorities and to work safely, effectively, and efficiently can delay patient treatment in a critical situation and result in serious life-threatening consequences. The ability of nurses to think critically and to make sound clinical judgments is essential to providing

safe, competent, and high-quality nursing care. New realities of health care require nurses to master complex

information, to coordinate a variety of care experiences, to use advanced technology for healthcare delivery and evaluation of patient outcomes, and to assist patients with managing and navigating an increasingly complex system of care. Some of the trends that have added to the complexities of the healthcare environment include increases in longevity, markedly shortened hospital stays (which are moving patients out of the hospital “quicker and sicker”), scientific advances and major advances in technology, increased diversity in the U.S. population, and an increased incidence of chronic diseases and infectious diseases (AACN, 2008). Complicating things is the phenomenon known as information overload or cognitive overload, which is the interpretation that one makes in response to breakdowns, interruptions, or imbalances between demand and capacity. The interpretation of overload is affected by the situation, including the developmental level and expertise of the registered nurse (Sitterding, 2015), making it imperative that nurses enter the profession with experiences that enable effective interpretation and clinical judgment to function efficiently in the complex healthcare system.

The responsibilities of a professional registered nurse (RN) have increased significantly over the years. Nurses and nursing students must be able to function within the complicated environment of the healthcare system. The effect of advanced technology and the increased acuity level and complexity of patients, combined with the accountability and responsibility nurses have in the delivery of safe and effective care, make it essential, now more than ever, for nurses to possess the ability to think critically. In nursing, critical thinking is the ability to think in a systematic and logical manner, solve problems, make decisions, and establish priorities in the clinical setting. Critical thinking is the competent use of thinking skills and abilities to make sound clinical judgments and safe

decisions. Critical thinking in nursing is an essential component of professional

accountability and high-quality nursing care. Concern for patient safety has grown as high rates of error and injury continue to be reported. To improve patient safety, nurses must be able to recognize changes in patient condition, perform independent nursing interventions, anticipate orders, and prioritize.

New nurses need to be prepared to practice safely, accurately, and compassionately, in varied settings, where knowledge and innovation increase at astonishing rates (Benner, Sutphen, Leonard, & Day, 2010). Nursing students must use a complex array of nursing skills and knowledge at the same time and practice thinking in changing situations, always for the good of the patient (Benner et al., 2010).

Recent studies indicate that new nursing graduates have deficiencies in critical thinking ability, including recognition of problems, reporting of essential clinical data, initiating independent nursing interventions, anticipating relevant medical orders, providing relevant rationale to support decisions, and differentiating urgency (Fero, Witsberger, Wesmiller, Zullo, & Hoffman, 2009). New graduate nurses practice at the novice or advanced beginner level (Benner, 1984). New graduate nurses are at the early stage of developing a skill set and applying critical thinking (Figure 4-2). For the novice, the beginning nursing student, the difficulty encountered in setting priorities is that all tasks, requests, and concerns seem to be of equal weight or importance and they must all be done (Benner et al., 2010). Determining which tasks are most important or urgent requires deliberate thought because the student has not yet learned to see the big picture or gained the skill to recognize quickly what is most urgent or most important in each clinical situation; this level of thinking is often difficult for the novice (Benner et al., 2010). For example, you are about to administer medications to a patient. What is the bigger

picture? Why is the patient being given these medications? Alternatively, you have a patient who has just returned from surgery. What should be carried out in the first hours after surgery?

Figure 4-2 The nurse at the novice or new beginner stage must specifically think through questions in order to set priorities.

© Maridav/Shutterstock

Thinking Like a Nurse The cognitive work of nurses is invisible but includes clinical reasoning over a specific period of time for multiple patients that is informed by both obvious and subtle changes that require knowledge and situational awareness that lead to clinical judgments. Clinical decision making in nursing requires the use of a cognitive workload management strategy known as cognitive stacking in order to negotiate multiple care delivery requirements, maintain a mental list of tasks that must be accomplished, prevent error, and minimize bad outcomes despite working in a complex environment plagued by interruptions, inadequate communication, and design flaws (Sitterding & Ebright, 2015, p. 16). To prepare nursing students for the multifaceted role of professional nurse, the learning process involves components that will provide a solid foundation for developing clinical judgment and clinical reasoning skills. In other words,

the student must learn to think like a nurse. What does it mean to think like a nurse? How does one begin to think like a nurse?

Clinical judgment is a complex observed outcome that includes critical thinking, problem solving, ethical reasoning, and decision making. According to Tanner (2006), clinical judgment is developed through reflection, thus enhancing critical thinking skills. What exactly is clinical judgment? According to Tanner, clinical judgment refers to “an interpretation or conclusion about a patient’s needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient’s response” (p. 204). How does that differ from clinical reasoning? Again, according to Tanner, clinical reasoning refers to “the processes by which nurses and other clinicians make their judgments, and includes both the deliberative process of generating alternatives, weighing them against the evidence, and choosing the most appropriate, and those patterns that might be characterized as engaged, practical reasoning,” including recognition of a pattern, an intuitive clinical grasp, or a response without evident forethought (pp. 204–205).

Based on a review of nearly 200 studies, Tanner (2006, p. 204) proposed the following:

Clinical judgments are more influenced by what nurses bring to the situation than by the objective data about the situation at hand. Sound clinical judgment rests to some degree on knowing the patient and his or her typical pattern of responses as well as engagement with the patient and his or her concerns. Clinical judgments are influenced by the context in which the situation occurs and the culture of the nursing unit. Nurses use a variety of reasoning patterns alone or in combination. Reflection on practice is often triggered by a breakdown in clinical

judgment and is critical for the development of clinical knowledge and improvement in clinical reasoning.


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential VII: Clinical Prevention and Population Health

7.9 Use clinical judgment and decision-making skills as appropriate, timely nursing care during disaster, mass casualty, and other emergency situations (p. 25).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

Tanner (2006) concludes that thinking like a nurse is a form of engaged moral reasoning because nurses enter the care of the patient with a fundamental sense of what is good and right and a vision of what excellent care entails. Further, clinical reasoning should occur in relation to the particular patient and situation and be informed by the knowledge of the nurse and rational processes but “never as a detached objective exercise, with the patient’s concerns as a sidebar” (p. 210).

Another concept that is important to learning to “think like a nurse” is mindfulness. Weick and Sutcliffe (2007, p. 32) define mindfulness as “a rich awareness of discriminatory detail.” In other words, when people act, they are aware of context, of ways in which details differ, and of deviations from their expectations. Mindfulness is similar to situation awareness but is different in the sense that mindfulness involves “the combination of ongoing scrutiny of existing expectations and continuous

refinement and differentiation of expectations based on newer experiences” (p. 32). Mindfulness also involves a “willingness and capability to invent new expectations that make sense of unprecedented events, a more nuanced appreciation of context and ways to deal with it, and identification of new dimensions of context that improve foresight and current functioning” (p. 32).

Weick and Sutcliffe (2007) also note that certain conditions improve awareness. Awareness improves when attention is not distracted, when attention is focused on the present situation, when one is able to keep attention on the problem of interest, and when one is wary of fixing attention on preexisting categories. This pattern of awareness and attention is known as mindfulness and is used in many industries to facilitate quality and safety. In terms of nursing practice, mindfulness implies keeping attention focused in the present, resulting in the ability to see salient aspects of the clinical situation and to take decisive action to prevent harm.

What Is Critical Thinking? Critical thinking is an integral part of nursing practice that promotes high-quality nursing care and positive patient outcomes. Although critical thinking is widely regarded as a component of clinical reasoning and decision making, it is difficult to define, and there is no single, simple definition that explains critical thinking. In nursing, critical thinking for clinical decision making is the ability to think in a systematic and logical manner, with openness to question and reflect on the reasoning process used to ensure safe nursing practice and high-quality care. It is providing effective care based on sound reasoning (Scriven & Paul, 2017). Critical thinking in nursing is an essential component of professional accountability and high-quality nursing care. Critical thinkers exhibit the

following habits of mind: confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection. In nursing, critical thinkers practice the cognitive skills of analyzing, applying standards, discriminating, seeking information, reasoning logically, predicting, and transforming knowledge (Scheffer & Rubenfeld, 2000).

There is a strong link between critical thinking and clinical judgment. The following definition offers a comprehensive description of elements incorporating critical thinking from a nursing prospective. Critical thinking and clinical judgment in nursing (1) are purposeful, informed, outcome- focused thinking; (2) carefully identify key problems, issues, and risks; (3) are based on principles of nursing process, problem solving, and the scientific method; (4) apply logic, intuition, and creativity; (5) are driven by patient, family, and community needs; (6) call for strategies that make the most of human potential; and (7) require constant reevaluating (Alfaro- Lefevre, 2009). Thus, critical thinking, problem solving, and decision making are processes that are interrelated. Decision making and critical thinking need to occur concurrently to produce reasoning, clarification, and potential solutions.


You are assigned to care for Ms. C., an 81-year-old patient who was admitted today with symptoms of increasing shortness of breath over the last week. She is currently receiving oxygen through a nasal cannula at 3 L/min. You go into the room to assess her. You find that she is sitting up in bed at a 60-degree angle. She is restless and her respirations appear labored and rapid. Her skin is pale with circumoral cyanosis. You ask if she feels more short of breath. Because she is unable to catch her breath enough to speak, she nods her head yes. Which action should you take first?

Listen to her breath sounds.

• • •

Ask when the shortness of breath started. Increase her oxygen flow rate to 6 L/min. Raise the head of the bed from 75 to 85 degrees

Based on knowledge you have learned, you realize the patient’s symptoms indicate acute hypoxemia, so improving oxygen delivery is the priority. The other actions also are appropriate, but they are not as critical as the initial action.

Competence in critical thinking is one of the expectations of nursing education. Critical thinkers are described as well informed, inquisitive, open minded, and orderly in complex matters. Critical thinking competence is an outcome for quality nursing care and for the development of clinical judgment. The ability to think critically is also described as reducing the research practice gap and fostering evidence- based nursing (Wangensteen, Johansson, Bjorkstrom, & Nordstrom, 2010).

Learning to be a nurse requires more than memorizing facts. It requires that you learn to think like a nurse, to think through and reason at a greater depth, and to draw a more sophisticated or deeper understanding of what you are doing in clinical practice so that you provide safe, good-quality patient care. Nursing is not a careless, mindless activity. All acts in nursing are deeply significant and require the nurse’s mind to be fully engaged. The following illustration shows that nursing involves both thinking and doing: The physician has ordered an intravenous (IV) line to be placed in a patient. How do you choose between a butterfly and an IV intracath? First, you have to consider why the line is being placed. You take into consideration whether it is a short- term, keep-open IV with limited medications; if so, then the butterfly IV is more comfortable and presents less of a threat of phlebitis. Doctors vary in their preferences as well, and this has to be considered. In addition,

the condition of the patient and his or her veins makes a great deal of difference. For example, special skill is required with older patients. The veins look as though they are going to be easy to get because they look large, but they are very fragile. If you do not use a very slight tourniquet, the vein will pop open (Benner, 1984).

Characteristics of Critical Thinking How do you know when critical thinking is taking place? Critical thinking has some of the following characteristics (Wilkinson, 2007):

Critical thinking is rational and reasonable. Critical thinking involves conceptualization. Critical thinking requires reflection. Critical thinking involves cognitive (thinking) skills and attitudes (feelings). Critical thinking involves creative thinking. Critical thinking requires knowledge.

Critical thinking is rational and reasonable. It is based on reasons rather than on preferences, prejudice, or self-interest. It uses facts and observations to draw conclusions. For example, suppose that during an election you decide to vote for the Democratic candidate because your family has always voted for Democrats. This decision is based on preference, prejudice, and, possibly, self-interest. By contrast, suppose you took the time to reflect on what the candidates in the election said about the issues and based your choice on that. Even though you still might vote for the Democrat, you would be thinking rationally, using facts and observations to draw your conclusions (Wilkinson, 2007).

Critical thinking involves conceptualization. Conceptual thinking is the ability to understand a situation by identifying patterns or connections,

focusing on key underlying issues, and integrating them into a conceptual framework. It involves using professional training and experience, creativity, and inductive reasoning that lead to solutions or alternatives that may not be easily identified. Conceptual thinking involves a willingness to explore and having an openness to a new way of seeing things or “looking outside the box.” Consider, for example, a case in which a patient with heart failure is coughing up yellow sputum. If the nurse suspects that the patient is short of breath from infection, he or she will evaluate other indicators of infection. The nurse will check the patient for an elevated temperature and will assess the last white blood cell count in the patient’s chart to see if it is elevated. The nurse will also consider factors that may place the patient at risk for infection, such as immobility, poor nutrition, or immune suppression (Craven & Hirnle, 2007).


What do all of the following scenarios have in common?

An elderly male becomes acutely confused and refuses to follow directions for his safety. A teen comes into an urgent care setting requesting information about sexually transmitted infections. A mother visits a school nurse and requests information about how the school handles sex education. A team leader needs to rearrange assignments when one team member goes home sick. Nursing staff in an intensive care unit need to develop an evacuation plan.

Answer: They all require critical thinking skills.

Critical thinking uses reflection. Reflective thinking is deliberate thinking and careful consideration. It is the process of analyzing, making

judgments, and drawing conclusions. Reflective thinking involves creating an understanding through one’s experiences and knowledge and exploring potential alternatives—assessing what you know, what you need to know, and how to bridge that gap. Processes of reflective thinking involve the following:

Determine what information is needed (what you need to know) for understanding the issue. Examine what you have already experienced about an issue. Gather the available information. Synthesize the information and opinions. Consider the synthesis from different perspectives and frames of reference. Create some meaning from the relevant information and opinions.

Reflective thinking is important during complex problem-solving situations because it provides an opportunity to step back and think about how to actually solve problems and how problem-solving strategies are used for achieving set goals. Reflection allows students to observe and reflect, pulling together what they learn in the clinical and classroom settings in taking care of patients. Students can build and integrate knowledge and skills. Reflecting on a nursing experience or situation can assist nurses in critically reflecting on their practice. Choose a clinical situation and ask yourself some of the following questions:


You will be taking care of a patient in a nursing home for the first time. Your assignment is to care for an older man who has heart disease. In addition, he has five other medical problems and takes 20 medications. While developing a plan of care for this patient, you can identify 8 to 10 nursing problems. You have no previous experience with nursing homes, and most of what you have heard and read about

them is negative. Will you find yourself dreading the clinical day and expecting a negative experience before you even begin?

What was my role in this situation? Did I feel comfortable or uncomfortable? Why? What actions did I take? How did others and I respond? Was it appropriate? How could I have improved the situation for myself, the patient, and others involved? What can I change in the future? What have I learned through this situation? Did I expect anything different to happen? What and why? Has this situation changed my way of thinking in any way? What knowledge from theory and research can I apply in this situation? What broader issues, for example, ethical, social, or political, arise from this situation?

Through reflection, students manage to be more organized and effective because they have a better understanding of who the patient is and what his or her care needs are. Reflection on practice helps the student develop a self-improving practice (Benner et al., 2010).

Critical thinking involves cognitive (thinking) skills and attitudes (feelings). Critical thinking involves having thinking skills as well as the motivation to use them. It involves the willingness to use complex thought processes compared to easily understood ones. Critical thinkers do not oversimplify. Critical thinking is about being willing and able to think.

Critical thinking involves creative thinking. Creativity is part of the thinking process. When you brainstorm potential problem solutions or possible decisions, you are using creativity. Creative and critical thinkers combine ideas and information in ways that form new solutions or innovative ideas. A creative thinker is an open-minded thinker. Nurses

can use creative thinking when encountering a patient situation in which traditional methods are not effective. For example, a pediatric nurse is caring for 9-year-old Pauline, who has ineffective respirations following abdominal surgery. The physician has ordered incentive spirometry breathing treatments, but Pauline is frightened by the equipment and she quickly tires during the treatments. The nurse offers Pauline a bottle of soap bubbles and a blowing wand. The nurse knows that the respiratory effort in blowing bubbles will promote alveolar expansion and suggests that Pauline blow bubbles between incentive spirometry treatments (Wilkinson, 2007).

Critical thinking requires knowledge. In most academic disciplines, the educational system uses an expert to deliver a body of knowledge to the unpracticed novice, who will later be expected to go out and apply the knowledge and rules learned in school to various work situations. In nursing, a specific educational knowledge base is required before applying that knowledge in patient care. It is important to know that the process is being applied correctly. In essence, to become a nurse you must learn the knowledge to think like a nurse. On the flip side of this, as the level of experience of the nurse increases, so will the scientific knowledge base that the nurse applies. For example, you are caring for a patient with heart failure. After obtaining the vital signs, what heart rate would prevent you from ambulating this patient? If you did not have knowledge regarding heart failure or did not know that the normal heart rate was between 60 and 100 beats per minute, you could not make the good decision that ambulation should be postponed if the heart rate is above 100 beats per minute for this patient.

What Are the Characteristics of a Critical Thinker?

Nurses are required to think critically in all settings. Nurses’ ability to think critically is one of their most important skills, and a commitment to think critically increases the nurse’s ability to care for patients most effectively. A critical thinker has many characteristics, including the following:


Examples of applicable Nurse of the Future: Nursing Core Competencies


Knowledge (K2) Understands critical thinking and problem-solving processes

Skills (S2a) Uses systematic approaches in problem solving

Skills (S2b) Demonstrates purposeful, informed outcome-oriented thinking

Attitudes/Behaviors (A2) Values critical thinking processes in the management of client care situations

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Critical thinkers are flexible—they can tolerate ambiguity and uncertainty. Critical thinkers base judgments on facts and reasoning, not personal feelings. They identify inherent biases and assumptions. Critical thinkers separate facts from opinions. Critical thinkers do not oversimplify. Critical thinkers examine available evidence before drawing conclusions.

Critical thinkers think for themselves and do not simply go along with the crowd. Critical thinkers remain open to the need for adjustment and adaptation throughout the inquiry stages. Critical thinkers accept change. Critical thinkers empathize; they appreciate and try to understand others’ thoughts, feelings, and behaviors. Critical thinkers welcome different views and value examining issues from every angle. Critical thinkers know that it is important to explore and understand positions with which they disagree. Critical thinkers discover and apply meaning to what they see, hear, and read.

Approaches to Developing Critical Thinking Skills As students develop in their nursing role, they learn and build critical thinking skills and apply them to real healthcare situations. Critical thinking requires conscious, deliberate effort. Critical thinking does not just come naturally; people tend to believe what is easy to believe or what those around them believe (Wilkinson, 2007). With effort and practice, everyone can achieve some level of critical thinking to become an effective problem solver and decision maker. As the elements of critical thought develop into a habit, nurses improve their ability to assess complex situations and engage in the practice of nursing. The objectives for critical thinking in nursing include the ability to ask pertinent questions, analyze multiple forms of evidence, and evaluate options before coming to a conclusion. Following are examples that can be used as approaches to developing critical thinking skills.

The Nursing Process The ANA standards have set forth the framework necessary for critical thinking in the application of the nursing process. The nursing process is the tool by which all nurses can become equally proficient at critical thinking. The nursing process contains the following criteria: (1) assessment, (2) identifying the problem (nursing diagnosis), (3) planning, (4) implementation, and (5) evaluation. Through the application of each of these components, the nurse can become proficient at critical thinking. Nurses use critical thinking in each stage of the nursing process. This approach to critical thinking entails purposeful, informed, outcome- focused thinking, which requires identification of the nursing and healthcare needs of clients (Knapp, 2007).


Examples of applicable Nurse of the Future: Nursing Core Competencies


Knowledge (K1b) Justifies clinical decisions

Skills (S1b) Exercises critical thinking and clinical reasoning within standards of practice

Attitudes/Behaviors (A1b) Shows commitment to provision of high- quality, safe, and effective patient care

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

The nursing process is a systematic, problem-solving approach to giving nursing care that allows the nurse to be accountable by using

critical thinking before taking action. Nurses provide effective care based on sound reasoning, which is the reasonable reflection on nursing problems before selecting one of a variety of solutions. This is accomplished by regularly employing the elements of critical thought, such as defining the problem, identifying the goal, and analyzing the evidence (Caputi, 2010).

Each of the following thinking skills is commonly used when a nurse gathers data (Caputi, 2010):

Assessing systematically and comprehensively Checking accuracy and reliability Clustering related information Collaborating with coworkers Determining the importance of information Distinguishing relevant from irrelevant information Gathering complete and accurate data and then acting on those data Judging how much ambiguity is acceptable Recognizing inconsistencies Using diagnostic reasoning

Each of the following thinking skills is commonly used when nurses provide care to patients (Caputi, 2010):

Applying the nursing process to develop a treatment plan Communicating effectively Predicting and managing potential complications Resolving conflicts Resolving ethical dilemmas Setting priorities Teaching others

Assessment The nursing assessment answers the questions of what

is happening or what could happen (Figure 4-3). It involves systematically collecting, organizing, and analyzing information about the client patient. Once data or information have been collected and it is determined that the data are accurate and complete, the nurse performs data analysis or data interpretation. What are the client’s patient’s actual and/or potential problems? A problem list is then developed based on the data, and the nurse prioritizes the client’s problems. The nurse performs an ongoing assessment throughout the implementation of the nursing process.

Figure 4-3 Collecting and analyzing assessment data are critical components of the nursing process that enable the nurse to prioritize problems and determine appropriate interventions.

© Monkey Business Images/Shutterstock

Diagnosis The nurse analyzes and derives meaning from the assessment information and selects a diagnosis. Diagnosis is the identification of a problem. It is a statement that describes a specific response to an actual or potential health problem. For example, a nursing diagnosis for a selected patient might be “decreased cardiac output

related to inability of the heart to pump effectively, and occlusion and constriction of vessels impairing blood flow.”

Planning During planning, the nurse develops a plan to provide consistent, continuous care that meets the client’s unique needs. Planning includes developing expected outcomes and working with the client to identify goals and to determine appropriate nursing actions and interventions that will reduce the identified problem. The nurse uses critical thinking to develop goals and nursing interventions for problems that require an individualized approach. Nurses use judgment to determine which interventions have a probability of achieving desired outcomes. To continue with the previous example, expected outcomes might include the following:


Examples of applicable Nurse of the Future: Nursing Core Competencies

Patient-Centered Care:

Knowledge (K1) Identifies components of nursing process appropriate to individual, family, group, community, and population health care needs across the life span

Skills (S1a) Provides priority-based nursing care to individuals, families, and groups through independent and collaborative application of the nursing process

Skills (S1b) Demonstrates cognitive, affective, and psychomotor nursing skills when delivering patient care

Attitudes/Behaviors (A1a) Values use of scientific inquiry, as demonstrated in the nursing process, as an essential tool for provision

of nursing care

Attitudes/Behaviors (A1b) Appreciates the difference between data collection and assessment

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Patient will be free of chest pain during my shift. Patient will maintain O2 saturation of 90% during my shift. Vital signs will remain stable: T < 99.0°F, HR > 60 < 110 beats/min, R > 12 < 24 breaths/min, and SBP > 90 mm Hg while under my care. Patient will have no further weight gain and will have a decrease in edema during my shift.

Implementation Implementation is carrying out the plan of care and depends on the first three steps of the nursing process. These steps provide the basis for nursing actions performed during the implementation phase of the nursing process (Figure 4-4). The nurse carries out nursing interventions individualized to the patient, reassesses the client, and validates that the plan of care is accurate and successful. In this stage, to each patient care situation the nurse applies knowledge and principles from nursing and from related courses. The ability to apply, not just memorize, principles is a component of critical thinking (Wilkinson, 2007). For the patient with decreased cardiac output, the nurse could implement some of the following individualized interventions:

Figure 4-4 The nurse carries out nursing interventions individualized for the patient that are grounded in the nurses clinical judgment and based on the previous steps in the nursing process.

© Monkey Business Images/Shutterstock

Assess level of consciousness—confusion, anxiety. Provide reassurance to the patient. Monitor vital signs every 4 hours. Assess heart rate and rhythm; monitor telemetry or electrocardiography. Monitor for jugular vein distension. Monitor for chest pain. Monitor peripheral pulses; assess capillary refill. Auscultate lung sounds; monitor respiratory rate and rhythm; monitor oxygen saturation; assess for cough and sputum. Look at skin color and temperature. Monitor for fatigue and activity tolerance. Assess intake and output, daily weight, and edema in dependent areas. Assess abdomen for distension or bloating, ascites, and bowel function. Monitor lab and X-rays: complete blood count, prothrombin time/partial thromboplastin time, electrolytes, cardiac enzymes, arterial blood gases, and chest X-ray. Elevate head of bed to improve gas exchange. Administer oxygen as ordered to improve gas exchange.

Administer morphine sulfate as prescribed to relieve chest pain, provide sedation and vasodilation, and monitor for respiratory depression and hypotension after administration. Administer diuretics as prescribed to reduce preload, enhance renal excretion of sodium and water, reduce circulating blood volume, and reduce pulmonary congestion; closely monitor potassium level, which might decrease as a result of diuretic therapy. Provide teaching: Identify precipitating risk factors of heart failure and prescribed medication regimen; notify physician if unable to take medications because of illness; avoid large amounts of caffeine; provide cardiac diet instruction; look for signs of exacerbation; monitor fluids; balance periods of activity and rest; avoid isometric activities that increase pressure in the heart.

Evaluation During evaluation, the nurse compares the patient’s current status to the patient’s goals. Were the goals achieved? The nurse analyzes outcomes to determine if the interventions worked, and if not, why? The information provided during evaluation can be used to begin another plan of care sufficient to meet the patient’s needs. Continuing with the previous example, the evaluation might include the following:

Patient denies chest pain on my shift. Patient rates pain 0 on pain scale. Patient’s O2 saturation dropped to 85% when oxygen at 3 L nasal cannula was removed. With oxygen on, patient’s O2 saturation remained at 92%. Vital signs were: T, 101.0°F; HR, 100–110 beats/min; R, 32 breaths/min and labored; BP, 90/50 mm Hg. Patient’s weight was 241 pounds with 2+ edema in lower extremities.

Concept Mapping Concept mapping is a visual representation of the relationships among concepts and ideas. The concepts are represented by boxes and linked with lines. In nursing, concept maps are used to organize and link information about a patient’s health problems. This allows the nurse to see relationships among the patient’s problems and helps to plan interventions that can address more than one problem.

To begin a concept map, start in the center of the page with the main idea or central theme and work outward in all directions, producing a growing organized structure composed of key words or pictures. Place words or pictures around the main idea to illustrate how they relate to one another and to the central theme. Pictures, words, or a combination of both can be used to create a map.

Concept maps are useful for summarizing information, consolidating information from different sources, thinking through complex problems, and presenting information in a format that shows the overall structure of your subject. Figure 4-5 illustrates a mind mapping technique used by students with a patient case.

Figure 4-5 Mind mapping techniques.

Journaling Keeping a journal of clinical experiences that were meaningful or troubling to you is a recommended way to help enhance and develop reasoning skills. Think about and record experiences that bother you and consider what you could and would do differently in the future. This is a form of reflection and allows you to view your own thinking, reasoning, and actions. It helps create and clarify meaning and new understandings of a particular experience. When you encounter a similar situation, you should be able to recall what you did or would do differently as well as the reasoning behind your actions (Raingruber & Haffer, 2001).

Some suggestions you should try to address when journaling your

nursing experience include the following:

What happened? What are the facts? What was my role in the event? What feelings and senses surrounded the event? What did I do? How and what did I feel about what I did? Why? What was the setting? What were the important elements of the event? What preceded the event, and what followed it? What should I be aware of if the event recurs?

It is important that you write in your journal as soon as possible after an event to capture the essence of what happened in the clinical experience. The following is an example of a journal excerpt that illustrates reflection on events and the feelings elicited by those events over the course of many patient care encounters during the career of a nurse:


Think about a clinical experience that was troubling to you. Reflect on what bothered you about the experience. What could you have done differently? What were the reasons behind your actions? Try to create and clarify meaning or a new understanding of the particular situation.

I have learned, not so easily, that my job is not just about saving a life, trying to keep people well, or helping them get well when they are ill, but importantly, it also entails providing that same dedicated care to them as they take their last breaths in life. It is my job, my duty, and, I have learned, my privilege. As I care for a dying patient, listening to the rise and fall of methodical

machines imitating life, I hope I never am calloused to the point that I say, “I do this every day. It is just another patient.” I want to appreciate that every individual’s life has been remarkable in some way—which they are remarkable in some way. I want to make my patient’s journey through this last chapter in their life a little easier, provide comfort, recognize their fears, hold their hand, and always realize this is not another patient but a person.


Beginning nursing students often tend to focus primarily on their routines, including to get their list of tasks done, including assessments, ordered treatments, daily care, and charting. What if an unexpected situation occurred during the day? Do you think you would be able to reason, plan, and take appropriate action—think critically?

Group Discussions and Reflection Another way to enhance critical thinking skills is by using group discussions to explore alternatives and arrive at conclusions (Figure 4- 6). Group discussions among nursing students and teachers can take place in the classroom or following clinical experiences. During discussions, students are encouraged to formulate alternatives to clinical or ethical decisions. Teacher and learner group discussions over clinical and ethical scenarios should encourage questions, analysis, and reflection. Group discussions can assist nursing students in connecting clinical events or decisions with information obtained in the classroom. This form of cooperative learning occurs when groups work together to maximize their own and one another’s learning. For example, following a clinical experience, students and teacher use reflection and discussion on a certain clinical experience that a student encountered. Together they

discuss different scenarios of “What if?,” “What else?,” and “What then?” to encourage the formulation of alternatives or clinical decisions. Other examples of this process include the following:

Figure 4-6 Working through a case study in class is one way to enhance critical thinking skills through discussion and reflection.

© Jacoblund/iStock/Getty Images Plus

You are going into a patient’s room—what are you going to do? When you go in there, what are you going to do? Walk yourself through it step by step. What are you going to do first? What should be done first? Which one takes importance and then where do you go from there? This is the patient, and this happens. What do you do next? These are your assessment findings. What else do you need to know?

You are working in an acute care clinical situation. After receiving the report, you have started your morning routines. Everything is going as planned, and you are about to start preparing your medications. The wife of a patient reports that the oxygen is burning his nose and wants you to get an oxygen humidifier. All of a sudden, the daughter of another patient, Mr. Peary, rushes toward you and informs you that her father is spitting up blood. He looked fine when you observed him a few minutes ago. You walk rapidly toward the patient’s room, thinking, “What am I going to do

when I get there? I have to get the oxygen humidifier for room 202. His nose was burning, and his wife was waiting for me. What could be happening with Mr. Peary?”


Examples of applicable Nurse of the Future: Nursing Core Competencies


Knowledge (K4c) Understands the importance of reflection to advancing practice and improving outcomes of care

Skills (S4b) Demonstrates ability for reflection in action, reflection for action, and reflection on action

Attitudes/Behaviors (A4c) Values and is committed to being a reflective practitioner

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

You enter the room, and the first thing you think is: “He’s lying flat,” and you think to yourself, “I need to elevate his head. That is what I did on the respiratory unit where I recently worked.” The daughter tells you that Mr. Peary coughed up some blood in the emesis basin. There is a small amount of bright red blood in it. You do not know what to do next. An RN stops by the room and tells you that the wife of the patient in room 202 is asking about the burning in her husband’s nose again. Your mind does not seem to be able to think about anything. Do you feel scattered and things seem out of control at this point? Do you feel a little overwhelmed and cannot think what to do next? The RN says she will

take over with Mr. Peary while you follow up with the patient in room 202. Later, you recall the situation and cannot believe you did not think to take Mr. Peary’s blood pressure, count respirations, ask about pain, or listen to his lungs or anything else. All you did was just raise his head. You wonder why you missed so many things.

What do you think was going on in the situation that influenced what was happening and caused you to lose your ability to think and plan what to do next? What would you do differently in this situation after having a chance to reflect on it? Prioritize the order in which you would have done things. If this had happened to you and no one helped you through it, what would you have done to mobilize yourself to think about what to do?

Conclusion In nursing, critical thinking is the ability to think in a systematic and logical manner, solve problems, make decisions, and establish priorities in the clinical setting. Nurses need to develop critical thinking skills to make sound clinical judgments and to provide safe, competent patient care. Nursing requires constant decision making. What should I do first? What is the most important thing to do at this time? Prioritizing nursing actions involves recalling important nursing information as well as using complex problem-solving skills to make decisions in order to provide safe and effective patient care. Other tips for nurses at the bedside to improve safety include practicing mindfully, communicating clearly, reporting unsafe conditions and errors, responding to error justly, and recognizing personal limitations (Hershey, 2015).

All of us want to believe that we will never be involved in an error that harms a patient. But as is evident, errors that result in patient harm do occur. This creates what has become known as the second victim, a term coined by Wu (2000) to describe the pain and suffering experienced after making a healthcare error. A nonjudgmental, supportive, and compassionate environment is recommended with the use of such responses as “This must be difficult, are you okay?” or “Can we talk about it?” or “You are a good nurse working in a complex environment” (Hershey, 2015, p. 149). Creating a defensive environment does not allow the nurse at the sharp end of care to contribute to the safety process and therefore does nothing to increase patient safety. Thus, “responding to second victims with openness and compassion is not only the right thing to do, it is also the safe thing to do” (Hershey, 2015, p. 149).










Jim Fuller is a 40-year-old male patient. He is currently in the recovery room following an inguinal hernia repair under general anesthesia. His vital signs are T, 99.0°F; BP, 120/80 mm Hg; HR, 80 beats/min; R, 18 breaths/min.

Case Study Questions

Are Mr. Fuller’s vital signs within normal limits? List normal adult ranges.

What factors might affect body temperature?

List sites where a nurse might take a patient’s pulse. What sites are most commonly used?

What factors might influence respiratory rate?

Two hours postoperative, Mr. Fuller begins to complain of abdominal pain. Vital signs at this time are T, 99.5°F; BP, 90/60 mm Hg; HR, 122 beats/min; R, 24 breaths/min.

Case Study Questions

What could Mr. Fuller’s vital signs indicate?

What nursing interventions are indicated? What should the nurse assess in Mr. Fuller at this time?

What clinical signs associated with an elevated temperature might the nurse assess?

If Mr. Fuller’s fever persists and increases, what might the nurse suspect is happening, and what might be done?

Classroom Activity 4-1

Critical thinking gives you the power to make sense of something by deliberately choosing how to respond to events that you encounter. You take in information, examine and ask questions about it, look at new perspectives, and identify a plan. You use problem-solving and decision-making strategies.

Choose a decision that you need to make soon and write it down. What goal or desired outcomes do you seek from this decision? Prioritize goals or desired outcomes and write them down. Identify who and what will be affected by your decision and indicate how your decision will affect them. Identify any available options you might have. Taking into account and evaluating your information, identify a plan or decide what you are going to do. After you have made your decision, evaluate the result.

Classroom Activity 4-2

You are receiving morning reports on the following patients from the night-shift nurse. After receiving the report, which patient would you choose to see first? As you make your decision, think about your thought processes and how you made your decision.

a. A woman who is scheduled to have a biopsy on a breast lump this morning and who is scared and crying

b. An 85-year-old man who was admitted during the night because of increased confusion who remains disoriented this morning

c. A woman who had lung surgery the previous day and who has two

chest tubes in place with minimal drainage d. A man who is scheduled to have a colon resection in 2 hours and is

complaining of chills

Answer: You should have answered the client who is scheduled for surgery and is exhibiting symptoms of infection. This patient needs to be assessed immediately for infection and the doctor notified. If an infection is present, the surgery needs to be postponed. The other patients are stable, and their needs do not have to be addressed immediately.

References Agency for Healthcare Research and Quality. (2008). Patient safety and quality: An evidence-based handbook for nurses (Vols. 1–3). Rockville, MD: U.S. Department of Health and Human Services.

Alfaro-Lefevre, R. (2009). Critical thinking and clinical judgment: A practical approach to outcome-focused thinking (4th ed.). St. Louis, MO: Saunders Elsevier.

American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from

American Nurses Association. (2015). Nursing: Scope and standards of practice (3rd ed.). Silver Spring, MD: Author.

Benner, P. (1984). From novice to expert. Menlo Park, CA: Addison- Wesley.

Benner, P. E., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey- Bass.

Caputi, L. (2010). Developing critical thinking in the nursing student. In L. Caputi (Ed.), Teaching nursing: The art and science (2nd ed., pp. 381– 390). Glen Ellyn, IL: College of DuPage Press.

Craven, R. F., & Hirnle, C. J. (2007). Fundamentals of nursing: Human health and function (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Fero, L., Witsberger, C., Wesmiller, S., Zullo, T., & Hoffman, L. (2009). Critical thinking ability of new graduate and experienced nurses. Journal of Advanced Nursing, 65(1), 139–148.

Hershey, K. (2015). Culture of safety. Nursing Clinics of North America, 50, 139–152.

Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academy Press.

Knapp, R. (2007). Nursing education—the importance of critical thinking. Retrieved from

Massachusetts Department of Higher Education. (2010). Nurse of the future: Nursing core competencies. Retrieved from

Massachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. Retrieved from

Quality and Safety Education for Nurses. (2018). Project overview. Retrieved from

Raingruber, B., & Haffer, A. (2001). Using your head to land on your feet: A beginning nurse’s guide to critical thinking. Philadelphia, PA: F. A. Davis.

Scheffer, B. K., & Rubenfeld, M. G. (2000). A consensus statement on critical thinking in nursing. Journal of Nursing Education, 39(8), 352– 359.

Scriven, M., & Paul, R. (2017). Defining critical thinking. Retrieved from

Sitterding, M. C. (2015). An overview of information overload. In M. C. Sitterding & M. Broome (Eds.), Information overload: Framework, tips, and tools to manage in complex healthcare environments (pp. 1–9). Silver Spring, MD: American Nurses Association.

Sitterding, M. C., & Ebright, P. (2015). Information overload: A framework for explaining the issues and creating solutions. In M. C. Sitterding & M. Broome (Eds.), Information overload: Framework, tips, and tools to

manage in complex healthcare environments (pp. 11–33). Silver Spring, MD: American Nurses Association.

Tanner, C. A. (2006). Thinking like a nurse: A research based mode of clinical judgment in nursing. Journal of Nursing Education, 4(6), 204– 211.

Technology Informatics Guiding Education Reform. (2009). The TIGER initiative. Collaborating to integrate evidence and informatics into nursing practice and education: An executive summary. Retrieved from

Wangensteen, S., Johansson, I. S., Bjorkstrom, M. E., & Nordstrom, G. (2010). Critical thinking dispositions among newly graduated nurses. Journal of Advanced Nursing, 66(10), 2170–2181.

Weick, K. E., & Sutcliffe, K. M. (2007). Managing the unexpected: Resilient performance in an age of uncertainty (2nd ed.). San Francisco, CA: Jossey-Bass.

Wilkinson, J. (2007). Nursing process and critical thinking (4th ed.). Upper Saddle River, NJ: Pearson.

Wu, A. (2000). Medical error: The second victim: The doctor who makes the mistake needs help too. British Medical Journal, 320, 726–727.

© James Kang/EyeEm/Getty Images


Education and Socialization to the Professional Nursing Role Kathleen Masters and Melanie Gilmore

Learning Objectives

After completing this chapter, the student should be able to:

1. Discuss the essential features of nursing. 2. Describe the stages of educational socialization. 3. Describe the process of socialization or formation in professional


4. Identify factors that facilitate professional role development.

Key Terms and Concepts

Socialization Formation Professional values Novice Advanced beginner Competent Ethical comportment Proficient Salience Expert Role transition

Nursing continues to evolve into a profession with a distinct body of knowledge, specialized practice, and standards of practice. According to the American Nurses Association (ANA), “nursing is a learned profession built on a core body of knowledge that reflects its dual components of science and art” (2015b, p. 7), and as such it is a scientific discipline as well as a profession. The science of nursing, based on the nursing process, is an analytical framework for critical thinking. Nursing practice also requires knowledge of the principles of biological, physical, behavioral, and social sciences. The art of nursing is based on respect for human dignity and caring, although it is important to note that a compassionate approach to care carries a mandate to provide competent care. The professional nurse is responsible for practice that incorporates

this specialized body of knowledge and standards of practice with care that demonstrates respect and caring (ANA, 2015b).

Socialization to professional nursing is the process of acquiring the knowledge, skills, and sense of identity that are characteristic of the profession. It is a process by which a student internalizes the attitudes, beliefs, norms, values, and standards of the profession into his or her own behavior pattern. Professional socialization has four goals: (1) to learn the technology of the profession—the facts, skills, and theory; (2) to learn to internalize the professional culture; (3) to find a personally and professionally acceptable version of the role; and (4) to integrate this professional role into all the other life roles (Cohen, 1981). Benner, Sutphen, Leonard, and Day (2010) make the case for using the term formation to describe this process that occurs over time because it better denotes “the development of perceptual abilities, the ability to draw on knowledge and skilled know-how, and a way of being and acting in practice and in the world” (p. 166). Whatever terminology is chosen, the process described in this chapter refers to the transformation of the layperson into a skilled nurse who is prepared to respond skillfully and respectfully to persons in need of nursing care, or, as described by Benner et al. (2010), “the lay student moves from acting like a nurse to being a nurse” (p. 177). This development of professional identity occurs initially through the formal educational process and culminates in the practice setting.

Professional Nursing Roles and Values What is it that professional nurses do? The scope of nursing practice describes the “who,” “what,” where,” “when,” “why,” and “how” of nursing practice (ANA, 2015b, p. 2). The standards of professional nursing practice are authoritative statements that describe the duties that all registered nurses are expected to competently perform. The standards of professional nursing practice are composed of standards of practice and standards of professional performance. The standards of practice describe competent nursing care as demonstrated by use of the nursing process. The standards of professional performance describe a competent level of behavior in the professional nursing role (ANA, 2015b).

According to the ANA (2010), there are seven essential features of nursing. These features include the provision of a caring relationship that facilitates health and healing, attention to the range of experiences and responses to health and illness within the physical and social environments, and integration of assessment data with knowledge gained from an appreciation of the patient or group. In addition, nursing includes the application of scientific knowledge to the processes of diagnosis and treatment through the use of judgment and critical thinking, advancement of professional nursing knowledge through scholarly inquiry, influence on social and public policy to promote social justice, and assurance of safe, high-quality, and evidence-based practice (ANA, 2010).

The American Association of Colleges of Nursing (AACN, 2008) lists the roles of the professional nurse as provider of care, designer/manager/coordinator of care, and member of a profession. As a

provider of direct and indirect care, the nurse is a patient advocate and patient educator. The nurse provides care based on best, current evidence and from a holistic, patient-centered perspective. Professional nurses are members of the healthcare team delivering care in an increasingly complex healthcare environment. Nurses function autonomously and interdependently within the healthcare team to provide patient care and are accountable for the care provided and for the tasks delegated to others. The nurse as a professional implies the formation of a professional identity and accountability for the professional image portrayed. Nursing requires a broad knowledge base for practice as well as strong communication, critical reasoning, clinical judgment, and assessment skills. In addition, professional nursing requires the development of an appropriate value set and ethical framework for practice (AACN, 2008).


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential VIII: Professionalism and Professional Values

8.3 Promote the image of nursing by modeling the values and articulating the knowledge, skills, and attitudes of the nursing profession (p. 28).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

Professional values are considered a component of excellence, and the existence of a code is considered a hallmark of professionalism.

Professional values are beliefs or ideals that guide interactions with patients, colleagues, other professionals, and the public. The development of professional values begins with professional education in nursing and continues along a continuum throughout the years of nursing practice. Professional values associated with nursing are outlined in the ANA’s Code of Ethics (ANA, 2001, 2015a). The values of (1) commitment to public service, (2) autonomy, (3) commitment to lifelong learning and education, and (4) a belief in the dignity and worth of each person epitomize the caring, professional nurse. Caring is a concept central to the profession of nursing and inherent in this value is a strong commitment to public service. Nursing is a helping profession directed toward service to the public through health promotion and disease prevention for individuals, families, and communities. The role of the nurse is focused on assessing and promoting the health and well-being of all humans. Registered nurses remain in nursing to promote, advocate, and protect the health and safety of patients, families, and communities (ANA, 2015b).


Examples of applicable Nurse of the Future: Nursing Core Competencies


Knowledge (K4a) Describes factors essential to the promotion of professional development

Skills (S4a) Participates in lifelong learning

Attitudes/Behaviors (A4a) Committed to lifelong learning

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Autonomy is the right to self-determination as a professional. The role of the professional nurse is to honor and assist individuals and families to make informed decisions about health care and to provide information so that they can make informed choices. The professional nurse respects patients’ rights to make decisions about their health care.

Commitment to lifelong learning and education is necessary in the dynamic healthcare arena that surrounds nursing practice in this century. Nurses need continuous education to maintain a safe level of practice and to expand their level of competence as professionals. With new technologies and the rapid growth of medical and nursing knowledge, the nurse must actively and continuously seek to expand professional knowledge. Professional nursing involves a commitment to be resourceful, to respond to the dynamic challenges of delivering health care, to incorporate technology into their caring, and to remain visionaries as the future unfolds (ANA, 2010).

Human dignity is respect for the inherent worth and uniqueness of individuals and communities and is such a deeply held value in the profession of nursing that it is the topic of Provision 1 in the Code of Ethics for Nurses (ANA, 2015a). According to the International Council of Nurses’ Code of Ethics for Nurses (2012), “inherent in nursing is respect for human rights, including cultural rights, the right to life and choice, to dignity and to be treated with respect. Nursing care is respectful of and unrestricted by considerations of age, color, creed, culture, disability or illness, gender, sexual orientation, nationality, politics, race or social status” (p. 1).


As a nursing student, do you share the values of commitment to public

service, autonomy, commitment to lifelong learning and education, and the belief in the dignity and worth of each person? Do nurses with whom you have interacted demonstrate these values?


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential VIII: Professionalism and Professional Values

8.9 Recognize the impact of attitudes, values, and expectations on the care of the very young, frail older adults, and other vulnerable populations (p. 28).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

The Socialization (or Formation) Process Socialization into a profession is a process of adapting to and becoming a part of the culture of the profession (Ousey, 2009). This process begins during the student’s formal educational program and continues after graduation and licensure in the practice setting.

Socialization Through Education Students new to the nursing profession begin to learn the role while still in the educational setting. Cohen (1981) used the theories of cognitive development to create a model of professional nursing socialization through education. The model describes four stages students must experience as they begin to internalize the roles of a profession. In stage 1, Unilateral Dependence, the individual places complete reliance on external controls and searches for the one right answer (Cohen, 1981). In essence, the student looks to the instructor for the right answers and is unlikely to question the authority. As the student gains foundational knowledge and skill, there begins the process of questioning the authority.

During stage 2, Negative/Independence, the student begins to pull away from external controls and is characterized by cognitive rebellion. The student begins to think critically and begins to question the instructor and relies more on his or her own judgments.

Stage 3, Dependence/Mutuality, marks the beginning of empathy and commitment to others (Cohen, 1981). In this stage, the student begins to apply knowledge to practice and tests information and facts. “Students

have a knowledge base upon which to anchor critical thought and can relate new material to their previous knowledge base” (Cohen, 1981, p. 18). In this stage, the student is actively engaged in the learning, thinking through problems. For this stage to emerge, the learning environment must support and value risk taking. The role of the teacher is that of coach, mentor, and senior learner. The mentor helps the student link theory to practice while in the clinical areas, thus helping the student to learn from experiences and to improve practices to support professional socialization.

Stage 4, Interdependence, occurs when neither mutuality nor autonomy is dominant. Learning from others and gaining the ability to solve problems independently are evident. This is the stage of the professional lifelong learner who demonstrates reflection in practice and is responsible for continued learning. Professional socialization toward the stage of interdependence requires a supportive educational climate that values autonomy, independent thinking, and authenticity. Students become professionals.

Professional Formation Several models in the literature describe professional socialization. Regardless of the model embraced, socialization into the nursing profession or formation into a professional nurse must include new competencies for the 21st century. The Institute of Medicine (IOM, 2011) reported that nurses need requisite competencies, including leadership, health policy, system improvement, research and evidence-based practice, and teamwork and collaboration, to meet the needs of the current dynamic healthcare environment. Nursing educators must provide students with opportunities to develop the requisite skills that equip them for the profession as well as instill in them the desire to become lifelong

learners because nurses currently need continuous education to maintain a safe level of practice and to expand their level of competence as professionals.


Examples of applicable Nurse of the Future: Nursing Core Competencies


Knowledge (K4c) Understands the importance of reflection to advancing practice and improving outcomes of care

Skills (S4b) Demonstrates ability for reflection in action, reflection for action, and reflection on action

Attitudes/Behaviors (A4c) Values and is committed to being a reflective practitioner

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Benner (1984) describes the development of the professional clinical practice of nurses. Benner’s model identifies the stages of novice, advanced beginner, competent, proficient, and expert that are based on the nurse’s experience in practice. With an understanding of this progression of knowledge and skills, educational programs have developed supportive curricula using a continuum of experiences to enhance skill and knowledge development. Healthcare environments have also incorporated this model to facilitate the nurse’s professional practice by assessing the nurse’s stage of development. This model is not limited to the student experience or to that of the new graduate nurse.

Experienced nurses also benefit from experiences designed to move the nurse toward the stage of expert.

The first stage, novice, is characterized by a lack of knowledge and experience. In this stage, the facts, rules, and guidelines for practice are the focus. Rules for practice are context-free, and the student’s task is to acquire the knowledge and skills. The stage of novice is not related to the age of the student but rather to the knowledge and skill in the area of study. For example, learning how to give injections would be presented with the procedural guidelines, and the novice would then practice the skill. At this stage, much of the student’s energy and attention are aimed at remembering the rules. Because the focus is on remembering rules, the student’s practice is inflexible, the student is unable to use discretionary judgment, and the student is dependent on and has confidence in those with greater expertise rather than having confidence in his or her own judgment (Benner, 1984; Benner, Tanner, & Chelsea, 2009). This stage can be compared to an experience that most nursing students can relate to, the experience of learning to drive a car. Initially, the experience is characterized by halting progress as the student driver actively tries to gauge the pressure required on the gas pedal and the brake, remember how many feet before the corner to use the turn signal, and remember how many feet to keep between cars. This analogy simplifies the stage of novice related to nurse formation, but most can remember the excitement and the frustrations of learning to drive a car as well as the transition when driving began to require less effort.

In the next stage, advanced beginner, the nurse can formulate principles that dictate action. For example, the advanced beginner grasps the rationale behind why different medications require different injection techniques. However, advanced beginners still lack the experience to know how to prioritize in more complex situations and might feel at a loss in terms of what they can safely leave out, making the patient care

situation appear as a perplexing set of problems they must figure out how to solve.

The advanced beginner will still emphasize tasks that need to be accomplished, as well as rules, but does not have the experience to adjust or adapt the rules to the situation. In this stage action and interpretation are the central focus rather than decision making. Both knowledge and experience are limited in the advanced beginner nurse, which means that subtle cues about a patient’s condition may be missed (Sitterding, 2015). The nurse in the stage of advanced beginner still requires guidance (Figure 5-1). Given the complexity of nursing practice and the range of clinical experiences, new graduates can be described as advanced beginners (Benner, 1984; Benner et al., 2009).

Figure 5-1 The nurse at the advanced beginner stage still requires guidance from more experienced nurses.

© Monkey Business Images/Shutterstock.

Benner’s stage 3, competent, is characterized by the ability to look at situations in terms of principles, analyze problems, and prioritize, and thus a nurse in this stage has the ability to plan as well as to alter plans as necessary. The nurse in this stage has improved time management and organizational skills as well as technical skills. The nurse in the competent stage will also demonstrate increased ability in diagnostic reasoning, which means he or she is able to make a clinical case for action to other members of the healthcare team. Movement from one

stage to the next does not cross distinct boundaries, but the nurse at this stage has had experience in a variety of clinical situations and can draw on prior knowledge and experience; typically, the nurse will have 1 to 2 years of experience in a similar job situation. The competent stage of learning is important in the formation of the ethical comportment of the nurse. Ethical comportment refers to good conduct born out of an individualized relationship with the patient that involves engagement in a particular situation and entails a sense of membership in the relevant professional group. It is socially embedded, lived, and embodied in practices, ways of being, and responses to a clinical situation that promote the well-being of the patient (Day & Benner, 2002). Continued active learning and mentoring are important for movement to the proficient stage. Students who have the opportunity to have extended internships in a specialty area during their education can graduate entering this stage (Benner, 1984; Benner et al., 2009).

Stage 4, proficient, refers to the professional nurse who can grasp the situation contextually as a whole and whose performance is guided by maxims. This nurse has a solid grasp of the norms as well as solid experiences that shed light on the variations from the norm. Based on an intuitive grasp of the situation, the nurse recognizes the most salient aspects of the situation or the most salient recurring meaningful components of the situation. Salience is a perceptual stance or embodied knowledge whereby aspects of a situation stand out as more or less important (Benner, 1984); therefore, the nurse at this stage knows what can wait and what cannot. The nurse has moved into a place where he or she can engage in a clinical situation and connect with the patient and family in ways that are truly beneficial. Incorporated into practice is the ability to test knowledge against situations that might not fit and to solve problems with alternative approaches. In this stage, the professional tests the rules and theories and looks at cases that can lead

to developing alternative rules and theories. One might say that this is the stage when the professional begins to “break the rules” because he or she sees that the rules do not always apply. Achieving this level of proficiency in nursing typically takes 3 to 5 years of practice with similar patient populations (Benner, 1984; Benner et al., 2009).

Benner’s final stage, expert, means the nurse has moved beyond a fixed set of rules (Figure 5-2). The expert has an internalized understanding grounded in a wealth of experience as well as depth of knowledge. Benner describes the expert nurse as demonstrating embodied intelligence. The expert nurse is able to skillfully manage multiple tasks simultaneously and knows not only what to do and when to do it but also how to do what is needed. The expert nurse has a grasp of the whole with an ability to move beyond the immediate clinical situation but to remain attuned to the clinical situation at a level that allows a “mindful reading” of the patient responses even without conscious deliberation. The nurse may have difficulty explaining how he or she knows something because the recognition and assessment language are so linked with actions and outcomes that they are obvious to the expert nurse, although not obvious to others. The expert is always learning and always questioning using subjective and objective knowing. Benner (1984, 1999; Benner et al., 2009) proposes that not all nurses can obtain this stage; when it is obtained, it is only after extensive experience.

Figure 5-2 Critically ill patients require care from nurses with extensive experience. © NOAH SEELAM/AFP/Getty Images


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential VIII: Professionalism and Professional Values

8.13 Articulate the value of pursuing practice excellence, lifelong learning, and professional engagement to foster professional growth and discipline (p. 28).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

The typical career in nursing is not a linear process. There is considerable variation in progression of nurses related to degree

attainment and career growth. In addition, with the focus of increasing the percentage of nurses with baccalaureate degrees and doctoral degrees in nursing (IOM, 2011), many nurses are returning to school for additional academic degrees in order to advance their careers. This often results in a change in the nurse’s practice role. It can be stressful to transition from a role where the nurse is an expert to a new role where the nurse will not function at the same level of expertise. For example, when the expert pediatric nurse graduates from a pediatric nurse practitioner program, passes the certification exam, and begins to function in the advanced practice role, the nurse will not be an expert pediatric nurse practitioner. With experience in the new, advanced practice role, he or she will again transition through the stages of professional development. The same type of role transition occurs when the expert clinician changes practice roles to become a nurse educator or nurse researcher.

Facilitating the Transition to Professional Practice Professional socialization requires that the student learn the technology of the profession, learn to internalize the professional culture, find a personally and professionally acceptable version of the role, and integrate this professional role into all of his or her other life roles (Cohen, 1981).

Students are taught an ideal, theoretical, research-based practice that shelters them from the realities of the world where nursing practice consists of not only theory and research but also of human emotion and response, along with the policies and procedures of the particular working environment. This concept of idealism is important to the profession because it contributes to a high standard of professional practice. The perceived disconnection between education and practice is known as role discrepancy. Therefore, when students enter the practice environment, the culture of the classroom and the culture of clinical practice can seem worlds apart. Reality shock has been the traditional phrase to describe the transition from nursing student to registered nurse (Kramer, 1974).

Reality shock occurs when the perceived role (how an individual believes he or she should perform in a role) comes into conflict with the performed role (Catalano, 2009). Many new graduates experience this reality shock of knowing what to do and how to do it but encountering circumstances that prevent them from performing the role in that way (Figure 5-3). Role conflict exists when a nurse cannot integrate the ideal, the perceived, and the actual performed role into one professional role.

Figure 5-3 Role transition shock can result in role conflict and overwhelming stress for the new graduate nurse.

© GoodMood Photo/Shutterstock, Inc.

Role transition shock is the experience of moving from the known role of student to the role of practicing professional (Duchscher, 2009). For many nursing students, role conflict occurs when they transition from the role of student to that of registered nurse (Pellico, Brewer, & Kovner, 2009). The new graduate moves from a perceived role of what the professional nurse is and does to the actual performed role where his or her actions and beliefs might be challenged.


What do you think are the barriers to the process of professional socialization or formation? Do you think different environments might foster or hinder the process of professional socialization or formation? Do you think that the personal characteristics of nurses might influence the process of professional socialization or formation?

The reality shock or role transition shock that new graduates experience can be reduced to some extent. Many schools of nursing

have implemented opportunities for externships or prolonged preceptor clinical experiences with a professional nurse before graduation. Research (Ruth-Sahd, Beck, & McCall, 2010) shows how participation in extern programs eases the gap between education and practice. One goal of this experience is to help the student assimilate the role of the professional nurse just before graduation. During this time, the student can experience a more realistic view of clinical practice in the real-world environment. As one student commented, “All the lectures and assignments in nursing school cannot compare with the application of theory that this externship offered” (Ruth-Sahd et al., 2010, p. 83). Externships and preceptor clinical experiences can help nursing students begin the role transition from perceived role expectations to actual role expectations, thus easing the transition from student nurse to practicing professional.

In addition to internship and externship programs before the graduation of the nurse, some hospitals are also offering nurse residency programs to facilitate the socialization into the profession. Nurse residency programs go beyond the orientation focused on policies and procedures that occurs to prepare the nurse to function in a particular setting. A residency program that focuses on transition into practice is formalized and focused on facilitating the transition of the newly licensed nurse from education to practice (Spector et al., 2015).

Hospitals offering formalized graduate nurse residency programs provide graduates with rotations through a number of clinical areas that include preceptor support. Evidence suggests that a sense of belonging contributes to professional socialization (Zarshenas et al., 2014). After the completion of residency programs, new nurses report gaining a sense of belonging, thus supporting claims that these programs can lead to enhanced socialization into the clinical workplace (McKenna & Newton, 2009). In addition to formal education, preceptors can assist students to

develop skills of assertion, reflection, and critical thinking that are required to provide holistic, evidence-based care (Mooney, 2007).

Nurse residency programs focused on transition to practice also result in decreased stress and increased job satisfaction, with research demonstrating decreased attrition during the first year of practice for newly licensed nurses. In addition to promoting retention and assisting the new nurse to adjust to the practice environment, nurse residency programs also affect quality and safety. Newly licensed nurses in hospitals with established transition to practice programs also demonstrated higher competency levels, fewer patient errors, and fewer negative safety practices (Spector et al., 2015).

In response to evidence on the effect of nurse residency programs, the National Council of State Boards of Nursing (NCSBN) has developed a model for transitioning new nurses into practice. The NCSBN Transition to Practice (TTP) model comprises five transition models that include patient-centered care, communication and teamwork, evidence-based practice, quality improvement, and informatics with a goal of promoting “public safety by supporting newly licensed nurses during their critical entry period and progression into practice” (Spector, 2013, p. 55). These modules are designed as a 6-month program and are available at a cost per module or cost per program basis. In addition, a preceptor module is available to nurse preceptors to learn about the roles and responsibilities of preceptors and effective behaviors and strategies to foster growth in new graduates (NCSBN, 2018).

Conclusion The goal in the socialization of nurses today and for the future is to achieve caring with autonomy. The challenge for the profession is capitalizing on the strengths of everyone and finding a means of accommodating all individuals as a way of maintaining the viability of the profession (Leduc & Kotzer, 2009). Professional socialization of nurses in a profession that fully embraces caring for self and others reflects the internalization of what Roach (1991) refers to as “the five C’s: compassion, competence, confidence, conscience, and commitment” (p. 132), representing a framework for human response from which professional caring is expressed.

Nursing education should be humanistic and caring, with caring experts as role models who contribute to the socialization of future generations of nurses and help them become caring experts in nursing practice. Through their research, Condon and Sharts-Hopko (2010) report that reflection can be an effective means of understanding human emotion and responses. One student stated, “I think the most important time is after the clinical training when I go home. I think about the information I get from the patient. What does it mean? What does it mean for the patient? I should connect to it” (Condon & Sharts-Hopko, 2010, p. 169). Regarding role development and socialization, it is important to remember that we learn what we live (Becker-Hentz, 2004).

Classroom Activity 5-1

Incorporate actual quotes from the nurses who were interviewed in Benner’s book From Novice to Expert (1984) in class discussions to

illustrate the differences among each of the stages: novice, advanced beginner, competent, proficient, and expert. This activity is simple but enlightening to students.

Classroom Activity 5-2

Read excerpts from the 2006 article “What Do Nurses Really Do?” by Suzanne Gordon (available at in class to stimulate discussion, and ask the following questions:

What do you think nurses actually do? What do you think about the current image of nurses? What do you think about the effect of the focus on caring over the knowledge of nurses?

References American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author.

American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Washington, DC: Author.

American Nurses Association. (2010). Nursing’s social policy statement: The essence of the profession. Silver Spring, MD: Author.

American Nurses Association. (2015a). Code of ethics for nurses with interpretive statements. Silver Spring, MD: Author.

American Nurses Association. (2015b). Nursing: Scope and standards of practice (3rd ed.). Silver Spring, MD: Author.

Becker-Hentz, P. (2004). Understanding relationships: Learning what we live. Unpublished manuscript.

Benner, P. (1984). From novice to expert. Menlo-Park, CA: Addison- Wesley.

Benner, P. (1999). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley.

Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.

Benner, P. E., Tanner, C. A., & Chelsea, C. A. (2009). Expertise in nursing practice: Caring, clinical judgment, and ethics (2nd ed.). New York, NY: Springer.

Catalano, J. (2009). Nursing now! (5th ed.). Philadelphia, PA: F. A. Davis. Cohen, H. A. (1981). The nurse’s quest for a professional identity. Menlo- Park, CA: Addison-Wesley.

Condon, E., & Sharts-Hopko, N. (2010). Socialization of Japanese

nursing students. Nursing Education Perspectives, 31(3), 167–169. Day, L., & Benner, P. (2002). Ethics, ethical comportment, and etiquette. American Journal of Critical Care, 11(1), 76–79.

Duchscher, J. E. B. (2009). Transition shock: The initial stage of role adaptation for newly graduated registered nurses. Journal of Advanced Nursing, 65(5), 1103–1113. doi:10.1111/j.1365-2648.2008.04898.x

Gordon, S. (2006). What do nurses really do? Topics in Advanced Practice Nursing eJournal, 6(1). Retrieved from

Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington. DC: National Academy Press.

International Council of Nurses. (2012). The ICN code of ethics for nurses. Geneva, Switzerland: Author. Retrieved from

Kramer, M. (1974). Reality shock, why nurses leave nursing. St. Louis, MO: Mosby.

Leduc, K., & Kotzer, M. (2009). Bridging the gap: A comparison of the professional nursing values of students, new graduates and seasoned professionals. Nursing Education Perspectives, 30(5), 279–284.

Massachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. Retrieved from

McKenna, L., & Newton, J. M. (2009). After the graduate year: A phenomenological exploration of how new nurses develop their knowledge and skill over the first 18 months following graduation. Contemporary Nurse: A Journal for the Australian Nursing Profession, 31(2), 153–162.

Mooney, M. (2007). Professional socialization: The key to survival as a newly qualified nurse. International Journal of Nursing Practice, 30, 75–80.

National Council of State Boards of Nursing. (2018). NCSBN learning extension: Transition to practice. Retrieved from

Ousey, K. (2009). Socialization of student nurses—the role of the mentor. Learning in Health and Social Care, 8(3), 175–184.

Pellico, L. H., Brewer, C. S., & Kovner, C. T. (2009). What newly licensed registered nurses have to say about their first experiences. Nursing Outlook, 57, 194–203.

Roach, M. S. (1991). Creating communities of caring. In National League for Nursing (Ed.), Curriculum revolution: Community building and activism (pp. 123–138). New York, NY: National League for Nursing Press.

Ruth-Sahd, L. A., Beck, J., & McCall, C. (2010). Transformative learning during a nursing externship program: The reflections of senior nursing students. Nursing Education Perspectives, 31(2), 78–83.

Sitterding, M. C. (2015). An overview of information overload. In M. C. Sitterding & M. E. Broome (Eds.), Information overload: Framework, tips, and tools to manage in complex healthcare environments (pp. 1– 9). Silver Spring, MD: American Nurses Association.

Spector, N. (2013). Transition to practice: An essential element of quality and safety. In K. S. Amer (Ed.), Quality and safety for transformational nursing: Core competencies. Boston, MA: Pearson, 2013: 48–60.

Spector, N., Blegen, M. A., Silvestre, J., Barnsteiner, J., Lynn, M. R., Ulrich, B., . . . Alexander, M. (2015). Transition to practice in hospital settings. Journal of Nursing Regulation, 6(1), 4–13.

Zarshenas, L., Farhondeh, S., Molazem, Z., Khayyer, M., Zare, N., & Ebadi, A. (2014). Professional socialization in nursing: A content analysis. Iranian Journal of Nursing and Midwifery Research, 14(4), 432–438.

© James Kang/EyeEm/Getty Images


Advancing and Managing Your Professional Nursing Career Mary Louise Coyne and Cynthia Chatham

Learning Objectives

After completing this chapter, the student should be able to:

1. Discuss the difference between a job and a career. 2. Articulate the importance of proactively managing his or her

nursing career. 3. Discuss the benefits of a mentoring relationship.

4. Explore the effect of work-related stress.

Key Terms and Concepts

Career management Professional portfolio Mentoring Burnout Compassion fatigue

Successful management of your professional nursing career does not occur by accident or default. Rather, it is a deliberate, purposeful, informed process requiring self-appraisal of your need for further professional growth and development, attentiveness to projected trends in healthcare delivery, dialogue with nurse colleagues who have demonstrated success in advancing their careers, exploration of nursing education programs that will support your career advancement, consideration of how to balance work and study demands and remain healthy, and investment of self to pursue these professional nursing career options. Be reflective and proactive in seizing opportunities to shape and refine your professional nursing career.

Nursing: A Job or a Career? Your initial motivators for choosing to become a professional registered nurse (RN) may be far different from the reasons why you stay in professional nursing practice. Over time, nurses begin to appreciate that the practice of professional nursing as a career is a serious, sustained, and rewarding undertaking, dedicated to “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations” (American Nurses Association [ANA], 2015b, p. 1). Further, many seasoned nurses come to realize that a career in professional nursing requires academic preparation at the bachelor of science in nursing (BSN) degree level or higher, engagement in lifelong learning to expand knowledge and clinical and management competencies, willingness to translate research evidence into practice on a continuous basis, and commitment to advance the health of patients and the profession of nursing.

Professional nursing is a career to be managed and not just a job where you “punch in and punch out.” Table 6-1 compares two views of nursing as a job and as a career. In advocating for career management in nursing, Daggett (2014) notes,

TABLE 6-1 Do You View Nursing as a Job or as a Professional Career?

Factor View Nursing as a Job

View Nursing as a Career

Academic preparation

Obtains the least amount needed for nursing licensure

Obtains a BSN and often pursues an advanced nursing

degree: master of science in nursing (MSN), doctor of nursing practice (DNP), and/or doctor of philosophy (PhD)

Continuing education

Obtains the minimum continuing education (CE) units required for licensure and/or the job

Engages in formal and informal lifelong learning experiences across the nurse’s professional career in order to: Deepen and broaden knowledge and skill competencies Improve the delivery of safe, cost-effective, quality-based patient care Improve patient outcomes

Level of commitment

Continues with the job as long as it meets his or her personal needs; expects reasonable work for reasonable pay; responsibility ends with shift

Actively and joyfully engages in practicing the art and science of professional nursing as a member and, possibly, leader in professional nursing initiatives within the nurse’s healthcare agency and in

professional nursing organizations (local, regional, state, national, and/or international levels)

A degree and a nursing license might be the ticket that gets you started on the journey, but without a destination, an itinerary, and a map, you will not travel very far. Like any important journey, a career requires research and planning; otherwise, you risk missing opportunities and critical milestones along the way. One should always assess the current location before planning future directions. Just as you track progress with a map while on a road trip, you should have a plan for managing your career, lest you find yourself wandering in the wilderness without making any true progress toward your career goals. (p. 168)


Do you view nursing as a career or as a job? What are your professional goals related to nursing?

Purposefully manage your career—no one else can do this for you! Do not rely on healthcare employers to manage your career. Your best interests are yours and yours alone. Your career management and your short- and long-term goals are yours. For the career-oriented nurse, goals usually include (1) pursuit of an academic program to obtain a BSN degree or graduate-level nursing education for advanced practice, administration, teaching, or research within a specified time frame, and/or (2) assuming a new position within a healthcare organization that has more responsibility and accountability in order to advance his or her nursing career.

Direction is needed to accomplish these goals. Without such a career map, nurses may wander aimlessly. Where am I going? How am I going? Part of career management is having the map to accomplish goals. Career mapping provides nurses with a clear direction, including short- term stops to accomplish goals and a realistic time of arrival at the ultimate career destination. This may include position changes within an agency or a change in agencies. The map includes the skills obtained, the skills needed, and the resources needed to obtain skills (Hein, 2012). The pathway usually includes yearly goals as well as long-term goals. Without goals, nurses may leave the profession or risk beginning to view nursing as only a job that pays the bills.

Trends That Affect Nursing Career Decisions Healthcare agencies are constantly changing, with the goal of providing care to the community while containing costs. Although there is sufficient evidence demonstrating a professional nursing shortage in many areas across the United States, healthcare agencies are confronted with escalating costs, stringent cost containment initiatives, streamlined reimbursement systems, and a plethora of state and federal regulations that often constrain how well or poorly these agencies are able to deliver health care. In response to these budgetary constraints, many hospitals have responded by moving traditional inpatient care to outpatient settings, hiring fewer professional nurses, training more unlicensed assistive nursing personnel, cutting nursing salaries, hiring more RNs to part-time positions to avoid providing health and retirement benefits, and relying on fewer RNs to cover unfilled positions.

As you consider how to advance your nursing career, it is critical to examine projected trends in health care, particularly as they apply to (1) where health care is delivered, (2) the type of practitioners needed, and (3) the nursing educational preparation required to provide this care. The U.S. Department of Labor, Bureau of Labor Statistics (2016) reported that 94% of RNs worked in the following areas:

61% hospitals; state, local, and private 18% ambulatory healthcare services 7% nursing and residential care facilities 5% government 3% educational services; state, local, and private

In forecasting the future needs of the U.S. healthcare delivery system, the Institute of Medicine (IOM, 2010) projects that by 2020, the profession of nursing will need to double the number of nurses with a doctorate and increase the number of nurse practitioners in hospitals, home health, hospice, and nursing homes. In addition, the American Association of Colleges of Nursing (AACN, 2015b) reports that the nursing shortage may be easing in some parts of the country, but the demand for RNs prepared with baccalaureate, master’s, and doctoral degrees continues to increase.

Investigate where the shortages are in the location where you will be practicing, what types of practitioners are needed to meet these needs, and what type of advanced nursing education is required for these positions. Remember, you are in charge of making choices that best fit your short- and long-term career goals. You are your own best advocate in planning your nursing career!

Crafting the direction of your professional nursing career and executing the plan is transformational. The IOM (2011) report, The Future of Nursing: Leading Change, Advancing Health, provides a blueprint for how the entire profession must be transformed in order to advance the health of patients and simultaneously direct needed changes in the healthcare delivery system. In setting the agenda for nursing’s future, the IOM Committee on Nursing identified four key messages and eight related recommendations that have potential for the greatest effect and for accomplishment within the next decade. The four key messages are:

Nurses should practice to the full extent of their education and training. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.

BOX 6-1

• •

Nurses should be full partners, with physicians and other healthcare professionals, in redesigning health care in the United States. Effective workforce planning and policy making require better data collection and an improved information infrastructure (IOM, 2011, p. 4).

The eight specific recommendations include:

Remove scope of practice barriers Expand opportunities for nurses to lead and diffuse collaborative improvement efforts Implement nurse residency programs Increase the proportion of nurses with a baccalaureate degree to 80% by 2020 Double the number of nurses with a doctorate by 2020 Ensure that nurses engage in lifelong learning Prepare and enable nurses to lead change to advance health Build an infrastructure for the collection and analysis of interprofessional healthcare workforce data (IOM, 2011, pp. 9–14)

The IOM report on the future of nursing is a great starting point for setting your professional nursing career goals and planning your career trajectory. Careful deliberation on these initiatives and recommendations provides insight into the questions that you might ask in setting your own professional nursing career goals. See Box 6-1 for a list of questions to ask yourself as you plan your career goals.


What is the future of nursing for me? Am I currently practicing to the fullest extent of my nursing education

and training? (IOM, 2011, Initiative 1) What changes need to occur in my current practice in order to actualize this personal vision of my career? What are the projected employment trends and opportunities for nursing in my area? Have I achieved the highest level of education and training (IOM, 2011, Initiative 2) to support my desired career goals? What career path am I best equipped for and motivated to pursue to lead change and advance health? Should I pursue a BSN, MSN, DNP, or PhD, and if so, what specialization should I consider: a nurse practitioner, a nurse educator, a nurse anesthetist, a nurse– midwife, a nurse researcher, and/or a nurse executive? Have I sought out and had a dialogue with seasoned colleagues who have demonstrated success in advancing their nursing careers and elicited their input on trends in nursing practice and nursing education options? Have I explored nursing education program options at accredited academic institutions that will support my career advancement interests? Have I pursued ways to pay for advancing my nursing education through reimbursement at work, state and federal scholarships and traineeships, and/or public and private foundations? How will I balance work/family/study demands and remain physically, psychologically, and financially healthy? Last and perhaps most important, am I ready to take action in advancing my professional nursing career?

Showcasing Your Professional Self Showcasing your nursing story is an important aspect of career management and includes how you present yourself in your professional portfolio and in the interview process. A résumé and cover letter will assist in getting an interview, but a complete professional portfolio may be what secures you the new position. A portfolio provides several advantages, including self-enlightenment, career enhancement, a record of growth and development, a record of performance over time, and a tool for planning, and it can act as a resource for others looking to create one (Masor, 2013).

A professional portfolio, whether a print or electronic version, contains a cover letter; a résumé; examples of accomplishments cited but not elaborated upon in your résumé; selections of high-quality projects, papers, presentations, teaching tools/programs, patient or nursing care forms, policies, or procedures that you may have developed or codeveloped across your career; and copies of licensure, certifications, awards, and professional organizational membership cards. In today’s culture, being bilingual can be a definite advantage. Each language and dialect, if appropriate, should be included in your portfolio, including competencies in reading, understanding, speaking, and writing. Awards received can be a testament to your diligence in a position and willingness to go beyond the job requirements. Being an officer in an organization shows leadership abilities (Schmidt, n.d.).

The portfolio will look different depending on the position you are seeking and the competencies you wish to showcase. Examples of some differences in the portfolio based on experience and desired position are as follows:

If you are applying for a first-time position as a new RN, the portfolio can be used to showcase your competencies, intellectual skills, and teamwork while a student. New graduates, in particular, have to showcase themselves to stand apart from other applicants (Health eCareers Network, 2012). If you are applying for an advanced practice position, the IOM (2011) recommends that the portfolio be used as a means to document competencies and experience with patient populations. If you are applying for a staff position, you may consider providing a short case study describing the types of patients you have cared for and the specific skills and competencies you demonstrated in caring for this patient population. If you are applying for a management position, you may consider providing examples of leadership/management situations you have been engaged in, such as decision-making situations, schedules completed, and quality improvement initiatives.

Your cover letter should be directed to the human resources director, one page in length, word-processed, and printed on white stock paper with black ink, and should clearly identify the correct title of the position you are seeking, the length of time you have been an RN, a request for an interview, and your contact information.

Your résumé provides a brief overview of your professional career. Most résumés contain the following sections: identification, education, licensure and certifications, professional nursing employment history, professional committee engagement, and professional nursing organizations. Most résumés are one page in length and order entries from most recent to distant. See Figure 6-1 for an example résumé.

Figure 6-1 Example résumé.

First impressions made during the interview are also important. Arriving early and dressing professionally are a good beginning. Being prepared with answers for potential questions will only enhance the impression you make. Information concerning the job requirements, including duties, patient census and type, salary, and benefits, should be

provided by the interviewer. Your follow-up questions assist you in understanding the expectations of the position. In “What Every Nursing Student Should Know When Seeking Employment: An Interview Tip Sheet for Baccalaureate and Higher Degree Prepared Nurses,” the AACN (n.d.-c) discusses characteristics of the organization that the applicant should assess. These eight hallmarks or characteristics are in the following list. Prior to your interview, refer to the brochure, which is available on the AACN website, for specific questions under each of the categories. The brochure is available at

Manifest a philosophy of clinical care emphasizing quality, safety, interdisciplinary collaboration, continuity of care, and professional accountability. Recognize the value of nurses’ expertise on clinical care quality and patient outcomes. Promote executive-level nursing leadership. Empower nurses’ participation in clinical decision making and organization of clinical care systems. Demonstrate professional development support for nurses. Maintain clinical advancement programs based on education, certification, and advanced preparation. Create collaborative relationships among members of the healthcare team. Use technological advances in clinical care and information systems.

It is illegal for employers to ask certain questions. Knowing those questions and, more important, knowing the questions that are allowed are key in preparation for the interview (Compare Business Products, 2013). Many interviewers use silence as a tool to evaluate the candidate. Use the silence to gather your thoughts and let the interviewer break the

silence. At the conclusion of the interview, thank the interviewer for his or her time and ask about the timeline for filling the position. Send a follow- up note thanking the person for the interview and state that you are looking forward to a response.


What kind of first impression do you make when searching for a new position?

Mentoring The IOM report on The Future of Nursing (2011) recommends mentoring to assist in increasing the readiness and retention of nurses to improve patient outcomes (Figure 6-2). Mentoring is a relationship between two nurses in which the more experienced nurse provides leadership and guidance to the nurse with less experience, often referred to as the “mentee” (Minority Nurse, 2013). Preceptors and mentors play different roles. A mentor provides counsel regarding career management, and the mentoring relationship may take place in the beginning of a nursing career, when changing positions, or when a nurse is furthering his or her education. The mentor–mentee relationship may be a long-term relationship. In contrast, a preceptor provides direct short-term coaching to a new graduate nurse, a newly hired nurse, or a nurse who transfers to another unit and orients the nurse to roles and responsibilities on the unit and within the organization. A mentor may also serve as a preceptor; however, a preceptor is not a mentor. It is not uncommon for mentees to become mentors, guiding others in their pursuit of professional growth and development.

Figure 6-2 Mentoring is a formalized relationship with a more experienced nurse providing guidance to a nurse with less experience.

© Monkey Business Images/Shutterstock

Being a mentor takes time and requires patience. The mentor must be reasonable, competent, committed to assisting the mentee in being successful in his or her career, adept at providing feedback, and open to sharing knowledge. Professional growth should be the outcome for both mentor and mentee. It is the responsibility of the person seeking career mentorship to find a mentor. The mentor may be a nursing faculty member, an experienced nurse within a healthcare organization or nursing school, or a nurse from a professional nursing organization. This relationship has benefits for both. The mentor receives confirmation from witnessing the career development and advancement of the mentee in professional nursing. The benefits of being mentored are many and include:


Examples of applicable Nurse of the Future: Nursing Core Competencies


Knowledge (K4b) Describes factors essential to the promotion of professional development

Skills (S3b) Provides and receives constructive feedback to/from peers

Attitudes/Behaviors (A3b) Values collegiality, openness to critique, and peer review

Attitudes/Behaviors (A4b) Values the mentoring relationship for professional development

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Increased self-confidence Enhanced leadership skills Accelerated acclimation to the culture of the unit/facility Advancement opportunities Enhanced communication skills Reduced stress Improved networking ability Political savvy Legal and ethical insight

Problems with mentoring may occur with either person (Minority Nurse, 2015). The mentee may outgrow the mentor in knowledge and in the profession. The commitment in time and energy of the mentor may become overwhelming. The relationship may even become toxic if the mentor becomes inaccessible or harmful to the mentee and may even block the learning and progression of the mentee. If any of these become evident in the relationship, both must communicate and discuss the situation. They may agree to a separation or to repairing the relationship.

Education and Lifelong Learning The profession of nursing needs a more educated workforce for the sake of increasing healthcare quality and patient safety. The ANA standards of professional nursing practice, Standard 12, indicate that it is the responsibility of every nurse to seek “knowledge and competence that reflects current nursing practice and promotes futuristic thinking” (2015b, p. 76). The competencies associated with this standard reflect commitment to lifelong learning, the maintenance of a professional portfolio, and a commitment to mentoring. Every state board of nursing should require mandatory continuing education for all practicing RNs, but not all do. The call for a more educated professional nursing workforce to lead change and advance health has been mandated in the initiatives of the IOM (2011):

“Increase the proportion of nurses with a baccalaureate degree to 80 percent by 2020.” (Initiative 4) “Double the number of nurses with a doctorate by 2020.” (Initiative 5) “Ensure that [all] nurses engage in lifelong learning.” (Initiative 6)

In 2010, the U.S. Department of Health and Human Services, Health Resources and Services Administration reported that the distribution of RNs by highest nursing or nursing-related educational preparation was as follows:

13.9% were diploma-prepared RNs. 36.1% of RNs had an associate degree in nursing (ADN). 36.8% had a BSN. 3.2% had a master’s or doctoral degree.

According to, as of 2018, in the United States of 50 states,

the District of Columbia, and 2 territories:

34% (18) had no mandatory continuing education (CE) requirement for RN licensure. 66% (35) had a mandatory CE requirement ranging from 14 to 30 CEs every 2 years or, in some cases, only if the RN was not engaged in practice during the previous renewal time.

The profession of nursing expects that nurses will practice the science of nursing with care. At the core of ADN and BSN academic programs are foundational science courses in biology, anatomy, physiology, microbiology, chemistry, pathophysiology, pharmacology, and statistics (Figure 6-3). These courses serve as the basis for translating research evidence into the science of nursing practice in such courses as adult health, pediatrics, obstetrics, psychiatric-mental health, and community health nursing. Although we readily acknowledge the essence of nursing as “caring for patients,” we often do not embrace that nurses are also scientists committed to practicing the science of nursing with care and compassion toward patients. Caring is not enough. Science is not enough. Nursing is both an art and a science that is continuously evolving based on research findings, resulting in a deepening and broadening of the knowledge base fundamental to professional nursing practice. As nurses, we must be committed to and actively engaged in lifelong professional learning across our careers. Ongoing nursing education through CE programs, certification programs, and/or formal academic programs to pursue a BSN, an MSN, a DNP, and/or a PhD must be an expectation of professional nurses if we are to keep pace with the science of nursing, have credibility as a profession, and maintain our commitment to patients. It is only in this way that the profession of nursing will actualize the IOM mandates for leading change and advancing health.

Figure 6-3 Formal academic education is required to become eligible for both nursing licensure and advanced practice certification.

© alejandrophotography/E+/Getty Images

Advancing your nursing career often means returning to school. In an unprecedented move advocating support for academic progression in nursing, the American Association of Community Colleges, the Association of Community College Trustees, the AACN, the National League for Nursing, and the National Organization for Associate Degree Nursing issued a powerful joint statement calling for nursing to

work together in order to facilitate unity of nursing education programs and advance opportunities for academic progression, which may include seamless transition into associate, baccalaureate, master’s, and doctoral programs. Collectively, we agree that every nursing student and nurse should have access to additional nursing education, and we stand ready to work together to ensure that nurses have the support needed to take the next step in their education. (AACN, 2015a, para. 3)

At the core of a seamless academic progression in nursing is respect for the academic integrity of educational programs provided by community colleges, colleges, and universities and efforts made to enable nursing students and nurses to readily progress from ADN to RN- BSN or RN-MSN to DNP or PhD programs. The AACN (n.d.-a) website provides a user-friendly search engine called Nursing Program Search

for academic programs in nursing at every level, such as RN-BSN, RN- MSN, LPN to BSN, entry-level BSN, accelerated BSN, BSN to DNP, BSN to PhD, entry-level MSN, MSN, CNL, MSN to DNP, DNP, and PhD programs.

If you are contemplating or have decided to return to school to pursue a BSN or an advanced graduate degree in nursing, be sure that you consider and investigate the following:

Possess certainty about the specific courses that will successfully transfer and knowledge of the specific courses and their associated credit hours that need to be taken prior to admission. Prepare for and take any preliminary test required, such as the Graduate Record Examination, and know the expected scores for admission. Adhere to the application process, including admission dates. Be knowledgeable of the cost of the program in its entirety: tuition, books, and fees, such as online fees, clinical fees by course, and fees for validation credits of previously earned coursework that has been successfully completed. Some programs advertise that they give “life experience” credits. Be sure you receive in writing what these experiences are, whether you meet the criteria or if additional courses need to be taken or papers written describing these experiences, how many credit hours are awarded, and what the fees are for transferring these credits into your program of study. Be aware of tuition reimbursement options through work and the expected time commitment in return for tuition assistance. Be cognizant of and investigate opportunities and requirements for scholarships, loans, and/or traineeship programs awarded by the state government, the federal government, private foundations, and/or professional nursing organizations.


Examples of applicable Nurse of the Future: Nursing Core Competencies


Skills (S4a) Participates in lifelong learning Skills (S8g) Develops goals for health, self-renewal, and professional development Attitudes/Behaviors (A4a) Committed to lifelong learning

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Information is power! In appraising your nursing career options, be informed about specialty areas available and of interest to you. The BSN degree is the sole academic portal of entry for graduate studies in nursing (MSN, DNP, and PhD) for such roles as nurse practitioner, nurse anesthetist, clinical nurse leader, nurse executive, nurse educator, and nurse researcher. There are several nursing career paths supported by graduate-level academic programs for you to consider:

An expert clinician is an advanced practice registered nurse prepared at the graduate level, such as an adult, family, geriatric, or psychiatric-mental health nurse practitioner, nurse anesthetist, or nurse–midwife, who provides safe, evidence-based, and cost- effective care to a specific patient population (academic level: MSN, DNP). A clinical nurse leader (CNL) guides nurse colleagues and interdisciplinary teams in direct patient care situations to implement

clinical practice guidelines and to enable these patient populations to achieve positive outcomes (academic level: MSN, DNP). A nurse executive directs the infrastructure of the practice of nursing within an organization on clinical and fiscal levels and represents and advocates for nursing within the context of the business of health care (academic level: MSN, DNP, PhD). A nurse educator works in academic settings, guiding students to deepen and broaden their knowledge and practice of safe, quality- based professional nursing practice (academic level: MSN, DNP, PhD). A nurse researcher is dedicated to executing and translating evidence-based research into practice and expanding the body of knowledge fundamental to the art and science of nursing (academic level: MSN, DNP, PhD).

The Graduate Nursing Student Academy, established by the AACN (n.d.- b), has established a series of webinars to inform you of areas of specialization and graduate degrees that may be of interest to you as you plan your career.

Professional Engagement Professional engagement is a characteristic that discriminates between a person employed in a job and one pursuing a career. A professional nurse who is managing and advancing his or her career will actively engage in professional nursing initiatives within the nurse’s healthcare agency and in professional nursing organizations.


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential I: Liberal Education for Baccalaureate Generalist Nursing Practice

1.9 Value the ideal of lifelong learning to support excellence in nursing practice (p. 12).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

Engagement in Your Healthcare Organization As you are planning your nursing career path, seize opportunities now to actively engage in quality improvement activities that are currently under way within your healthcare organization. Examples of quality initiatives include, but are not limited to, committees within your agency that address nursing policy and procedures, quality improvement, core measures, clinical practice guidelines, safety, the Hospital Consumer

Assessment of Healthcare Providers and Systems Hospital Survey of Customer Satisfaction, and the Medicare and Medicaid Survey Process for Nursing Homes or Home Health Agencies.

Engagement in programs to improve quality for patients, staff, and your organization will help you gain experience in clinical problem resolution, aid you in translating clinical practice guidelines and research evidence into practice, assist you with co-contributing to the creation of a milieu of safety and quality, and connect you in a collegial manner with the quality champions in your organization. If you are not sure how to get connected with these committees, start by meeting with your nurse manager and/or chief nursing officer and express your interest in serving on one or more of these committees. You will learn from your participation on these committees and you will maximize your visibility as an engaged, motivated employee.

Engagement in Professional Nursing Organizations Engaging in professional nursing organizations connects students and RNs with membership and leadership opportunities. Some of the benefits of participating in these organizations include ongoing growth and development pertinent for your career and areas of specialization, receiving mentorship and guidance from seasoned members, obtaining reduced membership rates for students, and accessing scholarship and grant opportunities for members to supplement tuition in academic programs.

You may join many professional nursing organizations as a student or as an RN. These organizations include, but are not limited to, the ANA and its affiliate state nurses associations; Sigma Theta Tau International Honor Society of Nursing; American Organization of Nurse Executives;

American Association of Nurse Practitioners; American Association of Nurse Anesthetists; American Association of Critical-Care Nurses; Association of Women’s Health, Obstetric and Neonatal Nurses; and American College of Nurse-Midwives. A more thorough list of professional nursing organizations at national, state, and international levels is provided by the ANA (n.d.).


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential VIII: Professionalism and Professional Values

8.13 Articulate the value of pursuing practice excellence, lifelong learning, and professional engagement to foster professional growth and development (p. 28).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

Expectations for Your Performance Assessment of your performance as an RN is conducted on several levels, such as self-appraisal, work performance evaluations conducted by nurse managers on behalf of healthcare organizations, and collegial evaluations. Many performance appraisals for nurses and nursing students have their roots in professional documents, such as Nursing: Scope and Standards of Practice (ANA, 2015b), Nurse of the Future: Nursing Core Competencies (Massachusetts Department of Higher Education, 2016), The Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 2008), and The Essentials of Master’s Education in Nursing (AACN, 2011) as well as criteria established by specialty-based professional nursing organizations.


Examples of applicable Nurse of the Future: Nursing Core Competencies


Knowledge (K4b) Describes the role of a professional organization in shaping the culturally congruent practice of nursing

Skills (S8c) Advocates for professional standards of practice using organizational and political processes

Skills (S8i) Assumes professional responsibility through participation in professional nursing organizations

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

The core questions in most of these assessments are: “Am I currently practicing competently?” and “Am I currently practicing to the fullest extent of my nursing education and training in my current position?” (IOM, 2011, Initiative 1). It is important to know proactively the expectations of professional nurse competency in your specific setting so that you can meet and exceed them and continuously use them as indicators for identifying your strengths and areas that need further professional growth and development. Assessment of your performance as an RN is your own personal quality improvement program and is essential for professional growth and development. This should not be just an annual event but an ongoing process of improving one’s practice. Here are some suggestions for the evaluation of your performance as an RN:

Conduct your own self-appraisal first in order to have a more informed dialogue with your nurse manager. Identify your areas of strength and areas in need of growth. Pursue continuing education to both enhance your strengths and narrow your limitations. Accept constructive feedback with respect, gratitude, and civility. If feedback does not make sense to you, ask the person to clarify what he or she said. Develop an ongoing plan of quality improvement for yourself.

Taking Care of Self A nurse is a person who is present at birth, at death, and during the entire life span. A nurse makes life and death decisions. A nurse interacts with everyone in the healthcare community. A nurse interacts with people from every walk of life. A nurse must multitask during every shift. A nurse works every shift, weekends, and holidays. A nurse experiences stress unknown to most other professions. To prevent overwhelming stress, a nurse must take care of him- or herself by:


Do you plan to be a part of a professional organization after graduation? Why or why not? What do you anticipate will be your level of involvement?

Eating a balanced diet Getting enough sleep Avoiding addictive substances Exercising on a regular basis Paying attention to mental and spiritual health Being vigilant in coping with stress triggers at work and at home

Seig (2015) notes that “more than 40 percent of hospital nurses today suffer from the physical, emotional, or mental exhaustion characteristic of burnout. The result of unmanaged stress, burnout accounts for what is often a negative perception among nurses of their work and workplaces” (para. 1). Managing time is essential to preventing burnout and compassion fatigue. Francisco and Abarra (n.d.) present the following 12 tips for time management. Nurses can use these tips at work and

during off time.



Example of applicable Nurse of the Future: Nursing Core Competencies


Knowledge (K8b) Recognizes the relationship between personal health, self-renewal, and the ability to deliver sustained quality care

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Do you have the courage to ask for honest feedback? Do you have the courage to give honest feedback to a friend or colleague? How do you respond to negative feedback?

Be organized. Make a list of the tasks you will need to do and post it in a place that you can easily see. Before making your rounds, make a checklist of the things you need to do for each patient. When doing rounds, always see your most critical patient first. Don’t do other tasks when giving medications. Pay attention to time. Learn how to write quickly. Always bring easy-to-eat snacks. Be keen on details.

Learn how to communicate. Learn to multitask. Be realistic.

Burnout and compassion fatigue may be the end result of stress not being managed. Burnout is progressive and involves disengagement and withdrawal. Compassion fatigue is acute and may present itself as overinvolvement in patient care (Lombardo & Eyre, 2011). The two concepts may occur simultaneously. In caring for patients, the nurse may be depleted physically, emotionally, and spiritually. These indicators involve compassion fatigue. Burnout causes physical symptoms that lead to feelings of being constantly tired. Some observed signs are avoiding certain patients; not feeling compassion for your patients and their families; experiencing headaches, digestive problems, fatigue, mood swings, anxiety, and/or poor concentration; and/or feeling underappreciated and overworked. In response, nurses may not want to go to work and/or just go through the motions when at work.


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential VIII: Professionalism and Professional Values

8.14 Recognize the relationship between personal health, self-renewal, and the ability to deliver sustained quality care (p. 28).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

The healthcare workplace is demanding, requiring many caregiving

responsibilities from various members of the interdisciplinary team that must be accomplished and communicated within an abbreviated time. Sustained workplace stress can dramatically influence how we interact with colleagues, how professionally satisfied we are with current career choices, and employee retention rates.

Stress at work can be managed in a civil environment. Civility builds community and allows for efficient functioning units. Civility is defined as respect for others (Clark, 2010). A code of conduct establishes ways of behaving for interacting with people. The ANA (2015a) developed a Code of Ethics for Nurses with Interpretive Statements that requires nurses to communicate with respect when interacting with colleagues, patients, and students. Civil behavior is not always easy to accomplish; it requires courage and genuine concern for others. We have the choice to be colleagues who habitually respect and assist one another and who are instrumental in creating a milieu of civility and safety or to be colleagues who are engaged either overtly or subtly in lateral and vertical workplace violence exhibited by bullying, harassing, speaking ill of one another, demeaning one another, and excluding colleagues.


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential IX: Baccalaureate Generalist Nursing Practice

9.12 Create a safe care environment that results in high quality patient outcomes. (p. 31).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

The first step toward managing stress and creating a civil milieu is to assess your work environment. Some of the characteristics of healthy collegial relationships include being a reliable and respectful colleague who works his or her scheduled days, arrives on time, shares equally in patient care and management responsibilities, provides care in a timely manner, and actively volunteers to help a colleague who needs assistance.

Self-care strategies that promote resilient nurses may include:

Saying no to additional shifts and reducing overtime in order to conserve energy Taking a day off in order to renew energy Changing shift or unit in order to gain a new outlook on being a nurse

Consulting a social worker, a chaplain, your preceptor, and/or your mentor can provide you with resources for caring for self, managing burnout and compassion fatigue, and sustaining a resilient self.

Conclusion You are responsible for actively managing and advancing your nursing career across your entire life span as a professional nurse. This means that you will need to make purposeful and strategic choices about your professional practice, academic preparation, and continuing education. Mentors, preceptors, and engagement in your healthcare organization and professional nursing organization serve as guides for advancing your professional path. Creating a healthy lifestyle and reducing the risk of burnout and compassion fatigue are essential for sustaining your personal and professional life.


Examples of applicable Nurse of the Future: Nursing Core Competencies


Knowledge (K8d) Contributes to building and fostering a nurturing and healthy work environment, promoting health safety in the workplace

Attitudes/Behaviors (A8b) Values and upholds altruistic and humanistic principles

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Classroom Activity 6-1

Have students begin creating a career map that includes short-term and long-term goals and strategies to achieve those goals. The Nursing License Map (available at may be useful in this activity if students want to compare educational requirements and salaries as they consider career goals.

Classroom Activity 6-2

Have students begin working on a professional portfolio that contains a cover letter and résumé, along with examples of accomplishments and selections of high-quality projects, papers, and presentations.

References American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from

American Association of Colleges of Nursing. (2011, March 21). The essentials of master’s education in nursing. Retrieved from

American Association of Colleges of Nursing. (2015a). Joint statement on academic progression for nursing students and graduates. Retrieved from Statements-White-Papers/Academic-Progression

American Association of Colleges of Nursing. (2015b). Talking points: HRSA report on nursing workforce projections through 2025. Retrieved from Nursing-Workforce-Projections.pdf

American Association of Colleges of Nursing. (n.d.-a). Students: Member program directory. Retrieved from

American Association of Colleges of Nursing. (n.d.-b). GNSA webinars. Retrieved from

American Association of Colleges of Nursing. (n.d.-c). What every nursing student should know when seeking employment: An interview tip sheet for baccalaureate and higher degree prepared nurses. Retrieved from nursing-student-should-know-when-seeking-employment.pdf

American Nurses Association. (2015a). Code of ethics for nurses with

interpretive statements. Retrieved from excellence/ethics/code-of-ethics-for-nurses/

American Nurses Association. (2015b). Nursing: Scope and standards of practice (3rd ed.). Silver Spring, MD: Author.

American Nurses Association. (n.d.). Nursing organizations. Retrieved from

Clark, C. (2010). Why civility matters. Retrieved from features/Vol36_1_why-civility-matters

Compare Business Products. (2013). 30 interview questions you can’t ask and 30 legal alternatives. Retrieved from you-cant-ask-and-30-sneaky-legal-get

Daggett, L. M. (2014). Career management and care of the professional self. In K. Masters (Ed.), Role development in professional nursing practice (3rd ed., pp. 167–193). Burlington, MA: Jones & Bartlett Learning.

Francisco, M. E. V., & Abarra, J. (n.d.). 12 time management tips every nurse should know. Retrieved from

Health eCareers Network. (2012, December 11). 5 common career myths for nurses. Retrieved from myths-for-nurses

Hein, R. (2012, December 5). Career mapping offers a clear path for both employees and employers. Retrieved from offers-a-clear-path-for-both-employees-and-employers.html

Institute of Medicine. (2010). Report brief: The future of nursing: Focus

on education. Retrieved from Future-of- Nursing/Future%20of%20Nursing%202010%20Report%20Brief.pdf

Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. Washington, DC: National Academy Press. Retrieved from

Lombardo, B., & Eyre, C. (2011). Compassion fatigue: A nurse’s primer. Online Journal of Issues in Nursing, 16. Retrieved from 16-2011/No1-Jan-2011/Compassion-Fatigue-A-Nurses-Primer.html

Masor, M. B. (2013). Let your light shine: Portfolio principles. In J. Phillips & J. M. Brown (Eds.), Accelerate your career in nursing: A guide to professional advancement and recognition (pp. 29–44). Indianapolis, IN: Sigma Theta Tau International Honor Society of Nursing.

Massachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. Retrieved from

Minority Nurse. (2013). Mentoring nurses toward success. Retrieved from (2018). Nursing CE requirements by state. Retrieved from

Schmidt, K. (n.d.). Top 10 details to include on a nursing resume [Web log]. Retrieved from on-a-nurse-resume/

Seig, D. (2015). 7 habits of highly resilient nurses. Retrieved from

U.S. Department of Health and Human Services, Health Resources and Services Administration. (2010, March). The registered nurse population: Findings from the 2008 national sample survey of

registered nurses. Retrieved from

U.S. Department of Labor, Bureau of Labor Statistics. (2016). Occupational outlook handbook. Retrieved from

© James Kang/EyeEm/Getty Images


Social Context and the Future of Professional Nursing Mary W. Stewart, Katherine E. Nugent, and Kathleen Masters

Learning Objectives

After completing this chapter, the student should be able to:

1. Describe the social context of professional nursing. 2. Identify factors that influence the public’s image of professional


3. Identify ways that nurses can promote an accurate image of professional nursing.

4. Discuss the gender gap in nursing. 5. Recognize connections between changing demographics and

cultural competence. 6. Evaluate current barriers to health care in our society. 7. Discuss present trends in society that influence professional

nursing. 8. Identify present trends associated with the profession of nursing.

Key Terms and Concepts

Stereotypes Cultural competence Access to care Incivility Violence Global aging Consumerism Complementary and alternative medicine Disaster preparedness Nursing shortage Nursing faculty shortage

When you hear the word nurse, what images, thoughts, perceptions, and assumptions come to mind? Ask yourself, “Why did I have those perceptions and assumptions about nurses?” The answer to your question reveals much about the social context of nursing or how society

views nurses and the nursing profession. For many, the image that first comes into view is one of a white female who is dressed in a meticulously ironed white uniform with white hose and white shoes and wearing a stiff white cap. For those of us in nursing, we recognize that this traditional American view of nursing is rarely seen in the real world of professional nursing. How do we communicate the true image of nursing in the 21st century?

In this chapter, we explore the social context of professional nursing and identify major influences that affect nursing in today’s society. This quest for a deeper understanding of nursing challenges us to identify our individual responsibilities in educating our patients and the public about professional nursing as well as meeting our professional obligations to the public. The result is not necessarily an immediate change in the picture that comes to mind when one says “nursing”; however, we might begin to see nursing and those of us committed to nursing in new, more accurate ways.

Nursing’s Social Contract with Society A mutually beneficial relationship exists between nursing and society. The profession of nursing grew out of a need within society and continues to evolve based on the needs of society. Because nursing has a responsibility to society, the interests of the profession must be perceived as serving the interests of society. Society provides the nursing profession with the authority to practice, grants the profession authority over functions, and grants autonomy over professional affairs. The profession is expected to regulate itself and to act responsibly. This relationship is the essence of nursing’s social contract with society (American Nurses Association [ANA], 2010).

Foundational to nursing’s social contract with society are some basic values. In brief, these values include that humans manifest an essential unity of mind, body, and spirit; human experience is contextually and culturally defined; health and illness are human experiences; and the relationship between the nurse and the patient occurs within the context of the values and beliefs of the patient and the nurse. In addition, public policy and the healthcare delivery system influence the health and well- being of society and professional nursing, and individual responsibility and interprofessional involvement are essential (ANA, 2010).

According to Nursing’s Social Policy Statement (ANA, 2010), nursing is particularly active in relation to six key areas of health care that include the organization, delivery, and financing of high-quality health care; provision for the public’s health through health promotion, disease prevention, and environmental measures; and expansion of nursing and healthcare knowledge (through research and evidence in practice) and

application of technology. Also included are expansion of healthcare resources and health policy to enhance the capacity for self-care; definitive planning for health policy and regulation; and duties under extreme conditions, which means that nurses weigh their duty to provide care with obligations to their own health during extreme emergencies.

Public Image of Nursing The public values nursing. According to a Gallup poll in 2017, nurses received the top ranking for honesty and ethical standards (Brenan, 2017). The honor of being the most trusted profession has been bestowed on the profession of nursing every year but one since 1999, when nursing was first added to the Gallup poll. The only year when nurses did not rank number one was in 2001 when firefighters took the top spot after the September 11 terrorist attacks. When asked to defend this nationwide trust of nurses, people often respond with anecdotal stories of personal experiences with nurses. Popular stories include those of relatives or friends who are nurses and positive experiences with nurses in a clinical setting. The fact that nurses serve society seems to have an automatically positive effect on society’s value of nursing.

Although the trust is evident, there remains a gap between the public’s perception of the nursing profession and the reality of nursing. For example, the general public might think that it requires only 2 years to become a registered nurse (RN), with the “training” consisting primarily of learning to administer medications, providing personal care, and sitting at the bedside. However, reality provides a stark revelation that nurses are educated at the baccalaureate, master’s degree, and doctoral levels and work in areas of education, research, and independent clinical practice.

Nurses are aware of the gaps in society’s knowledge of nursing. Hence, nurses should take the lead in ensuring that the public has an accurate picture of the vast knowledge and expertise that are present in the 3 million RNs in the United States (U.S. Department of Health and Human Services [USDHHS], 2010b). Where do we start? We must first begin with the realization that not all nurses are the same. As previously

stated, many well-educated persons do not understand the various educational programs available to become an RN. Likewise, knowledge about the differences in preparation and responsibility of licensed practical nurses, RNs, and advanced practice nurses is lacking.

As you are preparing to be a professional nurse, ask yourself, “How do I clarify and communicate the significance of professional nursing?” First, become familiar with the scope of practice of professional nurses and understand the multifaceted roles for which you are being educated. Second, be able to identify the unique place that professional nurses have in the healthcare system. This comes by acquiring knowledge of the nursing profession and by being aware of the roles, responsibilities, and contributions of other healthcare professionals. Most important, it is imperative that you share your story of nursing. Although the public holds nurses in high regard, they know very little about what nurses actually do (Buresh & Gordon, 2000, 2006, 2013). Without articulating more clearly and loudly on our profession’s behalf, we might be at a loss when trying to defend our place in the current healthcare system.

Suzanne Gordon, an award-winning journalist, has dedicated much of her career to telling the stories of nursing. Not a nurse herself, Gordon writes to empower nurses to find their voices and to be heard. Gordon is committed to obtaining a firsthand account from nurses as they face the real challenges of being a nurse that include (1) inconvenient problems of improving patient safety (Gordon, Buchanan, & Bretherton, 2008); (2) the challenges of standing up for themselves, their patients, and the nursing profession (Gordon, 2010); and (3) the effect of cutting healthcare costs on patient care (Gordon, 2005), to name a few. If a journalist can commit to sharing “our” stories, that should provide a spark of motivation in us to share our experiences, triumphs, and defeats.


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential VIII: Professionalism and Professional Values

8.3 Promote the image of nursing by modeling the values and articulating the knowledge, skills, and attitudes of the profession (p. 28).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

When nurses are asked about the nurse’s reluctance to promote nursing effectively, the responses are riddled with excuses, such as a lack of time, resources, and support from colleagues. Professional nurses work in very demanding, stressful, and taxing jobs. Frequently, we are so consumed with the responsibilities of our work that we fail to notice what we are actually accomplishing. In addition, we rarely take the time to become fully aware of and to celebrate what our nursing colleagues are doing within the profession. Professional nursing organizations exist to communicate and support these achievements. However, only a small percentage of RNs are actually members of their professional nursing associations.

Better insight into professional nursing must start with nurses at all levels of practice and education. Once we have obtained the necessary insight, we can provide a clear picture of the nursing profession to society. When these two actions are taken, the public image of nursing will be directly reflective of the reality of nursing. We want to maintain the positive impression the public now holds of nursing and to sustain the earned trust, but nursing and the public deserve a great deal more than

that. All of us should be convinced of the expertise that professional nursing offers: mastery of complicated technological skills; appreciation for the whole person; commitment to public health for all people; a keen knowledge of anatomy, physiology, pathophysiology, biochemistry, pharmacology, and other disciplines; the ability to think critically and to connect the dots in today’s ever-changing healthcare system; and proficiency in communication. The list continues.


Examples of applicable Nurse of the Future: Nursing Core Competencies Professionalism:

Knowledge (K5b) Understands the culture of nursing, cultural congruence and the healthcare system

Skills (S5b) Promotes and maintains a positive image of nursing

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Media’s Influence It is obvious that the media (television, radio, Internet) play a major role in how society views professional nursing. Historically, the nurse has been portrayed in the media in a variety of ways. First, the nurse appears as a young, seductive female whose principal qualification is the length of her slender legs and the amount of cleavage showing through her uniform. Needless to say, this nurse is usually depicted as one who is not educated and who lacks common sense and intelligence. Another

popular view of the nurse as portrayed by the media is an unattractive, overweight, and mean female. Her intelligence is not questioned, but her compassion for others is highly debatable. This nurse is shown as threatening and uncaring. Neither of these views is accurate, and probably no one would argue with this. At the same time, we continue to be perplexed when asked to define or describe the professional nurse.

In their book From Silence to Voice: What Nurses Know and Must Communicate to the Public, Buresh and Gordon (2006) state that “a profession’s public status and credibility are enhanced by having its expertise acknowledged in the journalistic media” (p. 1). Buresh and Gordon also cite the study “Who Counts in News Coverage of Health Care,” where the data show that many professional groups had a greater voice on health issues compared to nurses. Physicians were quoted the most in media, followed by government, business, education, public relations, and so forth. This is significant and shocking because nurses are the largest group of healthcare professionals, yet we are the most silent group. As nurses, we have been complacent about refuting the negative stereotypes portrayed in the media. Furthermore, we have been lax in articulating our expertise to the media.

Buresh and Gordon (2006, p. 4) describe three communication challenges faced by the nursing profession that need to be addressed:

1. Not enough nurses are willing to talk about their work. 2. When nurses and nursing organizations do talk about their work, too

often they intentionally project an inaccurate picture of nursing by using a “virtue” instead of a “knowledge” script.

3. When nursing groups give voice to nursing, they sometimes bypass, downplay, or even devalue the basic nursing work that occurs in direct care of the sick while elevating an image of “elite” nurses in advanced practice, administration, and academia.

Nurses should face the stereotypes present in our society and erase the lines that define us. To do this, we must first recognize our value to society and ourselves. When introducing ourselves in the professional role, we should do so with confidence and clarity. For example, we can say, “Good morning, Mr. Smith. I’m Susan Jones, your registered nurse.” Such day-to-day engagement is important. We must tell the world what we do.

In From Silence to Voice, the authors identify the following actions to promote the real image of nursing:

Educate the public in daily life. Describe the nurse’s work. Make known the agency—independent thinker—of the RN. Deal with the fear of angering the physician. Accept thanks from others. Be ready to take advantage of openings to promote nursing. Respond to queries with real-life stories from nursing. Tell the details. Avoid using nursing jargon. Be prepared ahead of time to tell your story. Do not suppress your enthusiasm. Reflect the nurse’s clinical judgment and competency. Connect your work to pressing contemporary issues. Respect patient confidentiality. Deal with and confront the fear of failure.


How can you, as a student nurse, tell members of society what professional nurses do?

In an effort to address the challenges faced by nursing, Buresh and Gordon (2000, 2006, 2013) present a history and understanding of modern media and provide examples of how to interconnect with them. Knowing how news media work, how to write a letter to the editor, how to present oneself on television or radio, and how to converse with community groups are among the guidelines provided. Being proactive is essential, especially at a time when healthcare costs and cuts demand that only the fundamental players are left standing. Society needs to know that nurses are fundamental players.

Sigma Theta Tau International commissioned the 1997 Woodhull Study on Nursing and the Media, which reported the lack of representation that nurses have in the media (Sigma Theta Tau International, 1998). In approximately 20,000 articles from 16 major news publications, nurses were cited fewer than 4% of the time. Although nurses are highly relevant participants in patients’ stories, they were neglected in almost every case. Key recommendations from the Woodhull Study include the following:

Nurses and media should be proactive in establishing ongoing dialogue. If the aim is to provide comprehensive coverage of health care, the media should include information by and about nurses. Training should be provided to nurses on how to speak about business, management, and policy issues. Health care needs to be clearly identified as the umbrella term for specific disciplines, such as medicine and nursing. Nurses with doctoral degrees should be identified correctly as doctors, and those with medical doctorate (MD) degrees should be identified as physicians. Language needs to reflect the diverse options for health care by

avoiding such phrases as “Consult your doctor.” Rather, media need to state, “Consult your primary healthcare provider.”

In recent years, we have seen more accurate portrayals of nurses supported in the media. Instead of portraying sexual prowess or disrespect and anger, nurses have been presented as intelligent, competent, and essential to patient care. Johnson & Johnson continues the Campaign for Nursing’s Future to raise public awareness of professional nursing. This positive promotion has supported student and faculty recruitment into the profession. Johnson & Johnson has taken additional steps to recognize the courageous efforts of many nurses, including those who were intensely engaged in responding during national crises, such as Hurricane Katrina. Nurses must continually evaluate the portrayal of nurses in the media. After all, if the image is inaccurate, we have a responsibility to correct it.

The Gender Gap

Women in Nursing In Western culture, women have traditionally been socialized as the more passive of the genders—to avoid conflict and to yield to authority. The implications of this conventional thought are still evident in nursing practice today. Many nurses lack confidence in dealing with conflict and in communicating with those in authority. For some, it is a matter of a short supply of energy and too many other commitments. Others perceive assertiveness as clashing with people’s expectations. We should ask ourselves, “Isn’t the reward of knowing we do a good job enough?” For female nurses who assume multiple personal and professional roles, career is often not at the top of our priorities. This can be attributed to the fact that the role of women in past society was primarily geared toward family responsibility, not career. Many women who chose nursing did so without the expectation of a long-term commitment to the profession. Rather, nursing was a “good job” when and if a woman needed to work. This centeredness on service continues in nursing today, albeit with less intensity than in the past.

The women’s movement in the 1960s empowered intelligent career- seeking women to enter professions other than the traditional ones of teaching and nursing. After some years of competing for students, nursing saw a return of interest in the 1980s and 1990s. At this point, more women chose nursing as a career because nursing provided a natural complement to their gifts, not because it was one of only a few options available to them. As the message of varied opportunities for women and men in nursing is shared, the social status of all nurses is


Men in Nursing At the start of the new millennium, men represented approximately 5.4% of the RN population in the United States (Trossman, 2003). By 2004, men comprised 5.8% of the RN population and then 6.6% in 2008 (USDHHS, 2010b). In 2011, 9% of all nurses were men, with male representation greatest at 41% among nurse anesthetists (U.S. Census Bureau, 2013).

This steady increase can be attributed to recruitment campaigns focused on attracting men into nursing. For example, the Oregon Center for Nursing (2002) created a poster of men in nursing with the slogan “Are you man enough to be a nurse?” The Mississippi Hospital Association published an all-male calendar with monthly features of men in nursing, ranging from men who were nursing students to practicing professionals in a variety of roles. The calendar was used as a recruiting tool to help encourage men, young and old, to consider career opportunities in nursing (Health Careers Center, 2012). These strategies help diminish the stigma associated with men in nursing.

The ANA inducted the first man into its Hall of Fame in 2004 (ANA, 2007). Dr. Luther Christman was recognized for his 65-year career and contributions to the profession, including the founding of the American Assembly for Men in Nursing. In 2007, the ANA established the Luther Christman Award to recognize the contributions of men in nursing. Current literature also helps to keep the discussion of men in nursing at the forefront. In 2006, the Men in Nursing journal was launched as the first professional journal dedicated to addressing the issues and topics facing the growing number of men who work in the nursing field.

Although a seemingly recent topic, men have served in nursing roles

throughout history. In the 13th century, men played a vital role in providing nursing care to vulnerable individuals. John Ciudad (1495– 1550) opened a hospital in Grenada, Spain, so that he (along with friends) could provide care to the mentally ill, the homeless, and abandoned children (Blais, Hayes, Kozier, & Erb, 2001). Saint Camillus de Lellis (1550–1614) was the founder of the Nursing Order of Ministers of the sick. Men in this order were charged with providing care to alcoholics and to those affected by the plague (Blais et al., 2001). In the United States, in the 1700s James Derham was an African American man who worked as a nurse in New Orleans and was subsequently able to buy his freedom and become the first African American physician in the United States.

Despite her many contributions to the nursing profession, Florence Nightingale did not encourage the participation of men in nursing. She believed that such traits as nurturance, gentleness, empathy, and compassion were needed to provide care and that these traits existed primarily in women. Nightingale opposed men being nurses and stated that their “hard and horny” hands were not fit to “touch, bathe, and dress wounded limbs, however gentle their hearts may be” (Chung, 2000, p. 38). Thus, nursing became a predominantly female discipline in the late 1800s.

Even with negative societal perceptions and stereotypes, men are now more open to pursuing nursing as a career choice (Figure 7-1). In the fall of 2003, the percentage of men enrolled in undergraduate schools of nursing was 8.4%. In 2014, the percentage of male students enrolled in baccalaureate nursing programs increased to 11.7%. Male students enrolled in master’s degree nursing programs represented 10.8% of that group of students. Male students represented 9.6% of the students enrolled in research-focused doctoral programs and 11.7% of students enrolled in practice-focused doctoral programs (American Association of

Colleges of Nursing [AACN], 2015). In 2016, males comprised 12% of students enrolled in baccalaureate and graduate nursing programs (AACN, 2017a). These increases are largely the result of diminishing misconceptions and increased recruiting efforts. Men tend to prefer distinct practice areas, including high-technology, fast-paced, and intense environments. Emergency departments, intensive care units, operating rooms, and nurse anesthesiology are examples of areas to which men are often attracted. Some speculate that men make these choices to avoid potential role strain if they were to choose other areas, such as obstetrics and pediatrics, and because they prefer areas that require more technical expertise (American Society of Registered Nurses, 2008).

Figure 7-1 More males are choosing a career in nursing, although they do tend to prefer specific practice areas.

© Monkey Business Images/iStock/Getty Images

There is some debate that men in nursing have an advantage over their female peers. It is not unusual for patients to assume that a male nurse is a physician or a medical student. On the other hand, men in nursing have been mistaken for orderlies. However, the percentage of

men in leadership roles in nursing is much higher than the percentage of men in nursing overall. This is partly because male nurses are more oriented and motivated to upgrade their professional status (American Society of Registered Nurses, 2008). As a result, women in nursing are challenged to learn how to promote themselves within the profession.

What issues and challenges do men face in nursing? According to research conducted by Armstrong (2002) and Keogh and O’Lynn (2007), male nurses may be unfairly stereotyped in the profession as homosexuals, low achievers, and feminine. These false assumptions and perceptions deter other men from entering the profession, create gender- based barriers in nursing schools, and decrease retention rates of male nurses once they are licensed. Also, because most nursing faculty are female, most nursing textbooks are written by females, and most leaders in nursing are female, men might have to learn new ways of thinking and understanding to find a comfortable place of belonging in the nursing profession. For example, it is reported that a male nursing student was having difficulty answering questions on a nursing examination. When the student shared a sample question with his wife (who was not a nurse), she answered the question correctly (Brady & Sherrod, 2003).


What advantages do women have in nursing? What advantages do men have in the profession? What are the risks of being gender exclusive?

As a consequence of gender bias, some patients might refuse or feel reluctant to allow men in the nursing role to care for them (American Society of Registered Nurses, 2008; Cardillo, 2001). During labor and delivery, patients and their partners might request a female nurse to be at the bedside. Overall, the presence of a male nurse alone in the room with

a patient is out of the ordinary. On the other hand, male nurses are assumed to be physically stronger and willing to do the heavier tasks of nursing care, such as lifting and moving patients (Cardillo, 2001). Still, many men and women are learning to appreciate and enjoy the emerging culture in the profession (Meyers, 2003). The old biases continue to disappear as patients and providers become more educated about the need for gender diversity in nursing.

Changing Demographics and Cultural Competence Despite national trends of increasing diversity, with ethnic and racial minorities reaching almost one-third of the U.S. population, minorities overall are underrepresented in the healthcare professions. The 2010 U.S. Census reports that 63.7% of the population is white and non- Hispanic. In contrast, the RN population remains predominantly female (91%) and 83.2% white, non-Hispanic (U. S. Census Bureau, 2013). Although currently most RNs are white women, more minority students are enrolling in nursing programs now than in past decades. In 2014, 30.1% of students enrolled in baccalaureate programs were minorities, as were 31.9% of nurses enrolled in master’s programs, 28.7% of nurses enrolled in practice-focused doctoral programs, and 29.7% of nurses enrolled in research-focused doctoral programs. In 2016, 32.3% of students enrolled in baccalaureate programs were minorities, as were 33.6% of nurses enrolled in master’s programs and 32.8% of nurses enrolled in research-focused doctoral programs. These numbers have increased since 2014 and have increased substantially since 2005, when only 24.1% of students enrolled in baccalaureate programs, 22% of nurses enrolled in master’s programs, and 18.4% of nurses enrolled in research-focused doctoral programs were minorities (AACN, 2015, 2017d).

In 2003, the Institute of Medicine (IOM) warned of the “unequal treatment” minorities sometimes face when encountering the healthcare system. Cultural differences, a lack of access to health care, high rates of poverty, and unemployment contribute to the substantial ethnic and racial disparities in health status and health outcomes (IOM, 2003b). Health

services research shows that minority health professionals are more likely to serve minority and medically underserved populations. Increasing the number of underrepresented minorities in the health professions as well as improving the cultural competency of providers are key strategies for reducing health disparities (Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003; IOM, 2003b).

Cultural competence in multicultural societies continues as a major initiative for health care and specifically for nursing. The mass media, healthcare policymakers, the Office of Minority Health and other governmental organizations, professional organizations, the workplace, and health insurance payers are addressing the need for individuals to understand and become culturally competent as one strategy to improve quality and eliminate racial, ethnic, and gender disparities in health care (Purnell & Paulanka, 2008).


Examples of applicable Nurse of the Future: Nursing Core Competencies

Communication (Collegial Communication & Conflict Resolution):

Knowledge (K6) Identifies cultural variations in approaches to interactions with others

Skills (S6) Applies self-reflection to better understand one’s own manner of communicating with others

Attitudes/Behaviors (A6) Identifies how one’s own personality, preferences, and patterns of behavior impact communication with others

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Culturally competent healthcare providers increase access to and satisfaction with health care. The beginning of cultural competence is self-awareness. Culture has a powerful unconscious effect on health professionals and the care they provide. Purnell and Paulanka (2008) indicate that self-knowledge and understanding promote strong professional perceptions that free healthcare providers from prejudice and facilitate culturally competent care.

Nursing has a long history of incorporating culture into nursing practice (DeSantis & Lipson, 2007). In 2008, the AACN released a publication identifying cultural competency in baccalaureate nursing education (AACN, 2008a). Yet some maintain that no matter how culturally competent the nurse might be, the patient’s experience remains structured in the nurse’s culture (Dean, 2005). Despite nurses’ best efforts to understand the culture of the patient, nurses often fail to understand that the patient might be experiencing health care for the first time not in his or her own culture but in the nurse’s culture of healthcare delivery. The understanding of this concept associated with cultural competence increases the reality of the urgency of increasing the diversity in the nursing workforce.

The Joint Commission and the National Committee for Quality Assurance also identified the need for healthcare professionals to recognize and respect cultural differences, including dialects, regional differences, and slang (Levine, 2012). In an effort to respond to this national message, many hospitals and healthcare agencies have initiated the use of interactive patient-engagement technology as part of their education programs. These services are provided in several languages, including Russian, Spanish, and Mandarin. Nurses know that illness and associated stress, pain, and fear can hinder patients’ comprehension

when learning about their condition and treatment plan. Language barriers compound the problem, resulting in major obstacles to learning and subsequent issues with adhering to the treatment plan. As nursing focuses more on cultural behaviors, norms, and practices, healthcare outcomes can move in a positive direction (Levine, 2012).


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential I: Liberal Education for Baccalaureate Generalist Nursing Practice

1.5 Apply knowledge of social and cultural factors to the care of diverse populations (p. 12)

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

As the general population of healthcare consumers becomes increasingly diverse, there is a greater need for culturally competent care (Jacob & Carnegie, 2002). To provide such nursing care, we must strive for a nursing population that more accurately represents the communities we serve. As the population continues to become more diverse, culturally competent care will be the basis for high-quality care, access to care, and alleviation of health disparities, thus promoting healthier population outcomes. Being culturally competent—that is, having the ability to interact appropriately with others through cultural understanding—is an expectation for people entering the nursing profession (Grant & Letzring, 2003), keeping in mind that there is a difference between learning of

another culture and learning from another culture.

Access to Health Care Many Americans have health insurance coverage and access to some of the best healthcare professionals in the nation. However, a large number of individuals experience disparities in our healthcare system. These disparities, or unfair differences in access, can result in poor quality and quantity of health care. According to the Agency for Healthcare Research and Quality (AHRQ, 2010), individuals who are at greatest risk for experiencing healthcare disparities are racial and ethnic minorities and those with a low socioeconomic status. Lack of health insurance is the most significant contributing factor to a decrease in disease prevention and thus is one of the foci of the Patient Protection and Affordable Care Act. Although lack of health insurance has a major effect on access to health care, other factors, such as continuity of care, economic barriers, geographic barriers, and sociocultural barriers, have a detrimental effect on the health and quality of life of individuals and are discussed in the following subsections.

Continuity of Care Individuals who have a provider or facility where they receive routine care are more likely to receive preventive health care (AHRQ, 2010). These individuals usually have better health outcomes and experience reduced disparities. In 2008, the percentage of people with a specific source of ongoing care was significantly lower for poor people than for high-income people (77.5% compared with 92.1%). The AHRQ also notes that having a routine provider of care correlates with a greater trust in the provider and an increased likelihood that the person coordinates care with the provider. In this regard, one role and responsibility of the nurse is to

educate the community and patients on the importance of continuity of care with a routine healthcare provider and/or facility.


Examples of applicable Nurse of the Future: Nursing Core Competencies

Patient-Centered Care:

Knowledge (K4c) Understands how human behavior is affected by socioeconomics, culture, race, spiritual beliefs, gender identity, sexual orientation, lifestyle, and age

Knowledge (K4d) Understands the effects of health and social policies on persons from diverse backgrounds and cultures

Skills (S4b) Implements nursing care to meet holistic needs of patient on socioeconomic, cultural, ethnic, and spiritual values and beliefs influencing health care and nursing practice

Attitudes/Behaviors (A4a) Values opportunities to learn about all aspects of human diversity and the inherent worth and uniqueness of individuals and populations

Attitudes/Behaviors (A4b) Recognizes impact of personal attitudes, values, and beliefs regarding delivery of care to diverse clients

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Economic Barriers Undoubtedly, poverty poses the greatest risk to health status (Kavanagh, 2001). The United States has a long-standing reputation for providing the

highest quality health care to persons in the highest socioeconomic strata. Likewise, the lowest quality health care is provided to those at the other end of the socioeconomic continuum (Jacob & Carnegie, 2002). As the largest segment of the healthcare industry, RNs can have a positive effect on the change required in this established system. Recognizing the stronghold that poverty currently has on the health care of citizens is a beginning to the much-needed work in the fight for equality.

Although stereotypes communicate to us that poverty is limited to certain groups, we understand that poverty affects people of all cultures and ethnicities. We must recognize the effect that poverty has on healthcare practices. If poverty were eradicated, there would be no homelessness, none who are uninsured, and no more choices between food and medicine. Until that time, nursing continues to face the challenge of meeting the needs of all people.

Geographic Barriers Those living in rural areas have unique concerns regarding access to care. As many rural hospitals close because of a lack of financing, more communities find themselves struggling to find primary care providers who will work in those areas. State and national efforts attempt to provide more service to these areas, but the demand outweighs the supply.

Urban dwellers are not immune to geographic barriers. Large cities have economically depressed sections with fewer healthcare providers than the more affluent areas. Dependency on public transportation is another factor to be managed. Finally, most rural and many urban communities do not support a full range of healthcare services in one location. These variables affect patients’ access to care and their continuation in prescribed treatment plans. It is imperative for the nurse to collaborate with other members of the healthcare team to become

aware of various services available to enhance the health and quality of life of patients.

Sociocultural Barriers The need for cultural and ethnic diversity in the nursing workforce has been discussed. Moreover, healthcare settings are challenged to provide an environment where people of various sociocultural backgrounds are respected. For example, having translators on site or within easy contact is critical for ensuring safe care to non-English-speaking clients. Written materials should also be provided in appropriate languages and at an appropriate reading level. It is not feasible or cost effective to provide educational materials and products to patients who will not use them because they are in a foreign language or too advanced. Specifically, consent forms for surgery and other procedures must be available in the client’s language. To ignore the need for language-appropriate literature leads to patient harm as well as disrespect for the uniqueness of others.

Societal Trends At any time in history, societal trends affect the nursing profession. Major current movements include incivility, violence in the workplace, global aging, consumerism, complementary and alternative care, and disaster preparedness. Discussion of these issues allows us to see more clearly the social landscape and some of the challenges we face as a profession.

Incivility Incivility, or bullying, has been exposed in the media to a great extent in the past few years. This heightened attention is partly the result of media coverage of suicide attempts and homicides that were instigated by harassment at the physical, verbal, and electronic levels. Incivility is seen in every area of society, including high school, college, and even on the job. Nursing is not immune to this behavior. Greater light has been shed on the incidence and prevalence of bullying in nurse-to-nurse, faculty-to- student, and even student-to-faculty interactions. Rocker (2008) reports that some of the behaviors include criticism, humiliation in front of others, undervaluing of effort, and teasing. It is also reported that bullying contributes to burnout, school dropout, isolation, and even attempted suicides. Bullying is costly to organizations because it contributes to increased leave, nurse attrition, and decreased nurse productivity, satisfaction, and morale.

In light of this, it is vital that the nursing profession take an active step in preventing incivility not only in our communities but also in nursing programs and places of employment. The ANA (2012) has taken such action by developing a booklet, Bullying in the Workplace: Reversing a

Culture, to help nurses recognize, understand, and deal with bullying in the work environment. The ANA supports zero-tolerance policies related to workplace bullying.


What barriers to health care do you see in your community? How are the underprivileged served in our current healthcare system?

In addition, in its professional performance standards, the ANA (2015) indicates that nurses are required to take a leadership role in the practice setting and within the profession. Two of the competencies listed that demonstrate the expected performance related to this standard include communicating in a way that manages conflict and contributing to environments that support and maintain respect, trust, and dignity.

Violence in the Workplace The violence in our society is evident and appears to be increasing in frequency and severity. What is more alarming is our desensitization to the constant exposure by Internet, radio, and television. As nurses, we can easily put a face on violence. We see the man in the emergency department with a gunshot wound to the chest. Only 30 minutes before, he was leaving work for a weekend with family when someone decided that they needed his car more than this man needed his life. We see violence at the women’s shelter when we rotate through that clinical site in community health nursing. We also see troubled individuals who take out their frustration on children, colleagues, and supervisors by going on a shooting rampage, leaving a path of death and destruction. All these examples affect nurses because we are caring for the ones who are injured and sometimes also providing care to the injurer. Nurses are

required to know how to act and to provide competent care when violent incidents occur.

Nurses must become socially aware and politically involved in preventing violence. We have to support legislation that proactively addresses violence and lobby for funding that provides nursing research into violence prevention and treatment. In every potential case, nurses must use keen assessment skills to identify people at risk and to promote reporting, treatment, and rehabilitation.

Global Aging In 2010, adults 62 years of age or older comprised 16.2% of the U.S. population (49.9 million) compared to 14.7% (41.2 million) in the year 2000. By 2030, it is estimated that the population of older adults will rise to 71 million (Howden & Meyer, 2011). By 2050, it is estimated that one in five Americans will be 65 years or older, with the greatest increases being in the group over 85 years (USDHHS, 2014).

However, this is not a trend unique to the United States. The Year of the Older Person—this is what the United Nations called the year 1999 to recognize and reaffirm global aging and the fact that our global population is aging at an unprecedented rate (Figure 7-2) (Kinsella & Velkoff, 2001). After World War II, fertility increased and death rates of all ages decreased. Not only are people in developed countries living longer and healthier but also so are those in the developing world. In the 1990s, developed countries had equal numbers of young (people 15 years or younger) and old (people 55 years or older), with approximately 22% of the population in each category. On the other hand, 35% of the people in developing countries were children compared with 10% who were older. Still, absolute numbers of older persons are large and growing. In the year 2000, more than half of the world’s older people (59%, or 249 million

people) lived in developing nations.

Figure 7-2 Nurses will care for an increasing number of older persons as this population continues to grow.

© Monkey Business Images/iStock/Getty Images

In the United States, a decrease in fertility, an increase in urbanization, better education, and improved health care all contribute to this social phenomenon. In addition, the older baby boomers who have turned 65 years of age have started to affect health care significantly with increasing numbers receiving Medicare benefits. The effect this will have on our healthcare system is daunting. According to the USDHHS (2014), more than 60% of older adults manage more than one chronic medical condition, such as diabetes, arthritis, heart failure, and dementia. Currently 46% of critical care patients and 60% of medical-surgical patients in U.S. hospitals are older adults. These acute care patients are challenging for nurses and resource intensive to the healthcare system because these vulnerable patients generally have multiple chronic conditions to treat simultaneously (Ellison & Farrar, 2015).

There is a need for clear health policy at a national level if we are to be prepared to care for the increasing number of aging citizens.

Preventive health services for older adults are delineated as provisions made in the Affordable Care Act of 2010. Healthy People 2020 included objectives specifically for older adults that should be used by healthcare professionals, including nurses, to promote healthy outcomes, including improved health, function, and quality of life for this population. Issues that emerge as nurses promote these outcomes may include coordination of care and helping older adults manage their own care (USDHHS, 2014).


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential V: Healthcare Policy, Finance, and Regulatory Environments

5.6 Explore the impact of sociocultural, economic, legal, and political factors influencing healthcare delivery and practice (p. 21).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

In response to the global aging phenomenon and the specialized set of skills required to care for older adults, most schools of nursing have either incorporated gerontology courses or increased the geriatric content throughout the curriculum. Geriatric nurse practitioner programs have grown in number, and some schools offer dual-track adult/geriatric nurse practitioner and geriatric psychiatric mental health nurse practitioner programs in graduate programs. Clinical experiences in nursing programs include many experiences with older persons. Still, as a nation, we lack an organized plan to make certain that healthcare needs will be

BOX 7-1

1. 2. 3.



met—not only for the aging but also for those who come after them.

Consumerism Since the American Hospital Association’s development of A Patient’s Bill of Rights in 1973, consumers have assumed more control of their healthcare experiences; this shift is called consumerism. The 1992 version of the document was replaced by the brochure The Patient Care Partnership: Understanding Expectations, Rights, and Responsibilities (American Hospital Association, 2003). This brochure is available in several languages and can be accessed in its entirety via the American Hospital Association website at 01/aha-patient-care-partnership.pdf. A summary of the original document is presented in Box 7-1. Gone are the days when patients blindly followed the instructions of their physicians. This is cause for celebration in the nursing arena because nursing has long sought to empower patients to take responsibility for their own health. Although pockets of medical paternalism may continue to exist, a shift has occurred, and consumers of health care now hold healthcare providers to a higher standard than ever before.


What to expect during your hospital stay:

High-quality patient care A clean and safe environment Involvement in your care

Discussing your medical condition and information about medically appropriate treatment choices Discussing your treatment plan

c. d. e.

4. 5. 6.

Getting information from you Understanding your healthcare goals and values Understanding who should make decisions when you cannot

Protection of your privacy Preparing you and your family for when you leave the hospital Help with your bill and filing insurance claims

The Picker Institute (2012) is another organization that has provided a road map to assist healthcare organizations in making rapid, dramatic advances in patient-centered care using what they call Always Events. Always Events refer to aspects of the patient or consumer experience that are so important to patients and families that healthcare providers should always get them right and include improving communication, providing consistent transitions, partnering effectively with patients and families, and improving patient safety.

Information technology has given patients an enormous resource for gaining knowledge about diseases, medications, and treatment options as well as support groups and other self-help resources. In today’s environment, healthcare consumers search for answers to their healthcare questions and compare provider and healthcare system outcomes online. Based on the information available, they are able to make informed choices related to health care.

Complementary and Alternative Approaches As the consumer’s perspective grows in influence, and individuals take on greater responsibility in their healthcare decisions, they explore approaches to health care that can actually contrast with Western traditions. Different terminology has been used synonymously to define this growing field, such as complementary care practices and alternative

medicine. According to the National Center for Complementary and Alternative Medicine (2012), “Complementary and alternative medicine is a group of diverse medical and healthcare systems, practices, and products that are not presently considered to be part of conventional medicine.” Complementary medicine refers to an approach that combines conventional medicine with less conventional options, whereas alternative medicine is an approach used instead of conventional medicine. Major types of complementary and alternative medicine include the following:

Alternative medical systems (built on complete systems of practice, such as homeopathic medicine or naturopathic medicine) Mind–body interventions (techniques designed to enhance the mind’s capacity to affect bodily function, such as meditation, prayer, music, and support groups) Biologically based therapies (use of substances found in nature, such as herbs, foods, and vitamins) Manipulative and body-based methods (based on manipulation or movement of one or more parts of the body, such as chiropractic manipulation or massage) Energy therapies (involves the use of energy fields through either biofield therapies, such as therapeutic touch, qi gong, or Reiki, or bioelectromagnetic-based therapies, such as magnetic therapy)


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential IX: Baccalaureate Generalist Nursing Practice

9.17 Develop a beginning understanding of complementary and

alternative modalities and their role in health care (p. 32).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

Alternative and complementary therapies affect the selection of traditional choices for treatment and ignoring their existence is not an option. People persist in the use of alternative and complementary therapies for obvious reasons: (1) the therapies have been found valuable, and (2) Western medicine has limited options. Many people are inclined not to divulge information about complementary therapy to their healthcare provider; however, some alternative therapies may interact with medications and may be contraindicated in certain circumstances, so it is imperative that healthcare providers seek out this information. Nurses should provide a safe, trusting atmosphere where patients feel free to discuss their healthcare routines and preferences.

Disaster Preparedness Prior to the turn of this century, disaster preparedness was not a major topic of discussion in programs of nursing. The key roles that professional nurses now play in preparing and responding to disasters have been explored only in recent history. The World Trade Center attack in 2001 and the shock of Hurricane Katrina in 2005 opened the nation’s eyes to our vulnerabilities and our strengths. As a result, disaster management has become common language in our schools, agencies, and communities.

Disaster management, plans designating responses during an emergency, are coordinated by local, state, and federal groups. Firefighters, police officers, and healthcare professionals are part of

response teams. Disaster training is also available to other volunteers. We have learned that caring for large groups affected by disaster requires an organized, thoughtful, unbiased approach. Professional nurses carry the burden of being knowledgeable about potential disasters, educating the public about the risks, and responding when persons are affected.

Disaster resources are available from many organizations. The American Red Cross and the ANA make available policies, resources, and educational opportunities on disaster preparedness for nurses. In addition, the IOM (2009) provides guidance for entities establishing standards of care for disaster preparedness. The Centers for Disease Control and Prevention (CDC) Clinician Outreach and Communication Activity program formed in 2011 in response to the anthrax attacks in the United States. The mission of the outreach program is to help healthcare professionals provide optimal care by facilitating communication between clinicians and the CDC about emerging health threats, identifying clinical issues during emergencies to help inform outreach strategies, and disseminating evidence-based health information and public health emergency messages (CDC, 2012).


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential IX: Baccalaureate Generalist Nursing Practice

9.20 Understand one’s role and participation in emergency preparedness and disaster response with an awareness of environmental factors and the risks they pose to self and patients (p. 32).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

Trends in Nursing The profession of nursing is currently facing some daunting challenges that include a projected nursing shortage, workplace issues, the education–practice gap, unclear practice roles, and changes in population demographics. Although it is true that each of these issues is not a new challenge to nursing practice, it is critical to now acknowledge the collective influence of all these together in the contemplation of future directions in professional nursing practice.

Nursing is rich in history, resilient in its journey to develop as a profession and discipline and adaptive in its practice to meet the healthcare needs of the patient. Throughout the history of nursing, there are identifiable periods of time in which the practice and education of nurses responded to the evolving changes in health care and society. Today nursing is again at the crossroads of a major transition in its education and practice. An awareness of the merging of these issues creates urgency when contemplating the role, practice, and education of nurses.

Nurse Shortage The shortage of nurses is not a new issue; the predicted nursing shortage has been prominent in the media for most of nursing’s history. Projections for the shortage are based on trends that include an increase in population, a larger proportion of elderly persons, and advances in technology and medical science. Other issues affecting the projected supply of nurses include declines in the number of nursing school graduates, aging of the RN workforce, declines in relative earning, and emergence of alternative job opportunities, especially for women, who

are still the prominent gender in nursing. History documents a cyclic pattern of nursing shortages, making it difficult to comprehend the seriousness of this shortage, especially viewed through the lens of history. The economic slowdown beginning in 2008 that resulted in decreased vacancies in healthcare agencies and the uncertainty of the consequences of healthcare reform given the Affordable Care Act (USDHHS, 2010a) further complicated predictions related to future nursing workforce needs.

Beginning in 2008, employers in various parts of the United States began to report a decrease in the demand for RNs, and nursing students report that it is more challenging after graduation to find employment. These findings have led many people to question whether the nursing shortage still existed. Experts claimed that the recession might have given some hospitals a temporary reprieve from chronic shortages, but it is not curing the longer term problem and might be making it worse (OR Manager, 2009). The Tri-Council for Nursing (2010) released a joint statement cautioning stakeholders about declaring an end to the nursing shortage. The statement says, “The downturn in the economy has led to an easing of the shortage in many parts of the country, a recent development most analysts believe to be temporary” (p. 1). The council raised serious concerns about slowing the production of RNs given the projected demand for nursing services, particularly in light of healthcare reform. It further states that diminishing the pipeline of future nurses could put the health of many Americans at risk, particularly those from rural and underserved communities, and leave our healthcare delivery system unprepared to meet the demand for essential nursing services.

Where do we stand today? A report from the Bureau of Labor Statistics (2017) on employment projections identifies the registered nursing workforce as one of the top occupations in terms of job growth through 2024, with predictions that include expected growth in the

registered nurse workforce from 2.7 million in 2014 to 3.2 million in 2024, an increase of 16%. Projections also include growth in nursing positions as well as the need for 649,100 replacement nurses, bringing the total number of job openings for nurses because of growth and replacements to 1.09 million by 2024. The AACN (2017b) reported a 3.6% enrollment increase in entry-level baccalaureate programs of nursing in 2016, but this increase will be not sufficient to meet the projected demand for nursing services. Although nursing school enrollments and graduations are increasing, “many more baccalaureate prepared nurses will be needed to meet the health care needs of the population” (AACN, 2012, p. 3).

Nurse Faculty Shortage In previous cycles of nursing shortages, the primary solution was to increase the enrollment in nursing programs. However, ample evidence supports the conclusion that a national nursing faculty shortage also exists, limiting the ability to increase student enrollment. Based on data from the 2015–2016 AACN survey, we know that the professoriate continues to age, and an exodus from the ranks of faculty looms due to retirement (Figure 7-3). The mean age of doctoral faculty holding the rank of professor is 62.2 years, for faculty holding the rank of associate professor it is 57.6 years, and for assistant professors it is 51.1 years. The national faculty vacancy rate is 7.9%. This shortage is limiting student capacity in nursing programs across the nation (AACN, 2017c).

Figure 7-3 The aging population also includes nurses and nursing faculty making solutions to the looming shortage of nurses more complicated than simply increasing enrollment in nursing


© Monkey Business Images/Shutterstock


As people age and experience health problems, their needs are often more complex and acute, thereby demanding an even more highly skilled nursing workforce. Considering the projections related to the nursing shortage, who will provide these healthcare services? Who will care for the old?

The number of nurses employed in nursing education has changed little since 1980, with 31,065 nurses working as faculty. When the number of nurse educators is compared to the increase in the number of RNs, the result is actually a decline (2.4%) in the percentage of nurses working in education (Health Resources and Services Administration [HRSA], 2010). The statistics associated with nursing faculty are concerning, especially in consideration of the nursing shortage and healthcare projections of nurse demand in the future.

Nursing Practice and Workplace Environment

Given the anticipated nursing shortage and the increased demand for nurses, it is important to address the issues associated with the practice of nursing and the environment where nurses work. It is understandable how the shortage of nurses affects the practicing nurse, especially in staff and patient ratios and workload and the resulting influences on nurse turnover rate. However, other issues associated with the nurse practice setting result in problematic quality outcomes, such as nurse job dissatisfaction, unsafe patient care, unhealthy workplace environment, and unclear role expectations.

It is evident that health care and healthcare delivery have changed significantly in the past 2 decades. Most of these changes have been associated with response to the increasing cost of care, the decreasing reimbursement to healthcare providers, increased use of technology in practice, and the knowledge explosion concerning disease management. A full discussion of each of these issues is beyond the scope of this chapter; however, it is important to note that most of the changes result from a focus on reducing the cost of health care. Cost containment strategies aim to determine the setting of the delivery of care, the length of stay in the hospital, the cost reimbursed to providers of care, and the designation of the appropriate provider of care.

Hospitals remain the most common employment setting for RNs in the United States, with 62.2% of employed RNs reporting hospitals as their primary place of employment (HRSA, 2010). Contrary to earlier predictions, the percentage of nurses working in hospitals increased from 2004 to 2008 (HRSA, 2010); however, note that the percentage of nurses working in home health services has also increased. Data from the national survey of RNs reflect that the percentage of nurses working in hospitals decreases with the increasing age of nurses, with only 50% of RNs age 55 years or older working in hospital settings.

Nurses in hospitals provide care for patients who are sicker, older,

and have more complex physical, psychosocial, and economic needs (Brown, 2004; Clark, 2004). The combination of older patients with higher acuity, sophisticated technology, and shorter hospital stays creates a chaotic environment and demands that nurses assume greater responsibility (Cram, 2011). This chaos increases not only the risk of errors in patient care but also the risk of health concerns for the nurse, such as the threat of infection, needle sticks, ever-increasing sensitivity to latex, back injuries, and stress-related health problems. In addition to these health risks, nurses are susceptible to workplace violence (e.g., physical violence, horizontal violence) and sexual harassment (Longo & Sherman, 2006; Ray & Ream, 2007; Smith-Pittman & McKoy, 1999; Valente & Bullough, 2004).

The issues associated with the hospital work environment have been shown to dominate problems and outcomes associated with nursing practice. Because of this environment, the profession of nursing has been challenged to evaluate its practice and outcomes. In fact, a majority of nurses completing surveys stated they perceived that the unsafe working environment interfered with their ability to provide quality patient care (ANA, 2011; Pellico, Djukic, Kovner, & Brewer, 2009). Staff nurses strongly desire a practice setting in which they feel that they have the ability to provide high-quality patient care (Schmalenberg & Kramer, 2008) and a work environment that facilitates clinical decision making.

Confounding the issues of the workplace environment are the shortage of qualified nonnurse healthcare workers, the supervision of unlicensed personnel, the appropriate delegation of care, mandatory overtime, and staffing ratios. The debate over the use of unlicensed personnel and the use of other licensed personnel in providing patient care is well documented in the literature (ANA, 1992, 1997, 1999; Zimmerman, 2006) despite the evidence from research studies that indicate that a decrease in RN staff increases patient care errors,

infection rates, readmission, and morbidity (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002; Sofer, 2005; Stanton & Rutherford, 2004).

Given that research indicates that a decrease in RN staff or the use of unlicensed personnel and other licensed personnel influences patient quality outcomes, what is a rationale for this practice? One answer that is quickly provided is the increased costs of a higher RN–patient ratio. Nurses represent about 23% or more of the hospital workforce. The salary of a licensed RN is higher compared to other nonphysician healthcare providers. Thus, the basic assumption is that to employ more unlicensed personnel or other licensed personnel reduces the cost of care. This assumption is not necessarily true when costs other than salary, such as costs of hiring, benefits, training, staff turnover, and responsibilities that must be assumed by a licensed care provider, are considered. Aiken et al. (2002) found that nurses in hospitals with low nurse–patient ratios are more than twice as likely to experience job- related burnout and dissatisfaction with their jobs when compared to nurses in hospitals with the highest nurse–patient ratios. Cooper (2004) and Kalisch and Kyung (2011) note that lower nursing staff ratios also indicate higher costs in a plethora of areas that reflect the actual reality of nursing practice. McCue, Mark, and Harless (2003) found that a 1% increase in nonnurse personnel increased operating costs by 0.18% and diminished profits by 0.021%. These data are significant in the overall budget considering the rising costs of health care and the current emphasis on the association of quality and safety indicators with reimbursement.

Nurse Retention There is a connection among nurse satisfaction, work environment, and nurse retention. The strongest predictor of nurse job dissatisfaction and

intent to leave a job is personal stress related to the practice environment. The various causes of job stress include patient acuity, work schedules, poor physician–nurse interactions, new technology, staff shortages, unpredictable workflow or workload, and the perception that the care provided is unsafe (Groff-Paris & Terhaar, 2010). Surveys of practicing nurses document that job dissatisfaction, patient safety concerns, decreases in the quality of care, inadequate staffing, patient care delays, and mandated overtime are issues that negatively affect nursing practice (Aiken et al., 2002; Cooper, 2004; Pellico et al., 2009). Nurses have also reported their concern about their own health and safety issues, with job stress the most frequent health problem reported.

Despite the effort to address the issues of the chaotic and potentially harmful work environment, strategies to address these issues have fallen short of the target, and the dissatisfaction of hospital nurses persists. In national studies, 41% of nurses currently working report being dissatisfied with their jobs, 43% score high in a range of burnout measures, and 22% are planning to leave their jobs in the next year. Of the latter group, 33% are younger than age 30 years (Beecroft, Dorey, & Wentin, 2008; Laschinger, Finegan, & Welk, 2009). These factors help to fuel the shortage of nurses.

In 2008, 29.3% of RNs reported that they were extremely satisfied with their principal nursing positions, 50.5% were moderately satisfied, and 11.1% were dissatisfied (HRSA, 2010). Nurses working in academic education, ambulatory care, and home health settings reported the highest rate of job satisfaction (86.6%, 85.5%, and 82.8%, respectively). Almost 12% of RNs employed in hospitals reported moderate or extreme dissatisfaction (HRSA, 2010).

The retention of competent professional nurses in jobs is a major problem of the U.S. healthcare industry, particularly in hospitals and long- term care facilities. An average yearly nurse turnover rate is reported as

between 5% and 21% (PricewaterhouseCooper’s Health Research Institute, 2007). Other research has found that during the first year of professional practice, new RNs experience turnover rates around 35% to 61% (Almada, Carafoli, Flattery, French, & McNamara, 2004). Kovner and colleagues (2007) found that 13% of newly licensed RNs had changed principal jobs after 1 year, and 37% reported that they felt ready to change jobs (Huntington et al., 2012; Pellico et al., 2009). In a comprehensive report initiated by the AHRQ, the authors found that the shortage of RNs, in combination with an increased workload, poses a potential threat to the quality of care. In addition, every 1% increase in nurse turnover costs a hospital about $300,000 a year.

Complexity of Nursing Work The healthcare workplace has changed over the past 20 years in response to economic and service pressures. However, some of these reforms have had undesirable consequences for nurses’ work in hospitals and the use of their time and skills. As the pace and complexity of hospital care increase, nursing work is expanding at both ends of the complexity continuum. Nurses often undertake tasks that less qualified staff could do, whereas at the other end of the spectrum they are unable to use their high-level skills and expertise. This inefficiency in the use of nursing time can also negatively affect patient outcomes. Nurses’ work that does not directly contribute to patient care, engage higher order cognitive skills, or provide opportunity for role expansion can decrease retention of well-qualified and highly skilled nurses in the health workforce (Duffield, Gardner, & Catling-Paull, 2008).

The major barrier to making progress in patient safety and quality is the failure to appreciate the complexity of the work in health care today. Current research focusing on work complexity and related issues enables an increased understanding of RN decision making, known as the

invisible, cognitive work of nursing, in actual care situations and demonstrates how both the knowledge and the competencies of RNs, as well as the complex environments in which RNs provide care, contribute to patient safety, quality of care, and healthy work environments or lack thereof (Ebright, 2010, Sitterding & Ebright, 2015).


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential IX: Baccalaureate Generalist Nursing Practice

9.22 Demonstrate tolerance for the ambiguity and unpredictability of the world and its effect on the healthcare system as related to nursing practice (p. 32).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

Krichbaum et al. (2007) identify a nurse care-delivery experience they term “complexity compression” and note that this experience occurs when nurses are expected to assume, in a condensed time frame, additional, unplanned responsibilities while simultaneously conducting their other multiple responsibilities. Nurses report that personal, environmental, practice, administrative, system, and technology factors, as well as autonomy and control factors, all contribute to this experience. Associated with complexity compression is the phenomenon of stacking. Stacking is the invisible, decision-making work of RNs about the what, how, and when of delivering nursing care to an assigned group of patients (Ebright, Patterson, Chalko, & Render, 2003). This process

results in decisions about what care is needed, what care is possible, and when and how to deliver this care (Figure 7-4).

Figure 7-4 Advances in health care technology over the past several decades have created complex care environments; simultaneously, nursing work has become increasingly complex.

© ERproductions Ltd/Blend Images/Getty Images

A commitment to understanding and appreciating the complexity involved in RN work is needed to guide the more substantive and sustained improvements required to achieve safety and quality. Attention to and action based on an understanding of the complexity of RN work and the value of safe, high-quality care; desired patient outcomes; and nurse recruitment and retention have the potential to achieve the goals of healthy work environments. Using complexity science to understand the work of nursing is becoming increasingly accepted as a very fitting approach to explaining healthcare organizational dynamics and the work of nursing (Lindberg & Lindberg, 2008).


Examples of applicable Nurse of the Future: Nursing Core Competencies Systems-Based Practice:

Knowledge (K2a) Understands the impact of healthcare system changes on planning, organizing, and delivering patient care at the work unit level

Attitudes/Behaviors (A2a) Appreciates the complexity of the work unit environment

Attitudes/Behaviors (A2b) Recognizes the complexity of individual and group practice on a work unit

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Nursing Education The healthcare system of the 21st century is complex, technologically rich, ethically challenging, and ever changing. The roles of all healthcare providers evolve continually, and boundaries of practice shift regularly. Knowledge explodes at unprecedented rates, and although the evidence base for practice grows stronger every day, healthcare providers must repeatedly make decisions and take action in situations that are characterized by ambiguity and uncertainty (Cowan & Moorhead, 2011).

Faculty in nursing have made efforts to transition curriculum and programs to accommodate the knowledge explosion and the advanced technology associated with health care. However, the transition within the programs of nursing has assumed a patchwork approach instead of significant reform. This is in part the result of the tradition associated with the history of nursing education, the inability to resolve the differences in prelicensure programs, and the faculty propensity to be reluctant to leave behind what is no longer successful in a changing practice arena. In addition, nurse educators are caught in the “perfect storm” composed of

a changing healthcare delivery system, changing practice models, nursing shortage, faculty shortage, changes in external standards of care and educational accreditation, university budget cuts, and changes in external funding that support new nursing programs.

In 2003, the IOM issued a report titled Health Professions Education: A Bridge to Quality (IOM, 2003a). This report, which focuses on knowledge that healthcare professionals need to provide high-quality care, states that students in the health professions are not prepared to address the shifts in the country’s demographics nor are they educated to work in interdisciplinary teams. It further states that students were not able to access evidence for use in practice, determine the reasons for or prevent patient care errors, or access technology to acquire the latest information. Specifically, the report expresses concern with the adequacy of nursing education at all levels, yet it focuses intensely on education at the prelicensure level. The report identifies five core competencies that all clinicians should possess: (1) provide patient-centered care, (2) work in interdisciplinary teams, (3) use evidence-based practice, (4) apply quality improvement and identify errors and hazards in care, and (5) utilize informatics (IOM, 2003a).

Despite these recommendations, new standards of instruction, and new competencies for postgraduates, the educational preparation of nurses has remained virtually unchanged for more than 50 years. Nursing education remains content focused and teacher centered (Valiga & Champagne, 2011). Recently the results of two national studies reinforced the belief that nursing education must be reformed. The two reports, Educating Nurses: A Call for Radical Transformation (Benner, Sutphen, Leonard, & Day, 2010) and The Future of Nursing: Leading Change, Advancing Health (IOM, 2011), explore the issue of whether nurses are entering practice equipped with the knowledge and skills needed for today’s practice and prepared to continue clinical learning for

tomorrow’s nursing, given the enormous changes in and complexity of current nursing practice and practice settings. In both reports the response is that nurses are not prepared for future healthcare change. Both reports challenge nursing education to make reforms in preparation of new graduates in terms of establishing new competencies and outcomes for graduates, new curriculum designs, new pedagogy, better evaluation models, and new models for clinical education, such as residency programs.


Examples of applicable Nurse of the Future: Nursing Core Competencies


Knowledge (K1) Identifies leadership skills essential to the practice of nursing

Skills (S1) Integrates leadership skills of systems thinking, communication, and facilitating change in meeting patient care needs

Attitudes/Behaviors (A1) Recognizes the role of the nurse as leader

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

In response to the changes in healthcare delivery and the call for new roles in nursing, two new degrees have been introduced by the AACN since the turn of the century: the doctor of nursing practice and the clinical nurse leader (AACN, 2007). The clinical nurse leader (CNL) is an advanced generalist role prepared at the master’s level of education. The CNL oversees the coordination of care for a group of patients,

assesses cohort risk, provides direct patient care in complex situations, and functions as part of an interdisciplinary team (AACN, 2007). The lateral integration of care has been what is missing in the delivery of care to patients with complex needs. No single person oversees patient care laterally and over time and is able to intervene, facilitate, or coordinate care for the entire patient experience. The CNL will be instrumental in helping all disciplines see the interdependencies that exist between and among them (Begun, Hamilton, Tornabeni, & White, 2006).

The other new program within nursing is the doctor of nursing practice (DNP). The need for this terminal practice degree is based on the series of reports from the IOM that address quality of health care, patient safety, and educational reform as well as following the movement of other healthcare professions to the practice doctorate. After much national debate, it was determined that a practice doctorate was needed that encompasses advanced nursing roles to influence healthcare outcomes for individual patients, management of care for individuals and populations, administration of nursing and health organization, and the development and implementation of health policy (AACN, 2004). It is clearly stated that this practice degree is not the same as the research doctoral degree and that graduates would be prepared to blend clinical, economic, organizational, and leadership skills and to use science in improving the direct care of patients, care of patient populations, and practice that supports patient care (Champagne, 2006).


How do changes in nursing education reflect nursing’s responsibility in the context of the social contract discussed earlier in this chapter?

The development of the DNP and CNL programs of study represents a bold effort by the profession of nursing to address new roles of nursing

and educational reform needed to prepare graduates to meet the healthcare needs of the future. Although questions and concerns related to the implementation of these new programs still exist, the evaluation of the implementation of these programs is mostly positive. One must applaud the spirit of evidence-based educational innovation.


Examples of applicable Nurse of the Future: Nursing Core Competencies


Knowledge (K5) Explains the importance, necessity, and process of change

Skills (S5a) Implements change to improve patient care

Attitudes/Behaviors (A5b) Values new ideas and interventions to improve patient care

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Closing the Education and Practice Gap The gap between education and practice looms larger as the healthcare setting continuously changes. In general, curricula in nursing programs have not evolved to keep pace with changes in the practice setting; however, the current emphasis on integrating clinical simulation, the dedicated education unit, and nurse residency programs are steps in the right direction.

Evidence supports that a better-educated nurse is needed in practice.

The initial educational preparation for the largest proportion of RNs is the associate degree. During the last national nurse survey in 2008, the initial educational level of RNs indicated that 20.4% were diploma, 45.4% were associate degree, and 34.2% were baccalaureate (HRSA, 2010). Leaders in nursing education must identify ways to move registered nurses to the desired graduate level of education more expediently.

Where do we go from here? The IOM (2011) report The Future of Nursing: Leading Change, Advancing Health provides us with a blueprint. The IOM and Robert Wood Johnson Foundation partnered to assess and respond to the need to transform nursing to ensure that the nursing workforce has the capacity, in terms of numbers, skills, and competence, to meet the present and future healthcare needs of the public. This transformation would enable nurses to be partners and leaders in advancing health for the future. The key messages of the study include the following: (1) nurses should practice to the full extent of their education and training; (2) nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression; (3) nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States; and (4) effective workforce planning and policy making require better data collection and an improved information infrastructure (IOM, 2011, p. 4). Recommendations include to (1) remove scope-of-practice barriers, (2) expand opportunities for nurses to lead and diffuse collaborative improvement efforts, (3) implement nurse residency programs, (4) increase the proportion of nurses with a baccalaureate degree to 80% by 2020, (5) double the number of nurses with a doctorate by 2020, (6) ensure that nurses engage in lifelong learning, (7) prepare and enable nurses to lead change to advance health, and (8) build an infrastructure for the collection and analysis of interprofessional healthcare workforce data. It is imperative that

professional nurses control their future and redefine their roles in practice; the recommendations and the strategies identified in this report provide the way.


Based on the trends and recommendations presented in this chapter, what do you think nursing education will look like in 2025? What do you think the profession of nursing will look like in the year 2025?

Conclusion Now, when you hear the word nursing, what image comes to mind? If the picture is blurry or confused by the expanding social context presented in this chapter—good! The cloudiness indicates that the tradition continues to be questioned. We have looked at some of the social phenomena and trends within the profession that help define nursing practice. Because those experiences change constantly, what we envision now will also be transformed. Are you ready to be a part of transforming professional nursing practice toward a future that continues to meet the needs of society?

Classroom Activity 7-1

Discuss what it means to be a professional nurse considering societal trends and the current trends in the healthcare environment and whether the identified trends pose barriers or opportunities for professional nursing practice. This could be a class discussion, online discussion, or prompt for an essay.

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Professional Nursing Practice and the Management of Patient


© James Kang/EyeEm/Getty Images


Safety and Quality Improvement in Professional Nursing Practice Kathleen Masters

Learning Objectives

After completing this chapter, the student should be able to:

1. Explore various definitions of safety. 2. Describe the system approach to patient care safety. 3. Describe organizational culture in relationship to patient safety.

4. Describe the role of nurses in delivering safe health care. 5. Explore the link between quality and safety. 6. Discuss the relationship of transparency and reporting to

healthcare quality. 7. Describe nursing-sensitive measures. 8. Discuss the need for continuous quality improvement (CQI) in

the provision of patient care. 9. Discuss the role of the nurse in quality improvement.

Key Terms and Concepts

Safety Error Culture of safety Just culture Patient handoff Never events Sentinel events Quality Quality improvement Care bundle Benchmarking Healthcare transparency Core measures Accountability measures Composite measures Nursing-sensitive measures Continuous quality improvement (CQI)

Patient Safety The definition of safety provided by the Quality and Safety Education for Nurses (QSEN) (Cronenwett et al., 2007; QSEN, 2007) project refers to the minimization of risk of harm to patients and providers through both system effectiveness and individual performance. The Massachusetts Department of Higher Education (2010) uses the QSEN definition in the development of its safety competencies for the “nurse of the future.”

In its landmark report To Err Is Human: Building a Safer Health System, the Institute of Medicine (IOM, 2000) defined patient safety as freedom from accidental injury. In the same report, it estimated that at least 44,000 and possibly up to 98,000 people died each year as the result of preventable harm while receiving health care that was supposed to help them. Subsequent to this report, the IOM produced nine more reports regarding patient quality and safety. Why? Because the original report brought attention to the problems related to patient safety that permeate the healthcare system.

Culture of Safety The IOM report (2000), although identifying alarming problems related to safety, was clear that the cause of the errors was defective system processes that either led people to make mistakes or failed to stop them from making a mistake, not the recklessness of individual providers. The report included such recommendations as the development of safer systems that would make it more difficult for humans to make mistakes.


Example of applicable outcomes expected of the graduate from a

baccalaureate program

Essential II: Basic Organizational and Systems Leadership for Quality Care and Patient Safety

2.7 Promote factors that create a culture of safety and caring (p. 14).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

The IOM report (2000) defined error as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim with the goal of preventing, recognizing, and mitigating harm. Adverse drug events and improper transfusions, surgical injuries and wrong site surgeries, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken patient identities were among the commonly occurring errors. Any aspect of required nursing care that is not provided or missed nursing care is classified as an error of omission (Kalisch, 2015) and by description is included in the IOM definition of an error.

When errors occur, it is possible to analyze the event in two ways, a person approach or a system approach. Historically, in healthcare organizations errors were viewed from the person approach to safety or finding out who is at fault. This approach results in making the person who committed the error the target of blame and creates an environment where providers fear admitting to mistakes and thus hide mistakes. This approach is counter to creating a culture of safety and transparency because it frequently results in disciplinary action. A safety culture, or culture of safety, is one that promotes trust and empowers staff to report risks, near misses, and errors (Hershey, 2015). Three key attributes in a culture of safety are trust of peers and management, reporting unsafe

conditions, and improvement. Trust and reporting are increased when staff can observe improvements being made to correct unsafe conditions (Chassin & Loeb, 2013). Trust is lacking in many healthcare organizations, with many staff believing that error reporting will be held against them (Agency for Healthcare Research and Quality [AHRQ], 2014). This lack of trust leads to underreporting of errors and to the potential for more errors (Hershey, 2015). In a culture of safety, the focus is on what went wrong rather than on who made the error. Patient safety initiatives can succeed when embedded in an organizational culture of safety (Rovinski-Wagner & Mills, 2014).

A system approach to safety includes viewing the error in the context of prevention of future errors by looking at all the factors related to the incident. Nurses working in an organization with a system approach to safety are more likely to admit to errors or near misses because the identification of system issues will lead to patient safety. The system approach does not negate the accountability of the nurse for his or her actions but allows for analysis of the error in a way that explores system problems to prevent future errors (Figure 8-1). This balance between not blaming individuals for errors and not tolerating careless or egregious behaviors is known as a just culture (Mitchell, 2008).

Figure 8-1 A person centered or blaming approach to error will not solve system issues and may lead to employees hiding errors due to fear of reprimand.

© Blaj Gabriel/Shutterstock, Inc.


Examples of applicable Nurse of the Future: Nursing Core Competencies Safety:

Knowledge (K4b) Describes factors that create a culture of safety

Skills (S4a) Participates in collecting and aggregating safety data

Skills (S4b) Uses organizational error reporting system for “near miss” and error reporting

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Measures of safety culture indicate that three areas of health care are in greatest need of improvement: a nonpunitive response to error, handoffs and transitions, and safe staffing (Hershey, 2015). If the

healthcare system does include disciplinary action for error, then the basis of the punishment should be the type of behavior rather than the outcome of the error. The types of behavior that may result in error are human behavior, negligence, intentional rule violations, and reckless conduct. Human error does not change because of disciplinary action. There are arguments for and against punishment for negligence. Much can be learned to create safer systems to prevent future errors that result from human error and negligence. In the case of intentional rule violations, it is important to look at the latent issues creating a situation in which staff are violating rules intended to promote patient safety rather than revert to discipline. However, in the case of reckless behavior, punishment is warranted (Marx, 2001).

A root cause analysis is one method to review error that has already occurred, and along with actions to eliminate risks, it is required by the Joint Commission for all sentinel events. A common approach to root cause analysis is a cause-and-effect diagram or fishbone diagram. During this process, the problem is clarified by completing an event flow diagram. The problem statement is the “head of the fish,” and the related processes or categories that are potential causes of the problem are clarified by completing an event flow diagram that consists of the main bones of the fish. Next, subcategories of causation or contributing factors are developed that create each of the smaller bones or branches of the diagram. The diagram is completed as relationships among causal chains are identified and causal statements are developed.

This process requires asking why the event happened in order to identify the underlying source of the error (Barnsteiner, 2012). This method considers elements of the total system rather than just the behavior of an individual involved in an error and can be used to review data over time to identify the system variables that contributed to errors during the identified period (Rovinski-Wagner & Mills, 2014). See Figure

8-2 for a typical fishbone diagram.

Figure 8-2 Typical fishbone diagram.

An example of the use of an ongoing root cause analysis to increase patient safety is the Taxonomy of Error, Root Cause Analysis, and Practice-Responsibility (TERCAP) initiative by the National Council of State Boards of Nursing (2013). The goal of the TERCAP initiative is to develop a data set to distinguish human and system errors from negligence or misconduct while identifying the areas of nursing practice breakdown in relation to standards of nursing practice (Malloch, Benner, Sheets, Kenward, & Farrell, 2010). Practice breakdown categories include safe medication administration, documentation, attentiveness/surveillance, clinical reasoning, prevention, intervention, interpretation of authorized providers’ orders, and professional responsibility/patient advocacy. System factors include communication, leadership/management, backup and support, environment, other health team members, staffing issues, and the healthcare team. Twenty-six state boards of nursing participate in TERCAP.


Examples of applicable Nurse of the Future: Nursing Core Competencies


Knowledge (K5) Describes how patients, families, individual clinicians, healthcare teams, and systems can contribute to promoting safety and reducing errors

Skills (S4f) Participates in safety surveys

Skills (S5) Participates in analyzing errors and designing systems improvements

Attitudes/Behaviors (A5) Recognizes the value of analyzing systems and individual accountability when errors or near misses occur

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from


Examples of applicable Nurse of the Future: Nursing Core Competencies Safety:

Knowledge (K6a) Describes processes used in understanding causes of error and in allocation of responsibility and accountability

Skills (S6b) Participates within methods for evaluating and improving the overall reliability of a complex system

Attitudes/Behaviors (A6b) Values the importance for using a model for applying the principles of reliability to healthcare systems: prevent failure, identify and mitigate failure and redesign processes on identified failure

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Another framework that is used to identify events or characteristics of a system that may allow potential errors is known as Reason’s Adverse Event Trajectory or the Swiss Cheese Model (Reason, 2000). This model explains how faults in different layers of the system can lead to error through triggers that can set up a sequence of events. Multiple defenses that have been set in place to prevent errors may at times line up, allowing multiple triggers to align and thus allow an error to occur. The lining up of triggers has been illustrated as an arrow and the lining up of defenses the alignment of holes in Swiss cheese (thus the name Swiss Cheese Model). When the defenses line up, the arrow or trigger goes through the defenses (holes) and an error may occur. When the defenses do not line up, then the trigger (arrow) is blocked and the error is averted.

Classification of Error Errors may be classified by type. Types of errors include communication, patient management, and clinical performance before, during, or after interventions. Improper delegation is an example of a patient management error. The potential for communication error occurs during transitions in care and handoffs. Standardization in handoff processes with face-to-face communication is key to patient safety. Standardized change of shift checklists and SBAR (situation, background, assessment, recommendation) are two frequently used approaches to effective communication (Barnsteiner, 2012). A patient handoff is the transfer of responsibility for a patient from one clinician to another (Rovinski-Wagner & Mills, 2014) and provides a frequent opportunity for error. Because of the vulnerability inherent in the patient handoff process, the Joint

Commission has published expectations for handoffs in the National Patient Safety Goals. These expectations include an opportunity for questioning between the giver and receiver; provision of current information regarding patient care, treatment, services, conditions, and any changes; verification of information in the form of repeat-back or read-back; the recipient of information having the opportunity to review patient data; and limits on interruptions during handoffs to minimize opportunities for information transfer failures (Barnsteiner, 2012).

Errors may also be classified according to where the error occurs in the healthcare system. These errors include latent failure, arising from decisions affecting such things as organizational policies or allocation of resources, and active failure, referring to errors or harm at the “sharp” end or in direct contact with the patient. Organizational system failures are those errors related to management, organizational culture, and system process; technical failure refers to indirect failure of facilities or external resources. These terms also help identify the root cause of harm or error (Mitchell, 2008). An example of a potential error that results from management decisions is related to staffing levels on patient care units. There is a clear and documented relationship among insufficient staffing, excessive workloads, staff fatigue, and adverse events in health care, with nurses working shifts longer than 12.5 hours being three times more likely to make a patient care error (Joint Commission, 2011).


Examples of applicable Nurse of the Future: Nursing Core Competencies Safety:

Knowledge (K3) Discusses effective strategies to enhance memory and recall and minimize interruptions

Skills (S3) Uses appropriate strategies to reduce reliance on memory and interruptions

Attitudes/Behaviors (A3) Recognizes that both individuals and systems are accountable for a safe culture

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Errors that result from human factors can be classified as skill-based, rule-based, or knowledge-based error (Henriksen, Dayton, Keyes, Carayon, & Hughes, 2008). Skill-based errors occur when there is a deviation in the pattern of a routine activity; for example, a skill-based error could result if a nurse is interrupted during medication administration. Workarounds and shortcuts by the nurse are examples of rule-based and knowledge-based errors that occur because of mistakes in conscious thought. Workarounds occur when nurses create a quick way to solve a problem caused by some obstruction to providing care. Workarounds generally occur because nurses are busy or the process is time consuming or complicated. Workarounds may result in harm to patients when system defense mechanisms are bypassed. Strategies to eliminate workarounds include the addition of nurses in workflow planning as well as mechanisms within organizations for reporting and solving workflow issues in a timely manner (Barnsteiner, 2012).


Examples of applicable Nurse of the Future: Nursing Core Competencies Safety:

Knowledge (K4a) Delineates general categories of errors and hazards in care

Skills (S4d) Utilizes timely data collection to facilitate effective transfer of patient care responsibilities to another professional during transitions in care (“handoffs”)

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Improving Patient Safety Reports prepared by the IOM propelled the quality and safety movement in the healthcare system during the first decade of the 21st century. The American Nurses Association (ANA) has contributed to patient safety through the development and dissemination of practice documents, such as Nursing’s Social Policy Statement (2010), Nursing: Scope and Standards of Practice (2015b), and Code of Ethics with Interpretive Statements (2015a), as well as through credentialing and legislative efforts (Rowell, 2003). Other organizations, such as the Joint Commission and the National Quality Forum (NQF), have also contributed to the effort to improve patient safety through the dissemination and development of standards and patient safety resources. In addition, the Centers for Medicare and Medicaid Services have linked quality indicators that relate to patient safety, such as pressure ulcer prevalence and hospital-acquired infections, with hospital payment, and some states have passed error-reporting laws. All these efforts have begun to affect patient safety.

To Err Is Human: Building a Safer Health System

In addition to drawing attention to the problem of error in the healthcare system, To Err Is Human: Building a Safer Health System (IOM, 2000) also identified system approaches to the implementation of change in the recommendation section of the report. The nine recommendations were the development of user-centered designs, avoidance of reliance on memory, attending to work safety, avoidance of reliance on vigilance, training concepts for teams, involving patients in their care, anticipating the unexpected, designing for recovery, and improving access to accurate, timely information.


Examples of applicable Nurse of the Future: Nursing Core Competencies Safety:

Knowledge (K1) Identifies human factors and basic safety design principles that affect safety

Knowledge (K2) Describes the benefits and limitations of commonly used safety technology

Skills (S1) Demonstrates effective use of technology and standardized practices that support safe practice

Skills (S2) Demonstrates effective use of strategies at the individual and systems levels to reduce risk of harm to self and others

Attitudes/Behaviors (A1) Recognizes the cognitive and physical limitations of human performance

Attitudes/Behaviors (A2) Recognizes the tension between professional autonomy and standardization

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

The development of user-centered designs builds on human strengths and avoids human weaknesses. The first step is to make things visible to users so that users can determine what actions are possible during processes. A second step is to include affordances and natural mappings in relation to equipment and workspace, which includes clear communication of how the equipment is to be used, whether by design or through symbols indicating operations. Finally, user-centered design also includes what are known as constraints or forcing functions. Constraints make it hard to do the wrong thing. A forcing function makes it impossible to do the wrong thing; for example, using different tubing connections for intravenous lines and enteral lines makes it impossible to inadvertently switch the connections. Standardization reduces reliance on memory and allows even those unfamiliar with a device to use it safely. When devices or medications cannot be standardized, they should be clearly distinguishable. In addition, simplifying procedures minimizes the chance of error because less problem solving and fewer steps are required. Work conditions, such as work hours, workloads, staffing ratios, and shift changes, that affect the circadian rhythm of the nurse affect both patient safety and worker safety. People cannot remain vigilant for long periods, so the use of checklists and auditory and visual alarms can increase patient safety by avoiding reliance on vigilance. Avoiding long work shifts also helps decrease errors related to the limitations in vigilance of humans. Because healthcare professionals work in teams, the establishment of training programs for interprofessional teams is recommended. As

team members, professionals must trust the judgment and expertise of colleagues. Patients and family members should be invited to be active partners in the care process. The healthcare team is able to provide better care when they are able to obtain accurate information from patients, and safety improves when patients and their caregivers know about their care. Whenever there are changes in an organization or technologies, healthcare professionals should anticipate the unexpected, which includes the possibility of an increase in error. Most organizations pilot new technologies prior to organization-wide implementation in order to test and modify as necessary to decrease the potential of unintended harm. Another recommendation includes the assumption that errors will occur and to design and plan for recovery from errors. An example of a strategy used to anticipate and plan for recovery from error is using simulation training to rehearse procedures for responding to adverse events. Finally, improving access to accurate, timely information, such as the use of decision-making tools at the point of care, will increase patient safety. Information coordinated across settings will also improve patient safety (Donaldson, 2008).

Crossing the Quality Chasm: A New Health System for the 21st Century Building on the previous IOM report (2000), Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001) introduced performance expectations to create a system in which patients are assured care that is safe, timely, effective, efficient, equitable, and patient

centered. These expectations are known as the six aims for improving healthcare quality and are sometimes referred to in the literature as STEEEP.

In addition, the report outlined 10 rules for redesign to move the healthcare system toward the identified performance expectations. Most of the rules relate primarily to quality, but one of the rules is specific to safety. Rule number six states that safety is a system property. This means that patients should be safe from harm caused by the healthcare system and that reducing risk and ensuring safety require attention to system processes.

Keeping Patients Safe: Transforming the Work Environment of Nurses Nurses are the healthcare professionals who spend the most time with patients and who provide the majority of direct care to patients. The IOM (2004) report Keeping Patients Safe: Transforming the Work Environment of Nurses specifically addressed the link between the work environment of nurses and patient quality and safety. The report identified six major concerns related to direct care in nursing: monitoring patient status and surveillance, physiologic therapy, helping patients compensate for loss of function, emotional support, education for patients and families, and integration and coordination of care. Some of the key safety recommendations of this report included that the chief nursing executive should have a leadership role in the organization, the creation of satisfying work environments for nurses, evidence-based nurse staffing and scheduling to control fatigue, giving nurses a voice in patient care delivery, and designing work environments and cultures that promote patient safety.

Medication error is an area that affects nurses and is directly affected

by nurses because nurses are primarily responsible for medication administration in acute care settings. Medication errors make up the largest category of errors, with 3% to 4% of patients experiencing a serious error during hospitalization (IOM, 2006). Medication error accounts for over 7,000 deaths per year; on average, a patient in an inpatient setting will experience at least one medication error per day (Aspen, Walcott, Bootman, & Cronenwett, 2007). In response to these errors, the IOM (2006) made several recommendations to decrease medication error and to increase patient safety. These recommendations included a paradigm shift in the patient–provider relationship in which the patient takes an active role in the healthcare process and the provider does a better job of educating the patient about medications (Figure 8-3). Additional recommendations included using information technology to reduce medication errors, improving medication labeling and packaging, and policy changes to encourage the adoption of practices that will reduce medication errors.

Figure 8-3 The nurse has a responsibility to educate the patient about medications. © phakimata

Other Safety Initiatives

The goal of the NQF (2010) is to improve the quality of health care by setting national goals for performance improvement, endorsing national consensus standards for measuring and public reporting on performance, and promoting the attainment of national goals. The original set of the NQF–endorsed safe practices was released in 2003, and it was updated in 2006, 2009, and again in 2010 with the most current evidence. The endorsed safe practices “were defined to be universally applied in all clinical settings in order to reduce the risk of error and harm for patients” (NQF, 2010, p. i). The NQF presents 34 practices that have been shown to decrease the occurrence of adverse health events. The practices are organized into seven categories for improving patient safety: creating and sustaining a culture of safety; informed consent, life-sustaining treatment, disclosure, and care of the caregiver; matching healthcare needs with service delivery capability; facilitating information transfer and clear communication; medication management; prevention of healthcare- associated infections; and condition and site-specific practices that include such topics as fall prevention, pressure ulcer prevention, and wrong site surgery (NQF, 2010).


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential III: Scholarship for Evidence-Based Practice

3.8 Acquire an understanding of the process for how nursing and related healthcare quality and safety measures are developed, validated, and endorsed (p. 16).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

The NQF (2010) also endorses a list of 29 preventable, measurable, serious adverse events for public reporting. These events are known as never events. Never events are not expected, and Medicare has eliminated reimbursement for certain never events. Example never events include patient suicide, sexual assault on a patient, abduction of a patient, patient death associated with a fall, infant discharged to the wrong person, surgery performed on the wrong body part, and patient death or disability associated with the use of restraints or bedrails (Haviley, Anderson, & Currier, 2014). These never events are organized into seven categories—six relating to provision of care (surgical or invasive procedure events, product or device events, patient protection events, care management events, environmental events, and radiologic events) and one category relating to four potential criminal events. The NQF acknowledges that a healthcare organization cannot eliminate all risk of adverse events; however, it can take measures to reduce risk.

In 2002, the Joint Commission introduced the National Patient Safety Goals in order to promote improvements in patient safety. These goals are reviewed and updated annually and focus on systemwide solutions to problems identified in healthcare organizations (Barnsteiner, 2012). National Patient Safety Goals are organized by setting but are very similar across settings. The Hospital National Patient Safety Goals for 2018 include identifying patients correctly, using medications safely, improving staff communication, using alarms safely, preventing infection, identifying patient safety risks (suicide risk), and preventing mistakes in surgery (Joint Commission, 2018a).

Never events are also sentinel events. A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof and is termed sentinel because the

event signals the need for immediate investigation and response. Organizations are not required to report sentinel events to the Joint Commission, but those accredited by the Joint Commission are encouraged to do so. Examples of sentinel events include wrong patient, wrong site, wrong procedure, delay in treatment, operative or postoperative complication, retention of foreign body, suicide, medication error, perinatal death or injury, and criminal events. Between 1995 and 2017, 13,688 sentinel events were reviewed by the Joint Commission, most of which were self-reported occurrences in hospital settings (Joint Commission, 2018d). State laws generally require the reporting of sentinel events.


Examples of applicable Nurse of the Future: Nursing Core Competencies Safety:

Knowledge (K6b) Discusses potential and actual impact of established patient safety resources, initiatives and regulations

Skills (S6a) Uses established safety resources for professional development and to focus attention on assuring safe practices

Attitudes/Behaviors (A6a) Values the systems’ benchmarks that arise from established safety initiatives

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

With all these reports and initiatives related to patient safety, have we made progress over the past decade? Progress toward IOM goals has

been slow, but studies show that there has been some measurable progress in relation to patient safety. Healthcare organizations have responded to incentive programs, accreditation standards, and public opinion. Professional organizations have responded with revisions to professional standards that place more emphasis on healthcare quality and patient safety. Educators have responded by revising curricula to infuse quality and safety concepts into student didactic and clinical experiences guided by such projects as the QSEN initiative (QSEN, 2007) and Nurse of the Future (Massachusetts Department of Higher Education, 2010, 2016).

When we talk about the reports and the data, we see the scope of the problem; however, when we see and hear patient stories, we understand the effect of healthcare error on patient lives. Numerous videos are available that relay the stories of patients who became victims of faulty systems and errors during their care. Some of the families of patient victims have used their devastating experience to try to improve the healthcare system and prevent other to patients and families from suffering.

Quality Improvement in Health Care The overall quality of health care and patient safety is improving, particularly for hospital care and for measures that are being publicly reported by the Centers for Medicare and Medicaid Services (CMS). According to the Agency for Healthcare Research and Quality, hospital care was safer in 2013 than it was in 2010, with 17% less harm to patients and an estimated 1.3 million fewer hospital-acquired conditions and 50,000 fewer deaths. We have come a long way; however, quality is still far from optimal, with millions of patients harmed by the care they receive and with only 70% of recommended care being delivered across a broad array of quality measures (AHRQ, 2015).

Many reports, such as the one just cited, refer to quality and safety together. But what do we mean in health care when we speak about quality? According to the IOM (2001), quality is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Because professional knowledge is continually increasing, quality is a moving target; because quality is a moving target, there will always be room for quality improvement.


Examples of applicable Nurse of the Future: Nursing Core Competencies Safety:

Skills (S4c) Communicates observations or concerns related to hazards and errors involving patients, families, and/or healthcare team

Skills (S4e) Discusses clinical scenarios in which sensitive and skillful

management of corrective actions to reduce emotional trauma to patients/families is employed

Attitudes/Behaviors (A4a) Recognizes the importance of transparency in communication with the patient, family, and health care team around safety and adverse events

(A4b) Recognizes the complexity and sensitivity of the clinical management of medical errors and adverse events

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

What is quality improvement? Quality improvement refers to the use of data to monitor the outcomes of care processes and uses improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems (Cronenwett et al., 2007; Massachusetts Department of Higher Education, 2010; QSEN, 2007). Quality improvement focuses on systems, processes, satisfaction, and cost outcomes, usually within a specific organization. Quality improvement models assume that the process is continuous and that quality can always be improved, whereas quality assurance models seek to ensure that current quality exists (Owens & Koch, 2015).

As mentioned previously, Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001) introduced performance expectations to create a system where patients are assured care that is safe, timely, effective, efficient, equitable, and patient centered (STEEEP). Safe care refers to avoiding harm to patients from care that is supposed to help them. Timely care includes reducing delays for those who receive care and for those who provide care. Effective care refers to the provision of services based on evidence to all who could benefit and

refraining from providing services to those not likely to benefit. Efficient care refers to avoiding waste. Equitable refers to providing care that does not vary in quality based on such characteristics as ethnicity, gender, socioeconomic status, or geographic location. Patient-centered care refers to providing care that is responsive to patient preferences, needs, and values and ensuring that patient values guide clinical decisions.

In addition, the report outlined principles or rules for redesign to move the healthcare system toward the identified performance expectations. The 10 rules for redesign follow:

Care is based on continuous healing relationships with patients receiving care whenever and wherever it is needed. Care can be customized according to the patient’s needs and preferences, even though the system is designed to meet the most common types of needs. The patient is the source of control and as such should be given enough information and opportunity to exercise the degree of control the patient chooses regarding decisions that affect him or her. Knowledge is shared and information flows freely so that patients have access to their own medical information.


How do best practices contribute to quality and safety?

Decision making is evidence based; that is, it is based on the best available scientific knowledge and should not vary illogically between clinicians or locations. Safety is a system property, and patients should be safe from harm caused by the healthcare system. Transparency is necessary where systems make information

available to patients and families that enable them to make informed decisions when selecting a health plan, hospital, or clinic or when choosing alternative treatments. Patient needs are anticipated rather than the system merely reacting to events. Waste of resources and patient time is continuously decreased. Cooperation among clinicians is a priority to ensure appropriate exchange of information and coordination of care (IOM, 2001).


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential II: Basic Organizational and Systems Leadership for Quality Care and Patient Safety

2.8 Promote achievement of safe and quality outcomes of care for diverse populations (p. 14).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

This IOM report and the quality reports that followed set the quality standard for the healthcare system. Because patient safety and the quality of health care cannot be separated, the report addressed both. Recommendations in this report have affected healthcare professional education, innovation in the realm of information technology for use in health care, accreditation, and regulation as well as policies to align payment for healthcare services with outcomes and purchasing of health care with outcomes.

Another organization that has contributed to the quality movement is the Institute for Healthcare Improvement (IHI). In 2001, the IHI and the Voluntary Hospital Association collaborated to determine specifically how to achieve good outcomes with high levels of reliability in critical care units. The result of this collaborative initiative was the development of the concept of care bundles. A care bundle is defined by IHI as a small set of evidence-based interventions for a defined population of patients and care settings. Several bundles have been developed, but the original two bundles developed from the initiative were the IHI ventilator bundle and the IHI central line bundle. The use of bundles has significantly increased quality of care and improved patient outcomes (Owens & Koch, 2015).

One of the best-known initiatives of the IHI was the 100,000 lives campaign when hospitals were challenged to extend or save 100,000 lives from January 2005 to June 2006 by deploying rapid response teams; delivering reliable, evidence-based care for acute myocardial infarction; preventing adverse drug events; preventing central line infections; preventing surgical site infections; and preventing ventilator- associated pneumonia. The goal of the next campaign was to prevent harm to 5 million lives from 2006 to 2008 by preventing pressure ulcers; reducing methicillin-resistant Staphylococcus aureus; preventing harm from high-alert medications; reducing surgical complications; delivering reliable, evidence-based care for congestive heart failure to reduce readmission; and getting boards of directors involved by defining and spreading new and leveraged processes for hospitals’ boards of directors so that they could become far more effective in accelerating the improvement of care (Berwick, 2014).

One of the most significant drivers of the quality movement in the healthcare system in the United States has been the implementation of pay for performance and more recently value-based purchasing. In a pay-for-performance approach, there is financial benefit for healthcare

providers to report measures and to give high-quality care. Value-based purchasing combines quality and payment but also includes strategies to direct purchasers to high-performing institutions and health plans. Examples of these approaches include hospitals not being paid for secondary diagnoses related to preventable adverse events, such as harm from fall, hospital-acquired infection, or wrong site surgery, and the systems that make these types of data available to consumers (Johnson, 2012).

Quality Improvement Measurement and Process Quality improvement is data driven. One must have data to measure the effectiveness of care or the outcomes of care in order to know how good the care was that was provided to the patient. Another requirement for data to be useful is that language is consistent across institutions. For example, if one institution reports a fall only if the patient lands on the floor and another institution reports a fall based on the patient falling, even though she is caught before landing on the floor, fall data will be measuring different phenomena in the two institutions (Johnson, 2012). For data to be meaningful, the measures must be valid. For data to be comparable across multiple institutions, the data must reflect measures of the same phenomena. Data collected can then provide information related to how much care varies among nurses, units, and organizations as well as from the standard that is based on current professional knowledge.


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential II: Basic Organizational and Systems Leadership for Quality Care and Patient Safety

2.6 Apply concepts of quality and safety using structure, process, and outcome measures to identify clinical questions and describe the process of changing current practice (p. 14).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

In addition, measures of quality may vary based on various perspectives. For example, hospital administrators may define quality in terms of patient satisfaction, physicians may define quality in terms of treatment of disease, and nurses may define quality in terms of meeting all goals made with patients (Amer, 2013). Regardless of the quality indicators chosen, measures are the most useful when they can be compared with measures that are considered the standard or best practice measures, thus allowing institutions to compare outcomes. Commonly, benchmarks are national or state averages and may include highest and lowest score by category (Johnson, 2012). Benchmarking may be defined as seeking out and implementing best practices or seeking to attain an attribute or achievement that serves as a standard for other institutions to emulate. Benchmarking may be either internal or external. Internal benchmarking may have the limitation of small numbers of units for comparison, whereas external benchmarking allows comparison with large numbers and top performers. Using benchmarking, data are compared to determine level of performance and use a systematic method to identify a problem, select best practices, determine how best practices fit the unit or organization, initiate a change process, and evaluate outcomes (Vottero, Block, & Bonaventura, 2012).


Examples of applicable Nurse of the Future: Nursing Core Competencies Quality Improvement:

Knowledge (K1) Describes the nursing context for improving care

Skills (S1a) Actively seeks information about quality initiatives in their own care settings and organization

(S1b) Actively seeks information about quality improvement in the care setting from relevant institutional, regulatory and local/national sources

Attitudes/Behaviors (A1) Recognizes that quality improvement is an essential part of nursing

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Benchmarking begins with identification of the quality indicator that will be measured. Quality indicators are classified as structure, process, or outcome indicators. Structure indicators reflect attributes of the care environment and may include elements like staffing or availability of technology. Process indicators include the evidence-based interventions or actions that help achieve outcomes. Outcome indicators include the end results of care delivery, such as hospital-acquired infection or pressure ulcer (Vottero et al., 2012).

Healthcare Quality Reporting Healthcare transparency tends to improve care because the public availability of data allows patients to make informed choices about where they want to receive healthcare services. Healthcare transparency, as defined by the IOM (2001), is making information on the healthcare system’s quality, efficiency, and consumer satisfaction with care, which includes safety data, available to the public so that patients and families can make informed decisions when choosing care and to influence the behavior of providers, payers, and others to achieve better outcomes.

Numerous websites are available that allow consumers to access information related to provider and healthcare system safety and quality. Some of the best-known sites include:

CMS: CMS Home Health Compare: The Joint Commission Quality Check: The Leapfrog Group Hospital Safety: United Health Foundation: IPRO: IPRO: Why Not the Best? The Commonwealth Fund:

In 1998, the Joint Commission launched the first national program for the measurement of hospital quality, initially requiring only the reporting of nonstandardized data on performance measures. In 2002, accredited hospitals were required to collect and report data for at least two of four core measure sets; these data were made publicly available by the Joint Commission in 2004 (Chassin, Loeb, Schmaltz, & Wachter, 2010).

From this beginning, we now have a healthcare quality landscape in which the National Quality Forum has endorsed more than 600 quality measures, and the CMS has begun to financially penalize hospitals based on performance (Chassin et al., 2010). The Joint Commission has collaborated with the CMS to align common measures to provide hospitals with some relief related to numerous data collection requirements. The system in place allows the same data sets to be used to satisfy multiple data requirements. For example, the Joint Commission and the CMS common measures, as well as Joint Commission–only measures, are used in the CMS Quality Reporting Programs, and the

CMS Hospital Compare website reflects measures that the CMS and the Joint Commission have in common (Joint Commission, 2018b).

In 2002, the Joint Commission introduced the core measures program. Core measures are standardized performance indicators. Because the indicators are standardized, they allow for comparison of the measures across healthcare organizations and over time (Haviley et al., 2014).

Measurement of performance indicator data reporting has been integrated into the accreditation process by the Joint Commission through what is known as the ORYX initiative. The initiative was one of the Joint Commission’s first steps to focus the accreditation process on an ongoing picture of performance to facilitate focus on continuous quality improvement related to patient care, treatment, and service issues versus looking at data only once every 3 years during the accreditation visit (Joint Commission, 2017b).

For several years hospitals were required to report on four mandatory measure sets: acute myocardial infarction, heart failure, pneumonia, and surgical care improvement. In 2012, the Joint Commission also reclassified process performance measures into accountability and nonaccountability measures. Accountability measures are evidence- based care processes closely linked to positive patient outcomes (Joint Commission, 2017a). Accountability measures are quality indicators that must meet four criteria and that are designed to identify measures that produce the greatest positive effect on patient outcomes when hospitals demonstrate improvement. The four criteria used to determine if an indicator is an accountability measure are as follows:

1. Research: Strong scientific evidence demonstrates that performing the evidence-based care process improves health outcomes.

2. Proximity: Performing the care process is closely connected to the

patient outcome. 3. Accuracy: The measure accurately assesses whether the care

process has actually been provided. 4. Adverse effects: Implementing the measure has little or no chance of

inducing unintended adverse consequences (Joint Commission, 2017a).

Measures that meet all four criteria can be used by organizations for purposes of accountability, such as public reporting and accreditation. Those measures that are not designated as reportable accountability measures are still useful for quality improvement within individual healthcare organizations (Joint Commission, 2018b).

Composite measures combine the results of related measures into a single percentage rating calculated by adding up the number of times recommended evidence-based care was provided to patients and dividing this sum by the total number of opportunities to provide this care. Composite accountability measures are derived from 44 accountability measures within the 10 sets of measures. The current 10 sets of measures are heart attack care, heart failure care, pneumonia care, surgical care, children’s asthma care, inpatient psychiatric services, venous thromboembolism care, stroke care, immunization, and perinatal care.

Hospitals now have greater flexibility in meeting the performance measure requirements. Data reporting requirements are intended to support healthcare organizations in their quality improvement efforts and are available to the public on the Joint Commission website at The public availability of performance measure data permits comparisons of hospital performance at the state and national levels by consumers (Joint Commission, 2017b, 2018c).

Measures of Nursing Care Quality measurement can be viewed in terms of structure, process, and outcome. Structure refers to the context of healthcare delivery and includes such things as buildings, staffing, and equipment. Process refers to the delivery of care, which includes the interactions between providers and patients. Finally, outcomes refer to the effect of health care on the health status of patients and populations. Using this framework, appropriate structure is required to support processes that will lead to desired outcomes (Donabedian, 1966). It stands to reason, then, that if the outcome measured has not achieved the desired standard, some attention should be given to the structures and processes in place that affect the outcome in order to achieve the desired standard. This framework is proving successful for increasing the quality of care provided to patients. It is important to note, however, that although tremendous strides have been made, most of the measures captured in the standardized data sets described previously relate to outcomes of medical care processes rather than reflect the effect of nursing care. The following sections describe some ongoing efforts to capture data that reflect the contribution of nursing to patient outcomes.

CAHPS Hospital Survey The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS, pronounced “H-CAPS”) survey, also known as the CAHPS Hospital Survey, is the only national survey that includes a measure of nursing quality. The survey asks a core set of questions, with four of the questions relating specifically to nursing. The standardized questions allow for comparisons of patient care experiences. For example, one question asks the patient about how often they got help as soon as they wanted after pushing the call button. The following

questions also are included in the category, How often did nurses communicate well with patients?


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential II: Basic Organizational and Systems Leadership for Quality Care and Patient Safety

2.9 Apply quality improvement processes to effectively implement patient safety initiatives and monitor performance measures, including nurse-sensitive indicators in the microsystem of care (p. 14).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

How often did nurses treat you with courtesy and respect? How often did nurses listen carefully to you? How often did nurses explain things in a way you could understand? (U.S. Department of Health and Human Services, 2011).

These are simple questions, yet one can see that they relate to quality in terms of the timeliness of care and the provision of patient- centered care. Standardized questions allow for comparisons of patient care experiences across settings.

National Voluntary Consensus Standards for Nursing- Sensitive Care Another effort to identify nursing-sensitive indicators to measure quality was born in 2003 when the Robert Wood Johnson Foundation (RWJF)

funded eight research projects to examine and evaluate existing indicators of nursing performance. The projects found that data typically did not include the specific variables that quantify aspects of nurses’ activities or contributions to quality of care. The studies also highlighted the need for “nursing-sensitive” measures. Nursing-sensitive measures were identified as patient-related processes or outcomes—or structural variables that serve as proxies to these processes and outcomes—that reflect the nurse-quality relationship (RWJF, 2011).

The RWJF turned to the NQF to endorse the compilation of nursing- sensitive measures through a consensus development process. In 2004, the NQF endorsed 15 voluntary consensus standards for nursing- sensitive care that could be used for performance measurement. These initial nursing-sensitive measures were referred to as the NQF-15 and included measures in three domains: patient-centered measures, nursing-centered measures, and system-centered measures (NQF, 2004). The original list of measures included three measures related to smoking cessation that have since been retired from the list. The current list includes 12 endorsed measures:

Death among surgical inpatients with treatable serious complications (“failure to rescue”): The percentage of major surgical inpatients who experience hospital-acquired complications and die Pressure ulcer prevalence: The percentage of inpatients who have a hospital-acquired pressure ulcer Falls prevalence: The number of inpatient falls per inpatient day Falls with injury: The number of inpatient falls with injury per inpatient day Restraint prevalence: The percentage of inpatients who have a vest or limb restraint Urinary catheter–associated urinary tract infection for intensive care

unit (ICU) patients: The rate of urinary tract infections associated with use of urinary catheters for ICU patients Central line catheter–associated bloodstream infection rate for ICU and high-risk nursery patients: The rate of bloodstream infections associated with the use of central line catheters for ICU and high-risk nursery patients Ventilator-associated pneumonia for ICU and high-risk nursery patients: The rate of pneumonia associated with the use of ventilators for ICU and high-risk nursery patients Skill mix: The percentage of registered nurse, licensed vocational/practical nurse, unlicensed assistive personnel, and contracted nurse care hours to total nursing care hours Nursing care hours per patient day: The number of registered nurses per patient day and the number of nursing staff hours (registered nurse, licensed vocational/practical nurse, unlicensed assistive personnel) per patient day Practice Environment Scale of the Nursing Work Index (composite plus five subscales):

Nurse participation in hospital affairs Nursing foundations for quality care Nurse manager ability, leadership, and support of nurses Staffing and resource adequacy Collegiality of nurse–physician relations

Voluntary turnover of nursing staff: The number of nurses who leave their jobs of their own volition during the month, by category (NQF, 2004, p. 14; RWJF, 2011, pp. 15–16)

The NQF report also identified a number of areas in which adequate measurements simply did not exist and called for further research about such topics as the relationship between nursing variables, including

staffing (turnover, experience, etc.) and patient outcomes, the contribution of nurses to pain management, and the relationship between patient outcomes and process measures for nursing-centered interventions, including measures that describe the distinctive contributions of nurses, such as assessment, problem identification, prevention, and patient education. The original work was intended to be a starting point rather than an ending point in identification of nursing- sensitive measures. The 2009 Implementation Guide for the National Quality Forum (NQF) Endorsed Nursing-Sensitive Care Performance Measures provided detailed specifications for the 12 national voluntary consensus standards for nursing-sensitive care endorsed by the NQF (Joint Commission, 2009); however, the work to identify a comprehensive set of nursing-sensitive measures is far from complete. Once rigorous studies that demonstrate reliability and validity related to a nursing- sensitive measure have been completed, they can be submitted to the NQF for possible endorsement.

National Database of Nursing Quality Indicators (NDNQI) In 1997, the American Nurses Association also began identifying nursing- sensitive measures. These data are now part of a repository known as the National Database of Nursing Quality Indicators (NDNQI). Some of the measures included in the NDNQI are also NQF-approved measures, but other measures are not included in the NQF approved measures list. The NDNQI provides reporting on structure, process, and outcome on 19 nursing-sensitive indicators at the unit level. Because the data from the NDNQI are unit-level data, they can be compared to other units in the organization or to similar units in other geographic locations. Because the data are unit based, the data have been used to demonstrate linkages between unit staffing levels and patient outcomes to demonstrate the contributions of nursing to quality patient care. Measures include patient

falls, nursing hours per patient day, staff mix, restraints, hospital-acquired pressure ulcers, nurse satisfaction, nurse education and certification, and pediatric pain assessment, among others (Montalvo, 2007). The NDNQI is currently owned and operated by Press Ganey, a healthcare improvement organization.

Quality Improvement Process and Tools Continuous quality improvement (CQI) is defined as a structured organizational process that involves personnel in planning and implementing the continuous flow of improvements in the provision of high-quality health care that meets or exceeds expectations. There are two typical pathways in the quality improvement process. The first process occurs as data that are regularly collected are monitored. If the data indicate that a problem exists, then an analysis is done to identify possible causes and a process is initiated to pilot a change. The second pathway involves the identification of a problem outside of the routine data monitoring system (Johnson, 2012).

In addition to data, CQI generally has a common set of characteristics that include a link to key elements of the organization’s strategic plan, a quality council composed of the organization’s leadership, training programs for personnel, mechanisms for the selection of improvement opportunities, the formation of process improvement teams, staff support for process analysis and redesign, policies that motivate and support staff participation in process improvement, and the application of current and rigorous techniques of scientific method and statistical process control (Sollecito & Johnson, 2013). Collaboration and evidence-based practice are also key elements of successful quality improvement programs (Caramanica, Cousino, & Petersen, 2003).

There are several quality improvement tools that can assist in monitoring measures. Common tools include histograms, control charts, run charts, and scattergrams (Figure 8-4). These tools can assist in the identification of problems by visually showing the frequency of events and events outside of set parameters (Johnson, 2012). Once problems are identified, the root cause analysis technique can be used to systematically identify the reason for the problem. A common approach to root cause analysis is to use a cause-and-effect diagram known as the Ishikawa or fishbone diagram, described previously in this chapter, which assists in identifying such problems as system issues with multiple dimensions. After all possible causes are identified, the team chooses the top two possible causes and then initiates a change process using one of several selected quality improvement methodologies.

Figure 8-4 Many types of tools are available to assist providers in monitoring quality. © Mc Satori/Shutterstock.


Examples of applicable Nurse of the Future: Nursing Core Competencies

Quality Improvement:

Knowledge (K4) Describes approaches for improving processes and outcomes of care

Skills (S4a) Participates in the use of quality improvement practices and implements changes in the delivery of care with consideration for population-based health care

Skills (S4b) Implements best practices for preventing harm

Attitudes/Behaviors (A4) Recognizes the value of what individuals and teams can do to improve care processes and outcomes of care

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Popularized by William Edwards Deming, the Deming cycle of Plan, Do, Check, Act or, as he later modified it, the Plan, Do, Study, Act (PDSA) process is the most commonly used quality improvement methodology in health care (Figure 8-5). The basic premise of the PDSA is to encourage innovation by experimenting with a change, studying the results, and making refinements as necessary to achieve sustained desired outcomes (Strome, 2013). The process includes questions and activities that guide each phase. Examples include:

Figure 8-5 Plan, Do, Study, Act (PDSA) cycle.

Plan: Begin with planning the changes to a process that are to be

implemented and tested. What is the objective? What is the test of change?

Do: Carry out the plan and make the desired changes to the process. Conduct the test. Document unexpected observations and problems.

Study: Review the effect and outcomes of the implemented changes. Analyze the data. Were the outcomes as expected? What was learned from the test?

Act: Determine if the changes can be implemented as is or if further cycles are necessary for refinement.

What modifications should be made? What is the next test? (Johnson, 2012, p. 126; Strome, 2013, p. 64)


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential II: Basic Organizational and Systems Leadership for Quality Care and Patient Safety

2.5 Participate in quality and patient safety initiatives, recognizing that these are complex system issues, which involve individuals, families, groups, communities, populations, and other members of the healthcare team (p. 14).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

Six Sigma is another quality improvement methodology frequently used in health care. The goal of Six Sigma is to decrease the defects or errors from the current level within an organization. Six Sigma uses an approach that “emphasizes the use of information and statistical analysis to rigorously and routinely measure and improve an organization’s performance, practices, and systems” (Strome, 2013, p. 71). Approaches to Six Sigma vary by organization, but initiatives generally have five elements in common. The common elements include intent, strategy, methodology, tools, and measurements. Six Sigma initiatives are undertaken with the intent of achieving significant improvement in a short time and can be applied at a corporate level or aimed strategically at an individual project. Several Six Sigma methodologies exist, but the most common one used in health care is what is known as DMAIC (Define, Measure, Analyze, Improve, Control). Tools involved in Six Sigma are numerous but fall into three categories: requirements gathering, statistical analysis, and experimentation. Finally, the most common measurements used in Six Sigma include defects/errors per unit, defects per million opportunities, and Sigma level (Strome, 2013).

The five phases of the Six Sigma methodology using the DMAIC, discussed in the following list, must always be followed in precisely the same order, but they provide a rigorous approach that is effective in identifying opportunities for improvement (Figure 8-6).

Figure 8-6 Five phases of the Six Sigma cycle. ©

Define: Clearly identify and state the problem that is the focus of the quality improvement initiative and outline the scope of the project. Determine the critical requirements and key benefits. Agree on the process to be improved and the plan to achieve the improvements. Measure: Review all available data, measure the extent of the quality problem, and obtain baseline performance information. Analyze: Use tools (such as a fishbone diagram) to study the root cause of the problem and to develop potential solution alternatives. Improve: Develop alternative processes to help achieve the desired outcomes. Evaluate the alternatives based on each one’s potential effect on the outcome, using statistical analysis to determine the highest likelihood of achieving the desired performance. Control: Sustain improvements through ongoing measurement and by conducting ongoing communication, reviews, and training (Strome, 2013, p. 72).

Another framework that is used to improve quality by identifying events or characteristics of a system that may allow potential errors to be

averted is the Reason’s Adverse Event Trajectory or the Swiss Cheese Model, discussed previously (Reason, 2000).

Regardless of the methodology chosen for a quality improvement initiative, there are some general commonalities among processes. In all successful quality improvement initiatives, the problem must be defined, opportunities for improvement must be identified, and improvement activities executed. Outcomes must be evaluated, and finally, change must be sustained (Strome, 2013).

The Role of the Nurse in Quality Improvement As early as the 1860s, Florence Nightingale measured patient outcomes in relation to environmental conditions and proposed standardization in the presentation of hospital statistics (Kovner, Brewer, Yingrengreung, & Fairchild, 2010; Owens & Koch, 2015). Today nurses continue to have a role in quality improvement.


Examples of applicable Nurse of the Future: Nursing Core Competencies Quality Improvement:

Knowledge (K3) Explains the importance of variation and measurement in providing high-quality nursing care with awareness of diverse populations and/or issues

Skills (S3) Participates in the use of quality improvement tools to assess performance and identify gaps between local and best practices

Attitudes/Behaviors (A3a) Appreciates how standardization supports high-quality patient care

(A3b) Recognizes how unwanted variation compromises care

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

The ANA standard of professional performance number 14 states that the registered nurse contributes to high-quality nursing practice with competencies that include the nurse’s role in various quality improvement activities, such as collecting data to monitor quality and collaboration with the interprofessional team to implement quality improvement plans and interventions (ANA, 2015b). Knowing that the registered nurse participates in quality improvement activities, the American Association of Colleges of Nursing (AACN, 2008) includes statements in The Essentials of Baccalaureate Education for Professional Nursing Practice related to the expectations of nurses graduating from programs of nursing in the realm of quality improvement. According to the AACN (2008), a graduate of a baccalaureate nursing program will “understand and use concepts, processes, and outcome measures . . . be able to assist or initiate basic quality and safety investigations; be able to assist in the development of quality improvement action plans; and assist in monitoring the results of these action plans” (p. 13).

The role of the nurse in quality improvement builds on the ability of the nurse to collect and analyze patient data, something all nursing students learn early in their programs of study. The novice nurse and the expert nurse alike participate in quality improvement initiatives. The novice nurse will be involved in data collection and will assist with improvement interventions, whereas the expert nurse may be leading the quality improvement initiative, but all nurses should be prepared for this nursing role (Figure 8-7).

Figure 8-7 The professional nurse is responsible for the use of quality improvement tools to assess performance and identify gaps between local and best practices.

© Blend Images - Jose Luis Pelaez Inc/Brand X Pictures/Getty.

The nurse’s role in quality improvement is especially important in hospitals that promote a culture of patient safety. Registered nurses at the bedside use quality improvement techniques that were once employed only by quality assurance personnel. Nurses actively monitor outcomes of patient care processes using spreadsheets, flow diagrams, computer programs, and control charts to record and monitor data when analyzing a clinical problem or situation. Trended data collected by nurses are provided by the risk management department or performance improvement council and disseminated to the units.


How can the commitment to quality improvement be integrated throughout all roles and at all levels of professional nursing practice?

In addition to the processes of data monitoring, analysis, and change that occur as a part of the routine quality improvement cycle, nurses are frequently involved in the identification of a problem outside of the routine

data monitoring system. Nurses may initiate the process of quality improvement based on observations of clinical issues in daily practice. These observations may lead to the conduct of health record audits to compare care provided to standards or evidence-based clinical practice guidelines. The results of such a health record audit lead to the development of a quality improvement plan to align practice with current best practices. The recommendations may be based on a variety of guidelines depending on the setting and patient population. Examples of possible guidelines for use in the audit include IHI care bundles or best practice guidelines from the Registered Nurses’ Association of Ontario. Based on the results of the health record audit, the nurse will present the data visually (as a control chart or histogram, for example) and collaborate with appropriate stakeholders to develop the quality improvement plan. The resulting quality improvement implementation plan will need to include a specific plan for sustainability and evaluation to be successful. An example template for a health record audit matrix based on guideline recommendations is provided in Table 8-1. In the example template, an x indicates that the guideline recommendation was documented in the health record. A blank indicates that there was no documentation of the recommended activity. The matrix may alternatively be marked with Y and N for yes and no because just as with a cause- and-effect diagram, there is no one correct way to create this document. The quality improvement tools should be developed in the format that best fosters data collection, analysis, and planning, evaluating, and sustaining quality outcomes.

TABLE 8-1 Example of a Simple Audit Matrix Template


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential II: Basic Organizational and Systems Leadership for Quality Care and Patient Safety

2.10 Use improvement methods, based on data from the outcomes of care processes, to design and test changes to continuously improve the quality and safety of health care (p. 14).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from


Examples of applicable Nurse of the Future: Nursing Core Competencies Quality Improvement:

Knowledge (K2) Comprehends that nursing contributes to systems of care and processes that affect outcomes

Skills (S2) Participates in the use of quality improvement models and tools to make processes of care interdependent and explicit

Attitudes/Behaviors (A2) Recognizes how team collaboration is

important to quality improvement and values the input from the interprofessional team

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Quality improvement is also tied into a nurse’s performance evaluation. Individual nurse and team goals for quality and safety are important components of each staff member’s annual review. As nursing leadership and staff foster a culture of safety and quality, they emphasize reporting near misses and unintended outcomes as a means to identify and fix weak links in processes of care (Caramanica et al., 2003). But nurses have identified challenges to their role in quality improvement processes, including adequacy of resources, engaging nurses from management to the bedside in the process, the increasing number of quality improvement activities, the administrative burden of quality improvement initiatives, and the lack of preparation of nurses in traditional nursing education programs for their role in quality improvement (Draper, Felland, Liebhaber, & Melichar, 2008). Thirty-nine percent of new graduates report that they are not prepared to adequately implement quality improvement initiatives or to use quality improvement techniques, despite having the content in their prelicensure programs (Kovner et al., 2010).

Conclusion Why is it important for nurses to be involved in quality improvement efforts? Nurses are at what is known as the sharp end of health care, meaning that nurses have significant, direct contact with patients at the bedside. Because of this closeness to clinical activity, nurses recognize the need for change, see the effects when the best care is not provided, and see the effect of changes. Thus, nurses are able to bring both clinical expertise and firsthand experience to discussions about quality improvement efforts within their organizations (Haviley et al., 2014). More than ever before, quality improvement is considered a core responsibility of the professional nurse.

Classroom Activity 8-1

Provide students with a list of measures and have students search some of the websites listed under the Healthcare Transparency heading to find safety and quality information about your local hospitals. Discuss the results in the context of quality outcomes and consumer choice.

Classroom Activity 8-2

Provide students with case studies that describe nursing errors, such as the historical case studies in Emrich (2010). Have students work in groups to either identify the root cause of the error using a fishbone diagram and then engage in a PDSA process to plan a small-scale quality improvement initiative or identify how to prevent errors such as

these using the Swiss cheese framework.

Classroom Activity 8-3

Provide small groups of students with chart audit results and appropriate clinical guidelines. The students should work together as a team to develop a quality improvement plan.

Classroom Activity 8-4

The IHI is a quality improvement organization dedicated to sharing information to improve healthcare safety. IHI Open School has free online courses and experiential learning opportunities available at Choose activities from the website for students to complete that meet specific course objectives.

Classroom Activity 8-5

Numerous classroom and clinical activities related to safety and quality improvement are available on the QSEN website at Choose activities from the website for students to complete that meet specific course objectives.

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Agency for Healthcare Research and Quality. (2015). 2014 national healthcare quality and disparities report (AHRQ Publication No. 15- 0007). Rockville, MD: Author.

American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author.

American Nurses Association. (2010). Nursing’s social policy statement: The essence of the profession. Silver Spring, MD: Author.

American Nurses Association. (2015a). Code of ethics with interpretive statements. Silver Spring, MD: Author.

American Nurses Association. (2015b). Nursing: Scope and standards of practice (3rd ed.). Silver Spring, MD: Author.

Amer, K. S. (2013). Quality and safety models. In K. S. Amer (Ed.), Quality and safety for transformational nursing: Core competencies (pp. 16–40). Boston, MA: Pearson.

Aspen, P., Walcott, J., Bootman, L., & Cronenwett, L. (2007). Identifying and preventing medication errors. Washington, DC: National Academies Press.

Barnsteiner, J. (2012). Safety. In G. Sherwood & J. Barnsteiner (Eds.), Quality and safety in nursing: A competency approach to improving outcomes (pp. 149–169). West Sussex, England: Wiley.

Berwick, D. M. (2014). Promising care: How we can rescue health care

by improving it. San Francisco, CA: Jossey-Bass. Caramanica, L., Cousino, J. A., & Petersen, S. (2003). Four elements of a successful quality program: Alignment collaboration, evidence-based practice, and excellence. Nursing Administration Quarterly, 27(4), 336– 343.

Chassin, M. R., & Loeb, J. M. (2013). High-reliability healthcare: Getting there from here. Milbank Quarterly, 91, 459–490.

Chassin, M. R., Loeb, J. M., Schmaltz, S. P., & Wachter, R. M. (2010). Accountability measures—Using measurement to promote quality improvement. New England Journal of Medicine, 363, 683–688. doi:10.1056/NEJMsb1002320

Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., . . . Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122–131.

Donabedian, A. (1966). Evaluating the quality of medical care. Milbank Memorial Fund Quarterly, 44(3 Suppl.), 166–206.

Donaldson, M. S. (2008). An overview of To Err Is Human: Re- emphasizing the message of patient safety. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses (Vol. 1, pp. 37–45; Publication No. 08-0043). Rockville, MD: Agency for Healthcare Research and Quality.

Draper, D. A., Felland, L. E., Liebhaber, A., & Melichar, L. (2008). The role of nurses in hospital quality improvement (Vol. 3). Washington, DC: Center for Studying Healthcare System Change.

Emrich, L. (2010). Practice breakdown: Medication administration. In P. E. Benner, K. Malloch, & V. Sheets (Eds.), Nursing pathways for patient safety (pp. 30–46). St. Louis, MO: Mosby.

Haviley, C., Anderson, A. K., & Currier, A. (2014). Overview of patient safety and quality of care. In P. Kelly, B. A. Vottero, & C. A. Christie- McAuliffe (Eds.), Introduction to quality and safety education for nurses

(pp. 1–37). New York, NY: Springer. Henriksen, K., Dayton, E., Keyes, M. A., Carayon, P., & Hughes, R. (2008). Understanding adverse events: A human factors framework. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses (Vol. 1, pp. 67–85; Publication No. 08-0043). Rockville, MD: Agency for Healthcare Research and Quality.

Hershey, K. (2015). Culture of safety. Nursing Clinics of North America, 50, 139–152.

Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academies Press.

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.

Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academies Press.

Institute of Medicine. (2006). Preventing medication errors: Quality chasm series. Washington, DC: National Academies Press.

Johnson, J. (2012). Quality improvement. In G. Sherwood & J. Barnsteiner (Eds.), Quality and safety in nursing: A competency approach to improving outcomes (pp. 113–132). West Sussex, England: Wiley.

Joint Commission. (2009). Implementation guide for the NQF endorsed nursing-sensitive care measure set, 2009. Retrieved from

Joint Commission. (2011). Sentinel event alert issue 48: Health care worker fatigue and patient safety. Retrieved from

Joint Commission. (2017a). Facts about accountability measures. Retrieved from Joint Commission. (2017b). Facts about ORYX® for hospitals (national hospital quality measures). Retrieved from

Joint Commission. (2018a). 2018 hospital national patient safety goals. Retrieved from

Joint Commission. (2018b). America’s hospitals: Improving quality and safety: Annual report 2017. Retrieved from

Joint Commission. (2018c). Quality check. Retrieved from

Joint Commission. (2018d). Summary data of sentinel events reviewed by the Joint Commission. Retrieved from

Kalisch, B. (2015). Errors of omission: How missed nursing care imperils patients. Silver Spring, MD: American Nurses Association.

Kovner, C. T., Brewer, C. S., Yingrengreung, S., & Fairchild, S. (2010). New nurses’ views of quality improvement education. Joint Commission Journal of Quality and Patient Safety, 36(1), 29–35.

Malloch, K., Benner, P., Sheets, V., Kenward, K., & Farrell, M. (2010). Overview: NCSBN practice breakdown initiative. In P. E. Benner, K. Malloch, & V. Sheets (Eds.), Nursing pathways for patient safety (pp. 1–29). St. Louis, MO: Mosby.

Marx, D. (2001). Patient safety and the “just culture”: A primer for health care executives. Medical event reporting system-transfusion medicine. New York, NY: Columbia University.

Massachusetts Department of Higher Education. (2010). Nurse of the future: Nursing core competencies. Retrieved from

Massachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. Retrieved from

Mitchell, P. (2008). Defining patient safety and quality care. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses (Vol. 1, pp. 1–6; Publication No. 08-0043). Rockville, MD: Agency for Healthcare Research and Quality.

Montalvo, I. (2007). The national database of nursing quality indicators (NDNQI). Online Journal of Issues in Nursing, 12(3). doi:10.3912/OJIN.Vol12No03Man02

National Council of State Boards of Nursing. (2013). Practice errors and risk factors (TERCAP). Retrieved from

National Quality Forum. (2004). National voluntary consensus standards for nursing-sensitive care: An initial performance measure set. Washington, DC: Author.

National Quality Forum. (2010). Safe practices for better healthcare 2010: A consensus report. Washington, DC: Author.

Owens, L. D., & Koch, R. W. (2015). Understanding quality patient care and the role of the practicing nurse. Nursing Clinics of North America, 50, 33–43.

Quality and Safety Education for Nurses. (2007). QSEN competencies. Retrieved from

Reason, J. (2000). Human error: Models and management. British Medical Journal, 320, 768–770.

Robert Wood Johnson Foundation. (2011). Measuring the contributions of nurses to high-value health care: Special report. Retrieved from

Rovinski-Wagner, C., & Mills, P. D. (2014). Patient safety. In P. Kelly, B. A. Vottero, & C. A. Christie-McAuliffe (Eds.), Introduction to quality and safety education for nurses (pp. 95–130). New York, NY: Springer.

Rowell, P. (2003). The professional nursing association’s role in patient safety. Online Journal of Issues in Nursing, 8(3). Retrieved from

Sollecito, W. A., & Johnson, J. K. (2013). McLaughlin and Kaluzny’s continuous quality improvement in health care (4th ed.). Burlington, MA: Jones & Bartlett Learning.

Strome, T. L. (2013). Healthcare analytics for quality and performance improvement. Hoboken, NJ: Wiley.

U.S. Department of Health and Human Services. (2011). National strategy for quality improvement in health care. Washington, DC: Author.

Vottero, B. A., Block, M. E., & Bonaventura, L. (2012). Benchmarking quality performance. In P. Kelly, B. A. Vottero, & C. A. Christie- McAuliffe (Eds.), Introduction to quality and safety education for nurses (pp. 221–247). New York, NY: Springer.

© James Kang/EyeEm/Getty Images


Evidence-Based Professional Nursing Practice Kathleen Masters

Learning Objectives

After completing this chapter, the student should be able to:

1. Describe the importance of evidence-based nursing care. 2. Identify barriers to the implementation of evidence-based nursing

practice. 3. Identify strategies for the implementation of evidence-based

nursing practice. 4. Describe how and where to search for evidence. 5. Identify methods to evaluate the evidence. 6. Discuss approaches to integrating evidence into practice. 7. Identify models of evidence-based nursing practice.

Key Terms and Concepts

Evidence-based practice PICO(T) Clinical practice guidelines

Evidence-Based Practice: What Is It? Evidence-based practice—it is more than a recent buzzword in nursing. Evidence-based practice is a mechanism that allows nurses to provide safe, high-quality patient care based on evidence grounded in research and professional expertise rather than on tradition, myths, hunches, advice from peers, outdated textbooks, or even what the nurse learned in school 5, 10, or 15 years ago. Advances in information technology have facilitated the dissemination of research and other types of evidence, making them widely available. Only 3 decades ago nurses had to hand search indexes and hard-copy journals to access research results, but nurses now have quick access to the most current evidence from professional journals and best practice guidelines available via the Internet.

Evidence-based practice provides a strategy to ensure that nursing care reflects the most up-to-date knowledge available so that what we do in practice matches what we know. Nursing practice that is based on evidence is now the accepted standard for practice as well as one of the six core competencies for all registered nurses identified in the Quality and Safety Education for Nurses (QSEN) project (Cronenwett et al., 2007). Nurses are accountable for the interventions they provide to patients. Evidence-based practice provides a systematic approach for decision making and offers a framework for the nurse to use to incorporate best nursing practices into the clinical care of patients (Pugh, 2012).


Example of applicable outcomes expected of the graduate from a

baccalaureate program

Essential III: Scholarship for Evidence-Based Practice

3.6 Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care (p. 16).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

According to the American Association of Colleges of Nursing (AACN, 2008), professional nursing practice is grounded in the translation of current evidence into practice. One of the skills expected of prelicensure graduates of nursing programs is the ability to base an individualized care plan on patient values, clinical expertise, and evidence (QSEN, 2015). In addition, Standard 13 of the standards of professional nursing practice indicates that the nurse will integrate evidence and research findings into practice (American Nurses Association [ANA], 2015).

Most nurses want to provide care for their patients based on the most current evidence, but for many nurses, trying to integrate evidence-based practice into patient care in the clinical environment raises questions. The goal of this chapter is to answer those questions. To begin with, what exactly is evidence-based practice?

Evidence-based practice is a framework used by nurses and other healthcare professionals to deliver optimal health care through the integration of best current evidence, clinical expertise, and patient/family values (QSEN, 2015). Houser (2008) describes this triad of evidence- based practice using the illustration of a three-legged stool. Just as each leg of the stool is necessary for the function of the stool, each of the three

components—best current evidence, clinical expertise, and incorporation of patient/family values—are all necessary for the effective use of evidence-based practice.


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential IX: Baccalaureate Generalist Practice

9.8 Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan (p. 31).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

Another question one might ask is, How is evidence-based practice relevant and applicable to nursing practice? Evidence-based practice is relevant to nursing practice because it does the following:

Helps resolve problems in the clinical setting Results in effective patient care with better patient outcomes Contributes to the science of nursing through the introduction of innovation to practice Keeps practice current and relevant by helping nurses deliver care based on current best research Decreases variations in nursing care and increases confidence in decision making Supports Joint Commission readiness because policies and procedures are current and include the latest research

Supports high-quality patient care and achievement of magnet status (Beyea & Slattery, 2006; Spector, 2007)

It takes approximately 17 years for clinical research to be integrated into patient care practices. Nurses and other healthcare providers can minimize the time from discovery to implementation through the process inherent in evidence-based practice that in turn will lead to improved patient outcomes. Because of the link between evidence-based practice and improved patient outcomes, the Institute of Medicine (IOM, 2008) has promoted the goal that by the year 2020, 90% of all health decisions will be based on evidence.


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential VII: Clinical Prevention and Population Health

7.5 Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan (p. 24).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

The evidence-based practice process enhances practice by encouraging reflection about what we know; it is applicable to virtually every area of nursing practice, including patient assessment, diagnosis of patient problems, planning, patient care interventions, and evaluation of patient responses. In addition, evidence can be used as the foundation for policies and procedures and as the basis for patient care

management tools, such as care maps, pathways, and protocols (Houser, 2011).

The seven steps involved in the evidence-based practice process address the question of how to begin.

1. Cultivate a spirit of inquiry and culture of evidence-based practice among nurses and within the organization.

2. Identify an issue and ask the question. 3. Search for and collect the most relevant and best evidence to answer

the clinical question. 4. Critically appraise and synthesize the evidence. 5. Integrate evidence with clinical expertise and patient preferences to

make the best clinical decision. 6. Evaluate the outcome of any evidence-based practice change. 7. Disseminate the outcomes of the change (Melnyk & Fineout-

Overholt, 2014).

Barriers to Evidence-Based Practice Because evidence-based practice is now the standard for professional nursing practice, one would think that practice based on evidence is commonplace; however, this is not the case. Practicing nurses cite many barriers to evidence-based practice. Common barriers to implementing evidence-based practice include the following:

Lack of value for research in practice Difficulty in changing practice Lack of administrative support Lack of knowledgeable mentors Insufficient time Lack of education about the research process Lack of awareness about research or evidence-based practice Research reports and articles not readily available Difficulty accessing research reports and articles No time on the job to read research Complexity of research report Lack of knowledge about evidence-based practice Lack of knowledge about the critique of articles Feeling overwhelmed by the process Lack of sense of control over practice Lack of confidence to implement change Lack of leadership, motivation, vision, strategy, or direction among managers (Beyea & Slattery, 2006; Revell, 2015; Spector, 2007)


Examples of applicable Nurse of the Future: Nursing Core


Evidence-Based Practice:

Knowledge (K2) Describes the concept of evidence-based practice (EBP), including the components of research evidence, clinical expertise, and patient/family values

Skills (S2) Bases individualized care on best current evidence, patient values, and clinical expertise

Attitudes/Behaviors (A2) Values the concept of EBP as integral to determining best clinical practice

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Additional barriers to using evidence-based practice include the overwhelming information available in the research literature that is sometimes contradictory as well as the perception that evidence-based practice is equivalent to “cookbook medicine.” In addition, there may be a perceived lack of authority for clinicians to make changes in practice or peer pressure to maintain the status quo (Houser, 2011).

Promoting Evidence-Based Practice Despite barriers, nurses are making a difference in patient outcomes through the use of evidence-based practice. Strategies that can be useful in the promotion of evidence in practice generally fall into two categories: strategies for individual nurses and organizational strategies.

Strategies for individual nurses include the following:

Educate yourself about evidence-based practice through such avenues as websites original research articles, evidence reports, conferences, and participation in professional organizations that provide resources related to evidence-based practice (Revell, 2015). Conduct face-to-face or online journal clubs that can be used to educate yourself about the appraisal of evidence, share new research reports and guidelines with peers, and provide support to other nurses. Share your results through posters, newsletters, unit meetings, or a published article to support a culture of evidence-based nursing practice within the organization and the profession. Adopt a reflective and inquiring approach to practice by questioning the rationale for approaches to care that do not result in desired patient outcomes and by continuously asking yourself and others within your organization such quesitons as “What is the evidence for this intervention?” or “How do my patients respond to this intervention?” (Beyea & Slattery, 2006; QSEN, 2015).


How do I know what I know about nursing practice? Are my nursing decisions based on myths, traditions, experience, authority, trial and

error, ritual, or scientific knowledge?


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential IX: Baccalaureate Generalist Nursing Practice

9.11 Provide nursing care based on evidence that contributes to safe and high-quality patient outcomes within healthcare microsystems (p. 31).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

Strategies for overcoming barriers and increasing adoption of evidence-based practice within an organization include:

Specific identification of the facilitators and barriers to evidence- based practice. This will require administrative support by providing the time and the funds for necessary resources as well as enhancement of job descriptions to include criteria related to evidence-based practice. Education and training to improve knowledge and strengthen beliefs related to the benefits of evidence-based practice. This may require offering incentives, such as a paid registration to a conference for the best clinical question in a unitwide contest. Creation of an environment that encourages an inquisitive approach to patient care. Achievement of this environment may require the development of a center of evidence-based practice, access to electronic resources in the workplace, providing opportunities for

nurses to collaborate with nurse researchers or faculty with nursing research expertise, and providing opportunities to disseminate the results of evidence-based practice projects (Houser, 2011, p. 12).

Whichever strategies are incorporated, it is important to note that multifaceted interventions are much more likely to be effective in facilitating evidence-based practice within an organization. It is also important to note that once evidence-based practice projects are complete, passive dissemination of results within an organization is ineffective in changing practice.

Searching for Evidence Competencies expected of the nurse include reading original research and evidence reports related to the practice area and the ability to locate relevant evidence reports and guidelines (QSEN, 2015). In order to find the evidence, the nurse must learn to ask clinical questions and to search electronic indexes and other resources (Figure 9-1).

Figure 9-1 The nurse must know both how to ask the question and how to search electronic resources for evidence.

© wavebreakmedia/Shutterstock, Inc.


How is new evidence disseminated to the bedside nurse in the organization in which you practice as a nursing student? How does the organization promote evidence-based practice? Do the nurses in the organization use current evidence in practice?

Asking the Question Nurses must learn to ask questions in a format that facilitates searching

for evidence. Developing a question that accurately reflects the practice to be evaluated, in a format that focuses the search for evidence, is a good place to begin (Tracy & Barnsteiner, 2014). It has been suggested that all nurses should learn how to use the PICO(T) format to ask clinical questions. PICO(T) is an acronym that assists in the formatting of clinical questions. Using this format helps the nurse to ask pertinent clinical questions, focus on asking the right questions, and choose relevant guidelines.

P = Patient, Population, or Problem How would I describe a group of patients similar to mine? What group do I want information on?

I = Intervention or Exposure or Topic of Interest Which main intervention am I considering? What event do I want to study the effect of?

C = Comparison or Alternate Intervention (if appropriate) What is the main alternative to compare with the intervention? Compared to what? Better or worse than no intervention at all or than another intervention?

O = Outcome What can I hope to accomplish, measure, improve, or affect?

What is the effect of the intervention? (Levin, 2006a) Some researchers also add the element of time or time frame to the

PICO question format and refer to the format as PICOT, although the time frame might not be applicable to all questions.

T = Time or Time Frame How much time is required to demonstrate an outcome? How long are participants observed?


Examples of applicable Nurse of the Future: Nursing Core Competencies

Evidence-Based Practice:

Knowledge (K1) Demonstrates knowledge of basic scientific methods and processes

Skills (S1a) Participates in the development of clinical questions for potential research (S1b) Critiques/appraises research for application to practice (S1c) Participates in data collection and other research activities (S1d) Follows the guidelines and requirements pertaining to Human Subject Protection for conducting research

Attitudes/Behaviors (A1a) Appreciates strengths and weaknesses of scientific bases for practice (A1b) Values the need for ethical conduct of practice and research

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

After determining the patient, intervention, comparison, and outcome of interest, the nurse then combines these four elements into a single question in combinations, such as the following examples:

In (patient or population), what is the effect of (intervention or exposure) on (outcome) compared with (comparison)? (Levin, 2006b) For (patient or population), does the introduction of (intervention or exposure) reduce the risk of (outcome) compared with (comparison intervention)? (Levin, 2006b)

Electronic Resources Because the PICO(T) question may have already been asked and answered by other nurses, beginning the search with sites that provide systematic reviews or guidelines is helpful (Tracy & Barnsteiner, 2014). Electronic resources are available that can assist the nurse in uncovering the most current evidence for practice in the form of systematic reviews and guidelines. Some of the most commonly used include these:

National Library of Medicine: Cochrane Library: National Guideline Clearinghouse: Joanna Briggs Institute: Agency for Healthcare Research and Quality (AHRQ): Centre for Health Evidence: Registered Nurses’ Association of Ontario: McGill University’s Ingram School of Nursing’s Clinical and Research Resources:

The Cochrane Library is a collection of databases that contain high- quality, independent evidence to inform healthcare decision making. Cochrane reviews represent the highest level of evidence on which to base clinical treatment decisions. In addition to the Cochrane systematic reviews, the Cochrane Library also offers other sources of information, including the Database of Abstracts of Reviews of Effects, Cochrane Controlled Trials Register, Cochrane Methodology Register, NHS Economic Evaluation Database, Health Technology Assessment Database, and Cochrane Database of Methodology Reviews.

Another site with high-quality evidence is the National Guideline Clearinghouse. As a part of the AHRQ, the National Guideline

Clearinghouse includes structured summaries containing information about each guideline, including comparisons of guidelines covering similar topics that show areas of similarity and differences; full text or links to full text; ordering details for full guidelines; annotated bibliographies on guideline development, evaluation, implementation, and structure; weekly email updates; and guideline archives. Guidelines may be searched by topic or by organization.

The Registered Nurses’ Association of Ontario provides high-quality best practice guidelines specifically focused on nursing care. Many of these guidelines are also available via the National Guideline Clearinghouse site. The guidelines are available online in full text and free of charge.

Electronic Indexes Reviews may also be indexed, but if no reviews or guidelines are found relevant to your PICO(T) question, then individual articles must be searched (Tracy & Barnsteiner, 2014). Electronic indexes provide options for narrowing or broadening a topic to identify relevant literature. Most electronic indexes provide citation information and will indicate if the selected articles are available locally in print form or if the items are available in an electronic format. Three of the most common electronic indexes used in health care are the Cumulative Index to Nursing and Allied Health Literature (CINAHL), available at; MEDLINE, available at; and PubMed, a web-based format of MEDLINE available at

Evaluating the Evidence Regardless of the source, the nurse needs to evaluate the quality of the evidence. By evaluating the rigor of the evidence, we can have confidence that the evidence is accurate. This is important because it could contribute to a decline rather than to an improvement in patient outcomes if we base changes to care on inaccurate research evidence (Sellers & McCrea, 2014). Begin by asking such questions as the following:

What is the source of the information? When was it developed? How was it developed? Does it fit the current clinical environment? Does it fit the current situation?

Levels of Evidence Best evidence for practice includes empirical evidence from randomized controlled trials, evidence from descriptive and qualitative research, and information from case reports, scientific principles, and expert opinion. When insufficient research is available, healthcare decision making is derived principally from nonresearch evidence sources, such as expert opinion and scientific principles (Titler, 2008).


Examples of applicable Nurse of the Future: Nursing Core Competencies

Evidence-Based Practice:

Knowledge (K3) Describes reliable sources for locating evidence reports and clinical practice guidelines

Skills (S3) Locates evidence reports related to clinical practice topics and guidelines within appropriate databases

Attitudes/Behaviors (A3) Appreciates the importance of accessing relevant clinical evidence

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Several classification systems exist to evaluate the level or strength of the evidence. The AHRQ serves as the recognized authority regarding the assessment of clinical research in the United States. Standard levels of evidence include the classifications listed here (Melnyk & Fineout- Overholt, 2014):

1. Meta-analysis or systematic reviews of multiple well-designed controlled studies

2. Well-designed randomized controlled trials 3. Well-designed nonrandomized controlled trials (quasiexperimental) 4. Observational studies with controls (retrospective, interrupted time,

case-control, cohort studies with controls) 5. Systematic review of descriptive and qualitative studies 6. Single descriptive or qualitative study 7. Opinions of authorities and/or reports of expert committees

Using this classification system, the strongest evidence comes from the first level, representing systematic reviews that integrate findings from multiple well-designed controlled studies. The weakest evidence is represented by the seventh level and is based on expert opinion (Polit &

Beck, 2017). In addition, grading the strength of a body of evidence should

incorporate three domains: quality, quantity, and consistency. Quality has to do with the extent to which a study minimizes bias in the design, implementation, and analysis. Quantity refers to the number of studies that have evaluated the research question as well as the sample size across the studies and the strength of the findings. The category of consistency refers to both the similarities and the differences of study designs that investigate the same research question and report similar findings (AHRQ, 2002; LoBiondo-Wood & Haber, 2014).

Appraisal of Research Prior to applying evidence in clinical practice, there must be an appraisal process (Figure 9-2). Key issues to address in an appraisal include the credibility of the study, including the researcher’s credentials and experience; any evidence of bias due to a conflict of interest of the researcher or the journal; the statement of a blind peer review; and dates included in the journal to indicate the timeliness of publication. In addition, appraisals should include questions about the design of the study, sample size, sampling procedures, reliability and validity of instrumentation, and appropriate statistical analysis (DelMonte & Oman, 2011).

Figure 9-2 The nurse is responsible for appraising the strength and relevance of evidence when choosing practice interventions.

© goodluz/Shutterstock.

The Critical Appraisal Skills Programme (CASP, 2010) is a resource that provides checklists that help the user to interpret research evidence. The checklists are specific to various types of research, including randomized controlled trials, systematic reviews, cohort studies, case- control studies, and qualitative studies. The checklists provide frameworks to determine the strength and reliability of research reports. CASP tools are available free of charge at (Sellers & McCrea, 2014).


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential III: Scholarship for Evidence-Based Practice

3.5 Participate in the process of retrieval, appraisal, and synthesis of evidence in collaboration with other members of the healthcare team to improve patient outcomes (p. 16).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

Appraisal of Clinical Practice Guidelines In addition to the appraisal of research, the nurse will need skill in the appraisal of guidelines to practice based on evidence. Clinical practice guidelines are developed to guide clinical practice and to represent an effort to put a large body of evidence into a manageable form. Clinical practice guidelines are usually based on systematic reviews and give specific recommendations for clinicians. Guidelines usually attempt to address all the issues relevant to a clinical decision, including risks and benefits.

The IOM (2011), at the request of the U.S. Congress, developed a set of eight standards for the development of rigorous and trustworthy clinical practice guidelines. To evaluate the effects of the standards on clinical practice guideline development and healthcare quality and outcomes, the IOM has encouraged the AHRQ to pilot test the standards and to assess their reliability and validity. The standards are:

Standard 1: Establishing transparency related to funding and development processes. Standard 2: Management of conflict of interest. Standard 3: Guideline development group composition should be multidisciplinary and balanced, including a variety of experts and patient populations. Standard 4: Use of systematic reviews that meet standards. Standard 5: Establishing evidence foundations for and rating strength of recommendations.

Standard 6: Articulation of recommendations maintains a standardized form. Standard 7: External review by stakeholders. Standard 8: Updating should occur when new evidence suggests the need for modification of clinically important recommendations.


Examples of applicable Nurse of the Future: Nursing Core Competencies

Evidence-Based Practice:

Knowledge (K4) Differentiates clinical opinion from research and evidence summaries

Skills (S4a) Applies research and evidence reports related to area of practice

(S4b) Understands the use of best practice and evidence at the patient level, clinical level, population level, and across the system

Attitudes/Behaviors (A4) Appreciates that the strength and relevance of evidence should be determinants when choosing clinical interventions

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

In addition to the relatively new IOM standards, there is an ongoing collaboration that has focused on improving the quality and effectiveness of clinical practice guidelines for over a decade. The group has established a framework for determining the quality of guidelines for diagnoses, health promotion, treatments, or clinical interventions. The instrument, known as the Appraisal of Guidelines for Research and

Evaluation (AGREE), can be used with new, existing, or updated guidelines. First published in 2003 by the AGREE Collaboration, the instrument has been revised and is now known as AGREE II (AGREE Next Steps Consortium, 2009). The AGREE II replaces the original instrument and is the preferred tool. The full version of the AGREE II instrument and training materials are available online at no cost at The AGREE instrument is composed of six categories containing the 23 items listed here as well as 2 final items that require an overall judgment about the practice guideline:

Scope and purpose Overall objectives of the guideline are specifically described. The health questions covered by the guideline are specifically described. The population (patients, public, etc.) to whom the guideline is meant to apply is specifically described.

Stakeholder involvement The guideline development group includes individuals from all relevant professions. The views and preferences of the target population (patients, public, etc.) have been sought. Target users of the guideline are clearly defined.

Rigor of development Systematic methods were used to search for evidence. The criteria for selecting the evidence are clearly described. The strengths and limitations of the body of evidence are clearly described. The methods used for formulating the recommendations are clearly described. The health benefits, side effects, and risks have been considered

in formulating recommendations. There is an explicit link between the recommendations and the supporting evidence. The guideline has been externally reviewed by experts prior to publication. A procedure for updating the guideline is provided.

Clarity and presentation Recommendations are specific and unambiguous. Different options for management of the condition or health issue are clearly presented. Key recommendations are easily identifiable.

Application The guideline describes facilitators and barriers to its application. The guideline provides advice and/or tools on how the recommendations can be put into practice. The potential resource implications of applying the recommendations have been considered. The guideline presents monitoring and/or auditing criteria.

Editorial independence The views of the funding body have not influenced the content of the guideline. Competing interests of guideline development group members have been recorded and addressed (AGREE Next Steps Consortium, 2009, pp. 2–3).

The usefulness of a guideline depends on whether the actual recommendations in the guideline are meaningful and practical. Recommendations should be practical in relation to implementation, be as unambiguous as possible, address the frequency of screening and follow-up, and address clinically relevant actions. Other questions that

the clinician must address in relation to guidelines include such factors as the setting of care, the patient population, and the strength of the recommendations (Beyea & Slattery, 2006).

Implementation Models for Evidence-Based Practice A number of models have been developed to guide the design and implementation and to strengthen evidence-based decision making. Forty-seven prominent evidence-based practice models can be identified in the literature (Stevens, 2013).

Differences exist among evidence-based practice models, but most models do have common elements that include selection of a practice topic, critique and synthesis of evidence, implementation, evaluation of the effect on patient care and provider performance, and consideration of the context in which the practice is implemented (Titler, 2008). No one model of evidence-based practice is a perfect fit for every organization. Some models focus on the perspective of the individual clinician, or the researcher, whereas others focus on institutional efforts. Therefore, before embarking on this journey, the nurse or organization should consider several models and select or adapt one that fits the needs of the nurse or organization.


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential III: Scholarship for Evidence-Based Practice

3.2 Demonstrate an understanding of the basic elements of the research process and model for applying evidence to clinical practice (p. 16).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

ACE Star Model of Knowledge Transformation The Center for Advancing Clinical Evidence (ACE) Star Model of Knowledge Transformation, developed by Dr. Kathleen Stevens, is available at The model involves five steps: knowledge discovery, evidence summary, translation into practice recommendations, integration into practice, and evaluation. Discovery refers to the original research. During the second step, the task is to synthesize all the related research into a meaningful whole. It is during this step that information is reduced to a manageable form. During the step of translation, the scientific evidence is considered in the context of clinical expertise and values. This results in clinical practice guidelines, best practices, protocols, standards, or clinical pathways. During the stage of implementation, changes take place in practice. During evaluation, the effect of the change is measured. Such variables as specific health outcomes, length of stay, or patient satisfaction are examples of possible outcomes that might be examined.

The Iowa Model of Evidence-Based Practice The Iowa Model of Evidence-Based Practice resembles a decision- making tree that identifies either problem-focused or knowledge-focused triggers that initiate the process in the organization. Problem-focused triggers within an organization can include risk management data, process improvement data, benchmarking data, financial data, or the identification of clinical problems. Knowledge-focused triggers within an organization can include the publication of new research or literature, a

change in organizational standards and guidelines, changes in philosophies of care within the profession or organization, or questions from an institutional standards committee. Once there is either a problem-focused or a knowledge-focused trigger within the organization, a team must identify whether the topic is a priority for the organization. If the topic is indeed a priority, evidence is examined, and the change in practice can be piloted. This process is followed by monitoring and analysis of both the process and the outcome data and finally by dissemination of the results.

Agency for Healthcare Research and Quality Model A model for maximizing and accelerating the transfer of research results from the AHRQ patient safety research portfolio to healthcare delivery includes three major stages of knowledge transfer: (1) knowledge creation and distillation, (2) diffusion and dissemination, and (3) organizational adoption and implementation. More specifically, knowledge creation and distillation refer to conducting research and then packaging relevant research findings into usable form, such as practice recommendations. The diffusion and dissemination stage involves partnering with professional leaders, professional organizations, and healthcare organizations to disseminate knowledge to potential users, such as nurses, physical therapists, or physicians. During the final stage of the process, the focus is on organizational adoption and implementation of evidence-based research findings and innovations in practice. In this model, the stages of knowledge transfer are viewed from the perspective of the researcher or the creator of new knowledge and begin with decisions about which research findings ought to be disseminated (Titler, 2008).


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential III: Scholarship for Evidence-Based Practice

3.7 Collaborate in the collection, documentation, and dissemination of evidence (p. 16).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from


Examples of applicable Nurse of the Future: Nursing Core Competencies

Evidence-Based Practice:

Knowledge (K5) Explains the role of evidence in determining best clinical practice

Skills (S5) Facilitates integration of new evidence into standards of practice, policies, and nursing practice guidelines

Attitudes/Behaviors (A5a) Questions the rationale of supporting routine approaches to care processes and decisions

(A5b) Values the need for continuous improvement in clinical practice based on new knowledge

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Johns Hopkins Nursing Evidence-Based Practice Model The process used in the Johns Hopkins Nursing Evidence-Based Practice Model is known as PET, which refers to asking a practice question, finding the evidence, and translating the evidence to practice (Newhouse, Dearholt, Poe, Pugh, & White, 2007). In the model, questions are stated in the PICO format. Next, the research and nonresearch evidence undergoes appraisal. Nonresearch evidence includes not only expert opinion, patient experience data, and guidelines but also evidence gathered from organizational experience, such as quality improvement reports, program evaluations, and financial data analysis. The final step of the PET process is translation, assessing the evidence-based recommendations for transferability to the practice setting. During this process, practices are implemented, evaluated, and communicated, leading to a change in nursing processes and outcomes.

Diffusion of Innovation Framework Rogers’s Diffusion of Innovation Framework (2003) posits that if a third of any group adopts a practice change based on new evidence, then the rest of the group will follow, considering the change in practice to be the norm. The key to using this framework to guide implementation is to work with people within the organization who are known to be innovators and early adopters of change. There are five steps included in the framework: knowledge, persuasion, decision, implementation/trial, and confirmation. During the knowledge step, the innovation is described so that the decision-making unit develops an understanding of the suggested change. Next, the change agent works to develop favorable attitudes toward the innovation and subsequently a decision is made to adopt or reject the innovation. During the implementation or trial step, the

innovation is in place and adjustments may occur. Finally, during the step of confirmation, the decision-making unit seeks reinforcement that the decision was correct, or they may choose to reverse the decision (Sellers & McCrea, 2014).

Conclusion Numerous models are available in the literature to guide nurses in the use of evidence-based practice. The models share similarities and differences but do have a common foundation because all use a planned action approach to moving knowledge to practice. The steps taken together provide a process for locating and synthesizing knowledge and for systematically using the change process for integrating and sustaining evidence-based changes in practice (Tracy & Barnsteiner, 2014).

Currently, the greatest challenge we face in fully implementing evidence-based practice in nursing as a profession is how to get the evidence to the practicing nurse. Nurses are very busy taking care of patients. From the perspective of the individual, it can indeed be daunting, especially when many practicing nurses are not knowledgeable about evidence-based nursing practice. Nevertheless, daunting or not, the impetus for evidence-based practice will continue to grow. As healthcare costs continue to climb, consistent, data-based answers to patient care problems are an expectation.


Mr. P. is a 52-year-old, married, Hispanic male who is approximately 100 pounds overweight. Mr. P. has developed hypertension and adult- onset diabetes. He is currently being followed in a clinic setting. As a nurse working in the clinic setting, you have noticed that many of the patients you see in the clinic who are demographically similar to Mr. P. experience poorer health outcomes as compared with your patients who are members of different patient populations.



Case Study Questions

What PICO(T) questions can you ask to generate evidence for the patient population and patient problem(s) represented in the case study?

Based on a search of the literature, your expertise, and what you know about the preferences of this patient population, what are some evidence-based nursing interventions that you might want to translate into clinical practice in this clinic setting?

Classroom Activity 9-1

Have students create clinical questions in the PICO(T) format for a patient in a case study provided by the instructor or for patient recently cared for in the clinical setting.

Classroom Activity 9-2

Have students bring laptops to class or go to the computer lab as a class and access evidence from such resources as CINAHL, the National Guideline Clearinghouse, or the Cochrane Library to plan evidence-based care based on the questions created in Classroom Activity 9-1. If laptops or a computer lab is not available, then adapt this activity by having either students or faculty access the sites via a computer projection system in the classroom and plan care as a group based on the search results. As an alternative, the students can do this activity outside of class and share their results during the following class.

Classroom Activity 9-3

Provide students with a clinical guideline (choose one that has recommendations students can audit for using the patient records provided), a clinical audit tool, and several example patient records. Have students perform an evidence-based clinical review (or audit) using the records provided to them. Have students summarize their findings for each recommendation and then suggest quality improvement actions to correct the identified problems.

Classroom Activity 9-4

Have students partner individually or as a group with a local clinical facility to work jointly on a project. Collaborate to identify PICO(T) questions, find evidence, and plan the process of translation of evidence into practice within the facility or on a nursing unit within the facility.

Classroom Activity 9-5

Numerous classroom and clinical activities related to evidence-based practice are available on the QSEN website at strategies/strategy-search/. Choose activities from the website for students to complete that meet specific course objectives.

References Agency for Healthcare Research and Quality. (2002). Systems to rate the strength of scientific evidence (Evidence Report/Technology Assessment No. 47, AHRQ Publication No. 02-E016). Rockville, MD: Author.

AGREE Collaboration. (2003). Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: The AGREE project. Quality and Safety in Health Care, 12, 18–23.

AGREE Next Steps Consortium. (2009). Appraisal of guidelines for research and evaluation. Ontario, Canada: AGREE Research Trust.

American Association of Colleges of Nursing. (2008). The essentials of baccalaureate nursing education for professional nursing practice. Washington, DC: Author.

American Nurses Association. (2015). Nursing: Scope and standards of practice (3rd ed.). Silver Spring, MD: Author.

Beyea, S. C., & Slattery, M. J. (2006). Evidence-based practice in nursing: A guide to successful implementation. Marblehead, MA: Healthcare Compliance.

Critical Appraisal Skills Programme. (2010). CASP checklists. Retrieved from

Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., . . . Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122–131.

DelMonte, J., & Oman, K. S. (2011). Preparing and sustaining staff knowledge about EBP. In J. Houser & K. S. Oman (Eds.), Evidence- based practice: An implementation guide for healthcare organizations

(pp. 55–71). Sudbury, MA: Jones & Bartlett Learning. Houser, J. (2008). Nursing research: Reading, using, and creating evidence. Sudbury, MA: Jones and Bartlett.

Houser, J. (2011). Evidence-based practice in health care. In J. Houser & K. S. Oman (Eds.), Evidence-based practice: An implementation guide for healthcare organizations (pp. 1–19). Sudbury, MA: Jones & Bartlett Learning.

Institute of Medicine. (2008). Evidence-based medicine and the changing nature of healthcare: 2007 IOM annual meeting summary. Washington, DC: National Academies Press.

Institute of Medicine. (2011). Clinical practice guidelines we can trust. Washington, DC: National Academies Press. Retrieved from Guidelines-We-Can-Trust.aspx

Levin, R. F. (2006a). Evidence-based practice in nursing: What is it? In R. F. Levin & H. R. Feldman (Eds.), Teaching evidence-based practice in nursing: A guide for academic and clinical settings (pp. 5–14). New York, NY: Springer.

Levin, R. F. (2006b). Teaching students to formulate clinical questions: Tell me your problems and then read my lips. In R. F. Levin & H. R. Feldman (Eds.), Teaching evidence-based practice in nursing: A guide for academic and clinical settings (pp. 27–36). New York, NY: Springer.

LoBiondo-Wood, G., & Haber, J. (2014). Integrating research, evidence- based practice, and quality improvement processes. In G. LoBiondo- Wood & B. Haber (Eds.), Nursing research: Methods and critical appraisal for evidence-based practice (8th ed., pp. 5–24). St. Louis, MO: Mosby.

Massachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. Retrieved from

Melnyk, B. M., & Fineout-Overholt, E. (2014). Evidence-based practice in nursing and healthcare: A guide to best practice (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Newhouse, R. P., Dearholt, S. L., Poe, S. S., Pugh, L. C., & White, K. M. (2007). Johns Hopkins nursing evidence-based practice: Model and guidelines. Indianapolis, IN: Sigma Theta Tau International.

Polit, D. F., & Beck, C. T. (2017). Nursing research: Generating and assessing evidence for nursing practice (10th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Pugh, L. C. (2012). Evidence-based practice: Context, concerns, and challenges. In S. L. Dearholt & D. Dang (Eds.), Johns Hopkins nursing evidence-based practice: Model and guidelines (2nd ed., pp. 5–23). Indianapolis, IN: Sigma Theta Tau International.

Quality and Safety Education for Nurses. (2015). Evidence-based practice. Retrieved from ksas/#evidence-based_practice

Revell, M. A. (2015). Role of research in best practices. Nursing Clinics of North America, 50, 19–32.

Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York, NY: Free Press.

Sellers, K. F., & McCrea, K. L. (2014). Evidence-based practice. In P. Kelly, B. A. Vottero, & C. A. Christie-McAuliffe (Eds.), Introduction to quality and safety education for nurses (pp. 339–370). New York, NY: Springer.

Spector, N. (2007). Evidence-based health care in nursing regulation. Chicago, IL: National Council of State Boards of Nursing.

Stevens, K. (2013). The impact of evidence-based practice in nursing and the next big ideas. Online Journal of Issues in Nursing, 18(2). Retrieved from

18-2013/No2-May-2013/Impact-of-Evidence-Based-Practice.html Titler, M. G. (2008). The evidence for evidence-based practice implementation. In R. G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses (pp. 1–49). Rockville, MD: Agency for Healthcare Research and Quality.

Tracy, M. F., & Barnsteiner, J. (2014). Evidence-based practice. In G. Sherwood & J. Barnsteiner (Eds.), Quality and safety in nursing: A competency approach to improving outcomes (pp. 133–148). West Sussex, England: Wiley.

© James Kang/EyeEm/Getty Images


Patient Education and Patient- Centered Care in Professional Nursing Practice Kathleen Masters

Learning Objectives

After completing this chapter, the student should be able to:

1. Describe the characteristics of patient-centered care (PCC) and family-centered care (FCC).

2. Discuss the dimensions of PCC.

3. Discuss communication in the context of PCC and FCC. 4. Describe patient education in the context of PCC. 5. Describe the evaluation of PCC.

Key Terms and Concepts

Patient-centered care (PCC) Family-centered care (FCC) Patient education Patient teaching Learning domains Andragogy Health Belief Model (HBM) Social Learning Theory Self-efficacy Readiness to learn Health literacy Age-related changes

What exactly is patient-centered care (PCC)? As one of the six dimensions of quality identified by the Institute of Medicine (IOM), PCC is defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions” (2001, p. 40). The Quality and Safety Education for Nurses (QSEN) initiative refined this definition in the formation of the PCC competency. PCC is defined by QSEN in terms of the nurse recognizing “the patient or designee as the source of control and full partner in providing compassionate and coordinated care based

on respect for the patient’s preferences, values, and needs” (Cronenwett et al., 2007, p.123). Another competency-based definition for PCC is that the nurse “will provide holistic care that recognizes an individual’s preferences, values, and needs and respects the patient or designee as a full partner in providing compassionate, coordinated, age and culturally appropriate, safe and effective care” (Massachusetts Department of Higher Education, 2016, p. 10).

All three definitions share a common focus. The provision of care that is appropriate for each patient is based on the patient’s preferences with the patient as a partner on the healthcare team. It is important to note that PCC is not the same as patient-focused care. In the patient-focused care scheme, the healthcare provider, rather than the patient, retains decision-making control (Walton & Barnsteiner, 2012). The remainder of this chapter focuses on the components of PCC and the nurse’s role in the maintenance of a patient-centered environment.


Examples of applicable Nurse of the Future: Nursing Core Competencies

Patient-Centered Care:

Knowledge (K2) Understands that care and services are delivered in a variety of settings along a continuum of care that can be accessed at any point

Skills (S2) Assesses patient values, preferences, decisional capacity, and expressed needs as part of ongoing assessment, clinical interview, implementation of care plan, and evaluation of care

Attitudes/Behaviors (A2a) Values and respects assessing the healthcare situation from the patient’s perspective and belief systems

Attitudes/Behaviors (A2b) Respects and encourages the patient’s participation in decisions about health care and services

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Dimensions of Patient-Centered Care Dimensions of PCC that are characteristic of a patient-centered environment include respect for patients’ values, preferences, and expressed needs; coordination and integration of care; information, communication, and education; physical comfort; emotional support; involvement of family and friends; and transition and continuity (Gerteis, Edgman-Levitan, Daley, & Delbanco, 1993).

Nurses show respect for patients as individuals by sharing information with them and by actively partnering to determine care priorities and the plan of care (Figure 10-1). In addition, tailoring the patient’s level of involvement based on his or her preferences rather than on the nurse’s preferences and revising the plan as the situation changes also demonstrate respect for patients (Gerteis et al., 1993). For PCC to be a reality, clinicians must relinquish the role of expert, realizing that although they are technical experts, the patient and family are the experts regarding their own life experiences.

Figure 10-1 It is the responsibility of the nurse to create a patient-centered care environment. © monkeybusinessimages/iStock/Getty Images.

The concept of compliance must be replaced by one of engagement and partnership, and clinicians must believe that the best decisions emerge through input from all who have knowledge relevant to a particular patient situation (Disch, 2012).

Coordination and integration of care are evident as members of the healthcare team communicate effectively with one another and in turn deliver consistent messages to the patient and as nurses create smooth transitions across episodes of care. The role of nursing in the coordination and integration of care is increasingly important as care becomes more complex because of the simultaneous existence of multiple chronic conditions, increasing numbers of care providers involved in the episodes of care, numerous settings for care, and shorter episodes of care (Gerteis et al., 1993).

Adapting education and communication based on the patient’s preference is a foundation of PCC. Information on clinical status, progress, and prognosis communicated to patients needs to make sense to patients and families and be at a level that they can understand.

Education provided to patients to facilitate self-care and health promotion must also be at a level that the patient can understand (Gerteis et al., 1993).

Physical comfort should form the basis for the individualized plan of patient care. Ensuring that the patient will be free of pain is an expectation of PCC, as are assistance with activities of daily living and a clean and private environment (Gerteis et al., 1993). Periodic assessments of patient comfort are essential, as are the timely administration of medications and the monitoring of the effects of medications and treatments (Walton & Barnsteiner, 2012). In addition to physical discomfort, patients may experience anxiety and distress during their experience of care. Patients frequently experience anxiety over their clinical status, treatments, and prognosis as well as the effect of the illness on themselves, their families, and their finances. The nurse is in a position that allows for spiritual and emotional support of the patient and family during the care experience (Gerteis et al., 1993).


Examples of applicable Nurse of the Future: Nursing Core Competencies

Patient-Centered Care:

Knowledge (K3) Understands multiple dimensions of patient-centered care including (a) Patient/family/community preferences, values (b) Coordination and integration of care (c) Information, communication and education (d) Physical comfort and emotional support (e) Involvement of family and significant other (f) Care transition and continuity

Skills (S3a) Communicates patient values, preferences, and expressed needs to other members of the health care team

Skills (S3b) Seeks information from appropriate sources on behalf of the patient

Attitudes/Behaviors (A3a) Respects the patient’s perspective regarding own health and concerns

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Patient/family-centered care or family-centered care (FCC) is an extension of PCC that “widens the circle of concern to include those persons who are important to the patient’s life” (Henneman & Cardin, 2002, p. 13), although it is important to note that FCC does not negate the patient’s right to privacy and control (Figure 10-2). FCC requires the structuring of all aspects of the process of engaging the patient’s family and friends around meeting the patient’s needs rather than around the convenience of the organization. This includes accommodating family and friends, including family in decision making (based on patient preference), recognizing the needs of the family, and providing support for the family in their caregiving role (Gerteis et al., 1993). It is important to view this aspect of PCC within the total context of the patient’s care rather than based on a few policies because FCC is a philosophy that considers the patient in the context of his or her family (Walton & Barnsteiner, 2012); however, policies that promote the inclusion of the family may reflect the family-centered care philosophy of an organization. It is also important to note that in the context of PCC, family refers to those persons whom the patient decides to call family rather than those defined by the provider (Walton & Barnsteiner, 2012).

Figure 10-2 The nurse, viewing the patient in the context of family, will encourage a family- centered care environment.

© Creatas Images/Creatas/Thinkstock.

Lastly, patients express anxiety about their ability to care for themselves once discharged from the healthcare setting. PCC includes support for patients as they transition to home, including information related to medications, diet, and symptoms to report, provided in a manner that patients understand. PCC also provides for continuity of care and assures that patients understand the plan, how to obtain support services, and whom to call for help once they are discharged from the acute care facility (Gerteis et al., 1993).

An eighth dimension, access to care, was added when these principles became known as the Picker Principles of Patient-Centered Care (Picker Institute, n.d.). This principle simply states that patients need to know that they can access care when it is needed and also deals with waits for admission and allocation of hospital beds.


One recent change on some nursing units has been the establishment

of walking rounds to patient rooms during change of shift report. Using this model, the nurses, patient, and family members (if the patient wishes) are all involved in the exchange of information during the transition of care to the nurse coming on shift. Can you think of any other changes that you have observed in the healthcare setting that help to facilitate a PCC environment?

In January 2010, the Joint Commission released a set of standards for patient-centered communication to advance effective communication, cultural competence, and PCC. One of the new requirements specifically states that a family member, friend, or other individual will be allowed to be present with the patient to provide emotional support and comfort and to alleviate fear during the course of the hospital stay (2010). This requirement is not meant to mandate visiting hours or other hospital policies; it is, however, intended to encourage patient-centered and FCC environments where policies allow for inclusion of those persons important to the patient.


Examples of applicable Nurse of the Future: Nursing Core Competencies

Patient-Centered Care:

Knowledge (K4b) Describes how cultural diversity, ethnic, spiritual and socioeconomic backgrounds function as sources of patient, family, and community values

Skills (S4a) Provides patient-centered care with sensitivity and respect for the diversity of human experience

Attitudes/Behaviors (A4b) Implements nursing care to meet the holistic needs of patient on socioeconomic, cultural, ethnic, and spiritual values and beliefs influencing health care and nursing practice

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Commonly cited components of PCC and FCC delivery models include many of the same types of strategies. Some of these components are:

Coordination of care conference that includes the patient and/or family, along with the interdisciplinary team, to discuss goals of treatment and to initiate discharge planning Hourly rounding by the nurse to complete treatments that also includes assessment of pain, elimination, and positioning as well as other concerns of the patient and/or family members Bedside report with the patient at the center of the discussion, with family and friends present at the discretion of the patient or patient advocate Use of a patient care partner (may be a family member, friend, or volunteer) selected by the patient to participate at various times in educational, psychological, physical, and spiritual support Individualized care that is established on admission to include the patient’s preferred name, the patient’s priorities for care, the patient’s learning style preference, and the patient’s care partner selection Open medical record policy that allows patients to view their medical record and document their perspective if they choose Eliminating visiting restrictions in relation to family members because, in the context of FCC, family members are members of the healthcare team rather than visitors Allowing family presence with a chaperone during resuscitation and other invasive procedures, thus never separating them from the

patient unless the patient requests it Silence and a healing environment where the patient is invited to report any discomfort with the noise level in their environment to the nurse, who will then intervene to decrease the noise level as much as is possible (Flagg, 2015; Hunter & Carlson, 2014).

Communication as a Strategy to Support Patient-Centered Care Effective communication between healthcare providers and the patient is an essential component of PCC (IOM, 2001). Communicating effectively in all areas of practice and with all members of the healthcare team, including the patient and the patient’s support network, is an expectation of all registered nurses (American Nurses Association [ANA], 2015), including entry-level nurses (American Association of Colleges of Nursing [AACN], 2008; QSEN, 2012). The nurse is responsible for assessment of his or her own communication skills, continuous improvement of communication skills, assessment of communication ability and preferences of patients, and communication of accurate information in a manner that demonstrates respect (ANA, 2015).


Examples of applicable Nurse of the Future: Nursing Core Competencies

Communication (Therapeutic Communication):

Knowledge (K1a) Understands the principles of effective communication through various means

Skills (S1a) Uses clear, concise, and effective written, electronic, and verbal communications

Attitudes/Behaviors (A1a) Accepts responsibility for communicating effectively

Attitudes/Behaviors (A1b) Recognizes one’s individual responsibility to

communicate effectively utilizing a collegial tone and voice

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

In terms of a competency, communication is defined as the nurse interacting “effectively with patients, families, and colleagues, fostering mutual respect and shared decision making, to enhance patient satisfaction and health outcomes” (Massachusetts Department of Higher Education, 2016, p. 32). This definition includes not only the standards for communication and PCC but also the desired outcomes of PCC.

The new standards published by the Joint Commission (2010) related to patient-centered communication were designed to improve the safety and quality of care for all patients and to promote better communication and patient engagement. The standards include requirements that the hospital identifies the patient’s oral and written communication needs, including the patient’s preferred language, and that the hospital communicates in a manner that meets the patient’s needs.

Communication may be viewed from different vantage points and may be manifested in a variety of formats and styles. For example, communication may be oral or written, empathetic or nonempathetic, and verbal or nonverbal (Bankert, Lazarek-LaQuay, & Joseph, 2014).

Empathetic communication refers to communication with someone from the vantage point of the other person’s feelings, values, and perspective (Figure 10-3). The nurse–patient relationship based on empathetic communication is characterized by a genuine respect for the patient’s opinions and decisions. Empathetic communication is the foundation for establishing relationships that are consistent with PCC (Bankert et al., 2014). Behaviors that facilitate empathetic communication


Figure 10-3 Engaging in empathetic communication is essential in creating a patient-centered care environment.

© Monkey Business Images/Shutterstock.

Listens carefully and reflects back a summary of the patient’s concerns Uses terms and vocabulary appropriate for the patient Calls the patient by his or her preferred name Uses respectful and professional language Asks the patient what he or she needs and responds promptly to those needs Provides helpful information Solicits feedback from the patient Uses self-disclosure appropriately Employs humor as appropriate Provides words of comfort when appropriate (Bankert et al., 2014, p. 165)


Examples of applicable Nurse of the Future: Nursing Core Competencies

Communication (Therapeutic Communication):

Knowledge (K2c) Describes the impact of one’s own communication style on others

Skills (S2e) Assesses barriers to effective communication

Skills (S2g) Assesses the impact of use of self in effective communication

Attitudes/Behaviors (A2b) Values mutually respectful communication

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Behaviors can also hinder empathetic communication. Some of these behaviors may include:

Interrupts the patient with irrelevant information Uses vocabulary that is either beneath the level of the patient or not understandable to the patient Uses language that may be perceived as patronizing or demeaning Uses nonprofessional language Reprimands or scolds the patient Preaches to the patient Provides the patient with inappropriate information Asks questions at inappropriate times or gives the patient advice inappropriately Self-discloses inappropriately (Bankert et al., 2014, p. 165)

Other elements to consider are verbal communication and nonverbal

behaviors that, although discussed separately, take place simultaneously. The empathetic communicator will be attentive to conflicting messages related to verbal and nonverbal communication, paying particular attention to nonverbal messages because these provide the nurse with insight into the patient’s inner feelings. Nonverbal behaviors that the nurse will want to observe include eye movement, body position and movement, facial expression, and tone of voice. To communicate effectively, the nurse must learn to attend to all these elements of the communication process (Bankert et al., 2014).


Examples of applicable Nurse of the Future: Nursing Core Competencies

Communication (Therapeutic Communication):

Knowledge (K3a) Understands the nurses’ role and responsibility in applying the principles of verbal and nonverbal communication

Knowledge (K3b) Understands the nurse’s role and responsibility in applying principles of active listening

Skills (S3b) Actively listens to comments, concerns, and questions

Skills (S3c) Demonstrates effective interviewing techniques

Skills (S3d) Provides opportunity to ask and respond to questions

Skills (S3e) Assesses verbal and non-verbal responses

Attitudes/Behaviors (A3a) Values the therapeutic use of self in patient care

Attitudes/Behaviors (A3b) Appreciates the dynamics of physical and emotional presence on communication

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Examples of specific questions, known as Kleinman’s questions, that can help clinicians relate to a patient on his or her level to provide PCC are included here. The questions are designed to elicit the patient’s perception of his or her illness. The wording of the questions can be revised based on the setting, illness, and characteristics of the patient.

What do you think has caused your problem? Why do you think it started when it did? What do you think your problem does inside your body? How severe is your problem? Will it have a short or long course? What kind of treatment do you think you should receive? What are the most important results you hope to receive from this treatment? What are the chief problems your illness has caused you? What do you fear most about your illness/treatment? (Kleinman, 1980)

Patient Education as a Strategy to Support Patient-Centered Care Patient education has formally been a part of nursing care since the time of Florence Nightingale (1860/1969). During the 1900s, patient education increasingly became identified as a role of the professional nurse; however, it was not until 1973 that the ANA defined patient education as a component of the practice of the registered nurse. Beginning in 1976, the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission, 1995) included patient and family education as a function critical to patient care. The AACN (1998, 2008) also recognized that the implementation of the professional nursing role requires that nurses are prepared to teach patients effectively. Standard 5 of the standards of professional nursing practice states that the nurse is responsible for implementation of an identified plan (ANA, 2015). A subcategory of this standard titled Health Teaching and Health Promotion indicates that the nurse employs strategies to promote health and a safe environment. Competencies under this standard include those related to the nurse providing health promotion education and health teaching (ANA, 2015). Thus, in contemporary nursing practice, patient education is both a professional expectation and a legal obligation of the nurse (Figure 10-4).

Figure 10-4 The nurse must possess the skills to effectively communicate with patients. © asiseeit/E+/Getty Images.

“Patient education is any set of planned, educational activities designed to improve patients’ health behaviors, health status, or both” (Lorig, 2001, p. xiii). There is nothing in this definition about improving knowledge, although a change in knowledge might be necessary to reach the goal of changing health status or health behaviors. In contrast, activities aimed at improving knowledge are known as patient teaching (Lorig, 2001). The point is that the purposes of patient education are more than a change in knowledge. The purposes of patient education are to maintain health, to improve health, or to slow deterioration of health. These purposes are met through changes in health-related behaviors and attitudes (Lorig, 2001), and these changes are not easily achieved. Effective patient education requires the nurse to have the ability to communicate effectively with patients to assess the individual needs, attitudes, and preferences of the patient that can affect health behaviors before any changes can be expected (Falvo, 2004, 2011).

Principles and Theories Related to Patient Education In addition to communication and assessment skills, if the nurse is to be effective as a patient educator, then he or she must also have sufficient knowledge of the information that needs to be taught. If the knowledge base of the nurse is insufficient, the nurse risks providing inadequate or inaccurate information to the patient (Falvo, 2004, 2011). Finally, to be an effective patient educator, it is important that the nurse have an understanding of how to conduct patient education. Many educational theories and principles can be used to guide the patient education process. Some that are most commonly used in the healthcare setting are presented here.

Domains of Learning First, we should examine the nature of learning in relationship to learning domains. Identification of the learning domain reflects the type of learning desired as a result of the patient education process. Learning occurs in three domains: the cognitive, the psychomotor, and the affective (Bloom, 1956). The framework includes categories or levels of learning that comprise knowledge, comprehension, application, analysis, synthesis, and evaluation. Each level builds on the previous one in a hierarchical fashion. In the cognitive and psychomotor domains, levels are arranged in order of increasing complexity. In the affective domain, levels are organized according to the degree of internalization of a value or attitude.


Examples of applicable Nurse of the Future: Nursing Core Competencies

Communication (Teaching/Learning):

Knowledge (K8d) Is aware of the three domains of learning: cognitive, affective, and psychomotor

Attitudes/Behaviors (A8d) Values the need for teaching in all three domains of learning

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

In the revised taxonomy (Anderson & Krathwohl, 2001), cognitive learning encompasses the intellectual skills of remembering, understanding, applying, analyzing, evaluating, and creating. The use of verbs rather than nouns to name the categories in the revised taxonomy underscores the dynamic nature of learning. Psychomotor learning refers to learning of motor skills and performance of behaviors or skills that require coordination. Affective learning requires a change in feelings, attitudes, or beliefs.

Understanding which domain is the target of learning helps guide the planning, implementation, and evaluation of learning. For example, if based on assessment you know that a patient is knowledgeable about insulin administration and is committed to administering the injection but has not yet been able to manipulate the syringe correctly to administer the injection, you know that your target domain for learning is the psychomotor domain. Thus, the focus of your objectives, planning, learning activities, and evaluation will be on the performance of the identified behaviors.

Andragogy Andragogy, initially defined as “the art and science of helping adults

learn” (Knowles, 1970), has taken on a broader meaning over the past 40 years and is currently used to refer to learner-focused education for people of all ages (Conner, 2004). The andragogic model asserts that the following four issues be considered and addressed in learning (Knowles, Swanson, & Holton, 1998, 2011):

Letting learners know why something is important to learn Showing learners how to direct themselves through information Relating the topic to the learners’ experiences Realizing that people will not learn until they are ready and motivated

Adults learn best when there is immediate opportunity for application. Adults in particular are motivated to learn when they recognize a gap between what they know and what they want to know or what they need to know (Knowles, 1970). Therefore, adult learners are rarely interested in learning detailed anatomy and physiology related to their chronic disease, but they are motivated to learn how to care for themselves after discharge from the hospital. Effective patient education will be based on principles that capitalize on these characteristics of the adult learner.

Health Belief Model The Health Belief Model (HBM) is one of the most widely used frameworks in research and programs related to health promotion and patient education. This model was originally developed to predict the likelihood of a person following a recommended action and to understand the person’s motivation and decision making regarding seeking health services (Hochbaum, 1958).

According to the HBM, the likelihood of a person acting in response to a health threat depends on six factors:

The person’s perception of the severity of the illness The person’s perception of susceptibility to illness and its

consequences The value of the treatment benefits (i.e., do the cost and side effects of treatment outweigh the consequences of the disease?) Barriers to treatment (i.e., expense, complexity of treatment) Costs of treatment in physical and emotional terms Cues that stimulate taking action toward treatment of illness (i.e., mass media campaigns, pamphlets, advice from family or friends, and postcard reminders from healthcare providers)

The HBM can provide a framework for assessing areas where patients have gaps in knowledge, such as severity of illness or susceptibility to illness, and then addressing those areas to increase the potential for compliance with the treatment regimen. Through use of the HBM, you can easily categorize and cover the essential components of your educational message, thus providing the patient with a basic understanding of the severity of the illness, the risk and consequences of the illness, the value of treatment, the barriers to treatment, and the costs of treatment.

Social Learning Theory According to Bandura’s Social Learning Theory, if a person believes that he or she is capable of performing a behavior (self-efficacy) and also believes that the behavior will lead to a desirable outcome, the person will be more likely to perform the behavior (Bandura, 1997). In contrast, if a person does not believe that he or she is capable of performing a behavior, he or she will have no incentive to do so, even if the person is actually capable. Perceptions of self-efficacy are particularly important in relation to a patient’s learning complex activities or long-term changes in behavior (Prohaska & Lorig, 2001).

There are four methods for developing or enhancing efficacy

expectations if assessment reveals a need for such enhancement:

Performance accomplishments Vicarious experience or modeling Verbal persuasion Interpretation of physiologic state

Performance accomplishment is the most direct and influential way to enhance self-efficacy. In this method, the patient first performs tasks that he or she can easily handle. By succeeding with these first tasks, the patient develops a sense of competence and enhancement of self- efficacy before proceeding to more difficult tasks. Along these same lines, it is also important to set short-term goals that are measurable so that patients can see their success and the effect of the change in their behavior. A patient who can see the benefits of a behavior change within a reasonable time is more likely to continue practicing the behavior.


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential VII: Clinical Prevention and Population Health

7.4 Use behavioral change techniques to promote health and manage illness (p. 24).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

The second method for enhancing self-efficacy is through modeling, where the patient observes others who appear to be similar and who are successfully performing behaviors. Modeling can also be achieved

through the use of illustrations in pamphlets or in programming materials by using illustrations and models that are of various cultures, body shapes, and ages (Prohaska & Lorig, 2001).

Verbal persuasion can also be an effective method of enhancing self- efficacy expectations. The content of the message needs to include basic factual information that emphasizes the importance of performing the behavior. It is usually better to ask for incremental changes or to ask the patient to do just slightly more than he or she is currently doing (Prohaska & Lorig, 2001). Encouragement and support not only from the nurse but also from family and friends help the patient to be successful.

Most illnesses present with symptoms, and most new behaviors cause some physiologic changes. Addressing the meaning of symptoms and physiologic states can influence self-efficacy. For example, a patient who is trying to quit smoking can expect withdrawal symptoms. If the patient understands the reasons for the symptoms and the limitation in the duration of the symptoms, the patient might decide that he or she has the ability to make the change. Without that knowledge, the patient might give up because he or she experiences physiologic changes that are not understood.


Think about your own life. Do you act to prevent a disease or accident when you perceive that you are not susceptible to the disease or at risk for the accident?

The Patient Education Process: Assessment According to Redman (2001, 2006), the process of patient education can be viewed as parallel to the nursing process. Each of these processes begins with assessment, negotiation of goals and objectives, planning,

intervention, and finally evaluation (Rankin, 2005; Rankin & Stallings, 2001; Rankin, Stallings, & London, 2005).

The goal of the nurse in the process of patient education is to assist the patient in obtaining the knowledge, skills, or attitude that will help the patient develop behaviors to meet needs and to maximize the potential for positive health outcomes (Falvo, 2004, 2011). Because no patient or situation is exactly the same, an assessment is required.


Examples of applicable Nurse of the Future: Nursing Core Competencies

Communication (Teaching/Learning):

Knowledge (K8c) Understands the principles of teaching and learning

Skills (S8c) Assists patients and families in accessing and interpreting health information and identifying healthy lifestyle behaviors

Attitudes/Behaviors (A8g) Accepts the role and responsibility for providing health education to patients and families

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Many available guides are helpful in assessing the learning needs of patients (Redman, 2003). Some nurses construct their own assessment tools to meet specific needs. Observation, interviews, open-ended questions, focus groups, and the patient’s medical record are additional ways to gather information for the assessment of learning needs. Rankin and Stallings (2001, p. 200) suggest some specific questions that must be addressed in the assessment of learning needs:

What information does the patient need? What attitudes should be explored? What skill does the patient need to be able to perform healthcare behaviors? What factors in the patient’s environment may be barriers to the performance of desired behaviors? Is the patient likely to return home? Can the family or caregiver handle the care that will be required? Is the home situation adequate or appropriate for the type of care required? What kinds of assistance will be required?

Learning Styles To provide the most effective patient teaching, the nurse must also assess patient learning style. Although most people learn best when multiple techniques are used in patient teaching, assessment of the patient’s learning style is a fundamental step before beginning any learning activity. Learning styles are methods of interacting with, taking in, and processing information that allow individuals to learn. Learning styles are generally categorized as visual, auditory, or tactile/kinesthetic.

The patient who is a visual learner prefers written instructions rather than oral instructions but prefers photographs and illustrations to written instructions. The nurse teaching the patient who is a visual learner should use a variety of interesting visual learning materials, including organized visual presentations, photographs, or computerized materials (Russell, 2006).


Examples of applicable Nurse of the Future: Nursing Core


Communication (Teaching/Learning):

Knowledge (K8a) Understands the influences of different learning styles on the education of patients and families

Knowledge (K8b) Identifies differences in auditory, visual, and tactile learning styles

Skills (A8b) Recognizes learning styles vary by individual

Attitudes/Behaviors (S8a) Assesses factors that influence the patient’s and family’s ability to learn, including readiness to learn, preferences for learning style, and levels of health literacy

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

The patient who is an auditory learner remembers oral instructions well and learns through discussion. The nurse teaching a patient who is an auditory learner will want to be sure that the patient is positioned to be able to hear and will want to rephrase what is said several different ways to be sure the intended message is communicated. The nurse might also want to use multimedia that incorporates sound in patient teaching (Russell, 2006).

The patient who learns best through getting physically involved is the tactile or kinesthetic learner. The kinesthetic learner learns through doing or experiencing physically. The kinesthetic learner has difficulty staying in one place for very long and enjoys hands-on activities. The nurse teaching the kinesthetic learner should provide activities during the session and should provide samples or supplies for practicing or demonstrating skills (Russell, 2006).

Readiness to Learn An important variable in the patient education process is readiness to learn. After a need to learn has been identified, a patient’s readiness or evidence of motivation to receive information at that particular time must also be assessed (Falvo, 2004, 2011; Joint Commission, 2003; Redman, 2001). A variety of factors, such as pain, anxiety, and emotional reactions, can affect a patient’s readiness to learn. Moderate to severe anxiety has been shown to interfere with a patient’s ability to concentrate and understand new information (Stephenson, 2007). If a patient is distracted by physical or emotional pain, attempts at patient teaching will not be successful. The better choice is to wait until the pain has subsided or to address the anxiety that the patient is experiencing, and then when the patient is ready, proceed with patient education activities (Redman, 2001, 2006; Stephenson, 2007).

Health Literacy Considering a patient’s health literacy is an important component in PCC. Health literacy is generally defined as the ability to read, understand, and act on health information. The IOM (2004) consensus report on health literacy defined the concept as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services they need to make appropriate health decisions” (p. 31).

Today there is more access to healthcare information than at any time in history. The low health literacy problem for most is not an issue of access to information but rather is a crisis of not understanding medical information (Doak & Doak, 2002). Research studies have demonstrated that patients with low health literacy skills make more errors with their medications and treatments (Baker et al., 1996; Williams, Baker, Honig, Lee, & Nowlan, 1998) and are also at risk for experiencing preventable

adverse events (Bartlett, Blais, Tamblyn, Clermont, & MacGibbon, 2008). They often fail to seek preventive care and are also at higher risk for hospitalization, which results in higher annual healthcare costs (Agency for Healthcare Research and Quality [AHRQ], 2011; Baker, Parker, Williams, & Clark, 1998; U.S. Department of Health and Human Services [USDHHS], 2012; Weiss, 1999).

In the United States, one in five adults and nearly two in five older adults and minorities read at the fifth-grade level or below. Only 12% of U.S. adults are considered to have proficient health literacy. The number of adults with only basic health literacy skills or below basic-level health literacy skills has reached 77 million. One-third of the U.S. adult population has difficulty with common health tasks, such as following instructions on a medication label (USDHHS, 2012). This is significant because persons with only basic health literacy skills or below basic-level health literacy skills have difficulty processing and understanding information and services and thus have difficulty making healthcare- related decisions (Miller & Stoeckel, 2011). Although health literacy is partially dependent on the patient’s skill set, it is also dependent on the complexity of the information as well as how information is communicated (USDHHS, 2012).

The National Patient Safety Foundation (2015) has developed a program called Ask Me 3. According to the foundation, this program promotes improved health outcomes by encouraging patients to become active members of their healthcare team through improved communication between patients and their healthcare providers. The following are the three questions the program encourages patients to ask their healthcare provider:

What is my main problem? What do I need to do?

Why is it important for me to do this?

Another program that is used by nurses to become more effective patient educators is ACTS, an acronym for assess; compare; teach three, teach back; and survey. The best education strategies begin by asking the patient to identify his or her main concern. This simple question will shift the focus of the interaction from the nurse to a patient-centered encounter. Next, the nurse must discover the needs and preferences of the patient as well as how the patient prefers to learn in order to individualize the teaching plan. Asking the patient or caregiver what they already know acknowledges his or her current level of expertise and supports the concepts of patient control and shared decision making. Finally, the nurse assesses patient core values and cultural, social, language, and physical influences. During the compare phase, the nurse compares the available resources to the needs and preferences of the patient to match relevant content to identified knowledge gaps. Teach three, teach back refers to the process in which patients are taught three or fewer key concepts or care skills in short segments and then the patient restates the concept in his or her own words or demonstrates the skill. If the patient has difficulty with restating or with skill demonstration, teaching should be repeated. Nurses should then close the loop by asking in an open-ended manner if there are additional questions or learning needs (French, 2015).

When information is complex or time is limited, nurses frequently provide printed materials for patients to read or review at home. These materials are helpful when they provide patients who have adequate reading skills with a resource to remind them of the instructions given by the nurse, but for those patients with low health literacy skills, the printed materials might be of no use. The average American reads at the eighth- to ninth-grade level. Most materials used for patient education are written

above the 10th-grade reading level (Doak & Doak, 2002; Doak, Doak, & Root, 1996). We know that when the reading level of printed materials is beyond the skill of the learner, comprehension is decreased, recall is sketchy and inaccurate, and motivation to learn is decreased (Redman, 2001, 2006).

Patients with low health literacy skills are generally too embarrassed to reveal to the nurse that they cannot read or cannot read well enough to understand the written instructions. It is therefore important that the nurse take the initiative in assessing the literacy skills of patients before using written materials in the patient education process and to provide educational materials in various formats when possible.

Direct questioning of patients about reading ability is usually not effective. How can you determine the reading ability of the patient? One option is to use one of several instruments that have been developed to assess patient literacy quickly. Some of the literacy assessment instruments most commonly used in healthcare settings include the Rapid Estimate of Adult Literacy in Medicine (Davis et al., 1993) and the Wide Range Achievement Test (Jastak & Wilkinson, 1993).

One of the best ways to assess literacy is simply through careful observation of your patient. Clues that might be observed in a patient with low health literacy skills include forms that are filled out incompletely or incorrectly, written materials that are handed to a person accompanying the patient, and aloofness or withdrawal during provider explanations. Additional clues might include surveillance of the behavior of others in the same situation to copy their actions or a request for help from staff or other patients. Verbal responses like “I will read this at home” or “I can’t read this now because I forgot my glasses” are also common (Bastable, 2006; Doak & Doak, 2002).

Health literacy tools continue to focus primarily on reading ability, despite the IOM’s recommendation that the focus change to skills-based

health literacy tools that use a combination of skills that patients can use to manage health, such as verbal, computer, or other skills (AHRQ, 2011). Because reading ability continues to be the prevalent focus, we consider assessment of readability of materials next.

Assessing the Readability of Patient Education Materials Many health-related teaching materials are written on a level that is above the average patient’s literacy level and contain too much medical jargon (National Center for Education Statistics, 2007). Written materials can still be useful supplements for patients with low health literacy skills if the written materials selected are appropriate to the reading level of the patient. Print materials for most patient populations should be written between the seventh- and eighth-grade reading levels. Print materials for patients with low health literacy skills should be written at or below the fifth-grade reading level (Doak & Doak, 2002).


Have you ever been assigned to read a book that had so many big words in it that you had to keep the dictionary by your side? If it was assigned for school, you probably struggled through it for the sake of not failing the test, but what about if you were not being graded? Would you bother to read it? If you did read it because you knew it would help you, would you have enough understanding to actually apply the information?

Several readability formulas are available to determine the grade level of materials (Flesch, 1948; Fry, 1968; McLaughlin, 1969). One of the easiest formulas to use is the SMOG formula, which predicts the reading grade level of materials within 1.5 grades 68% of the time (McLaughlin, 1969). The procedure for using the SMOG readability formula for printed materials is outlined in Box 10-1. Readability of

BOX 10-1






1. 2. 3.

materials available in an electronic format can be assessed using formulas embedded in word processing programs and also for free via several readability calculation websites on the Internet.


Choose 10 consecutive sentences near the beginning, 10 consecutive sentences from the middle, and 10 consecutive sentences from the end of the material. In these 30 sentences, count the number of words containing three or more syllables, including repetitions. Consider hyphenated words as one word. Proper nouns are also counted. Numerals and abbreviations should be counted as they would if the words were written out. When a colon divides words, each portion of the sentence is considered a separate sentence. Estimate the square root of the number of polysyllabic words counted. Add three to the square root. This gives the SMOG grading, which is the reading grade level that a person must have achieved to fully understand the material. The quickest way to assess reading grade level is to use the SMOG conversion table. Simply compare the total number of words containing three or more syllables in the 30 sentences with the SMOG conversion table.

However, not all written patient education materials contain 30 sentences. To assess materials with fewer than 30 sentences:

Count all the polysyllabic words. Count the number of sentences. Find the average number of polysyllabic words per sentence.

4. 5. 6.

Multiply that average by the number of sentences short of 30. Add that figure to the total number of polysyllabic words. Find the square root of the number you obtained in step 5 and add the constant of three. This procedure also gives you the SMOG grading.

SMOG Conversion Table

Word Count Grade Level

0–2 4 3–6 5 7–12 6 13–20 7 21–30 8 31–42 9 43–56 10 57–72 11 73–90 12 91–110 13 111–132 14 133–156 15 157–182 16 183–210 17 211–240 18

Data from Harold C. McGraw, Office of

Educational Research, Baltimore County Schools,

Towson, Maryland.


Examples of applicable Nurse of the Future: Nursing Core Competencies

Communication (Teaching/Learning):

Knowledge (K8e) Understands the concept of health literacy

Skills (S8a) Assesses factors that influence the patient’s and family’s ability to learn, including readiness to learn, preferences for learning style, and levels of health literacy

Attitudes/Behaviors (A8e) Accepts responsibility to insure the patient receives health information that is understandable

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Low health literacy can be a barrier to effective patient education, but the patient with low health literacy skills is capable of learning if the nurse is willing to invest the extra time that is required. It is important for the nurse to take extra care to present information in terms that the patient is familiar with rather than using medical jargon; to use alternate formats, such as pictographs, when possible; to restate information using simple words; and to verify the patient’s understanding by having him or her convey the information in his or her own words. The dividends for the extra effort include the patient who is able to manage his or her own illness, make informed health decisions, and make health-related behavior changes as a result of a patient education process that has accommodated for his or her weaknesses.

The Patient Education Process: Planning The patient and the nurse share the planning process for patient education, but it is the responsibility of the nurse to guide the process using goals and objectives. Learning goals are derived from the learning assessment, and nursing diagnoses and objectives are developed based on goals in collaboration with the patient. The use of goals and objectives helps the nurse to focus on what is important for the patient to learn and to keep patient education centered on outcomes (Rankin & Stallings, 2001; Rankin et al., 2005).

Patient education is directed toward behavioral change; therefore, the objectives for patient education are stated as behavioral objectives. There are three components of behavioral objectives: performance, conditions, and criteria (Mager, 1997). Performance refers to the activity that the patient will engage in and answers this question: What can the learner do? The condition refers to special circumstances of the patient’s performance and answers this question: Under what conditions will the learner perform the behavior? The criteria or evaluation component refers to how long or how well the behavior must be performed to be acceptable and answers this question: What is the performance standard? (Rankin & Stallings, 2001; Rankin et al., 2005).

The learning objectives should be specific, measurable, and attainable (Rankin, 2005; Rankin & Stallings, 2001; Rankin et al., 2005). Learning objectives are also written in a manner that is learning-domain specific. Recognizing the targeted domain of learning as cognitive, psychomotor, or affective helps guide the process of writing behavioral learning objectives and thus guides the selection of learning activities.

The Patient Education Process: Implementation The next stage of the process involves the actual intervention. Whether

the teaching will occur in a group or with an individual patient, learning activities need to be consistent with learning objectives.

Using various learning activities can make learning more fun and more effective. Some common learning activities include lectures, demonstrations, practice, games, simulations, role-playing, discussions, and self-directed learning through computer-assisted instruction or self- directed workbooks.

Patient education materials are frequently used in the implementation stage of the patient education process. Patient education materials can be designed to be used alone or to supplement other types of patient education activities but should be previewed before use and used only if consistent with learning objectives. There are many types of patient education materials currently on the market, or you might opt to produce your own materials.

Patient education materials generally include audiovisual materials, computer programs, Internet resources, posters, flip charts, charts, graphs, cartoons, slides, overhead transparencies, photographs, drawings, patient education newsletters, or written patient materials, such as handouts, brochures, or pamphlets. These materials, even if designed to be used alone, should not be used without some explanation as to why the patient is being instructed to view the video or read the brochure (Falvo, 2004, 2011). In addition, the nurse should keep the door of communication open by inviting questions that the patient might have as a result of exposure to the teaching materials.

You must evaluate a variety of factors as you look at the appropriateness of patient education materials. Three important criteria for judging patient education materials are the following (Doak, Doak, Gordon, & Lorig, 2001, p. 184):

The material contains the information the patient wants.

The material contains the information the patient needs. The patient understands and uses the material as presented.

It is an expectation of the Joint Commission that the right educational materials are used in patient and family education and that the materials are accurate, age specific, easily accessible, and appropriate to patient needs (Joint Commission, 2003). To address all these criteria, the nursre must conduct a needs assessment before preparing or choosing patient education materials.

Considerations: Patient Education with Older Adults When caring for older adults, one of the primary considerations related to the patient education process is accommodation for age-related barriers to learning (Figure 10-5). The age-related barriers particularly important in the patient education process include age-related changes in cognition, vision, and hearing. Research has demonstrated that teaching is not as effective if it does not accommodate age-related cognitive and sensory changes (Donlon, 1993; Masters, 2001; Weinrich, Weinrich, Boyd, Atwood, & Cervenka, 1994). Gerogogy in patient education has been defined as the transferring of essential information that has been designed, modified, and adapted to accommodate for the physiologic and psychologic changes in elderly persons by taking into account the person’s disease process, age-related changes, educational level, and motivation (Pearson, 2012).

BOX 10-2

Figure 10-5 The nurse must accommodate for age-related cognitive and sensory changes in older adults for teaching to be effective.

© Monkey Business Images/Shutterstock.

Age-related changes in cognitive function occur slowly and are thought to begin at approximately 60 years of age in healthy adults (Miller, 2004). Age-related visual changes are the most prevalent physical impairments affecting older adults. Hearing impairment ranks as one of the four most prevalent chronic conditions affecting the older population, occurring in one-third of the U.S. population between the ages of 65 and 74 years and in 47% of the population 75 years of age or older (National Institutes of Health, n.d.). Each of these age-related changes can have a profound effect on the teaching and learning process. Specific age- related changes in cognition, vision, and hearing are listed in Box 10-2.


Cognitive Changes in encoding and storage of information

BOX 10-3

Changes in the retrieval of information Decreases in the speed of processing information

Visual Smaller amount of light reaches the retina Reduced ability to focus on close objects Scattering of light resulting in glare Changes in color perception resulting in difficulty distinguishing

colors, such as dark green, blue, and violet Decrease in depth perception and peripheral vision

Hearing Reduced ability to hear sounds as loudly Decrease in hearing acuity Decrease in the ability to hear high-pitched sounds Decrease in the ability to filter background noise

Data from Merriam, S. B., & Caffarella, R. S. (1999). Learning in adulthood: A comprehensive

guide (2nd ed.). San Francisco, CA: Jossey-Bass; Merriam, S. B., Caffarella, R. S., &

Baumgartner, L. M. (2007). Learning in adulthood: A comprehensive guide (3rd ed.). San

Francisco, CA: Jossey-Bass; Miller, C. A. (2004). Nursing for wellness in older adults: Theory

and practice (4th ed.). Philadelphia, PA: Lippincott.

Specific strategies can be used during the patient education process to help overcome the age-related learning barriers in cognition, vision, and hearing. Some of these strategies are included in Box 10-3.


Cognitive Slow the pace of the presentation. Give smaller amounts of information at a time. Repeat information frequently. Reinforce verbal teaching with audiovisuals, written materials, and

practice. Reduce distractions. Allow more time for self-expression of the learner. Use analogies and examples from everyday experience to illustrate

abstract information. Increase the meaningfulness of content to the learner. Teach mnemonic devices and imaging techniques. Use printed materials and visual aids that are age specific

Visual Make sure patient’s glasses are clean and in place. Use printed materials with 14- to 16-point font and serif letters. Use bold type on printed materials, and do not mix fonts. Avoid the use of dark colors with dark backgrounds for teaching

materials; instead, use large, distinct configurations with high contrast to help with discrimination.

Avoid using blue, green, and violet to differentiate type, illustrations, or graphics.

Use line drawings with high contrast. Use soft white light to decrease glare. Light should shine from behind the learner. Use color and touch to help differentiate depth. Position materials directly in front of the learner.


Speak distinctly. Do not shout. Speak in a normal voice or speak in a lower pitch. Decrease extraneous noise. Face the person directly while speaking at a distance of 3 to 6 feet. Reinforce verbal teaching with visual aids or easy-to-read materials.

Data from Weinrich, S. P., Boyd, M., & Nussbaum, J. (1989). Continuing education: Adapting

strategies to teach the elderly. Journal of Gerontological Nursing, 15(11), 17–21; Oldaker, S. M.

(1992). Live and learn: Patient education for the elderly orthopaedic client. Orthopaedic

Nursing, 11(3), 51–56.

Cultural Considerations in Patient Education Developing an educational program that is culturally appropriate is not much different from creating any other patient education program. You begin with a needs assessment; then you write objectives and design the program. The difference is that you must be culturally sensitive and incorporate cultural information that you have learned about the target group into the patient education process (Bastable, 2006; Gonzalez & Lorig, 2001; Lengetti, Ordelt, & Pyle, 2007).

How important is it that you incorporate cultural information into the patient education process? Cultural awareness and sensitivity of nurses can influence the ability of patients to receive and apply information regarding their health care (Campinha-Bacote, Yahle, & Langenkamp, 1996). The way that information is communicated can influence a patient’s perception of the healthcare system and affect adherence to prescribed treatments. In a recent study, patients who received care from nurses with cultural sensitivity training showed improvement not only in use of social resources but also in overall functional capacity (Majumdar, Browne, Roberts, & Carpio, 2004).


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential VII: Clinical Prevention and Population Health

7.5 Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral, and follow-up throughout the lifespan (p. 24).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

In addition to the difference that it can make in relationship to patient outcomes, the standards of practice are clear that the nurse is responsible for using “health promotion and teaching methods in collaboration with the healthcare consumer’s values, beliefs, health practices, developmental level, learning needs, readiness and ability to learn, language preference, spirituality, culture, and socieoeconomic status” (ANA, 2015, p. 65). The Joint Commission standards also require not only that the patient’s learning needs, abilities, and readiness to learn are assessed but also that the patient’s preferences are assessed. This assessment must consider cultural and religious practices as well as emotional and language barriers (Joint Commission, 2003).


Example of applicable outcomes expected of the graduate from a baccalaureate program

Essential VII: Clinical Prevention and Population Health

7.7 Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion and disease and injury prevention interventions (p. 24).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

How do you incorporate cultural information into the patient education process? Gonzalez and Lorig (2001, p. 172) suggest the following:

Change the information into more specific or more relevant terminology. Create descriptions or explanations that fit with different people’s understanding of key concepts. Incorporate a group’s cultural beliefs and practices into the program content and process.

In addition, any visual aids that are used should reflect the target group or population. The use of culturally relevant analogies can also help people to understand complex, abstract, or foreign concepts (Gonzalez & Lorig, 2001).

The Patient Education Process: Evaluation Evaluation determines worth by judging something against a standard. The standard used in the patient education process is the learning objective. Thus, the term evaluation as used here implies measuring the outcomes resulting from systematically planned activities implemented as a part of a patient education program or patient education process against the learning objectives to determine whether learning occurred.

Initiation of the patient education evaluation process is the

responsibility of the nurse, and according to Rankin and Stallings (2001, p. 326), the evaluation process should include the following:

Measuring the extent to which the patient has met the learning objectives Identifying when there is a need to clarify, correct, or review information Noting learning objectives that are unclear Pointing out shortcomings in patient teaching interventions Identifying barriers that prevented learning

Nurses commonly use several methods to evaluate patient learning. These methods include direct observation, the teach-back method or asking patients to explain something in their own words, situational feedback to determine if the patient selects the appropriate behavior, records of health-related behaviors that patients report, patient interviews and questionnaires, and critical incidents, such as readmission, emergency department visits, and mortality (McNeill, 2012).


Examples of applicable Nurse of the Future: Nursing Core Competencies

Communication (Teaching/Learning):

Knowledge (K8g) Understands the purpose of health education

Skills (S8g) Evaluates patient and family learning

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

Evaluation of Patient-Centered Care The National Strategy for Quality Improvement in Health Care was established by the secretary of the USDHHS to set priorities to guide the nation to increase access to high-quality health care. One of the priorities identified was the delivery of PCC and FCC (USDHHS, 2011). We know that there is a link between PCC and high-quality health care, but identifying specific measures of PCC is challenging.

The HCAHPS (pronounced H-CAPS) survey, also known as the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospital Survey, was the first national, standardized, publicly reported survey of patients’ perspectives of hospital care. The intent of the survey is to provide a standard instrument to measure patient satisfaction with the hospital experience. The survey asks a core set of questions to assess patient satisfaction with the care provided by nurses, physicians, and other members of the healthcare team; the responsiveness of the hospital staff; pain management; communication about medications; and the cleanliness and quietness of the environment. The standardized questions allow for comparisons of patient care experiences.

A more recent addition to the CAHPS survey is the integration of a supplemental item set related to health literacy. The primary goal of the survey is to measure, from the patient’s perspective, how well health- related information was communicated to them by health professionals during their care. This survey is available in English and Spanish. CAHPS supplemental item sets are also now available to assess cultural competence, to assess technology use, and for the patient-centered medical home (USDHHS, 2012).

Patient satisfaction with the care provided is recognized as a valid

quality indicator (Bankert et al., 2014). As consumers, patients provide their perspectives on the quality of care, delivery of care, outcomes of care, and the extent to which they were included as an active participant. PCC requires that evaluation of the care experience include the perspective of the patient (Walton & Barnsteiner, 2012).




Conclusion The patient relationship with healthcare professionals has changed dramatically during the past few decades and continues to evolve. In just one generation, we have moved from a healthcare system in which the provider made all the decisions for the passive patient to a system where our goal is full partnership with the patient. This shift requires nurses to actively engage patients in all dimensions of their care while communicating in a manner that conveys empathy and respect for patient preferences.


Mr. Martin, an 82-year-old African American patient, is ready for discharge from the medical unit after a 3-day hospitalization resulting from exacerbation of heart failure. Before discharge from the hospital, the student nurse reviews the medication orders and provides Mr. Martin with standard patient education materials related to control of heart failure symptoms.

Case Study Questions

What else could the student nurse in the case study do to enhance the effectiveness of the patient education process for Mr. Martin?

Do you have any suggestions for the student nurse related to accommodating age-related changes of this patient?

Do you have any suggestions for the student nurse related to cultural considerations as she educates this patient?

Classroom Activity 10-1

Provide students with a copy of printed patient education materials. These can be obtained from a local healthcare organization or from online sources, such as the American Heart Association. Ask students to evaluate the materials for readability using the SMOG formula in Box 10-1. Next, ask students to evaluate the materials for use with older adults using the information presented in Box 10-2 and Box 10-3. Finally, have students evaluate the materials for use with a population of a different culture. Ask students to share their findings during informal presentations to classmates.

Classroom Activity 10-2

Divide the class into small groups and ask students to create a patient education brochure that conforms to recommended reading levels, considers age-related learning barriers, and accommodates cultural differences. The group may choose a fictitious case scenario or an actual scenario from a recent clinical experience. For this activity, several students will need to bring laptops to class or the class will need to have access to a computer lab. Alternately, this activity could be assigned to students to complete outside of class to be shared with the class or submitted for a grade.

Classroom Activity 10-3

Share highlights of the story of Lia Lee from Anne Fadiman’s book, When the Spirit Catches You and You Fall Down. Next, share the responses of Lia’s mother to Dr. Arthur Kleinman’s questions, available

at heal.html. Discuss the differing perspective of the issues once someone asks the patient and/or family what they think.

Classroom Activity 10-4

Numerous classroom and clinical activities related to PCC are available on the QSEN website at strategies/strategy-search/. Choose activities from the website for students to complete that meet objectives specific to your course.

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