COMMUNITY HEALTH CARE

SKILL 30-16 Assessing the Musculoskeletal System 578

Neurologic System 580 Mental Status 580, Level of Consciousness 581, Cranial Nerves 581, Reflexes 581, Motor Function 581, Sensory Function 581

SKILL 30-17 Assessing the Neurologic System 582

Female Genitals and Inguinal Area 589 SKILL 30-18 Assessing the Female Genitals and Inguinal Area 591

Male Genitals and Inguinal Area 593 SKILL 30-19 Assessing the Male Genitals and Inguinal Area 594 Anus 596 SKILL 30-20 Assessing the Anus 596

UNIT 8 Integral Components of Client Care 601

Chapter 31 Asepsis 602

Introduction 602

Types of Microorganisms That Cause Infections 603

Types of Infections 603

Nosocomial and Health Care–Associated Infections 604

Chain of Infection 604 Etiologic Agent 605, Reservoir 605, Portal of Exit from Reservoir 606, Method of Transmission 606, Portal of Entry to the Susceptible Host 606, Susceptible Host 606

Body Defenses Against Infection 607 Nonspecific Defenses 607, Specific Defenses 608

Factors Increasing Susceptibility to Infection 608

Nursing Management 609 SKILL 31-1 Performing Hand Hygiene 614 SKILL 31-2 Applying and Removing Personal Protective Equipment (Gloves, Gown, Mask, Eyewear) 621 SKILL 31-3 Establishing and Maintaining a Sterile Field 628 SKILL 31-4 Applying and Removing Sterile Gloves (Open Method) 632 SKILL 31-5 Applying a Sterile Gown and Gloves (Closed Method) 633

Chapter 32 Safety 640

Introduction 640

Factors Affecting Safety 640 Age and Development 640, Lifestyle 640, Mobility and Health Status 640, Sensory-Perceptual Alterations 641, Cognitive Awareness 641, Emotional State 641, Ability to Communicate 641, Safety Awareness 641, Environmental Factors 641

Chapter 30 Health Assessment 513

Introduction 514

Physical Health Assessment 514 Preparing the Client 515, Preparing the Environment 515, Positioning 516, Draping 516, Instrumentation 516, Methods of Examining 516

General Survey 519 Appearance and Mental Status 519

SKILL 30-1 Assessing Appearance and Mental Status 520

Vital Signs 522, Height and Weight 522

Integument 522 Skin 522

SKILL 30-2 Assessing the Skin 525 Hair 528, Nails 528

SKILL 30-3 Assessing the Hair 529 SKILL 30-4 Assessing the Nails 530

Head 531 Skull and Face 531

SKILL 30-5 Assessing the Skull and Face 532

Eyes and Vision 533

SKILL 30-6 Assessing the Eye Structures and Visual Acuity 534

Ears and Hearing 539

SKILL 30-7 Assessing the Ears and Hearing 540

Nose and Sinuses 544

SKILL 30-8 Assessing the Nose and Sinuses 544

Mouth and Oropharynx 545

SKILL 30-9 Assessing the Mouth and Oropharynx 546

Neck 549

Thorax and Lungs 550 Chest Landmarks 550

SKILL 30-10 Assessing the Neck 550 Chest Shape and Size 554, Breath Sounds 555

SKILL 30-11 Assessing the Thorax and Lungs 556

Cardiovascular and Peripheral Vascular Systems 560

Heart 560, Central Vessels 562

SKILL 30-12 Assessing the Heart and Central Vessels 562

Peripheral Vascular System 566

SKILL 30-13 Assessing the Peripheral Vascular System 566 Breasts and Axillae 568 SKILL 30-14 Assessing the Breasts and Axillae 568

Abdomen 571 SKILL 30-15 Assessing the Abdomen 573

Musculoskeletal System 577

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Chapter 34 Diagnostic Testing 718

Introduction 718

Diagnostic Testing Phases 718 Pretest 718, Intratest 719, Post-Test 719, Nursing Diagnoses 719

Blood Tests 719 Complete Blood Count 719, Serum Electrolytes 721, Serum Osmolality 721, Drug Monitoring 721, Arterial Blood Gases 722, Blood Chemistry 723, Metabolic Screening 723, Capillary Blood Glucose 723

SKILL 34-1 Obtaining a Capillary Blood Specimen to Measure Blood Glucose 726

Specimen Collection and Testing 728 Stool Specimens 729, Urine Specimens 731

SKILL 34-2 Collecting a Urine Specimen for Culture and Sensitivity by Clean Catch 732

Sputum Specimens 736, Throat Culture 737

Visualization Procedures 737 Clients with Gastrointestinal Alterations 737, Clients with Urinary Alterations 738, Clients with Cardiopulmonary Alterations 738, Computed Tomography 738, Magnetic Resonance Imaging 739, Nuclear Imaging Studies 739

Aspiration/Biopsy 740 Lumbar Puncture 740, Abdominal Paracentesis 741, Thoracentesis 742, Bone Marrow Biopsy 743, Liver Biopsy 743

Chapter 35 Medications 750

Introduction 751

Drug Standards 751

Legal Aspects of Drug Administration 752

Effects of Drugs 752

Drug Misuse 754

Actions of Drugs on the Body 754 Pharmacodynamics 755, Pharmacokinetics 755

Factors Affecting Medication Action 756 Developmental Factors 756, Gender 757, Cultural, Ethnic, and Genetic Factors 757, Diet 757, Environment 757, Psychological Factors 757, Illness and Disease 757, Time of Administration 757

Routes of Administration 758 Oral 758, Sublingual 758, Buccal 759, Parenteral 759, Topical 759

Medication Orders 759 Types of Medication Orders 760, Essential Parts of a Medication Order 760, Communicating a Medication Order 761

Systems of Measurement 762 Metric System 762, Apothecaries’ System 763, Household System 763, Converting Units of Weight and Measure 763, Methods of Calculating Dosages 764

Administering Medications Safely 767 Medication Administration Errors 768, Medication Reconciliation 769,

Nursing Management 643 SKILL 32-1 Using a Bed or Chair Exit Safety Monitoring Device 652 SKILL 32-2 Implementing Seizure Precautions 654 SKILL 32-3 Applying Restraints 663

Chapter 33 Hygiene 669

Introduction 669

Hygienic Care 669

Skin 670

Nursing Management 670 SKILL 33-1 Bathing an Adult Client 676 SKILL 33-2 Providing Perineal-Genital Care 682

Feet 684 Developmental Variations 684

Nursing Management 684 SKILL 33-3 Providing Foot Care 687

Nails 688

Nursing Management 688

Mouth 689 Developmental Variations 689

Nursing Management 689 SKILL 33-4 Brushing and Flossing the Teeth 692 SKILL 33-5 Providing Special Oral Care for the Unconscious Client 696

Hair 697 Developmental Variations 698

Nursing Management 698 SKILL 33-6 Providing Hair Care 700

Eyes 702

Nursing Management 702

Ears 704 Cleaning the Ears 704, Care of Hearing Aids 704

SKILL 33-7 Removing, Cleaning, and Inserting a Hearing Aid 705

Nose 706

Supporting a Hygienic Environment 706 Environment 707, Hospital Beds 707, Mattresses 707, Side Rails 707, Footboard or Footboot 708, Intravenous Rods 708

Making Beds 708 Unoccupied Bed 708

SKILL 33-8 Changing an Unoccupied Bed 710

Changing an Occupied Bed 713

SKILL 33-9 Changing an Occupied Bed 713

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SKILL 36-2 Irrigating a Wound 849 Supporting and Immobilizing Wounds 851

Bandages 853, Basic Turns for Roller Bandages 853

Circular Turns 854, Spiral Turns 854, Spiral Reverse Turns 854, Recurrent Turns 854, Figure- Eight Turns 855

Binders 855

Arm Sling 855, Straight Abdominal Binder 856

Heat and Cold Applications 856,

Local Effects of Heat 856, Local Effects of Cold 856, Systemic Effects of Heat and Cold 857, Thermal Tolerance 857, Adaptation of Thermal Receptors 857 Rebound Phenomenon 857

Applying Heat and Cold 858

Hot Water Bag 858, Aquathermia Pad 859, Hot and Cold Packs 859, Electric Heating Pads 860, Ice Bags, Ice Gloves, and Ice Collars 860, Compresses 860, Soaks 860, Sitz Baths 860, Cooling Sponge Baths 861

Chapter 37 Perioperative Nursing 865

Introduction 865

Types of Surgery 866 Purpose 866, Degree of Urgency 866, Degree of Risk 866

Preoperative Phase 867 Preoperative Consent 867

Nursing Management 868 SKILL 37-1 Teaching Moving, Leg Exercises, Deep Breathing, and Coughing 871 SKILL 37-2 Applying Antiemboli Stockings 876

Intraoperative Phase 878 Types of Anesthesia 878

Nursing Management 879

Postoperative Phase 881 Immediate Postanesthetic Phase 881, Preparing for Ongoing Care of the Postoperative Client 883

Nursing Management 883 SKILL 37-3 Managing Gastrointestinal Suction 889 SKILL 37-4 Cleaning a Sutured Wound and Changing a Dressing on a Wound with a Drain 892

UNIT 9 Promoting Psychosocial Health 903 Chapter 38 Sensory Perception 904

Introduction 904

Components of the Sensory Experience 904

Arousal Mechanism 904

Factors Affecting Sensory Function 905 Developmental Stage 905, Culture 905, Stress 905, Medications and Illness 905, Lifestyle and Personality 906

Sensory Alterations 906

Medication Dispensing Systems 770, Process of Administering Medications 771, Developmental Considerations 774

Oral Medications 775 SKILL 35-1 Administering Oral Medications 775

Nasogastric and Gastrostomy Medications 780

Parenteral Medications 780 Equipment 780, Preparing Injectable Medications 784

SKILL 35-2 Preparing Medications from Ampules 787 SKILL 35-3 Preparing Medications from Vials 788 SKILL 35-4 Mixing Medications Using One Syringe 790

Intradermal Injections 791, Subcutaneous Injections 791

SKILL 35-5 Administering an Intradermal Injection for Skin Tests 792 SKILL 35-6 Administering a Subcutaneous Injection 794

Intramuscular Injections 797

SKILL 35-7 Administering an Intramuscular Injection 801

Intravenous Medications 803

SKILL 35-8 Adding Medications to Intravenous Fluid Containers 803 SKILL 35-9 Administering Intravenous Medications Using IV Push 808

Topical Medications 811

SKILL 35-10 Administering Ophthalmic Instillations 813 SKILL 35-11 Administering Otic Instillations 815 SKILL 35-12 Administering Vaginal Instillations 818

Inhaled Medications 820

Irrigations 823

Chapter 36 Skin Integrity and Wound Care 828

Introduction 828

Skin Integrity 828

Types of Wounds 829

Pressure Ulcers 829 Etiology of Pressure Ulcers 829, Risk Factors 830, Stages of Pressure Ulcers 830

Wound Healing 832 Types of Wound Healing 834, Phases of Wound Healing 835, Types of Wound Exudate 836, Complications of Wound Healing 836, Factors Affecting Wound Healing 836

Nursing Management 837 SKILL 36-1 Obtaining a Wound Drainage Specimen for Culture 839

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Spiritual Health and the Nursing Process 959

Nursing Management 960

Spiritual Self-Awareness for the Nurse 965

Chapter 42 Stress and Coping 972

Introduction 972

Concept of Stress 972 Sources of Stress 972, Effects of Stress 972

Models of Stress 972 Stimulus-Based Models 973, Response-Based Models 973, Transaction-Based Models 974

Indicators of Stress 974 Physiological Indicators 975, Psychological Indicators 975, Cognitive Indicators 977

Coping 978

Nursing Management 979

Chapter 43 Loss, Grieving, and Death 989

Introduction 989

Loss and Grief 989 Types and Sources of Loss 989, Grief, Bereavement, and Mourning 990, Stages of Grieving 991, Manifestations of Grief 992, Factors Influencing the Loss and Grief Responses 992

Nursing Management 994

Dying and Death 996 Responses to Dying and Death 996, Definitions and Signs of Death 997, Death-Related Religious and Cultural Practices 997

Nursing Management 998

UNIT 10 Promoting Physiological Health 1009

Chapter 44 Activity and Exercise 1010

Introduction 1010

Normal Movement 1011 Alignment and Posture 1011, Joint Mobility 1012, Balance 1012, Coordinated Movement 1012

Factors Affecting Body Alignment and Activity 1012

Growth and Development 1012, Nutrition 1017, Personal Values and Attitudes 1017, External Factors 1017, Prescribed Limitations 1018

Exercise 1018 Types of Exercise 1018, Benefits of Exercise 1020

Effects of Immobility 1021 Musculoskeletal System 1022, Cardiovascular System 1022, Respiratory System 1023, Metabolic System 1024, Urinary System 1024, Gastrointestinal System 1025, Integumentary System 1025, Psychoneurologic System 1025

Nursing Management 1025

Sensory Deprivation 906, Sensory Overload 906, Sensory Deficits 906

Nursing Management 907

Chapter 39 Self-Concept 922

Introduction 922

Self-Concept 922

Formation of Self-Concept 923

Components of Self-Concept 924 Personal Identity 924, Body Image 924, Role Performance 925, Self-Esteem 925

Factors That Affect Self-Concept 926 Stage of Development 926, Family and Culture 926, Stressors 926, Resources 927, History of Success and Failure 927, Illness 927

Nursing Management 927

Chapter 40 Sexuality 934

Introduction 934

Development of Sexuality 934 Birth to 12 Years 934, Adolescence 934, Young and Middle Adulthood 936, Older Adulthood 936

Sexual Health 938 Components of Sexual Health 938

Varieties of Sexuality 939 Sexual Orientation 939, Gender Identity 939, Erotic Preferences 940

Factors Influencing Sexuality 940 Family 940, Culture 941, Religion 941, Personal Expectations and Ethics 941

Sexual Response Cycle 941

Altered Sexual Function 942 Past and Current Factors 943, Sexual Desire Disorders 943, Sexual Arousal Disorders 943, Orgasmic Disorders 944, Sexual Pain Disorders 944, Problems with Satisfaction 945

Nursing Management 945

Chapter 41 Spirituality 954

Introduction 954

Spirituality and Related Concepts Described 954

Spiritual Care or Spiritual Nursing Care? 955, Spiritual Needs, Spiritual Distress, Spiritual Health, and Religious Coping 955

Spiritual Development 955

Religious Practices That Nurses Should Know 956

Holy Days 956, Sacred Texts 956, Sacred Symbols 957, Prayer and Meditation 957, Beliefs Affecting Diet 958, Beliefs About Illness and Healing 958, Beliefs About Dress and Modesty 958, Beliefs Related to Birth 959, Beliefs Related to Death 959

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Essential Nutrients 1127 Carbohydrates 1128, Proteins 1128, Lipids 1129, Micronutrients 1130

Energy Balance 1130 Energy Intake 1130, Energy Output 1130

Body Weight and Body Mass Standards 1131

Factors Affecting Nutrition 1132 Development 1132, Sex 1132, Ethnicity and Culture 1132, Beliefs About Food 1132, Personal Preferences 1132, Religious Practices 1133, Lifestyle 1133, Economics 1133, Medications and Therapy 1133, Health 1133, Alcohol Consumption 1133, Advertising 1134, Psychological Factors 1134

Nutritional Variations Throughout the Life Cycle 1134

Neonate to 1 Year 1135, Toddler 1135, Preschooler 1135, School-Age Child 1136, Adolescent 1136, Young Adult 1136, Middle-Aged Adult 1137, Older Adults 1137

Standards for a Healthy Diet 1137 Dietary Guidelines for Americans 1139, Recommended Dietary Intake 1140, Vegetarian Diets 1142

Altered Nutrition 1142

Nursing Management 1143 SKILL 47-1 Inserting a Nasogastric Tube 1154 SKILL 47-2 Administering a Tube Feeding 1160 SKILL 47-3 Administering a Gastrostomy or Jejunostomy Feeding 1163 SKILL 47-4 Removing a Nasogastric Tube 1166

Chapter 48 Urinary Elimination 1174

Introduction 1174

Physiology of Urinary Elimination 1174 Kidneys 1174, Ureters 1175, Bladder 1175, Urethra 1176, Pelvic Floor 1176, Urination 1176

Factors Affecting Voiding 1176 Developmental Factors 1176, Psychosocial Factors 1178, Fluid and Food Intake 1178, Medications 1179, Muscle Tone 1179, Pathologic Conditions 1179, Surgical and Diagnostic Procedures 1179

Altered Urine Production 1179 Polyuria 1179, Oliguria and Anuria 1179

Altered Urinary Elimination 1180 Frequency and Nocturia 1180, Urgency 1180, Dysuria 1181, Enuresis 1181, Urinary Incontinence 1181, Urinary Retention 1181

Nursing Management 1181

SKILL 44-1 Moving a Client Up in Bed 1040 SKILL 44-2 Turning a Client to the Lateral or Prone Position in Bed 1041 SKILL 44-3 Logrolling a Client 1042 SKILL 44-4 Assisting a Client to Sit on the Side of the Bed (Dangling) 1043 SKILL 44-5 Transferring Between Bed and Chair 1046 SKILL 44-6 Transferring Between Bed and Stretcher 1048 SKILL 44-7 Assisting a Client to Ambulate 1053

Chapter 45 Sleep 1066

Introduction 1066

Physiology of Sleep 1066 Circadian Rhythms 1066, Types of Sleep 1067, Sleep Cycles 1068

Functions of Sleep 1068

Normal Sleep Patterns and Requirements 1068

Newborns 1068, Infants 1069, Toddlers 1069, Preschoolers 1069, School-Age Children 1069, Adolescents 1069, Adults 1070, Older Adults 1070

Factors Affecting Sleep 1070 Illness 1071, Environment 1071, Lifestyle 1072, Emotional Stress 1072, Stimulants and Alcohol 1072, Diet 1072, Smoking 1072, Motivation 1072, Medications 1072

Common Sleep Disorders 1072 Insomnia 1072, Excessive Daytime Sleepiness 1073, Parasomnias 1075

Nursing Management 1075

Chapter 46 Pain Management 1086

Introduction 1086

The Nature of Pain 1087 Types of Pain 1087, Concepts Associated with Pain 1088

Physiology of Pain 1089 Nociception 1089, Gate Control Theory 1091, Responses to Pain 1092

Factors Affecting the Pain Experience 1092

Ethnic and Cultural Values 1092, Developmental Stage 1093, Environment and Support People 1093, Previous Pain Experiences 1094, Meaning of Pain 1095

Nursing Management 1095 SKILL 46-1 Providing a Back Massage 1116

Chapter 47 Nutrition 1127

Introduction 1127

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Chapter 51 Circulation 1287

Introduction 1287

Physiology of the Cardiovascular System 1287

The Heart 1287, Blood Vessels 1291, Blood 1292

Lifespan Considerations 1293

Factors Affecting Cardiovascular Function 1293

Risk Factors 1294

Alterations in Cardiovascular Function 1296

Decreased Cardiac Output 1297, Impaired Tissue Perfusion 1298, Blood Alterations 1298

Nursing Management 1298 SKILL 51-1 Applying Sequential Compression Devices 1302

Chapter 52 Fluid, Electrolyte, and Acid–Base Balance 1308

Introduction 1308

Body Fluids and Electrolytes 1309 Distribution of Body Fluids 1309, Composition of Body Fluid 1309, Movement of Body Fluids and Electrolytes 1310, Regulating Body Fluids 1312, Regulating Electrolytes 1313

Acid–Base Balance 1316 Regulation of Acid–Base Balance 1316

Factors Affecting Body Fluid, Electrolytes, and Acid–Base Balance 1317

Age 1317, Sex and Body Size 1318, Environmental Temperature 1318, Lifestyle 1318

Disturbances in Fluid Volume, Electrolyte, and Acid–Base Balances 1318

Fluid Imbalances 1318, Electrolyte Imbalances 1320, Acid–Base Imbalances 1324

Nursing Management 1326 SKILL 52-1 Starting an Intravenous Infusion 1344 SKILL 52-2 Monitoring an Intravenous Infusion 1350 SKILL 52-3 Changing an Intravenous Container and Tubing 1353 SKILL 52-4 Discontinuing an Intravenous Infusion 1354 SKILL 52-5 Changing an Intravenous Catheter to an Intermittent Infusion Lock 1356 SKILL 52-6 Initiating, Maintaining, and Terminating a Blood Transfusion Using a Y-Set 1361

Appendix A Answers to Test Your Knowledge 1370

GLOSSARY 1403

INDEX 1429

SKILL 48-1 Applying an External Urinary Device 1189 SKILL 48-2 Performing Urinary Catheterization 1194 SKILL 48-3 Performing Bladder Irrigation 1200

Chapter 49 Fecal Elimination 1210

Introduction 1210

Physiology of Defecation 1210 Large Intestine 1210, Rectum and Anal Canal 1211, Defecation 1211, Feces 1212

Factors That Affect Defecation 1212 Development 1212, Diet 1213, Fluid Intake and Output 1214, Activity 1214, Psychological Factors 1214, Defecation Habits 1214, Medications 1214, Diagnostic Procedures 1215, Anesthesia and Surgery 1215, Pathologic Conditions 1215, Pain 1215

Fecal Elimination Problems 1215 Constipation 1215, Diarrhea 1216, Bowel Incontinence 1216, Flatulence 1217

Bowel Diversion Ostomies 1218 Permanence 1218, Anatomic Location 1218, Surgical Construction of the Stoma 1218

Nursing Management 1220 SKILL 49-1 Administering an Enema 1227 SKILL 49-2 Changing a Bowel Diversion Ostomy Appliance 1233

Chapter 50 Oxygenation 1241

Introduction 1241

Structure and Processes of the Respiratory System 1242

Structure of the Respiratory System 1242, Pulmonary Ventilation 1243, Alveolar Gas Exchange 1245, Transport of Oxygen and Carbon Dioxide 1245, Systemic Diffusion 1246

Respiratory Regulation 1246

Factors Affecting Respiratory Function 1246

Age 1246, Environment 1246, Lifestyle 1246, Health Status 1247, Medications 1247, Stress 1247

Alterations in Respiratory Function 1247 Conditions Affecting the Airway 1247, Conditions Affecting Movement of Air 1247, Conditions Affecting Diffusion 1247, Conditions Affecting Transport 1248

Nursing Management 1248 SKILL 50-1 Administering Oxygen by Cannula, Face Mask, or Face Tent 1262 SKILL 50-2 Oropharyngeal, Nasopharyngeal, and Nasotracheal Suctioning 1269 SKILL 50-3 Suctioning a Tracheostomy or Endotracheal Tube 1273 SKILL 50-4 Providing Tracheostomy Care 1276

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1 The Nature of Nursing

1 Historical and Contemporary Nursing Practice 2

2 Evidence-Based Practice and Research in Nursing 26

3 Nursing Theories and Conceptual Frameworks 37

4 Legal Aspects of Nursing 47

5 Values, Ethics, and Advocacy 73

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LEARNING OUTCOMES

After completing this chapter, you will be able to: 1. Discuss historical factors and nursing leaders, female and

male, who influenced the development of nursing. 2. Discuss the evolution of nursing education and entry into

professional nursing practice. 3. Describe the different types of educational programs for

nurses. 4. Explain the importance of continuing nursing education. 5. Describe how the definition of nursing has evolved since

Florence Nightingale. 6. Identify the four major areas of nursing practice.

INTRODUCTION Nursing today is far different from nursing as it was practiced years ago, and it is expected to continue changing during the 21st century. To comprehend present-day nursing and at the same time prepare for the future, one must understand not only past events but also con- temporary nursing practice and the sociologic and historical factors that affect it.

HISTORICAL PERSPECTIVES Nursing has undergone dramatic change in response to societal needs and influences. A look at nursing’s beginnings reveals its con- tinuing struggle for autonomy and professionalization. In recent de- cades, a renewed interest in nursing history has produced a growing amount of related literature. This section highlights only selected aspects of events that have influenced nursing practice. Recurring themes of women’s roles and status, religious (Christian) values, war, societal attitudes, and visionary nursing leadership have influenced nursing practice in the past. Many of these factors still exert their influence today.

Women’s Roles Traditional female roles of wife, mother, daughter, and sister have always included the care and nurturing of other family members. From the beginning of time, women have cared for infants and children; thus, nursing could be said to have its roots in “the home.” Additionally, women, who in general occupied a subservient and de- pendent role, were called on to care for others in the community who were ill. Generally, the care provided was related to physical main- tenance and comfort. Thus, the traditional nursing role has always entailed humanistic caring, nurturing, comforting, and supporting.

Religion Religion has also played a significant role in the development of nurs- ing. Although many of the world’s religions encourage benevolence, it was the Christian value of “love thy neighbor as thyself ” and Christ’s parable of the Good Samaritan that had a significant impact on the development of Western nursing. During the third and fourth centu- ries, several wealthy matrons of the Roman Empire, such as Fabiola, converted to Christianity and used their wealth to provide houses of

KEY TERMS

Alexian Brothers, 3 caregiver, 15 case manager, 16 change agent, 15 Clara Barton, 6 client, 13 client advocate, 15 communicator, 15 consumer, 13 continuing education (CE), 12 counseling, 15

demography, 20 Dorothea Dix, 4 Fabiola, 2 Florence Nightingale, 6 governance, 17 Harriet Tubman, 3 in-service education, 13 Knights of Saint Lazarus, 3 Lavinia L. Dock, 7 leader, 15 Lillian Wald, 7

Linda Richards, 6 Luther Christman, 8 manager, 15 Margaret Higgins Sanger, 7 Mary Breckinridge, 8 Mary Mahoney, 7 patient, 13 Patient Self-Determination

Act (PSDA), 20 profession, 16 professionalism, 17

professionalization, 17 Sairy Gamp, 5 socialization, 17 Sojourner Truth, 3 Standards of Practice, 15 Standards of Professional

Performance, 15 teacher, 15 telehealth, 20 telenursing, 20

1 Historical and Contemporary Nursing Practice

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7. Identify the purposes of nurse practice acts and standards of professional nursing practice.

8. Describe the roles of nurses. 9. Describe the expanded career roles of nurses and their functions.

10. Discuss the criteria of a profession and the professionaliza- tion of nursing.

11. Discuss Benner’s levels of nursing proficiency. 12. Describe factors influencing contemporary nursing practice. 13. Explain the functions of national and international nurses’

associations.

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soldiers led to a public outcry in Great Britain. The role Florence Night- ingale played in addressing this problem is well known. She was asked by Sir Sidney Herbert of the British War Department to recruit a con- tingent of female nurses to provide care to the sick and injured in the Crimea. Nightingale and her nurses transformed the military hospitals by setting up sanitation practices, such as hand washing and washing clothing regularly. Nightingale is credited with performing miracles; the mortality rate in the Barrack Hospital in Turkey, for example, was reduced from 42% to 2% in 6 months (Donahue, 2011, p. 118).

During the American Civil War (1861–1865), several nurses emerged who were notable for their contributions to a country torn by internal strife. Harriet Tubman and Sojourner Truth (Figures 1–2 and 1–3 •) provided care and safety to slaves fleeing to the North on the Underground Railroad. Mother Biekerdyke and Clara Barton searched the battlefields and gave care to injured and dying soldiers. Noted

care and healing (the forerunner of hospitals) for the poor, the sick, and the homeless. Women were not, however, the sole providers of nursing services.

The Crusades saw the formation of several orders of knights, including the Knights of Saint John of Jerusalem (also known as the Knights Hospitalers), the Teutonic Knights, and the Knights of Saint Lazarus (Figure 1–1 •). These brothers in arms provided nurs- ing care to their sick and injured comrades. These orders also built hospitals, the organization and management of which set a standard for the administration of hospitals throughout Europe at that time. The Knights of Saint Lazarus dedicated themselves to the care of people with leprosy, syphilis, and chronic skin conditions.

During medieval times, there were many religious orders of men in nursing. For example, the Alexian Brothers organized care for victims of the Black Plague in the 14th century in Germany. In the 19th century, they followed the same traditions as women’s religious nursing orders and established hospitals and provided nursing care.

The deaconess groups, which had their origins in the Roman Empire of the third and fourth centuries, were suppressed during the Middle Ages by the Western churches. However, these groups of nursing providers resurfaced occasionally throughout the centuries, most notably in 1836 when Theodor Fliedner reinstituted the Order of Deaconesses and opened a small hospital and training school in Kaiserswerth, Germany. Florence Nightingale received her “training” in nursing at the Kaiserswerth School.

Early religious values, such as self-denial, spiritual calling, and de- votion to duty and hard work, have dominated nursing throughout its history. Nurses’ commitment to these values often resulted in exploita- tion and few monetary rewards. For some time, nurses themselves be- lieved it was inappropriate to expect economic gain from their “calling.”

War Throughout history, wars have accentuated the need for nurses. Dur- ing the Crimean War (1854–1856), the inadequacy of care given to

Figure 1–1 • The Knights of Saint Lazarus (established circa 1200) dedicated themselves to the care of people with leprosy, syphilis, and chronic skin conditions. From the time of Christ to the mid-13th century, leprosy was viewed as an incurable and terminal disease. Battman/Corbis.

Figure 1–2 • Harriet Tubman (1820–1913) was known as “The Moses of Her People” for her work with the Underground Railroad. During the Civil War she nursed the sick and suffering of her own race. Universal Images Group/Getty Images.

Figure 1–3 • Sojourner Truth (1797–1883), abolitionist, Underground Railroad agent, preacher, and women’s rights advocate, was a nurse for more than 4 years during the Civil War and worked as a nurse and counselor for the Freedmen’s Relief Association after the war. National Portrait Gallery, Smithsonian Institution/Art Resources, NY.

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authors Walt Whitman and Louisa May Alcott volunteered as nurses to give care to injured soldiers in military hospitals. Another female leader who provided nursing care during the Civil War was Dorothea Dix (Figure 1–4 •). She became the Union’s superintendent of female nurses responsible for recruiting nurses and supervising the nursing care of all women nurses working in the army hospitals.

The arrival of World War I resulted in American, British, and French women rushing to volunteer their nursing services. These nurses endured harsh environments and treated injuries not seen before. A monument entitled “The Spirit of Nursing” stands in Arlington National Cemetery (Figure 1–5 •). It honors the nurses who served in the U.S. armed services in World War I, many of whom are buried in Section 21, which is also called the “Nurses Section” (Arlington National Cemetery, n.d.). Progress in health care occurred during World War I, particularly in the field of surgery. For example, advancements were made in the use of anesthetic agents, infection control, blood typing, and prosthetics.

World War II casualties created an acute shortage of caregivers, and the Cadet Nurse Corps was established in response to a marked shortage of nurses (Figure 1–6 •). Also at that time, auxiliary health care workers became prominent. “Practical” nurses, aides, and tech- nicians provided much of the actual nursing care under the instruc- tion and supervision of better prepared nurses. Medical specialties also arose at that time to meet the needs of hospitalized clients.

During the Vietnam War, approximately 11,000 American military women stationed in Vietnam were nurses. Most of them volunteered to go to Vietnam right after they graduated from nurs- ing school, making them the youngest group of medical personnel ever to serve in wartime (Vietnam Women’s Memorial Foundation, n.d.). Near the Vietnam Veterans Memorial (“The Wall”) stands the Vietnam Women’s Memorial (Figure 1–7 •).

Societal Attitudes Society’s attitudes about nurses and nursing have significantly influ- enced professional nursing.

Figure 1–4 • Dorothea Dix (1802–1887) was the Union’s superintendent of female nurses during the Civil War. Bettman/Corbis.

Figure 1–5 • A, Section 21 in Arlington National Cemetery honors the nurses who served in the Armed Services in World War I. B, The “Spirit of Nursing” monument that stands in Section 21. C, Monument plaque. Photo by Sherrilyn Coffman, RN, PhD.

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Before the mid-1800s, nursing was without organization, educa- tion, or social status; the prevailing attitude was that a woman’s place was in the home and that no respectable woman should have a ca- reer. The role for the Victorian middle-class woman was that of wife and mother, and any education she obtained was for the purpose of making her a pleasant companion to her husband and a responsible mother to her children. Nurses in hospitals during this period were poorly educated; some were even incarcerated criminals. Society’s at- titudes about nursing during this period are reflected in the writings of Charles Dickens. In his book Martin Chuzzlewit (1896), Dickens reflected his attitude toward nurses through his character Sairy Gamp (Figure 1–8 •). She “cared” for the sick by neglecting them, stealing from them, and physically abusing them (Donahue, 2011, p. 112). This literary portrayal of nurses greatly influenced the nega- tive image and attitude toward nurses up to contemporary times.

In contrast, the guardian angel or angel of mercy image arose in the latter part of the 19th century, largely because of the work of Florence Nightingale during the Crimean War. After Nightingale brought re- spectability to the nursing profession, nurses were viewed as noble, compassionate, moral, religious, dedicated, and self-sacrificing.

Another image arising in the early 19th century that has affected subsequent generations of nurses and the public and other profes- sionals working with nurses is the image of doctor’s handmaiden. This image evolved when women had yet to obtain the right to vote, when family structures were largely paternalistic, and when the medical profession portrayed increasing use of scientific knowledge that, at that time, was viewed as a male domain. Since that time, several im- ages of nursing have been portrayed. The heroine portrayal evolved from nurses’ acts of bravery in World War II and their contributions in fighting poliomyelitis—in particular, the work of the Australian nurse Elizabeth Kenney. Other images in the late 1900s include the nurse as sex object, surrogate mother, and tyrannical mother.

During the past few decades, the nursing profession has taken steps to improve the image of the nurse. In the early 1990s, the Tri-Council for Nursing (the American Association of Col- leges of Nursing, the American Nurses Association [ANA], the American Organization of Nurse Executives, and the National

Figure 1–7 • Vietnam Women’s Memorial. Four figures include a nurse tending to the chest wound of a soldier, another woman looking for a helicopter for assistance, and a third woman (behind the other figures) kneeling while staring at an empty helmet in grief. Radius Images/Alamy.

Figure 1–8 • Sairy Gamp, a character in Dickens’ book Martin Chuzzlewit, represented the negative image of nurses in the early 1800s. Stapleton Collection/Corbis.

Figure 1–6 • Recruiting poster for the Cadet Nurse Corps during World War II. Stocktrek Images, Inc./Alamy.

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In 1853 she studied in Paris with the Sisters of Charity, after which she returned to England to assume the position of superintendent of a charity hospital for ill governesses.

When she returned to England from the Crimea, a grateful English public gave Nightingale an honorarium of £4,500. She later used this money to develop the Nightingale Training School for Nurses, which opened in 1860. The school served as a model for other training schools. Its graduates traveled to other countries to manage hospitals and institute nurse-training programs.

Despite poor health that left her an invalid, Florence Nightingale worked tirelessly until her death at age 90. As a passionate statistician, she conducted extensive research and analysis (Florence Nightingale International Foundation, 2014). Nightingale is often referred to as the first nurse researcher. For example, her record keeping proved that her interventions dramatically reduced mortality rates among soldiers during the Crimean War.

Nightingale’s vision of nursing changed society’s view of nurs- ing. She believed in personalized and holistic client care. Her vision also included public health and health promotion roles for nurses. It is easy to see how Florence Nightingale still serves as a model for nurses today.

BARTON (1821–1912) Clara Barton (Figure 1–10 •) was a schoolteacher who volunteered as a nurse during the American Civil War. Her responsibility was to organize the nursing services. Barton is noted for her role in establish- ing the American Red Cross, which linked with the International Red Cross when the U.S. Congress ratified the Treaty of Geneva (Geneva Convention). It was Barton who persuaded Congress in 1882 to ratify this treaty so that the Red Cross could perform humanitarian efforts in time of peace.

RICHARDS (1841–1930) Linda Richards (Figure 1–11 •) was America’s first trained nurse. She graduated from the New England Hospital for Women and Children in 1873. Richards is known for introducing nurse’s notes and doctor’s orders. She also initiated the practice of nurses wearing uniforms (ANA, 2013b). She is credited for her pioneering work in psychiatric and industrial nursing.

League for Nursing [NLN]) initiated a national effort, titled “Nurses of America,” to improve the image of nursing. Launched in 2002, the Johnson & Johnson corporation continues their “Campaign for Nursing’s Future” to promote nursing as a positive career choice. Through various outreach programs, this campaign increases ex- posure to the nursing profession, raises awareness about its chal- lenges (e.g., nursing shortage), and encourages people of all ages to consider a career in nursing.

Nursing Leaders Florence Nightingale, Clara Barton, Linda Richards, Mary Ma- honey, Lillian Wald, Lavinia Dock, Margaret Sanger, and Mary Breckinridge are among the leaders who have made notable con- tributions both to nursing’s history and to women’s history. These women were all politically astute pioneers. Their skills at influencing others and bringing about change remain models for political nurse activists today. Contemporary nursing leaders, such as Virginia Henderson, who created a modern worldwide definition of nursing, and Martha Rogers, a catalyst for theory development, are discussed in Chapter 3 .

NIGHTINGALE (1820–1910) The contributions of Florence Nightingale to nursing are well documented. Her achievements in improving the standards for the care of war casualties in the Crimea earned her the title “Lady with the Lamp.” Her efforts in reforming hospitals and in producing and implementing public health policies also made her an accomplished political nurse: She was the first nurse to exert political pressure on government. Through her contributions to nursing education— perhaps her greatest achievement—she is also recognized as nursing’s first scientist-theorist for her work Notes on Nursing: What It Is, and What It Is Not (1860/1969).

Nightingale (Figure 1–9 •) was born to a wealthy and intel- lectual family. She believed she was “called by God to help others . . . [and] to improve the well-being of mankind” (Schuyler, 1992, p.  4). She was determined to become a nurse in spite of opposition from her family and the restrictive societal code for affluent young English women. As a well-traveled young woman of the day, she visited Kaiserswerth in 1847, where she received 3 months’ training in nursing.

Figure 1–9 • Considered the founder of modern nursing, Florence Nightingale (1820–1910) was influential in developing nursing education, practice, and administration. Her publication, Notes on Nursing: What It Is, and What It Is Not, first published in England in 1859 and in the United States in 1860, was intended for all women. Classic Clock/Corbis.

Figure 1–10 • Clara Barton (1821–1912) organized the American Red Cross, which linked with the International Red Cross when the U.S. Congress ratified the Geneva Convention in 1882. © Bettman/CORBIS.

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in  protest movements for women’s rights that resulted in the 1920 passage of the 19th Amendment to the U.S. Constitution, which granted women the right to vote. In addition, Dock campaigned for legislation to allow nurses rather than physicians to control their pro- fession. In 1893, Dock, with the assistance of Mary Adelaide Nutting and Isabel Hampton Robb, founded the American Society of Super- intendents of Training Schools for Nurses of the United States, a pre- cursor to the current National League for Nursing.

SANGER (1879–1966) Margaret Higgins Sanger (Figure 1–15 •), a public health nurse in New York, has had a lasting impact on women’s health care. Imprisoned for opening the first birth control information clinic in America, she is considered the founder of Planned Parent- hood. Her experience with the large number of unwanted pregnan- cies among the working poor was instrumental in addressing this problem.

MAHONEY (1845–1926) Mary Mahoney (Figure 1–12 •) was the first African American professional nurse. She graduated from the New England Hospital for Women and Children in 1879. She constantly worked for the ac- ceptance of African Americans in nursing and for the promotion of equal opportunities (Donahue, 2011, p. 144). The ANA (2013c) gives a Mary Mahoney Award biennially in recognition of significant con- tributions in interracial relationships.

WALD (1867–1940) Lillian Wald (Figure 1–13 •) is considered the founder of pub- lic health nursing. Wald and Mary Brewster were the first to offer trained nursing services to the poor in the New York slums. Their home among the poor on the upper floor of a tenement, called the Henry Street Settlement and Visiting Nurse Service, provided nurs- ing services, social services, and organized educational and cultural activities. Soon after the founding of the Henry Street Settlement, school nursing was established as an adjunct to visiting nursing.

DOCK (1858–1956) Lavinia L. Dock (Figure 1–14 •) was a feminist, prolific writer, political activist, suffragette, and friend of Wald. She participated

Figure 1–11 • Linda Richards (1841–1930) was America’s first trained nurse. National League for Nursing. National League for Nursing Records. 1894–1952. Located in: Archives and Modern Manuscripts Collection, History of Medicine Division, National Library of Medicine, Bethesda, MD; MS C 274.

Figure 1–13 • Lillian Wald (1867–1940) founded the Henry Street Settlement and Visiting Nurse Service (circa 1893), which provided nursing and social services and organized educational and cultural activities. She is considered the founder of public health nursing. National Portrait Gallery, Smithsonian Institution/Art Resources, NY.

Figure 1–14 • Nursing leader and suffragist Lavinia L. Dock (1858–1956) was active in the protest movement for women’s rights that resulted in the constitutional amendment in 1920 that allowed women to vote. Courtesy of The Gottesman Libraries at Teachers College, Columbia University.

Figure 1–12 • Mary Mahoney (1845–1926) was the first African American trained nurse. Schomberg Center for Research in Black Culture/NYPL/Art Resource.

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admission to the Military Nurse Corps during World War II based on gender. It was believed at that time that nursing was women’s work and combat was men’s work. During the 20th century, men were denied admission to most nursing programs. The ANA de- nied membership to male nurses until 1930 and many state nursing associations did not allow men to join until the 1950s (O’Lynn & Tranbarger, 2007, p. 68).

In 1971, a nurse who practiced in Michigan, Steve Miller, formed an organization called Men in Nursing. In 1974, Luther Christman organized a group of male nurses in Chicago. The two groups reor- ganized into the National Male Nurses Association with the primary focus of recruiting more men into nursing. In 1981, the organization was renamed the American Assembly for Men in Nursing (AAMN) (2011). The purpose of the AAMN is to provide a framework for nurses, as a group, to meet to discuss and influence factors that affect men as nurses. In 2009 and 2010, members of the AAMN discussed ways to change the image of men in nursing in both recruitment and retention. They subsequently introduced the theme “Do what you love and you’ll love what you do” (Figure 1–17 •). This idea led to the AAMN initiative “20 × 20 Choose Nursing,” which has the goal of increasing the enrollment of men in nursing programs nationally from the current 10% to 20% by 2020 (Anderson, 2011).

Luther Christman (1915–2011), one of the founders of the AAMN, graduated from the Pennsylvania Hospital School of Nurs- ing for Men in 1939 and did experience discrimination while in nursing school. For example, he was not allowed a maternity clini- cal experience, yet was expected to know the information related

BRECKINRIDGE (1881–1965) After World War I, Mary Breckinridge (Figure 1–16 •), a notable pioneer nurse, established the Frontier Nursing Service (FNS). In 1918, she worked with the American Committee for Devastated France, distributing food, clothing, and supplies to rural villages and taking care of sick children. In 1921, Breckinridge returned to the United States with plans to provide health care to the people of rural America. In 1925, Breckinridge and two other nurses be- gan the FNS in Leslie County, Kentucky. Within this organization, Breckinridge started one of the first midwifery training schools in the United States.

Men in Nursing Men have worked as nurses as far back as before the Crusades. Al- though the history of nursing primarily focuses on the female fig- ures in nursing, schools of nursing for men existed in the United States from the late 1880s until 1969. Male nurses were denied

Figure 1–15 • Nurse activist Margaret Sanger (1879–1966), considered the founder of Planned Parenthood, was imprisoned for opening the first birth control information clinic in Baltimore in 1916. © Bettman/CORBIS.

Figure 1–17 • Poster for American Assembly for Men in Nursing “20 3 20 Choose Nursing Campaign.” Courtesy American Association for Men in Nursing.

Figure 1–16 • Mary Breckinridge (1881–1965), a nurse who practiced midwifery in England, Australia, and New Zealand, founded the Frontier Nursing Service in Kentucky in 1925 to provide family-centered primary health care to rural populations. Newscom.

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programs are eligible to take the licensure examination to become an RN and also may continue into specialty roles such as nurse prac- titioner or nurse educator.

Although educational preparation varies considerably, all RNs in the United States take the same licensure examination, the National Council Licensure Examination (NCLEX-RN). This examination is administered in each state and the successful can- didate becomes licensed in that particular state, even though the examination is of national origin. To practice nursing in another state, the nurse must receive reciprocal licensure by applying to that state’s board of nursing. Some state legislatures have created a regulatory model called mutual recognition that allows for mul- tistate licensure under one license. States that enter into these rec- ognition agreements are referred to as compact states. Nurses who have received their training in other countries may be granted registration after successfully completing the NCLEX. Both licen- sure and registration must be renewed regularly in order to remain valid. For additional information about licensure and registration, see Chapter 4 .

The legal right to practice nursing requires not only passing the licensing examination, but also verification that the candidate has completed a prescribed course of study in nursing. Some states may have additional requirements. All U.S. nursing programs must be approved by their state board of nursing. In addition to state ap- proval, the Accreditation Commission for Education in Nursing (ACEN), formerly called the National League for Nursing Accred- iting Commission (NLNAC), provides accreditation for all levels of nursing programs, and the Commission on Collegiate Nurs- ing Education (CCNE) accredits baccalaureate and higher degree programs. Accreditation is a voluntary, peer review process. Ac- credited programs meet standard requirements that are evaluated periodically through written self-studies and on-site visitation by peer examiners.

Types of Education Programs Education programs available for nurses include practical or voca- tional nursing, registered nursing, graduate nursing, and continu- ing education. All levels of nursing are needed in health care today.

to that clinical experience for the licensing exam. After becoming licensed, he wanted to earn a baccalaureate degree in nursing, but was denied access to two universities because of gender. After re- ceiving his doctorate he accepted the position as dean of nursing at Vanderbilt University. He was the first man to be a dean at a univer- sity school of nursing. He accomplished many firsts: the first man nominated for president of the ANA, the first man elected to the American Academy of Nursing (he was named a “Living Legend” by this organization), and the first man inducted into ANA’s Hall of Fame for his extraordinary contributions to nursing (O’Lynn & Tranbarger, 2007).

Men comprised 9.6% of the nation’s nursing workforce in 2011 (U.S. Census Bureau, 2013). Men do experience barriers to becom- ing nurses. For example, the nursing image is one of femininity, and nursing has been slow to neuter this image. As a result, many people may believe that only homosexual men enter nursing, which is not true. Other barriers and challenges for male nursing students include the lack of male role models in nursing and caring (e.g., differences in caring styles between men and women) and suspicion surrounding intimate touch (MacWilliams, Schmidt, & Bleich, 2013). The nursing profession and nursing education need to address these issues. Im- proved recruitment and retention of men and other minorities into nursing will strengthen the profession.

NURSING EDUCATION The practice of nursing is controlled from within the profession through state boards of nursing and professional nursing organiza- tions. These groups also determine the content and type of educa- tion that is required for different levels or scopes of nursing practice. Originally, the focus of nursing education was to teach the knowl- edge and skills that would enable a nurse to practice in a hospital setting. However, as nursing roles have evolved in response to new scientific knowledge; advances in technology; and cultural, political, and socioeconomic changes in society; nursing education curricula have been revised to enable nurses to work in more diverse settings and assume more diverse roles. Nursing programs are increasingly based on a broad knowledge of biologic, social, and physical sciences as well as the liberal arts and humanities. Current nursing curricula emphasize critical thinking and the application of nursing and sup- porting knowledge to health promotion, health maintenance, and health restoration as provided in both community and hospital settings (Figure 1–18 •).

There are two types of entry-level generalist nurses: the reg- istered nurse (RN) and the licensed practical or vocational nurse (LPN or LVN). Responsibilities and licensure requirements differ for these two levels. The majority of new RNs graduate from associ- ate degree or baccalaureate degree nursing programs. In some states, a person can be eligible to take the licensure exam through other qualifications such as completing a diploma nursing program or challenging the exam as a military corps person or LVN after com- pleting specified coursework. There also are “generic” master’s and doctoral programs that lead to eligibility for RN licensure. These latter programs are for students who already have a baccalaureate degree in a discipline other than nursing. On completion of the program, which may be from 1 to 3 years in length, graduates ob- tain their initial professional degree in nursing. Graduates of these

Figure 1–18 • Nursing students learn to care for clients in community settings. Jim West/Alamy.

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ASSOCIATE DEGREE PROGRAMS Associate degree nursing programs, which arose in the early 1950s, were the first and only educational programs for nursing that were systematically developed from planned research and controlled experimentation. Most of these programs take place in community colleges. The graduating student receives an associate degree in nursing (ADN) or an associate of arts (AA), associate of science (AS), or associate in applied science (AAS) degree with a major in nursing. Several trends and events prompted the development of these programs: (a) the Cadet Nurse Corps, (b) the community college movement, (c) earlier nursing studies, and (d) Dr. Mildred Montag’s proposal for an associate degree.

The Cadet Nurse Corps of the United States was legislated and financed during World War II to provide nurses to meet both mili- tary and civilian needs. The corps demonstrated that qualified nurses could be educated in less time than the traditional 3 years of most diploma programs.

After World War II, the number of community colleges in the United States increased rapidly. The low tuition and open-door ad- mission policy of these colleges, as well as their location in towns and cities lacking 4-year colleges and universities, made higher education accessible to more individuals by offering the first 2 years of a 4-year college program as well as vocational programs that addressed com- munity needs.

Studies of nursing education, such as the Goldmark Report in 1923, the Committee on the Grading of Nursing Schools in 1934, and the Brown Report in 1948, also had a significant influence on the development of 2-year nursing programs. The recommenda- tions in all of these reports supported the idea of independent schools of nursing in institutions of higher learning separate from hospitals.

In the United States, associate degree nursing programs were started after Mildred Montag published her doctoral dissertation, “The Education of Nursing Technicians,” in 1951. This study pro- posed a 2-year education program for RNs in community colleges as a solution to the acute shortage of nurses that came about because of World War II. Dr. Montag conceptualized a “nursing technician” or “bedside nurse” able to perform nursing functions broader than those of a practical nurse, but lesser in scope than those of the profes- sional nurse. At the end of the 2 years, the student was to be awarded an ADN and be eligible to take the state board examination for reg- istered nurse licensure. The first ADN program was established at Columbia University Teacher’s College in 1952 under the direction of Dr. Montag. The number of ADN programs has grown steadily. Currently, 45.4% of all new RNs each year are educated in associate degree programs (HRSA, 2010).

Dr. Montag’s original idea that these graduates be nursing tech- nicians and that the degree become a terminal one did not last. In 1978, the ANA proposed that associate degree programs no longer be considered terminal, but part of a career upward-mobility plan. Today many students enter an associate degree program with the in- tention of continuing their education to the baccalaureate or higher level. Many community colleges have articulation agreements with colleges and university bachelor of science in nursing (BSN) pro- grams to facilitate the upward mobility toward the BSN. RN to master of science in nursing (MSN) programs are also available to the associ- ate degree nurse.

Each has a unique scope of practice and by working collaboratively can help meet the often complex needs of clients.

LICENSED PRACTICAL (VOCATIONAL) NURSING PROGRAMS Practical or vocational nursing programs are housed in community colleges, vocational schools, hospitals, or other independent health agencies. These programs generally last 9 to 12 months and include both classroom and clinical experience. At the end of the program, graduates take the NCLEX-PN to obtain licensure as a practical or vocational nurse. Some LPN and LVN programs articulate with as- sociate degree programs. In these ladder programs, the practical/ vocational education component comprises the first year of an associate degree program for registered nursing and, if successful in passing the NCLEX-PN, students can work while continuing their registered nurse education.

Practical nurses work under the supervision of a registered nurse in numerous settings, including hospitals, nursing homes, rehabilita- tion centers, and home health agencies. Although the scope of prac- tice varies by state regulation and agency policy, LPNs usually provide basic direct technical care to clients. Employment of LPNs has shifted away from acute care settings to care of older adults in community- based settings, including long-term care (NLN, 2011).

REGISTERED NURSING PROGRAMS Currently, three major routes lead to eligibility for RN licen- sure: completion of a diploma, associate degree, or baccalaureate program.

DIPLOMA PROGRAMS After Florence Nightingale established the Nightingale Training School of Nurses at St. Thomas Hospital in England in 1860, the concept traveled quickly to North America. Hospital administrators welcomed the idea of training schools as a source of nursing staff for free or inexpensive staffing for the hospital. Nursing education in early years largely took the form of apprenticeship programs. With little formal classroom instruction, students learned by doing—that is, by providing direct care to clients. There was no standardization of curriculum and no accreditation. Programs were designed to meet the service needs of the hospital, not the educational needs of the students.

Three-year diploma programs were the dominant nursing pro- grams and the major source of nursing graduates from the late 1800s until the mid-1960s. Today’s diploma programs are hospital-based educational programs that provide rich clinical experiences for nurs- ing students. These programs often are associated with colleges or universities.

Currently, 20.4% of RNs have obtained their initial nursing edu- cation in diploma programs (Health Resources and Services Admin- istration [HRSA], 2010). The number of diploma nursing programs has declined steadily since a resolution by the ANA in 1965 recom- mended that “education for those who work in nursing should be placed in institutions of learning within the general system of edu- cation,” that “minimal preparation for beginning professional nurs- ing practice at the present time should be the baccalaureate degree education in nursing,” and that “associate degree education in nursing should be the minimum preparation for beginning technical nursing practice” (ANA, 1965, p. 107).

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GRADUATE NURSING PROGRAMS Although graduate schools differ, typical requirements for admission to a graduate program in nursing include the following:

• Licensure as a registered nurse or eligibility for licensure. • A baccalaureate degree in nursing from an approved college or

university. Some graduate programs accept individuals with a diploma or associate degree in nursing and a baccalaureate degree in another field of study. Some accept individuals with an associ- ate degree in nursing as their only postsecondary education.

• Evidence of scholastic ability (usually a minimum grade point average of 3.0 on a 4.0 scale).

• Satisfactory achievement on a standard qualifying examina- tion such as the Graduate Record Examination (GRE) or Miller Analogies Test (MAT).

• Letters of recommendation from supervisors, nursing faculty, or nursing colleagues indicating the applicant’s ability to do graduate study.

MASTER’S DEGREE PROGRAMS The growth of baccalaureate nursing programs encouraged the development of graduate study in nursing. In 1953, the newly established NLN encouraged educators to develop programs for master’s degrees in nursing. Currently, 13.2% of licensed RNs hold a master’s or higher degree (HRSA, 2010). Master’s prepared nurses work in a variety of roles, including clinical nurse specialist (CNS), nurse practitioner (NP and also called advanced practice registered nurse [APRN]), nurse midwife (CNM), and nurse anesthetist (CRNA). The emphasis of master’s degree programs is on preparing nurses for advanced leadership roles in administration, clinical, or teaching (Figure 1–19 •).

An emerging nursing role developed by the AACN is the clini- cal nurse leader (CNL). The CNL is a master’s degree–prepared clinician who oversees the integration of care for a distinct group of clients and may actively provide direct client care in complex situa- tions (AACN, 2012d).

DOCTORAL PROGRAMS Doctoral programs in nursing began in the 1960s in the United States. Before 1960, nurses who pursued doctoral degrees chose related fields such as education, psychology, sociology, and physiology. The two primary doctoral degrees in nursing

BACCALAUREATE DEGREE PROGRAMS The first school of nursing in a university setting was established at the University of Minnesota in 1909. This program’s curriculum, however, differed little from that of a 3-year diploma program. It was not until 1919 that the University of Minnesota established its undergraduate baccalaureate degree in nursing. Most of the early baccalaureate programs were 5 years in length. They consisted of the basic 3-year diploma program plus 2 years of liberal arts education. In the 1960s, the number of students enrolled in baccalaureate programs increased markedly.

Approximately 34% of RNs in the United States are educated in baccalaureate programs (HRSA, 2010). Baccalaureate programs are located in senior colleges and universities and are generally 4 years in length. Programs include courses in the liberal arts, sciences, hu- manities, and nursing. Graduates must complete both the degree requirements of the college or university and the nursing program before being awarded a baccalaureate degree. The usual degree awarded is a BSN. Partially in response to the significant shortage of RNs, some schools have established accelerated BSN programs. These programs may include summer coursework in order to shorten the length of time required to complete the curriculum or may be a modified curriculum designed for students who already have a baccalaureate degree in another field. These “second degree” or “fast track” BSN programs can be completed in as little as 12 to 18 months of study.

Many baccalaureate programs also admit registered nurses who have a diploma or associate degree. These programs typically are re- ferred to as BSN completion, BSN transition, 2 1 2, or RN-BSN pro- grams. Most RN-BSN programs have a special curriculum designed to meet the needs of these students. Many accept transfer credits from other accredited colleges or universities and award academic credit for the nursing coursework completed previously in a diploma or as- sociate degree program. An increasing number of RN-BSN programs are offered online.

Because of changes in the practice environment, the nurse who holds a baccalaureate degree generally experiences more autonomy, responsibility, participation in institutional decision making, and career advancement than the nurse prepared with a diploma or associate degree. Some employers have different salary scales for nurses with a baccalaureate degree, as opposed to an associate de- gree or diploma. In addition, the American Nurses Credentialing Center (ANCC) requires a baccalaureate degree for initial basic certification in most nursing specialties, and certification often is rewarded with a salary increase. The Magnet Recognition Pro- gram®, developed by the ANCC to recognize health care organi- zations that provide nursing excellence, requires that 75% of nurse managers hold at least a baccalaureate degree; 100% compliance was required for magnet facilities as of 2013. Also, the Institute of Medicine’s (IOM’s) recent publication The Future of Nursing (2010) recommended that 80% of RNs be baccalaureate prepared by 2020. All of these points provide an incentive for nurses with diplomas and associate degrees to continue their formal preparation in bac- calaureate completion programs. This is reflected in the increasing enrollment in RN to BSN programs. For  example, enrollments in- creased by 15.8% from 2010 to 2011 (AACN, 2012a). Current issues regarding nursing education and entry into practice are discussed in Box 1–1.

Figure 1–19 • A nurse practitioner holds a master’s degree and assumes an advanced practice role. Custom Medical Stock Photo/Alamy.

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and shorter. Participants may receive certificates of completion or specialization.

CE is the responsibility of all practicing nurses. Constant up- dating and growth are essential to keep abreast of scientific and technologic changes and changes within health care and the nursing profession. A variety of educational and health care institutions con- duct CE programs on site, via home study, and online.

CE programs usually are designed to meet one or more of the following needs: (a) to inform nurses of new techniques and knowl- edge; (b) to help nurses attain expertise in a specialized area of prac- tice, such as critical care nursing; and (c) to provide nurses with information essential to nursing practice, such as knowledge about legal and ethical aspects of nursing. Some states require nurses to ob- tain a certain number of CE credits to renew their license. Required contact hours typically range from 15 to 30 hours per 2-year license renewal period. A few states also require a certain number of hours

BOX 1–1 Entry into Practice and Nursing Education: Current Issues

1. In 1985, the ANA endorsed the BSN as the necessary education for entry into professional nursing practice. Only graduates of baccalaureate programs in nursing would be licensed under the legal title “registered nurse.” Associate degree graduates would be considered technical nurses and licensed under the title “associate nurse (AN).” The proposal sparked sharp debates that continue 25 years later. Many students, graduates, and educators, particularly in associate degree programs, perceive that the proposal undervalues associate degree graduates. As a result, the National League for Nursing (NLN) suggested that the title of associate nurse be replaced by “registered associate nurse.” This suggestion has not, however, eliminated the controversy. Many argue that ADN graduates have held the title registered nurse since the inception of associate degree programs and should retain that title.

2. As a professional organization, ANA cannot legislate these changes. It is the right and responsibility of each state to define the legal boundaries of nursing practice and to designate the title to be used by those practitioners who meet the state’s criteria for licensure. For ANA’s proposal to be accepted nationally, each state needs to implement its own changes in its licensure laws.

3. If the ANA proposal were implemented, a grandfather clause would need to be considered for existing associate degree or diploma graduate registered nurses. Under such a clause, these nurses would continue to be licensed as registered nurses, provided their performance meets established standards. However, grandfather clauses would protect only the nurse’s license, not their specific nursing job.

4. Status of diploma nurses and LPNs is not discussed in the proposal.

5. In this proposal, new standardized examinations would be developed in order to test two levels of competence.

6. Some individuals believe that the first step in resolving practice and title issues related to educational preparation should be clarification of the knowledge, skills, and abilities of graduates of each type of nursing program. Because all licensed nurses currently function under the same practice acts and often earn the same salary, the need for differentiated competencies has been debated for years. Differentiated nursing practice is defined by level of education, expected skills, job descriptions, compensation, and participation in decision making. Research

has shown that differentiated practice models foster positive outcomes for job satisfaction, nurse turnover rates, and positive patient outcomes (AACN, 2012a).

7. During the past decade, policy makers, researchers, and nursing practice leaders have recognized that a nurse’s level of education impacts nursing practice. For example, in 2005, the American Organization of Nurse Executives (AONE) released a statement calling for all RNs to be educated in baccalaureate programs because of the increasingly complex and challenging nursing roles (AACN, 2012c). In 2009, Dr. Patricia Benner and her team released a study that recommended preparing all entry-level registered nurses at the baccalaureate level and requiring all RNs to earn a master’s degree within 10 years of initial licensure (Benner, Sutphen, Leonard, & Day, 2010). In 2010, the Tri-Council for Nursing issued a new consensus policy statement on the educational advancement of registered nurses. The Tri-Council organizations include the AACN, ANA, AONE, and NLN. All of these organizations agreed that “a more highly educated nursing profession is no longer a preferred future; it is a necessary future in order to meet the nursing needs of the nation and to deliver effective and safe care” (Tri-Council for Nursing, 2010). The Tri-Council encourages all nurses, regardless of their entry point into the profession to continue their education (e.g., baccalaureate, masters, and doctoral degrees). Also in 2010, the IOM released its landmark report on the future of nursing, which called for increasing the number of baccalaureate-prepared nurses to 80% and doubling the population of nurses with doctoral degrees by 2020 (IOM, 2010). Currently, only 50% of RNs are prepared at the baccalaureate or graduate degree level (AACN, 2012c). As a final point, a historic landmark agreement occurred in 2012. Five leading organizations in nursing education and community college leadership released a statement on academic progression for nursing students and graduates. This collaborative statement changed the focus from “requirements for initial preparation to how to seed lifelong learning, academic progress, and multiple entry points to professional practice in nursing (NLN, 2012b). It is projected that there will be a need for more than 1.2 million additional RNs by 2020 (NLN, 2012a). The joint statement on academic progression helps facilitate nurses pursuing higher levels of education needed for the current and future nursing workforce.

are the PhD and DNP (doctor of nursing practice). Nurses who earn a PhD in nursing generally assume faculty roles in nursing education programs or work in research programs. The DNP, which has been increasing in popularity, is the highest degree for nurse clinicians. In 2006, the AACN recommended the DNP degree as the entry-level degree for all APRNs by 2015. Currently, however, no NP certification boards require a DNP for the entry-level exam, nor does any state require a DNP as a condition of APRN licensure (Selway, 2012, p. 9). Doctorates in related fields such as education or public health are still highly relevant for nurses depending on their practice role.

CONTINUING EDUCATION The term continuing education (CE) refers to formalized expe- riences designed to enhance the knowledge or skills of practicing professionals. Compared to advanced educational programs, which result in an academic degree, CE courses tend to be more specific

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of practice, either independently or in lieu of study hours, before licensure renewal.

An in-service education program is a specific type of CE program that is offered by an employer. It is designed to upgrade the knowledge or skills of employees, as well as to validate continu- ing competence in selected procedures and areas of practice. For example, an employer might offer an in-service program to inform nurses about a new piece of equipment or a new surgical procedure, new documentation procedures, or methods of implementing a nurse theorist’s conceptual framework for nursing. Some in-service programs are mandatory on a regular basis, such as cardiopulmonary resuscitation and fire or back safety programs.

CONTEMPORARY NURSING PRACTICE An understanding of contemporary nursing practice includes a look at definitions of nursing, recipients of nursing, scope of nursing, set- tings for nursing practice, nurse practice acts, and current standards of clinical nursing practice.

Definitions of Nursing Florence Nightingale defined nursing nearly 150 years ago as “the act of utilizing the environment of the patient to assist him in his recovery” (Nightingale, 1860/1969). Nightingale considered a clean, well-ventilated, and quiet environment essential for recovery. Often considered the first nurse theorist, Nightingale raised the status of nursing through education. Nurses were no longer untrained house- keepers but people educated in the care of the sick.

Virginia Henderson was one of the first modern nurses to de- fine nursing. She wrote, “The unique function of the nurse is to as- sist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge, and to do this in such a way as to help him gain indepen- dence as rapidly as possible” (Henderson, 1966, p. 3). Like Nightin- gale, Henderson described nursing in relation to the client and the client’s environment. Unlike Nightingale, Henderson saw the nurse as concerned with both healthy and ill individuals, acknowledged that nurses interact with clients even when recovery may not be feasible, and mentioned the teaching and advocacy roles of the nurse.

In the latter half of the 20th century, a number of nurse theorists developed their own theoretical definitions of nursing. Theoretical definitions are important because they go beyond simplistic com- mon definitions. They describe what nursing is and the interrela- tionship among nurses, nursing, the client, the environment, and the intended client outcome: health (see Chapter 3 ).

Certain themes are common to many of these definitions:

• Nursing is caring. • Nursing is an art. • Nursing is a science. • Nursing is client centered. • Nursing is holistic. • Nursing is adaptive. • Nursing is concerned with health promotion, health maintenance,

and health restoration. • Nursing is a helping profession.

Professional nursing associations have also examined nursing and developed their definitions of it. In 1973, the ANA described nursing practice as “direct, goal oriented, and adaptable to the needs of the individual, the family, and community during health and illness” (ANA, 1973, p. 2). In 1980, the ANA changed this defi- nition of nursing to this: “Nursing is the diagnosis and treatment of human responses to actual or potential health problems” (ANA, 1980, p. 9). In 1995, the ANA recognized the influence and contri- bution of the science of caring to nursing philosophy and practice. The current definition of nursing remains unchanged from the 2003 edition of Nursing’s Social Policy Statement: “Nursing is the protection, promotion, and optimization of health and abilities, preventions of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” (ANA, 2010, p. 10).

Research to explore the meaning of caring in nursing has been increasing. Details about caring are discussed in Chapter 25 .

Recipients of Nursing The recipients of nursing are sometimes called consumers, some- times patients, and sometimes clients. A consumer is an individual, a group of people, or a community that uses a service or commod- ity. People who use health care products or services are consumers of health care.

A patient is a person who is waiting for or undergoing medical treatment and care. The word patient comes from a Latin word mean- ing “to suffer” or “to bear.” Traditionally, the person receiving health care has been called a patient. Usually, people become patients when they seek assistance because of illness or for surgery. Some nurses be- lieve that the word patient implies passive acceptance of the decisions and care of health professionals. Additionally, with the emphasis on health promotion and prevention of illness, many recipients of nurs- ing care are not ill. Moreover, nurses interact with family members and significant others to provide support, information, and comfort in addition to caring for the patient.

For these reasons, nurses increasingly refer to recipients of health care as clients. A client is a person who engages the advice or services of another who is qualified to provide this service. The term client presents the receivers of health care as collaborators in the care, that is, as people who are also responsible for their own health. Thus, the health status of a client is the responsibility of the individual in collaboration with health professionals. In this book, client is the preferred term, although consumer and patient are used in some instances.

Scope of Nursing Nurses provide care for three types of clients: individuals, families, and communities. Theoretical frameworks applicable to these client types, as well as assessments of individual, family, and community health, are discussed in Chapters 7 and 24 .

Nursing practice involves four areas: promoting health and well- ness, preventing illness, restoring health, and caring for the dying.

PROMOTING HEALTH AND WELLNESS When health is defined broadly as actualization of human potential, it has been called wellness (Pender, Murdaugh, & Parsons, 2011, p. 20).

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• Teaching clients about recovery activities, such as exercises that will accelerate recovery after a stroke

• Rehabilitating clients to their optimal functional level following physical or mental illness, injury, or chemical addiction.

CARING FOR THE DYING This area of nursing practice involves comforting and caring for people of all ages who are dying. It includes helping clients live as comfortably as possible until death and helping support persons cope with death. Nurses carrying out these activities work in homes, hospitals, and extended care facilities. Some agencies, called hospices, are specifically designed for this purpose.

Settings for Nursing In the past, the acute care hospital was the main practice setting open to most nurses. Today many nurses work in hospitals, but increas- ingly they work in clients’ homes, community agencies, ambulatory clinics, long-term care facilities, health maintenance organizations (HMOs), and nursing practice centers (Figure 1–20 •).

Nurses have different degrees of nursing autonomy and nurs- ing responsibility in the various settings. They may provide direct care, teach clients and support persons, serve as nursing advocates and agents of change, and help determine health policies affecting

Nurses promote wellness in clients who are both healthy and ill. This may involve individual and community activities to enhance healthy lifestyles, such as improving nutrition and physical fit- ness, preventing drug and alcohol misuse, restricting smoking, and preventing accidents and injury in the home and workplace. See Chapter 16 for details.

PREVENTING ILLNESS The goal of illness prevention programs is to maintain optimal health by preventing disease. Nursing activities that prevent illness include immunizations, prenatal and infant care, and prevention of sexually transmitted infections.

RESTORING HEALTH Restoring health focuses on the ill client, and it extends from early detection of disease through helping the client during the recovery period. Nursing activities include the following:

• Providing direct care to the ill person, such as administering medications, baths, and specific procedures and treatments

• Performing diagnostic and assessment procedures, such as mea- suring blood pressure and examining feces for occult blood

• Consulting with other health care professionals about client problems

Figure 1–20 • Nurses practice in a variety of settings. (Bottom middle) Lisa S./Shutterstock.

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Teacher As a teacher, the nurse helps clients learn about their health and the health care procedures they need to perform to restore or main- tain their health. The nurse assesses the client’s learning needs and readiness to learn, sets specific learning goals in conjunction with the client, enacts teaching strategies, and measures learning. Nurses also teach unlicensed assistive personnel (UAP) to whom they del- egate care, and they share their expertise with other nurses and health professionals. See Chapter 27 for additional details about the teaching–learning process.

Client Advocate A client advocate acts to protect the client. In this role the nurse may represent the client’s needs and wishes to other health profes- sionals, such as relaying the client’s request for information to the health care provider. They also assist clients in exercising their rights and help them speak up for themselves (see Chapter 5 ).

Counselor Counseling is the process of helping a client to recognize and cope with stressful psychological or social problems, to develop improved interpersonal relationships, and to promote personal growth. It in- volves providing emotional, intellectual, and psychological support. The nurse counsels primarily healthy individuals with normal ad- justment difficulties and focuses on helping the person develop new attitudes, feelings, and behaviors by encouraging the client to look at alternative behaviors, recognize the choices, and develop a sense of control.

Change Agent The nurse acts as a change agent when assisting clients to make modifications in their behavior. Nurses also often act to make changes in a system, such as clinical care, if it is not helping a client return to health. Nurses are continually dealing with change in the health care system. Technologic change, change in the age of the client population, and changes in medications are just a few of the changes nurses deal with daily. See Chapter 28 for additional information about change.

Leader A leader influences others to work together to accomplish a specific goal. The leader role can be employed at different levels: individual client, family, groups of clients, colleagues, or the community. Effec- tive leadership is a learned process requiring an understanding of the needs and goals that motivate people, the knowledge to apply the leadership skills, and the interpersonal skills to influence others. The leadership role of the nurse is discussed in Chapter 28 .

Manager The nurse manages the nursing care of individuals, families, and communities. The nurse manager also delegates nursing activities to ancillary workers and other nurses, and supervises and evaluates their performance. Managing requires knowledge about organiza- tional structure and dynamics, authority and accountability, lead- ership, change theory, advocacy, delegation, and supervision and evaluation. See Chapter 28 for additional details.

consumers in the community and in hospitals. For information about the models for delivery of nursing, see Chapter 6 .

Nurse Practice Acts Nurse practice acts, or legal acts for professional nursing practice, regulate the practice of nursing in the United States with each state having its own act. Although nurse practice acts differ in various jurisdictions, they all have a common purpose: to protect the pub- lic. Nurses are responsible for knowing their state’s nurse practice act as it governs their practice. For additional information, see Chapter 4 .

Standards of Nursing Practice Establishing and implementing standards of practice are major functions of a professional organization. The purpose of the ANA Standards of Practice is to describe the responsibilities for which nurses are accountable. The ANA developed standards of nursing practice that are generic in nature, by using the nursing process as a foundation, and provide for the practice of nursing regardless of area of specialization. Various specialty nursing or- ganizations have further developed specific standards of nursing practice for their area. The ANA Standards of Professional Performance describe behaviors expected in the professional nursing role.

ROLES AND FUNCTIONS OF THE NURSE Nurses assume a number of roles when they provide care to clients. Nurses often carry out these roles concurrently, not exclusively of one another. For example, the nurse may act as a counselor while provid- ing physical care and teaching aspects of that care. The roles required at a specific time depend on the needs of the client and aspects of the particular environment.

Caregiver The caregiver role has traditionally included those activities that assist the client physically and psychologically while preserving the client’s dignity. The required nursing actions may involve full care for the completely dependent client, partial care for the partially depen- dent client, and supportive-educative care to assist clients in attaining their highest possible level of health and wellness. Caregiving encom- passes the physical, psychosocial, developmental, cultural, and spiri- tual levels. The nursing process provides nurses with a framework for providing care (see Chapters 10 through 14 ). A nurse may pro- vide care directly or delegate it to other caregivers.

Communicator Communication is integral to all nursing roles. Nurses communi- cate with the client, support persons, other health professionals, and people in the community.

In the role of communicator, nurses identify client problems and then communicate these verbally or in writing to other members of the health care team. The quality of a nurse’s communication is an important factor in nursing care. The nurse must be able to commu- nicate clearly and accurately in order for a client’s health care needs to be met (see Chapters 15 and 26 ).

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of human subjects, (c) participate in the identification of significant researchable problems, and (d) be a discriminating consumer of research findings.

Expanded Career Roles Nurses are fulfilling expanded career roles, such as those of NP, clini- cal nurse specialist, nurse midwife, nurse educator, nurse researcher, and nurse anesthetist, all of which allow greater independence and autonomy (see Box 1–2).

CRITERIA OF A PROFESSION Nursing is gaining recognition as a profession. A profession has been defined as an occupation that requires extensive education or a calling that requires special knowledge, skill, and preparation. A pro- fession is generally distinguished from other kinds of occupations by (a) its requirement of prolonged, specialized training to acquire a body of knowledge pertinent to the role to be performed; (b) an

Case Manager Nurse case managers work with the multidisciplinary health care team to measure the effectiveness of the case management plan and to monitor outcomes. Each agency or unit specifies the role of the nurse case manager. In some institutions, the case manager works with primary or staff nurses to oversee the care of a specific caseload. In other agencies, the case manager is the primary nurse or provides some level of direct care to the client and family. Insurance compa- nies have also developed a number of roles for nurse case managers, and responsibilities may vary from managing acute hospitalizations to managing high-cost clients or case types. Regardless of the setting, case managers help ensure that care is oriented to the client, while controlling costs.

Research Consumer Nurses often use research to improve client care. In a clinical area, nurses need to (a) have some awareness of the process and language of research, (b) be sensitive to issues related to protecting the rights

BOX 1–2 Selected Expanded Career Roles for Nurses

NURSE PRACTITIONER A nurse practitioner (NP) has an advanced education and is a grad- uate of a nurse practitioner program. These nurses are certified by the American Nurses Credentialing Center in areas such as adult- gerontology, family, neonatal, pediatric, women’s health/gender related, or psychiatric-mental health. They are employed in health care agencies or community-based settings. Those choosing the NP role with a pediatric or adult population focus must further select either acute care or primary care. Acute care NPs often function in hospitals managing the care of critically ill patients (Selway, 2012, p. 9). Primary care NPs practice in clinics, home and hospice care, and specialty practices.

CLINICAL NURSE SPECIALIST A clinical nurse specialist has an advanced degree or expertise and is considered to be an expert in a specialized area of practice (e.g., gerontology, oncology). The nurse provides direct client care, edu- cates others, consults, conducts research, and manages care. The American Nurses Credentialing Center provides national certification of clinical specialists.

NURSE ANESTHETIST A nurse anesthetist has completed advanced education in an ac- credited program in anesthesiology. The nurse anesthetist carries out preoperative visits and assessments, and administers general anesthetics for surgery under the supervision of a physician pre- pared in anesthesiology. The nurse anesthetist also assesses the postoperative status of clients.

NURSE MIDWIFE A nurse midwife has completed a program in midwifery and is certi- fied by the American College of Nurse Midwives. The nurse midwife gives prenatal and postnatal care and manages deliveries in nor- mal pregnancies. The midwife practices in association with a health care agency and can obtain medical services if complications occur. The nurse midwife may also conduct routine Papanicolaou smears, family planning, and routine breast examinations.

NURSE RESEARCHER Nurse researchers investigate nursing problems to improve nurs- ing care and to refine and expand nursing knowledge. They are

employed in academic institutions, teaching hospitals, and re- search centers such as the National Institute for Nursing Research in Bethesda, Maryland. Nurse researchers usually have advanced education at the doctoral level.

NURSE ADMINISTRATOR The nurse administrator manages client care, including the delivery of nursing services. The administrator may have a middle manage- ment position, such as head nurse or supervisor, or a more senior management position, such as director of nursing services. The functions of nurse administrators include budgeting, staffing, and planning programs. The educational preparation for nurse admin- istrator positions is at least a baccalaureate degree in nursing and frequently a master’s or doctoral degree.

NURSE EDUCATOR Nurse educators are employed in nursing programs, at educational institutions, and in hospital staff education. The nurse educator usu- ally has a baccalaureate degree or more advanced preparation and frequently has expertise in a particular area of practice. The nurse educator is responsible for classroom and, often, clinical teaching. There is now a process to become a certified nurse educator (CNE).

NURSE ENTREPRENEUR A nurse entrepreneur usually has an advanced degree and manages a health-related business. The nurse may be involved in education, consultation, or research, for example.

FORENSIC NURSE The forensic nurse provides specialized care for individuals who are victims and/or perpetrators of trauma. Forensic nurses have knowl- edge of the legal system and skills in injury identification, evalua- tion, and documentation. After tending to the client’s medical needs, the forensic nurse collects evidence, provides medical testimony in court, and consults with legal authorities. Forensic nurses work in a variety of fields including sexual assault, domestic violence, child abuse and neglect, mistreatment of older adults, death investiga- tion, and corrections. They may be called on in mass disasters or community crisis situations (International Association of Forensic Nurses, n.d.). Nurses complete a certification process to become a forensic nurse.

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orientation of the individual toward service, either to a community or to an organization; (c) ongoing research; (d) a code of ethics; (e)  autonomy; and (f) a professional organization.

Two terms related to profession need to be differentiated: pro- fessionalism and professionalization. Professionalism refers to professional character, spirit, or methods. It is a set of attributes, a way of life that implies responsibility and commitment. Nursing professionalism owes much to the influence of Florence Nightingale. Professionalization is the process of becoming professional, that is, of acquiring characteristics considered to be professional.

Specialized Education Specialized education is an important aspect of professional status. In modern times, the trend in education for the professions has shifted toward programs in colleges and universities. Many nursing educators believe that the undergraduate nursing curriculum should include liberal arts education in addition to the biologic and social sciences and the nursing discipline.

In the United States today, there are five means of entry into registered nursing: hospital diploma, associate degree, baccalaureate degree, master’s degree, and doctoral degree. These programs are dis- cussed in Chapter 2 .

Body of Knowledge As a profession, nursing is establishing a well-defined body of knowledge and expertise. A number of nursing conceptual frame- works (discussed in Chapter 3 ) contribute to the knowledge base of nursing and give direction to nursing practice, education, and on- going research.

Service Orientation A service orientation differentiates nursing from an occupation pur- sued primarily for profit. Many consider altruism (selfless concern for others) the hallmark of a profession. Nursing has a tradition of service to others. This service, however, must be guided by certain rules, policies, or codes of ethics. Today, nursing is also an important component of the health care delivery system.

Ongoing Research Increasing research in nursing is contributing to nursing practice. In the 1940s, nursing research was at a very early stage of development. In the 1950s, increased federal funding and professional support helped establish centers for nursing research. Most early research was directed at the study of nursing education. In the 1960s, studies were often related to the nature of the knowledge base underlying nursing practice. Since the 1970s, nursing research has focused on practice- related issues. Nursing research as a dimension of the nurse’s role is discussed further in Chapter 2 .

Code of Ethics Nurses have traditionally placed a high value on the worth and dig- nity of others. The nursing profession requires integrity of its mem- bers; that is, a member is expected to do what is considered right regardless of the personal cost.

Ethical codes change as the needs and values of society change. Nursing has developed its own codes of ethics and in most instances

has set up means to monitor the professional behavior of its mem- bers. See Chapter 5 for additional information on ethics.

Autonomy A profession is autonomous if it regulates itself and sets standards for its members. Providing autonomy is one of the purposes of a pro- fessional association. If nursing is to have professional status, it must function autonomously in the formation of policy and in the con- trol of its activity. To be autonomous, a professional group must be granted legal authority to define the scope of its practice, describe its particular functions and roles, and determine its goals and responsi- bilities in delivery of its services.

To practitioners of nursing, autonomy means independence at work, responsibility, and accountability for one’s actions. Autonomy is more easily achieved and maintained from a position of authority. For example, all states have passed legislation granting NPs super- visory, collaborative, or independent authority to practice (Phillips, 2010), and currently, 27 states do not require physician oversight of NPs to practice (Selway, 2012).

Professional Organization Operation under the umbrella of a professional organization differen- tiates a profession from an occupation. Governance is the establish- ment and maintenance of social, political, and economic arrangements by which practitioners control their practice, their self-discipline, their working conditions, and their professional affairs. Nurses, therefore, need to work within their professional organizations.

The ANA is a professional organization that “advances the nurs- ing profession by fostering high standards of nursing practice, pro- moting the rights of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Congress and regula- tory agencies on health care issues affecting nurses and the public” (ANA, 2013a).

SOCIALIZATION TO NURSING The standards of education and practice for the profession are deter- mined by the members of the profession, rather than by outsiders. The education of the professional involves a complete socializa- tion process, more far reaching in its social and attitudinal aspects and its technical features than is usually required in other kinds of occupations.

Socialization can be defined simply as the process by which people (a) learn to become members of groups and society and (b) learn the social rules defining relationships into which they will enter. Socialization involves learning to behave, feel, and see the world in a manner similar to other persons occupying the same role as oneself (Hardy & Conway, 1988, p. 261). The goal of professional socialization is to instill in individuals the norms, values, attitudes, and behaviors deemed essential for survival of the profession.

Various models of the socialization process have been devel- oped. Benner’s model (2001) describes five levels of proficiency in nursing based on the Dreyfus general model of skill acquisition. The five stages, which have implications for teaching and learning, are novice, advanced beginner, competent, proficient, and expert. Benner writes that experience is essential for the development of pro- fessional expertise (see Box 1–3).

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One of the most powerful mechanisms of professional socializa- tion is interaction with fellow students. Within this student culture, students collectively set the level and direction of their scholastic ef- forts. They develop perspectives about the situation in which they are involved, the goals they are trying to achieve, and the kinds of activi- ties that are expedient and proper, and they establish a set of practices congruent with all of these. Students become bound together by feel- ings of mutual cooperation, support, and solidarity.

The National Student Nurses Association (NSNA) helps link nursing students with nursing leadership groups. This organization exposes student nurses to issues impacting the nursing profession while promoting collegiality and leadership qualities.

Critical Values of Nursing It is within the nursing educational program that the nurse develops, clarifies, and internalizes professional values. Specific professional nursing values are stated in nursing codes of ethics (see Chapter 5 ), in standards of nursing practice (discussed earlier in this chapter), and in the legal system itself (see Chapter 4 ). Additionally, in 2001, the NSNA adopted a code of academic and clinical conduct (see Box 1–4).

FACTORS INFLUENCING CONTEMPORARY NURSING PRACTICE To understand nursing as it is practiced today and as it will be prac- ticed tomorrow requires an understanding of some of the social forces currently influencing this profession. These forces usually affect the

BOX 1–3 Benner’s Stages of Nursing Expertise

STAGE I: NOVICE No experience (e.g., nursing student). Performance is limited, in- flexible, and governed by context-free rules and regulations rather than experience.

STAGE II: ADVANCED BEGINNER Demonstrates marginally acceptable performance. Recognizes the meaningful “aspects” of a real situation. Has experienced enough real situations to make judgments about them.

STAGE III: COMPETENT Has 2 or 3 years of experience. Demonstrates organizational and planning abilities. Differentiates important factors from less impor- tant aspects of care. Coordinates multiple complex care demands.

STAGE IV: PROFICIENT Has 3 to 5 years of experience. Perceives situations as wholes rather than in terms of parts, as in Stage II. Uses maxims as guides for what to consider in a situation. Has holistic understanding of the cli- ent, which improves decision making. Focuses on long-term goals.

STAGE V: EXPERT Performance is fluid, flexible, and highly proficient; no longer re- quires rules, guidelines, or maxims to connect an understanding of the situation to appropriate action. Demonstrates highly skilled intuitive and analytic ability in new situations. Is inclined to take a certain action because “it felt right.” From Novice to Expert: Excellence and Power in Clinical Nursing Practice, Commemorative Edition, by P. Benner, 2001. Electronically reproduced by permission of Pearson Education, Inc., Upper Saddle River, New Jersey.

BOX 1–4 National Student Nurses Association, Inc., Code of Academic and Clinical Conduct

PREAMBLE Students of nursing have a responsibility to society in learning the academic theory and clinical skills needed to provide nursing care. The clinical setting presents unique challenges and respon- sibilities while caring for human beings in a variety of health care environments.

The Code of Academic and Clinical Conduct is based on an un- derstanding that to practice nursing as a student is an agreement to uphold the trust with which society has placed in us. The statements of the Code provide guidance for the nursing student in the personal development of an ethical foundation and need not be limited strictly to the academic or clinical environment but can assist in the holistic development of the person.

A CODE FOR NURSING STUDENTS As students are involved in the clinical and academic environments we believe that ethical principles are a necessary guide to profes- sional development. Therefore within these environments we: 1. Advocate for the rights of all clients. 2. Maintain client confidentiality. 3. Take appropriate action to ensure the safety of clients, self,

and others. 4. Provide care for the client in a timely, compassionate, and

professional manner. 5. Communicate client care in a truthful, timely, and accurate

manner. 6. Actively promote the highest level of moral and ethical

principles and accept responsibility for our actions. 7. Promote excellence in nursing by encouraging lifelong learning

and professional development.

8. Treat others with respect and promote an environment that respects human rights, values, and choice of cultural and spiritual beliefs.

9. Collaborate in every reasonable manner with the academic faculty and clinical staff to ensure the highest quality of client care.

10. Use every opportunity to improve faculty and clinical staff understanding of the learning needs of nursing students.

11. Encourage faculty, clinical staff, and peers to mentor nursing students.

12. Refrain from performing any technique or procedure for which the student has not been adequately trained.

13. Refrain from any deliberate action or omission of care in the academic or clinical setting that creates unnecessary risk of injury to the client, self, or others.

14. Assist the staff nurse or preceptor in ensuring that there is full disclosure and that proper authorizations are obtained from clients regarding any form of treatment or research.

15. Abstain from the use of alcoholic beverages or any substances in the academic and clinical setting that impair judgment.

16. Strive to achieve and maintain an optimal level of personal health.

17. Support access to treatment and rehabilitation for students who are experiencing impairments related to substance abuse and mental or physical health issues.

18. Uphold school policies and regulations related to academic and clinical performance, reserving the right to challenge and critique rules and regulations as per school grievance policy.

Adopted by the NSNA House of Delegates, Nashville, TN, on April 6, 2001. Reprinted with permission.

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entire health care system, and nursing, as a major component of that system, cannot avoid the effects.

Health Care Reform With the passage of the Affordable Care Act (ACA) in 2010, health care reform was on a fast track. Transformation in health care deliv- ery and financing systems accelerated in 2014 when major provisions of the legislation were implemented (Buerhaus et al., 2012, p. 318). Health care delivery’s focus has shifted from acute care to primary preventive care and treatment of chronic conditions using health care teams and information technology. Also in 2010, an IOM report, The Future of Nursing: Leading Change, Advancing Health, provided rec- ommendations on what nursing needed to do to provide better cli- ent care in the new systems that would be part of health reform. This report identified four key areas: nurses practicing to the fullest extent of their skills and knowledge; nurses achieving higher levels of educa- tion; nurses being full partners with physicians and other health care professionals; and improving data collection and an information in- frastructure (IOM, 2010, p. 4).

Quality and Safety in Health Care Quality and safety are inherent universal values on which health care is based (Sherwood, 2011, p. 227). However, the report To Err is Human, published by the IOM in 2000 revealed a gap between the status of American health care and the quality Americans should re- ceive. Since then, the IOM has published a series of reports confirm- ing that “quality and safety are the leading contemporary issues in health care, contributing to costs and poor outcomes” (Sherwood & Barnsteiner, 2012, p. 3). The 2003 IOM report, Health Professions Ed- ucation: A Bridge to Quality, called for a redesign of the education for health care professions and described six core competencies needed to improve 21st-century health care: patient- centered care, team- work and collaboration, evidence-based practice, quality improve- ment, safety, and informatics. In 2005, the Robert Wood Johnson Foundation funded a project called Quality and Safety Education for Nurses (QSEN). The goal for the QSEN project was to “meet the challenge 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 Institute, n.d.). This project used the IOM six competencies along with the knowledge and experiences of QSEN faculty and a national advisory board to define quality and safety competencies for nursing. The project also proposed KSAs for each competency that could be used as guides for curriculum development in preli- censure nursing programs (see the table at the QSEN website).

Consumer Demands Consumers of nursing services (the public) have become an increas- ingly effective force in changing nursing practice. On the whole, peo- ple are better educated and have more knowledge about health and illness than in the past. Consumers also have become more aware of others’ needs for care. The ethical and moral issues raised by poverty and neglect have made people more vocal about the needs of minor- ity groups and the poor.

The public’s concepts of health and nursing have also changed. Most now believe that health is a right of all people, not just a privilege

of the rich. The media emphasize the message that individuals must assume responsibility for their own health by obtaining a physical examination regularly, checking for the seven danger signals of can- cer, and maintaining their mental well-being by balancing work and recreation. Interest in health and nursing services is therefore greater than ever. Furthermore, many people now want more than freedom from disease—they want energy, vitality, and a feeling of wellness.

Increasingly, the consumer has become an active participant in making decisions about health and nursing care. Planning com- mittees concerned with providing nursing services to a community usually have active consumer membership. Recognizing the legiti- macy of public input, many state nursing associations and regula- tory agencies have consumer representatives on their governing boards.

Family Structure New family structures are influencing the need for and provision of nursing services. More people are living away from the extended family and the nuclear family, and the family breadwinner is no lon- ger necessarily the husband. Today, many single men and women rear children, and in many two-parent families both parents work. It is also common for young parents to live at great distances from their own parents. These young families need support services, such as day care centers. For additional information about the family, see Chapter 24 .

Adolescent mothers also need specialized nursing services, both while they are pregnant and after their babies are born. These young mothers usually have the normal needs of teenagers as well as those of new mothers. Many teenage mothers are raising their children alone with little, if any, assistance from the child’s father. This type of single-parent family is especially vulnerable because motherhood compounds the difficulties of adolescence. Also, because many of these families live in poverty, the children often do not receive pre- ventive immunizations and are at increased risk for nutritional and other health problems.

Science and Technology Advances in science and technology affect nursing practice. For ex- ample, people with acquired immunodeficiency syndrome (AIDS) are receiving new drug therapies to prolong life and delay the on- set of AIDS-associated diseases. Nurses must be knowledgeable about the action of such drugs and the needs of clients receiving them. Biotechnology is affecting health care. For example, nurses are exposed to emerging genetic technology such as the field of can- cer gene therapy (Parsons, 2011). Nurses will need to expand their knowledge base and technical skills as they adapt to meet the new needs of clients.

In some settings, technologic advances have required that nurses be highly specialized. Nurses frequently have to use sophisticated computerized equipment to monitor or treat clients. As technologies change, nursing education changes, and nurses require increasing education to provide effective, safe nursing practice.

The space program has developed advanced technologies for space travel based on the need for long-distance monitoring of astro- nauts and spacecraft, lighter materials, and miniaturization of equip- ment. Health care has benefited as this new technology has been

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oversight of a nurse practitioner’s practice; however 16 states still require NPs to practice under severe restrictions (Selway, 2012, p. 11). As a result, NPs cannot easily move from state to state, which decreases access to care for clients. In 2008, 48 professional organi- zations, including the NCSBN developed a Consensus Model that provides guidance for states to adopt uniformity in the regulation of advanced practice registered nurses. Many states have adopted portions of the model elements, but variations remain from state to state (NCSBN, 2013).

Demography Demography is the study of population, including statistics about distribution by age and place of residence, mortality (death), and morbidity (incidence of disease). From demographic data, the needs of the population for nursing services can be assessed. For example:

• The total population in North America is increasing. The propor- tion of older adults has also increased, creating an increased need for nursing services for this group.

• The population is shifting from rural to urban settings. This shift signals an increased need for nursing related to problems caused by pollution and by the effects on the environment of concentra- tions of people. Thus, most nursing services are now provided in urban settings.

• Mortality and morbidity studies reveal the presence of risk factors. Many of these risk factors (e.g., smoking) are major causes of death and disease that can be prevented through changes in lifestyle. The nurse’s role in assessing risk factors and helping clients make healthy lifestyle changes is discussed in Chapter 16 .

The Current Nursing Shortage Registered nurses are the largest segment of the health care workforce. According to the Bureau of Labor Statistics (2013), the number of em- ployed RNs will grow from 2.7 million in 2012 to 3.2 million in 2022; this number increases by an additional 1.2 million when including replacements for nurses who leave or retire from the profession. Contrast that information with an AACN statement (2012b) that the United States is projected to have a nursing shortage that is expected to intensify as baby boomers age and the need for health care grows. Factors for this prediction include the concurrent nursing faculty shortage, the increasing average age of RNs, and the increasing num- ber of aging older adults along with their increasing health care needs.

Whereas there is a projected shortage of nurses by 2022, whether or not there is a current nursing shortage depends on where the nurses live and where they are willing to work. The supply and demand of nurses is not uniform. For example, the RN shortage is projected to be the most intense in the South and the West (AACN, 2012b). Currently, new graduates are having difficulty finding that first job as a consequence of the declining U.S. economy. Because of economic pressures and job losses in all industries, many nurses increased their hours and/or deferred retirement. Combined with lower hospital census, employers hiring new graduates with bacca- laureate degrees, many open RN positions requiring at least 2 years of experience, and the reputation of new graduates having a high turnover rate, many hospitals have stopped interviewing new gradu- ates (Stokowski, 2011). The health care setting is another factor. The growth of RN positions will occur in community-based settings

adapted in such health care aids as Viewstar (an aid for people with visual impairments), the insulin infusion pump, the voice-controlled wheelchair, magnetic resonance imaging, laser surgery, filtering de- vices for intravenous fluid control devices, and monitoring systems for intensive care.

Information, Telehealth, and Telenursing The Internet has already affected health care, with more and more clients becoming well informed about their health concerns. As a result, nurses may need to interpret Internet sources of information for clients and their families. Because not all of the Internet-based in- formation is accurate, nurses need to become information brokers so they can help people to access high-quality, valid websites; interpret the information; and then help clients evaluate the information and determine if it is useful to them.

The prefix tele means “distance,” and is used to describe the many health care services provided via technology. Telehealth is the “use of medical information exchanged from one site to another via elec- tronic communications to improve the patient’s health status.” The words telemedicine and telehealth are often used interchangeably. Telemedicine is often associated with direct client clinical services, whereas telehealth has a broader definition of remote health care services (IOM, 2012, p. 134). Telenursing is the use of telecommu- nications and information technology to provide nursing practice at a distance (Kumar & Snooks, 2011, p. 1). The delivery of telehealth care, however, is not limited to physicians and nurses; it includes other health disciplines such as radiology, pathology, and pharma- cology. These disciplines also deliver care using electronic infor- mation and telecommunications technologies and are accordingly called teleradiology, telepathology, and telepharmacy. Nurses engaged in telenursing practice continue to use the nursing process to provide care to clients, but they do so using technologies such as the Internet, computers, telephones, videoteleconferencing, and telemonitoring equipment. Telenursing continues to grow, especially in home health care and in rural communities.

Telehealth recognizes no state boundaries and, subsequently, licensure issues have been raised. For example, if a nurse licensed in one state provides health information to a client in another state, does the nurse need to maintain licensure in both states? The National Council of State Boards of Nursing (NCSBN) endorses a change from single-state licensure to a mutual recognition model. Many state leg- islatures have adopted mutual recognition language into statutes and are currently implementing it (see Chapter 4 ).

Legislation Legislation about nursing practice and health matters affects both the public and nursing. Legislation related to nursing is discussed in Chapter 4 . Changes in legislation relating to health also affect nurs- ing. For example, the Patient Self-Determination Act (PSDA) requires that every competent adult be informed in writing on admis- sion to a health care institution about his or her rights to accept or re- fuse medical care and to use advance directives. See Chapter 4 for more information about the PSDA and advance directives.

Health care reform and the shortage of physicians calls for an increase in advance practice registered nurses such as NPs. Cur- rently, there are wide variations in state regulation of nurse prac- titioner practice. For example, 27 states do not require physician

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BOX 1–5 Preparing for a Competitive Job Market

The following tips can help prepare you to be successful in obtain- ing your first nursing position: • Attend the NSNA Career Planning Conference and annual

convention before and after you graduate. • Continue your education: If you have a diploma or associate

degree, explore RN to BSN programs; if you have a BSN, explore MSN programs.

• Attend meetings of your alumni association. • Include a cover letter when you submit your resume and

application. • Practice interviewing skills. • Network with the nurses at the health care agencies where

you are completing your clinical practicum. • Take the NCLEX-RN as soon as possible after graduation. • When you get an interview, smile and show you are excited

about this opportunity. • Join a professional nursing organization. • Be open and flexible. Find an entry-level position that will give

you work and professional-growth experiences. • Look outside of acute care settings for entry-level positions. • Take a residency or internship even if it is not in your interest

area. • Stay current through continuing education and consider

completing certification opportunities. • Make sure that your resume truly reflects your education,

skills, and experience. From Realities of the Current Job Market, National League for Nursing and National Student Nurses Association, n.d. Retrieved from http://www.nsna.org/Portals/0/Skins/NSNA/pdf/ RealitiesOfTheCurrentJobMarket.pdf.

rather than acute care hospitals as an increasing proportion of the U.S. population has health care coverage through the Affordable Care Act (Sullivan, Fries, & Relf, 2012). Stokowski (2011) pointed out that many new graduates have unrealistic expectations (e.g., seeking only the day shift or working minimal weekends or only being available part-time). These types of demands will limit the graduate from getting a job, making flexibility for hours, shift, and unit key advantages. Together, the National League for Nursing and the National Student Nurse Association (n.d.) have published a bro- chure with helpful information and tips for the new graduate who is looking for a job (see Box 1–5).

As the economy improves, opportunities for new graduates should open up. One current solution to assist new graduates to transi- tion into practice is nurse residency programs. Some of these residency

programs are partnerships between the acute care setting and a school of nursing, and others are programs within the acute care institution. Evidence shows that substantive orientation plans for mentoring, residency, and other formal transition-to-practice programs result in higher retention rates of the new graduate (Sullivan et al., 2012).

Collective Bargaining More nurses are using collective bargaining to deal with their con- cerns. The ANA participates in collective bargaining on behalf of nurses through its economic and general welfare programs. Today, some nurses are joining other labor organizations that represent them at the bargaining table. Nurses have gone on strike over eco- nomic concerns and over issues about safe care for clients and safety for themselves.

Nursing Associations Professional nursing associations have provided leadership that affects many areas of nursing. Voluntary accreditation of nursing education programs by the Accreditation Commission for Education in Nursing (ACEN) and Commission on Collegiate Nursing Educa- tion (CCNE) has also influenced nursing. Many nursing programs have steadily improved to meet the standards for accreditation over the years. As a result, nurse graduates are better prepared to meet the demands of society.

To influence policy making for health care, a group of profes- sional nurses organized formally to promote political action in the nursing and health care arenas. Nurses for Political Action (NPA) formed in 1971 and became an arm of the ANA in 1974, when its name changed to Nurses’ Coalition for Action in Politics (N-CAP). In 1986, the name was changed to American Nurses Association— Political Action Committee (ANA-PAC). Through this group, nurses have lobbied actively for legislation affecting health care. A number of nursing leaders hold positions of authority in government. Attain- ing such positions is essential if nurses hope to exert ongoing political influence.

NURSING ORGANIZATIONS As nursing has developed, an increasing number of nursing organiza- tions have formed. These organizations are at the local, state, national, and international levels. The organizations that involve most North American nurses are the ANA, the National League for Nursing, the

The purpose of Bratt and Felzer’s (2011) repeated measures design study was to examine new graduates’ perceptions of their profes- sional practice competence and work environment throughout a yearlong nurse residency program. High stress levels and inexperi- ence make new graduates prone to error and turnover. The nurs- ing literature recommends that actions take place to ensure that new nurse graduates receive better transition experiences, such as nurse residency programs. The total sample consisted of 468 newly licensed registered nurses who were predominantly White females with associate’s degrees and worked primarily on medical–surgical units in urban hospitals. Data were collected at 3 months after hire, 6 months later, and at the conclusion of the residency program. The new graduates’ perceptions of their professional practice competency

were measured with two instruments, and their perceptions of work environment measured with three instruments. The number of nurses who completed surveys at all three measurements points was 227. On completion of the residency program, participants had higher means of job satisfaction, clinical decision-making ability, quality of nursing performance and organizational commitment, and lower means of stress compared with baseline or 6-month measures.

IMPLICATIONS Even though a limitation of the study was its nonexperimental de- sign, this study adds to the growing body of evidence showing the effectiveness of nurse residency programs. Continued research is needed to determine best practices for nurse residency programs.

Evidence-Based Practice Does a Nurse Residency Program Make a Difference for the New Graduate? EVIDENCE-BASED PRACTICE

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International Council of Nurses The International Council of Nurses (ICN) was established in 1899. Nurses from Great Britain, the United States, and Canada were among the founding members. The council is a federation of national nurses’ associations, such as the ANA and CNA.

The ICN provides an organization through which member national associations can work together for the mission of repre- senting nursing worldwide, advancing the profession, and influ- encing health policy. The five core values of the ICN are visionary leadership, inclusiveness, innovativeness, partnership, and trans- parency (ICN, 2012). The official journal of the ICN is Interna- tional Nursing Review.

National Student Nurses Association The NSNA is the official preprofessional organization for nursing students. Formed in 1953 and incorporated in 1959, the NSNA originally functioned under the aegis of the ANA and NLN; how- ever, in 1968 the NSNA became an autonomous body, although it communicates with the NLN and the ANA. To qualify for member- ship in the NSNA, a student must be enrolled in a state-approved nursing education program. The official journal of the NSNA is Imprint magazine.

International Honor Society: Sigma Theta Tau Sigma Theta Tau, the international honor society in nursing, was founded in 1922 and is headquartered in Indianapolis, Indiana. The Greek letters stand for the Greek words storga, tharos, and tima, meaning “love,” “courage,” and “honor.” The society is a member of the Association of College Honor Societies. The society’s purpose is pro- fessional rather than social. Membership is attained through academic achievement. Students in baccalaureate programs in nursing and nurses in master’s, doctoral, and postdoctoral programs are eligible to be selected for membership. Potential members, who hold a minimum of a bachelor’s degree and have demonstrated achievement in nursing, can apply for membership as a nurse leader in the community.

The official journal of Sigma Theta Tau, the Journal of Nursing Scholarship, is published quarterly. The journal publishes scholarly articles of interest to nurses. The society also publishes Reflections, a quarterly newsletter that provides information about the organiza- tion and its various chapters.

International Council of Nurses, and the National Student Nurses Association. The number of nursing specialty organizations is also increasing, for example, the Academy of Medical Surgical Nursing, the American Association of Nurse Anesthetists, the National Black Nurses Association, and the National Association of Pediatric Nurse Practitioners. Participation in the activities of nursing associations enhances the growth of involved individuals and helps nurses collec- tively influence policies affecting nursing practice.

American Nurses Association The ANA is the national professional organization for nursing in the United States. It was founded in 1896 as the Nurses Associated Alumnae of the United States. In 1911 the name was changed to the American Nurses Association. It was a charter member of the Inter- national Council of Nurses, along with organizations in Great Britain and Germany, in 1899. The purposes of the ANA are to foster high standards of nursing practice and to promote the educational and professional advancement of nurses so that all people may have bet- ter nursing care.

In 1982, the organization became a federation of state nurses’ as- sociations. Individuals participate in the ANA by joining their state nurses’ associations. The official journal of the ANA is American Nurse Today, and The American Nurse is the official newspaper.

National League for Nursing The NLN, formed in 1952, is an organization of both individuals and agencies. Its objective is to foster the development and improvement of all nursing services and nursing education. People who are not nurses but have an interest in nursing services, for example, hospi- tal administrators, can be members of the league. This feature of the NLN—involving nonnurse members, consumers, and nurses from all levels of practice—is unique.

The NLN presents continuing education workshops and semi- nars for its members. For schools of nursing, the NLN offers testing services including preadmission testing for potential students and achievement testing throughout the program. The NLN also con- ducts yearly surveys of nursing schools, newly registered nurses, and post-basic graduates. These surveys serve as a primary source of re- search data about nursing education in the United States. The ACEN, an independent body within the NLN, provides voluntary accredita- tion for educational programs in nursing. The official journal of the NLN is Nursing and Health Care Perspectives.

• Historical perspectives of nursing practice reveal recurring themes or influencing factors. For example, women have traditionally cared for others, but often in subservient roles. Religious orders left an imprint on nursing by instilling such values as compassion,

devotion to duty, and hard work. Wars created an increased need for nurses and medical specialties. Societal attitudes have influ- enced nursing’s image. Visionary leaders have made notable con- tributions to improve the status of nursing.

CHAPTER HIGHLIGHTS

Chapter 1 Review

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• With advanced education and experience, nurses can fulfill ad- vanced practice roles such as clinical nurse specialist, NP, nurse midwife, nurse anesthetist, educator, administrator, and researcher.

• A desired goal of nursing is professionalism, which necessitates specialized education; a unique body of knowledge, including spe- cific skills and abilities; a service orientation; ongoing research; a code of ethics; autonomy; and a professional organization.

• Socialization is the process by which people learn to become members of groups and society, and learn social rules defining relationships into which they will enter. Socialization to professional nursing practice is the process whereby the values and norms of the nursing profession are internalized into the nurse’s own behav- ior and self-concept. The nurse acquires the knowledge, skill, and attitudes characteristic of the profession.

• Although several models of the socialization process have been developed, Benner’s five stages of novice, advanced beginner, competent, proficient, and expert may serve as guidelines to es- tablish the phase and extent of an individual’s socialization.

• Contemporary nursing practice is influenced by health care re- form; quality and safety in health care; consumer demands; fam- ily structure; science and technology; information, telehealth, and telenursing; legislation; demographic and social changes; the nursing shortage; collective bargaining; and the work of nursing associations.

• Participation in the activities of nursing associations enhances the growth of involved individuals and helps nurses collectively influ- ence policies that affect nursing practice.

• Nursing education curricula are continually undergoing revisions in response to new scientific knowledge and technologic, cultural, political, and socioeconomic changes in society.

• Originally, the focus of nursing education was to teach the knowl- edge and skills that would enable a nurse to practice in a hospi- tal setting. Today, curricula have been revised to enable nurses to work in more diverse settings and assume more diverse roles.

• Some professional organizations have changed the focus from requirements for initial preparation to academic progression and multiple entry points to professional practice in nursing.

• Continuing education is the responsibility of each practicing nurse to keep abreast of scientific and technologic change and changes within the nursing profession.

• The scope of nursing practice includes promoting wellness, pre- venting illness, restoring health, and caring for the dying.

• Although traditionally the majority of nurses were employed in hos- pital settings, today the numbers of nurses working in home health care, ambulatory care, and community health settings are increasing.

• Nurse practice acts vary among states, and nurses are responsible for knowing the act that governs their practice.

• Standards of nursing practice provide criteria against which the effectiveness of nursing care and professional performance behav- iors can be evaluated.

• Every nurse may function in a variety of roles that are not exclusive of one another; in reality, they often occur together and serve to clarify the nurse’s activities. These roles include caregiver, commu- nicator, teacher, client advocate, counselor, change agent, leader, manager, case manager, and research consumer.

1. Which women made significant contributions to the nursing care of soldiers during the Civil War? Select all that apply. 1. Harriet Tubman 2. Florence Nightingale 3. Fabiola 4. Dorothea Dix 5. Sojourner Truth

2. Curricula for nursing education are strongly influenced by which of the following? Select all that apply. 1. Physician groups 2. Professional nursing organizations 3. Individual state boards of nursing 4. Hospital administrators 5. The National Council of State Boards of Nursing

3. Which is an example of continuing education for nurses? 1. Attending the hospital’s orientation program 2. Completing a workshop on ethical aspects of nursing 3. Obtaining information about the facility’s new computer

charting system 4. Talking with a company representative about a new piece

of equipment 4. Health promotion is best represented by which activity?

1. Administering immunizations 2. Giving a bath 3. Preventing accidents in the home 4. Performing diagnostic procedures

5. Who were America’s first two trained nurses? 1. Barton and Wald 2. Dock and Sanger 3. Richards and Mahoney 4. Henderson and Breckinridge

6. A nurse with 2 to 3 years of experience who has the ability to coordinate multiple complex nursing care demands is at which stage of Benner’s stages of nursing expertise? 1. Advanced beginner 2. Competent 3. Proficient 4. Expert

7. Which professional organization developed a code for nursing students? 1. ANA 2. NLN 3. AACN 4. NSNA

8. Which social force is most likely to significantly impact the future supply and demand for nurses? 1. Aging 2. Economics 3. Science/technology 4. Telecommunications

TEST YOUR KNOWLEDGE

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Suggested Readings Coleman, C. L. (2013). Man up! A practical guide for men in

nursing. Indianapolis, IN: Sigma Theta Tau International. The author and contributors to this book are all successful male nursing leaders. They provide expert advice, practical information, tools for success in the nursing profession, and a male student’s survival guide for nursing school. All nurses should read this book.

Heikkila, K. (2011). Sisterhood of war. Minnesota women in Vietnam. St. Paul, MN: Minnesota Historical Society. The author focuses on the experiences of 15 nurses from Minnesota who went to war in Vietnam. The story “rises to heights of excitement as they embarked on their gen- eration’s defining adventure, falls to depths of despair as they experienced the carnage of war, ascends again as they eagerly left the war zone and returned home, only to descend once more as they encountered public hostility, institutional indifference, and psychological stress in the aftermath of war” (p. 5).

References American Assembly for Men in Nursing. (2011). About us:

AAMN history. Retrieved from http://aamn.org/history.shtml American Association of Colleges of Nursing. (2012a). Degree

completion programs for registered nurses: RN to master’s degree and RN to baccalaureate programs. Retrieved from http://www.aacn.nche.edu/media-relations/fact-sheets/ degree-completion-programs

American Association of Colleges of Nursing. (2012b). Fact sheet. Nursing shortage. Retrieved from http://www.aacn .nche.edu/media-relations/fact-sheets/nursing-shortage

American Association of Colleges of Nursing. (2012c). Fact sheet. The impact of education on nursing practice. Retrieved from http://www.aacn.nche.edu/media-relations/ fact-sheets/impact-of-education

American Association of Colleges of Nursing. (2012d). Frequently asked questions. Retrieved from http://www .aacn.nche.edu/cnl/frequently-asked-questions

American Nurses Association. (1965). ANA’s first position on education for nursing. American Journal of Nursing, 65(12), 106–111.

American Nurses Association. (1973). Standards of nursing practice. Kansas City, MO: Author.

American Nurses Association. (1980). Nursing: A social policy statement. Kansas City, MO: Author.

American Nurses Association. (2010). Nursing’s social policy statement. Washington, DC: American Nurses Publishing.

American Nurses Association. (2013a). About ANA. Retrieved from http://www.nursingworld.org/FunctionalMenuCategories/ AboutANA/default.aspx

American Nurses Association. (2013b). Linda Anne Judson Richards. Retrieved from http://www.nursingworld.org/ LindaAnneJudsonRichards

American Nurses Association. (2013c). Mary Eliza Mahoney. Retrieved from http://www.nursingworld.org/ MaryElizaMahoney

Anderson, D. (2011). Man enough: The 20 3 20 choose nursing campaign. Retrieved from http:// www.minoritynurse.com/nursing-associations/ man-enough-20-x-20-choose-nursing-campaign

Arlington National Cemetery. (n.d.). Nurses memorial. Retrieved from http://www.arlingtoncemetery.mil/ VisitorInformation/MonumentMemorials/NursesMemorial .aspx

Benner, P. (2001). From novice to expert: Excellence and power in clinical nursing practice (Commemorative ed.). Upper Saddle River, NJ: Prentice Hall Health.

Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses. A call for radical transformation. Stanford, CA: Carnegie Foundation for the Advancement of Teaching.

Bratt, M. M., & Felzer, H. M. (2011). Perceptions of professional practice and work environment of new graduates in a nurse residency program.The Journal of Continuing Education in Nursing, 42(12), 559–568. doi:10.3928/00220124-20110516-03

Buerhaus, P. I., DesRoches, C., Applebaum, S., Hess, R., Norman, L. D., & Donelan, K. (2012). Are nurses ready for health care reform? A decade of survey research. Nursing Economics, 30(6), 318–329, quiz 330.

Bureau of Labor Statistics. (2013). The 30 occupations with the largest projected employment growth, 2010–2020. Retrieved from http://www.bls.gov/news.release/ecopro .t06.htm

Donahue, M. P. (2011). Nursing: The finest art. An illustrated history (3rd ed.). St. Louis, MO: Mosby.

Florence Nightingale International Foundation. (2014). The Florence Nightingale legacy. Retrieved from http://www .fnif.org/nightingale.htm

Hardy, M. E., & Conway, M. E. (1988). Role theory: Perspec- tives for healthy professionals (2nd ed.). Norwalk, CT: Appleton & Lange.

Health Resources and Services Administration (HRSA). (2010). The registered nurse population: Findings from the 2008 National Sample Survey of Registered Nurses. Retrieved from htpp://bhpr.hrsa.gov/healthworkforce/rnsurveys/ rnsurveyfinal.pdf

Henderson, V. (1966). The nature of nursing: A definition and its implications for practice, research, and education. New York, NY: Macmillan.

Institute of Medicine (IOM). (2010, October 5). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press.

Institute of Medicine. (2012). The role of telehealth in an evolving health care environment: Workshop summary. Washington, DC: National Academies Press.

International Association of Forensic Nurses. (n.d.). Welcome to IAFN. Retrieved from http://www.forensicnurse.org

International Council of Nurses. (2012). Our mission. Retrieved from http://www.icn.ch/about-icn/icns-mission

Kumar, S., & Snooks, H. (Eds.). (2011). Telenursing, health informatics. London, United Kingdom: Springer-Verlag.

MacWilliams, B. R., Schmidt, B., & Bleich, M. R. (2013). Men in nursing. American Journal of Nursing, 113(1), 38–44. doi:10.1097/01.NAJ.0000425746.83731.16

National Council of State Boards of Nursing. (2013). The consensus model for APRN regulation, licensure, accreditation, certification and education. Retrieved from https://www.ncsbn.org/4213.htm

National League for Nursing. (2011). Recognizing the vital contributions of the licensed practical/vocational nurse. Retrieved from http://www.nln.org/aboutnln/reflection_ dialogue/refl_dial_8.htm

National League for Nursing. (2012a). Joint statement on academic progression for nursing students and graduates. Retrieved from http://www.nln.org/aboutnln/ academicprogression.htm

National League for Nursing. (2012b). National league for nurs- ing applauds landmark joint statement on academic pro- gression for nursing students and graduates. Retrieved from http://www.nln.org/newsreleases/academicprogression.htm

National League for Nursing and National Student Nurses Association. (n.d.). Realities of the current job market. Re- trieved from http://www.nsna.org/Portals/0/Skins/NSNA/ pdf/RealitiesOfTheCurrentJobMarket.pdf

National Student Nurses Association House of Delegates. (2001). Code of academic and clinical conduct. Retrieved from http://www.nsna.org/ProgramActivities/ BylawsPolicies/Ethics.aspx

Nightingale, F. (1969). Notes on nursing: What it is, and what it is not. New York, NY: Dover. (Original work published 1860.)

O’Lynn, C. E., & Tranbarger, R. E. (Eds.). (2007). Men in nursing: History, challenges, and opportunities. New York, NY: Springer.

Parsons, M. (2011). Li-Fraumeni syndrome and the role of the pediatric nurse practitioner. Clinical Journal of Oncology Nursing, 15, 79–87. doi:10.1188/11.CJON.79-87

Pender, N., Murdaugh, C., & Parsons, M. A. (2011). Health promotion in nursing practice (6th ed.). Upper Saddle River, NJ: Pearson.

Phillips, S. J. (2010). 22nd annual legislative update: Regulatory and legislative successes for APNs. The Nurse Practitioner, 35, 24–27. doi:10.1097/ 01.NPR.0000366130.98728.34

QSEN Institute. (n.d.). Pre-licensure KSAs. Retrieved from http://qsen.org/competencies/pre-licensure-ksas

Schuyler, C. B. (1992). Florence Nightingale. In F. Nightingale, Notes on nursing: What it is, and what it is not (Commemo- rative ed., pp. 3–17). Philadelphia, PA: Lippincott.

Selway, J. (2012). Nurse practitioners: A vital force in healthcare delivery. American Nurse Today, 7(9), 8–11.

Sherwood, G. (2011). Integrating quality and safety science in nursing education and practice. Journal of Research in Nursing, 16, 226–240. doi:10.1177/1744987111400960

Sherwood G., & Barnsteiner, J. (2012). Quality and safety in nursing: A competency approach to improving outcomes. West Sussex, United Kingdom: John Wiley & Sons.

Stokowski, L. A. (2011). Looking out for our new nurse grads. Retrieved from http://www.medscape.com/ viewarticle/744221

Stokowski, L. A. (2012). Just call us nurses: Men in nursing. Retrieved from http://www.medscape.com/ viewarticle/768914

Sullivan, D. T., Fries, K. S., & Relf, M. V. (2012). Exploring the changing landscape of jobs for new graduates: Practice, education, and new graduate imperatives.Creative Nursing, 18(1), 17–24.

Tri-Council for Nursing. (2010). Educational advancement of registered nurses: A consensus position. Retrieved from http://www.aacn.nche.edu/Education/pdf/ TricouncilEdStatement.pdf

U.S. Census Bureau. (2013). Men in nursing occupations. American community survey highlight report. Retrieved from http://www.census.gov/people/io/files/Men_in_ Nursing_Occupations.pdf

Vietnam Women’s Memorial Foundation (n.d.). During the Vietnam era. . . . Retrieved from http://www .vietnamwomensmemorial.org/vwmf.php

Selected Bibliography Aiken, L. H. (2011). Nurses for the future. New England

Journal of Medicine, 364(3), 196–198. doi:10.1056/ NEJMp1011639

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

Auerbach, D. I., Buerhaus, P. I., & Staiger, D. O., (2012). The future nursing workforce: The authors reply. Health Affairs, 31, 652. doi:10.1377/hlthaff.2012.0120

Biletchi, J. (2013). Men work here too: How men can thrive in maternal–newborn nursing. Nursing, 43(3), 50–53. doi:10.1097/01.NURSING.0000425862.64948.1b

Cipriano, P. F. (2011). The future of nursing and health IT: The quality elixir. Nursing Economics, 29(5), 286–289.

Fairman, J. A., & Okoye, S. M. (2011). Nursing for the future, from the past: Two reports on nursing from the institute of medicine. Journal of Nursing Education, 50(6), 305–311. doi:10.3928/01484834-20110519-02

Hassmiller, S. B. (2011). The future of nursing institute of medicine report: One year later. (2011). Journal of Continuing Education in Nursing, 42(11), 479–480. doi:10.3928/00220124-20111024-01

READINGS AND REFERENCES

9. A registered nurse is interested in functioning as a health care advocate for individuals whose lives are affected by violence. This nurse will be investigating which expanded career role? 1. Clinical nurse specialist 2. Forensic nurse 3. Nurse practitioner 4. Nurse educator

10. Fill in the blank: Instead of debating academic requirements for RN preparation, nursing is now focusing on academic __________ for nursing students and graduates.

See Answers to Test Your Knowledge in Appendix A.

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Hinds, L. E. (2013). Patient-centered care: A nursing priority. Journal of Continuing Education in Nursing, 44(1), 10–11. doi:10.3928/00220124-20121227-70

Holland, C., & Moddeman, G. R. (2012). Transforming the journey for newly licensed registered nurses. Journal of Continuing Education in Nursing, 43(7), 330–336. doi:10.3928/00220124-20120402-16

Ierardi, J., Fitzgerald, D. A., & Holland, D. T. (2010). Exploring male students’ educational experi- ences in an associate degree nursing program. Journal of Nursing Education, 49, 215–218. doi:10.3928/01484834-20091217-04

Kelly, L., McHugh, M., & Aiken, L.H. (2011). Nurse out- comes in Magnet and non-Magnet hospitals. Journal of Nursing Administration, 41(10), 428–433. doi:10.1097/ NNA.0b013e31822eddbc

Kramer, M., Maguire, P., Halfer, D., Brewer, B., & Schmalenberg, C. (2011). Impact of residency programs on professional socialization of newly licensed registered

nurses. Western Journal of Nursing Research, 35(4), 459–496. doi:10.1177/0193945911415555

McEwen, M., White, M. J., Pullis, B. R., & Krawtz, S. (2012). National survey of RN-to-BSN programs. Journal of Nursing Education, 51(7), 373–380. doi:10.3928/01484834-20120509-02

Millan, A. (2012). Nurse shortage in the United States: A Hispanic perspective. Hispanic Health Care International, 10(2), 59–60. doi:10.1891/1540-4153.10.2.59

Moore, P., & Carolyn, S. C. (2012). The lived experience of new nurses: Importance of the clinical preceptor. Journal of Continuing Education in Nursing, 43(12), 555–565. doi:10.3928/00220124-20120904-29

Munkvold, J., Tanner, C. A., & Herinckx, H. (2012). Factors affecting the academic progression of associate degree graduates. Journal of Nursing Education, 51(4), 232–235. doi:10.3928/01484834-20120224-04

Pfeifer, G. M. (2013). The top nursing news story of 2012: Health care reform goes hand in hand with expanded

nursing roles. American Journal of Nursing, 113(1), 15. doi:10.1097/01.NAJ.0000425737.68484.17

Potempa, K. (2012). A future nursing shortage? Health Affairs, 31(3), 652. doi:10.1377/hlthaff.2012.0119

Stokowski, L. A. (2011). What happened to the cap? The dawn of the cap. Retrieved from http://www.medscape .com/viewarticle/741581_print

Stokowski, L. A. (2011). The demise of the nurse’s cap. Retrieved from http://www.medscape.com/ viewarticle/747498_print

Varner, K. D., & Leeds, R. A. (2012). Transition within a graduate nurse residency program. The Journal of Continuing Education in Nursing, 43(11), 491–499. doi:10.3928/00220124-20121001-28

Williams, T., & Heavey, E. (2014). How to meet the challenges of correctional nursing. Nursing, 44(1), 51–54. doi:10.1097/01.NURSE.0000438716.50840.04

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LEARNING OUTCOMES

After completing this chapter, you will be able to: 1. Explain the relationship between research and evidence-

based nursing practice. 2. Apply the steps of change used in implementing evidence-

based practice. 3. Describe limitations in relying on research as the primary

source of evidence for practice.

INTRODUCTION Current standards of professional performance for nurses include using evidence and research findings in practice. At the minimum, all nurses are expected to use evidence and research to determine proper nursing actions, to engage in research activities as appro- priate to their abilities, and to share knowledge with other nurses ( American Nurses Association, 2010). Additionally, nurses today are actively involved in generating and publishing evidence in order to improve client care and expand nursing’s knowledge base. These activities support the current emphasis on practice that is based on evidence and on all nurses needing to be able to locate, understand, and evaluate both research findings and nonresearch evidence. All nurses need a basic understanding of the research process and its re- lationship to evidence-based practice.

EVIDENCE-BASED PRACTICE Evidence-based practice (EBP), or evidence-based nurs- ing, occurs when the nurse can “integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care” (Cronenwett et al., 2007). See Figure 2–1 •. Thus, as evidence changes, so must practice. One model for changing practice as a result of evidence (Melnyk,

Fineout-Overholt, Stillwell, & Williamson, 2010) uses the follow- ing steps:

• Cultivate a spirit of inquiry. Nurses need to be curious and willing to investigate how various practices compare and which might be best for a specific client.

• Ask clinical questions. For consistency and efficiency, nurses should state the question in a standard format such as PICOT (see page 30).

• Search for the best evidence. In the previous step, key terms are identified that facilitate identifying relevant evidence in the literature.

• Critically appraise the evidence. Several toolkits or schema are available to assist the nurse in determining the most valid, reli- able, and applicable evidence. In some cases, relevant studies may already have been synthesized (see Box 2–1).

• Integrate the evidence with clinical expertise and client/family preferences and values. Evidence must not be automatically ap- plied to the care of individual clients. Each nurse must determine how the evidence fits with the clinical condition of the client, available resources, institutional policies, and the client’s wishes. Only then can an appropriate intervention be established.

• Implement and evaluate the outcomes of the intervention. The nurse gathers all relevant data that may indicate whether or not

KEY TERMS

comparative analysis, 31 confidentiality, 34 content analysis, 31 cost–benefit analysis, 31 critique, 32 dependent variable, 30 descriptive statistics, 31 ethnography, 29 evidence-based practice

(EBP), 26

extraneous variables, 28 grounded theory, 29 hypothesis, 30 independent variable, 30 inferential statistics, 31 logical positivism, 28 measures of central

tendency, 31 measures of variability, 31 methodology, 30

naturalism, 29 phenomenology, 29 pilot study, 30 protocols, 30 qualitative research, 29 quantitative research, 28 reliability, 30 research, 27 research design, 30 research process, 29

sample, 30 scientific validation, 31 statistically significant, 31 target population, 30 validity, 30

2 Evidence-Based Practice and Research in Nursing

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4. Differentiate the quantitative approach from the qualitative approach in nursing research.

5. Outline the steps of the research process. 6. Describe research-related roles and responsibilities for nurses. 7. Describe the nurse’s role in protecting the rights of human

participants in research.

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4. Not all published research is robust and flawless. 5. EBP should promote cost-effective care, but cost is often not in-

cluded in traditional research studies.

NURSING RESEARCH Using research findings to guide decisions about client care is noth- ing new. As early as 1854, Florence Nightingale demonstrated how research findings could be used to improve nursing care. When Nightingale arrived in the Crimea in 1854, she found the military hospital barracks overcrowded, filthy, infested with fleas and rats, and lacking in food, drugs, and essential medical supplies. By systemati- cally collecting, organizing, and reporting data, Nightingale was able to institute sanitary reforms and significantly reduce mortality rates from contagious diseases and infection. Although the Nightingale tradition influenced the establishment of American nursing schools, her ideas about the importance of research did not take hold in nurs- ing until early in the 20th century.

Currently, accrediting organizations require all baccalaure- ate and higher degree programs to include coursework in research and evidence-based practice. Many associate degree and diploma programs also include content in these important areas. Research- related role expectations for nurses with different levels of educa- tional preparation were reaffirmed by the American Association of Colleges of Nursing (AACN) in 2006 and are presented in Table 2–1. All nurses, however, have a responsibility to identify nursing issues that require research and to participate in research studies to the extent they are able.

The journal Nursing Research was first published in 1952 to serve as a vehicle for communicating nurses’ research findings. The publication of many other nursing research journals followed, some dedicated to research and others combining clinical and research ar- ticles. The breadth and diversity of nursing research is reflected in the examples of recent nursing studies shown in Box 2–2.

In 1985, after intense lobbying by the American Nurses Associa- tion (ANA), the U.S. Congress passed a bill creating the National Cen- ter for Nursing Research as a part of the National Institutes of Health. The center was elevated to institute status in 1993 and became the National Institute of Nursing Research (NINR). The establishment of NINR puts nursing research on an equal footing with research by other health-related professions by supporting research training and research related to client care. The budget of the NINR reflects a steady increase in federal funding for nursing research. Current pri- ority areas for research funding by NINR are health promotion and disease prevention, symptom management, innovation, developing nurse scientists, and palliative/end-of-life care (NINR, 2011). Many nursing specialty organizations also regularly identify priority areas for research funding.

Approaches to Nursing Research Nurse researchers use two major approaches to investigating clients’ responses to health alterations and nursing interventions. These ap- proaches, quantitative and qualitative research, originate from differ- ent philosophical perspectives and generate different types of data. Both approaches make valuable contributions to evidence-based practice.

Figure 2–1 • Components of evidence-based practice.

Clinical Expertise

EBP

Best Evidence

Patient Values &

Preferences

BOX 2–1

Cochrane Collaborative Database of Abstracts of Reviews of Effects (DARE) Evidence Based Nursing Journal Health Information Resource Database Johanna Briggs Institute National Guidelines Clearinghouse Essential Evidence Plus/Patient-Oriented Evidence That Matters

(POEMS) Worldviews on Evidence-Based Nursing

Sources of Synthesized Knowledge

the intervention was successful. If the outcomes varied from those reported in the evidence, this evaluation can help determine the reasons for the variable responses and will contribute to improv- ing the evidence available for future situations.

Some scholars contend that, while evidence includes theories, opinions of recognized experts, clinical expertise, clinical experi- ences, and findings from client assessments, findings from research studies are often given the most weight in the decision-making process. This emphasis is because research entails using formal and systematic processes to address problems and answer questions. The disciplined thinking and the careful planning and execution that characterize research means that the resulting findings should be accurate, dependable, and free from bias.

Other scholars and practitioners express concerns about the cur- rent prominence and conception of EBP as primarily using research as the source of evidence. Some believe that the best evidence for EBP is theory rather than research (Fawcett, 2012). Reasons for concerns about reliance solely on research for EBP include the following:

1. Research is often done under very controlled circumstances, which is very different from the real world of health care delivery.

2. Research evidence suggests that there is one best solution to a problem for all clients and this limited perspective stifles creativity.

3. Research may ignore the significance of life events to the indi- vidual. Nursing care should consider feasibility, appropriateness, meaningfulness, and effectiveness (FAME) of interventions and plans (Pearson, Jordan, & Munn, 2012).

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TABLE 2–1 Research-Related Role Expectations for Nurses with Different Levels of Educational Preparation

Educational Preparation Identified Expectations

Baccalaureate degree Basic understanding of the research process. Able to understand and apply research findings from nursing and other disciplines in clinical practice. Understand the basic elements of evidence-based practice. Work with others to identify potential research problems. Collaborate on research teams.

Master’s degree Evaluate research findings. Implement evidence-based practice guidelines. Form and lead research teams in work settings and professional groups. Identify practice and systems problems that require study. Work with scientists to initiate research.

Practice-focused doctoral (DNP) degree

Focus on the evaluation and use of research rather than the conduct of research. Translate scientific knowledge into complex clinical interventions tailored to meet individual, family, and community health and illness needs. Use leadership skills to evaluate the translation of research into practice. Collaborate with scientists on new health policy research opportunities that evolve from the translation and evaluation processes.

Research-focused doctoral (PhD) degree

Conduct independent research. Seek needed support for the initial phases of a research program. Involve others in research projects.

Postdoctoral preparation Establish and pursue a focused research agenda. From AACN Position Statement on Nursing Research, by American Association of Colleges of Nursing, 2006, Washington, DC: Author.

BOX 2–2

• The feeding method of neonates and babies and, especially, the issue of breast-feeding is one of the most important for public health. The Greek study by Daglas and Anoniou (2012) reviewed studies about cultural practices and beliefs for breast-feeding. The research question focused on how cultural and social standards influence breast-feeding in a society. They discovered that breast-feeding is often not determined by biologic factors, but is mainly based on the habits, standards, and behaviors existing in each society. Public health policies worldwide must take into account and study the cultural status of a society in order to create favorable conditions for the initiation and duration of breast-feeding.

• Howie and Dutton (2012), a nurse anesthetist–physician team, conducted a prospective, case-controlled observational study to determine whether an evidence-based checklist for removing clients from a ventilator (extubation) following surgical anesthesia would increase providers’ documentation of extubation criteria and reduce the occurrence of preventable extubation failures in the early postoperative period. More than 600 adult and pediatric clients were studied. Following use of the extubation checklist, documentation of clients’ readiness for extubation increased and extubation failures decreased.

• The purpose of a study by Massey (2012) was to provide evidence from a randomized clinical trial regarding the return of bowel sounds as an indicator of the end of intestinal immobility (ileus) after abdominal surgery. The number of days until return of bowel sounds after abdominal surgery was compared to the days until first postoperative flatus, an indicator of the end of ileus. There was no correlation between return of bowel sounds and time to first flatus. Thus, the results of this study support that the traditional nursing practice of listening to bowel sounds as an indicator of the end of ileus is not evidence based.

• Because no published randomized controlled trials existed concerning methods to guide practice in ongoing placement verification of temporary feeding tubes, Stepter (2012) conducted a systematic review of the literature. Only six studies specific to ongoing bedside verification methods of tube placement after initial radiologic confirmation were found between 2005 and 2010. A critical appraisal of current evidence and best practice recommendations regarding temporary feeding tubes is provided.

Additional examples of research are found in the more than 50 Evidence-Based Practice boxes featured throughout this textbook.

Examples of Current Nursing Research Studies

QUANTITATIVE RESEARCH Quantitative research entails the systematic collection, statistical analysis, and interpretation of numerical data. Quantitative research is characterized by planned and fixed study processes, careful attention to extraneous variables (any variables that could influence the results of the study other than the specific variable[s] being studied for their influence) or contaminating factors in the study environment, and an objective and distanced relationship between the researcher and what is being studied. Reports of quantitative research are characterized

by statistical information, tables, and graphs, which can make them intimidating to read. The quantitative approach to research is linked to the philosophical perspective of logical positivism, which main- tains that “truth” is absolute and can be discovered by careful measure- ment. This perspective proposes that phenomena are best understood by examining their component parts; this is referred to as a reduction- istic perspective. Positivism is the philosophical perspective of natural sciences such as biology and chemistry. It focuses on the who, what, where, when, why, and how questions (Cannon, 2014).

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In addition, compared to quantitative research, there are few publi- cations that summarize the findings and implications from groups of qualitative studies on related topics. However, the nurse must still be able to evaluate qualitative research in order to determine its rel- evance to the questions and problems central to nursing.

Table 2–2 compares the quantitative and qualitative approaches to research.

Overview of the Research Process The research process is a process in which decisions are made that result in a detailed plan or proposal for a study, as well as the actual implementation of the plan. Nurses who are reading research reports to inform their practice need a basic understanding of the research process in order to judge the credibility of a study’s findings and their usefulness for EBP. Nurses who are assisting with a study as a member of a research team need to understand the research process in order to provide meaningful input into a study and help ensure that it results in credible and useful information. Although the research process unfolds somewhat differently for quantitative and qualitative studies, the same general steps are involved: formulating the research prob- lem and purpose, determining study methods, collecting research data, analyzing research data, communicating research findings, and using research findings in practice.

FORMULATING THE RESEARCH PROBLEM AND PURPOSE The researcher’s first task is to narrow a broad area of interest into a more specific problem that indicates the issue of concern behind the study. Ideas for research problems may arise from recurrent problems encountered in practice, questions that are difficult to resolve because of contradictions in the literature, or areas in which minimal or no re- search has been done. Because conducting a study requires resources and the time and effort of study participants, a research problem should be significant to nursing and offer the potential to improve client care. The problem must also be feasible to study in light of the resources (including time and skill) that are available to conduct the study. Taking shortcuts because of insufficient resources can com- promise the quality of study findings. A research problem also must be something that can be answered by scientific investigation. Ques- tions that deal with moral or ethical issues such as “Should assisted

A quantitative approach to research is useful for research ques- tions such as these:

• What causes ___________? • Which treatment for a condition is more effective? • What factors are associated with a specific condition or outcome? • If I know X, to what extent can I predict the occurrence of Y?

QUALITATIVE RESEARCH Qualitative research is the systematic collection and thematic analysis of narrative data. In other words, the research collects and analyzes words, rather than numbers. The qualitative approach to research is rooted in the philosophical perspective of naturalism (sometimes referred to as constructivism), which maintains that real- ity is relative or contextual and constructed by individuals who are experiencing a phenomenon. This philosophical perspective is re- flected in the human sciences such as anthropology, sociology, and existential psychology.

A qualitative approach to research is characterized by flexible and evolving study processes and by minimized “distancing” between the researcher and study informant. In contrast to a quantitative study, where objectivity is sought and valued, in a qualitative study, the researcher’s subjectivity and values are seen as inevitable and even desirable. Qualitative research has a holistic perspective and results in a report that may read like a story. Nurse researchers tend to use one of three distinct qualitative traditions: phenomenology, ethnography, or grounded theory. Phenomenology focuses on lived experiences, ethnography focuses on cultural patterns of thoughts and behav- iors, and grounded theory focuses on social processes. Additional qualitative types include historical and case study research.

A qualitative approach to research is useful for research ques- tions such as these:

• What is the experience of receiving diagnosis X or undergoing treatment Y? (phenomenology)

• What are typical behaviors of certain groups of clients (who may be defined by a diagnosis or membership in a cultural or ethnic group)? (ethnography)

• How do individuals cope with X? (grounded theory)

Individual qualitative research studies are not designed with the intent to change nursing practice directly (Finfgeld-Connett, 2010).

TABLE 2–2 Comparison of Quantitative and Qualitative Research Approaches

Characteristic Quantitative Research Qualitative Research

Reality Stable Personal, contextual Data Numbers, “hard” data Words, “soft” data Perspective Outsider Insider Approach to knowing Reductionistic Contextual, holistic Research approach Objective, structured, rational, empirical Subjective, artistic, intuitive Research conditions Controlled, laboratory Naturalistic, fieldwork Goal Verification, test theory Discovery, generate theory Methods Measurement Thick description Data analyses Deductive, statistics Inductive, intuitive, themes Outcome Facts Meaning, understanding Findings/results Replicable, reliable, generalizable Valid, credible, transferable From Research Essentials: Foundations for Evidence-Based Practice (p. 55) by S. Norwood, 2010, Upper Saddle River, NJ: Prentice-Hall Health. Reprinted with permission.

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study findings are more reliable and accurate. There are two major types of research designs. With an experimental design, the researcher controls the independent variable by administering an experimen- tal treatment to some participants while withholding it from others. Experimental designs are used to determine cause-and-effect rela- tionships. With a nonexperimental design, there is no manipulation of the independent variable; in fact, there may be no identifiable in- dependent and dependent variables in the study. Nonexperimental designs are used for descriptive research studies.

Another key methodological decision is determining who (or what) will provide the data for the study. The sample or sources of in- formation for a study may be humans, events, behaviors, documents, or biologic specimens. Samples are carefully selected so that they are as accurate a representation as possible of the target population, or the universe of elements to which the researcher wishes to be able to apply the study’s findings. The sample is a carefully chosen segment of the target population. Sampling decisions are also a key factor in the usefulness of a study’s findings for evidence-based practice, since findings are more likely to be replicated in practice settings when there is a close match between the characteristics of the study sample and the characteristics of the client population to which the study findings will be applied.

Nurse researchers use a wide variety of data collection strategies, including questionnaires, interviews, observation, record reviews, and biophysical measures. Data collection decisions spell out how any intervention that is going to be administered to study partici- pants will be implemented. Data collection decisions interface closely with sampling decisions. For example, if a researcher is going to dis- tribute a questionnaire to collect data, study participants must be able to read it!

One quality control strategy in research is to conduct a pilot study. A pilot study is a “dress rehearsal” before the actual study begins. Pilot studies are helpful for detecting problems such as in- structions or questionnaire items that can be misunderstood and for providing a chance to correct these problems before formal data collection procedures get under way.

COLLECTING RESEARCH DATA During the actual data collection phase of a research study, all of the methodological decisions that have been made are implemented. Re- searchers expend great effort to ensure that data collection occurs in a consistent manner throughout the course of the study. Detailed data collection protocols or instructions and careful training of research assistants are strategies that can be used to ensure the consistency and integrity of data collection procedures. Various procedures are available for establishing the reliability and validity of research data. Reliability refers to the consistency of measures. Validity refers to the completeness and conceptual accuracy of measures. The way in which reliability and validity are established depends on the data col- lection procedure being used and the nature of the data being col- lected. Conducting a pilot test allows a researcher to do a preliminary estimate of reliability and validity.

ANALYZING RESEARCH DATA During the data analysis stage of the research process, the collected data are organized and analyzed to answer the research question(s) or test the study’s hypothesis. If a study has used a quantitative ap- proach, data analysis involves the application of a variety of statistical

suicide be allowed in this hospital?” are timely and relevant, but can- not be answered through research. Finally, because conducting a study requires a lot of time and energy, a research problem should be of interest to the researcher because the researcher’s enthusiasm and commitment to the problem can be a factor in the successful comple- tion of the study.

In addition to determining the specific problem that will be the focus of the study, the researcher must also decide on the purpose of the study or on the nature of information that it will provide. A study’s purpose statement is characterized by an action verb that indicates whether the study will provide descriptive information, explanatory information, cause-and-effect information, or information that will allow prediction and control. A study’s purpose statement has impor- tant implications for how the study will be conducted and how the data collected will be analyzed.

One strategy for stating the problem you wish to explore is to use the PICO format:

P – Patient, population, or problem of interest I – Intervention or therapy to consider for the subject of interest C – Comparison of interventions, such as no treatment O – Outcome of the intervention.

In some cases, additional components are added to make PICO into PICOD by adding study Design, PICOS by adding Setting or PICOC adding Context, and PICOT by adding Timeframe. Several other frameworks are available and are not limited to asking nursing ques- tions (Davies, 2011).

Formulating the research problem and purpose is facilitated by conducting a review of the relevant literature. This literature re- view helps the researcher become familiar with the current state of knowledge in regard to the problem area and build on that knowl- edge when designing the current study. Reviewing the literature can also help the researcher identify strategies that have been used suc- cessfully (and unsuccessfully) in the past to investigate the problem and to measure the variables of interest. A dependent variable is a behavior, characteristic, or outcome that the researcher wishes to explain or predict. An independent variable is the presumed cause of or influence on the dependent variable. In some studies, the re- searcher may develop a hypothesis or a predictive statement about the relationship between two or more variables.

DETERMINING STUDY METHODS A study’s methodology can be thought of as its logistics or mechan- ics. The methodological elements of the research process deal with how the study is organized, who or what will be the sources of in- formation for the study, and data collection details such as what data will be collected, how data will be collected, and the timing of data collection. The first methodological decision made by a researcher is whether the study will use a quantitative or qualitative research ap- proach. This decision has implications for subsequent methodologi- cal decisions about research design, sampling, and data collection, as well as data analysis.

Research design refers to the overall structure or blueprint or general layout of a study. The research design indicates how many times data will be collected in a study, the timing of data collection relative to other study events, the types of relationships between vari- ables that are being examined, the number of groups being compared in the study, and how extraneous variables will be controlled so that

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findings are statistically significant. It is important to keep in mind that just because results are statistically significant does not automati- cally mean that they are clinically significant.

If a research study uses a qualitative approach, data analy- sis involves searching for themes and patterns. This procedure is sometimes referred to as content analysis because the content of narrative materials is being analyzed. Qualitative researchers may synthesize their findings to develop a theory or conceptual frame- work of the phenomenon being studied.

COMMUNICATING RESEARCH FINDINGS Research findings must be made public if they are to become acces- sible and used to guide practice decisions. Research findings can be communicated through publication in journals or at conferences. Even small-scale research projects that are carried out in a clinical setting should be communicated. Newsletter articles and research posters are ideally suited for this purpose.

USING RESEARCH FINDINGS IN PRACTICE As described earlier, EBP entails using research findings and other sources of evidence to guide decisions about client care. Before a study’s findings are used to guide practice, they should undergo three types of evaluation: scientific validation, comparative analysis, and cost–benefit appraisal.

Scientific validation is a thorough critique of a study for its conceptual and methodological integrity. This means scrutiniz- ing how the study was conceptualized, designed, and conducted in order to make a judgment about the overall quality of its find- ings. Comparative analysis involves assessing study findings for their implementation potential. Three factors are considered: (1) how the study’s findings compare to findings from other studies about the problem; (2) how the study’s findings will transfer from the research conditions to the clinical practice conditions in which they will be used; and (3) practical or feasibility considerations that need to be addressed when applying the findings in practice. The closer the fit between the characteristics of the setting and sample of the study and the conditions and clients with which the findings will be used, the more likely it is that the desired outcomes will be achieved. Cost–benefit analysis involves consideration of the potential risks and benefits of both implementing a change based on a study’s findings and not implementing a change. Both imme- diate and delayed potential costs and benefits to clients, nursing staff, and the organization as a whole should be considered. With the evaluation of an EBP innovation, the research process begins again. See Figure 2–2 •.

Research-Related Roles and Responsibilities for Nurses In today’s EBP environment, all nurses, regardless of their educational preparation, need to be able to assume two research-related roles: that of research consumer and research team member.

RESEARCH CONSUMER Being a research consumer means routinely searching and reading the current research literature in order to stay current with new in- sights in client experiences and nursing and medical interventions. Two skills are fundamental to this role: locating relevant literature and critiquing research reports.

Descriptive Statistics: Measures of Central Tendency and VariabilityBOX 2–3

MEASURES OF CENTRAL TENDENCY Mean—the arithmetic average for a set of scores. The mean is

calculated by summing all scores and dividing by the number of scores.

Median—the middle value in a distribution of scores or the value above and below which 50% of the scores lie.

Mode—the most common or frequently occurring value in a data set.

MEASURES OF VARIABILITY Range—the difference or span between the lowest and highest

value for a variable. Standard deviation—the average amount by which a single score

in a distribution deviates or differs from the mean score.

procedures. Descriptive statistics are procedures that organize and summarize large volumes of data including measures of cen- tral tendency and measures of variability. Measures of central tendency provide a single numerical value that denotes the “average” value for a variable. Measures of variability describe how values for a variable are dispersed or spread out. Specific measures of central tendency and variability are defined in Box 2–3.

The use of inferential statistics allows researchers to test hypotheses about relationships between variables or differences between groups. Inferential statistics are particularly useful when a researcher wants to establish the effectiveness of an intervention. Commonly used inferential statistics are defined in Box 2–4.

After inferential statistics have been computed, the results are inspected for statistical significance. If results are statistically significant, it means that they are not likely to have occurred only by chance. The notion of statistical significance is linked to probabil- ity. By convention, probability (a p value) of less than .05 is consid- ered to indicate statistical significance. A p value of .05 means that the observed statistical results are likely to occur solely by chance only 5% of the time. Another measure of the significance of findings is the confidence interval (CI). The CI indicates the range within which the true value lies, with a specific level of confidence. For example, if a study indicates that something occurs, on average, 2.5 times more often in one group than in another, with a 95% CI of 1.9–3.2, this means that there is a 95% likelihood that it occurs between 1.9 and 3.2 times more often. As long as zero does not fall within the CI, the

BOX 2–4

Independent t-test—used to compare the mean performance of two independent groups (such as men and women).

Dependent (or paired) t-tests—used to compare the mean performance of two dependent or related groups (such as a before and after test given to the same individuals).

Analysis of variance (ANOVA)—used to compare the mean performance of three or more groups.

Pearson’s product-moment correlation coefficient (Pearson’s r)— used to describe and test the relationship between two continuous variables (such as age and weight).

Chi-squared—used to compare the distribution of a condition across two or more groups.

Commonly Used Inferential Statistics

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Figure 2–2 • The research process. When the effects of using research findings to guide practice are evaluated, the research process begins all over again.

Evaluate evidence-based practice

Communicate research findings

Determine study methods

Use research findings in practice

Formulate research problem

Collect research data

Analyze research data

LOCATING RESEARCH LITERATURE Increasingly, policies and procedures used in hospitals and other health care settings are evidence based, meaning that nurses who develop such documents must be familiar with the current evidence as it is presented in a variety of information sources. Searching the current information on a specific topic can be overwhelming. Because most literature searches are conducted by using key terms to locate information sources that are available through an electronic database, careful planning is important so that the sources identified stand the best chance of being relevant.

Once key terms have been identified, this information can be entered into one of the many health-related electronic databases that are available. The most comprehensive electronic database for nurses is CINAHL (Cumulative Index of Nursing and Allied Health Literature). CINAHL and other useful databases and the type of in- formation they include are listed in Box 2–5. Although many of these databases are fee based, authors and publishers are moving toward open-access (free full-text) scholarly journals. Tips for conducting a literature review are shared in Box 2–6.

CRITIQUING RESEARCH REPORTS In addition to locating research literature about current clinical topics and identified clinical problems, nurses must be able to critique or critically read and evaluate research articles. A  research critique enables the nurse, as a research consumer, to determine whether the findings of a study are of sufficient quality to be used to influence practice decisions. A research critique involves dissecting a study to determine its strengths and weaknesses, statistical and clinical significance, and the generalizability and applicability of its results. Conducting an effective critique of a research study entails reading it several times. First, scan the article from start to finish getting a general sense of how the study was conducted. Next, focus on the results and discussion sections of the article. A key question that guides the research critique process is “Do the study findings and the researcher’s interpretation of these findings make sense in view of how the study was conducted?” This is true for both quantitative and qualitative research studies. Characteristics of an “ideal” research study are listed in Table 2–3. Features of a published study can be compared to these characteristics to guide a research critique.

BOX 2–5

Academic Search Premier: Academic multidisciplinary database provides abstracts and other information for more than 13,600 publications, including full-text access for over 4,700 scholarly publications.

CINAHL (Cumulative Index of Nursing and Allied Health Literature): Indexes current nursing and allied health journals and publications dating back to 1937.

ERIC: Citations and abstracts from more than 1,180 educational and education-related journals.

Health Source: Scholarly full-text journals focusing on medicine. Health Source—Consumer Edition: Consumer-oriented health

topics including the medical sciences, food sciences and nutrition, child care, sports medicine, and general health.

MEDLINE®: The U.S. National Library of Medicine’s bibliographic database consists of more than 11 million articles from over 4,800 indexed titles.

ProQuest: An interdisciplinary index of magazines, newspapers, and scholarly journals.

PsychInfo: Published by the American Psychological Association. Contains more than 2 million citations and summaries of journal articles, book chapters, books, and dissertations, all in the field of psychology, dating as far back as 1840.

PubMed: Access to Medline and additional biomedical information resources.

Social Services Abstracts: This database abstracts and indexes more than 1,300 journals, dissertations, and citations in social work, human services, social welfare, social policy, and community development.

Useful Electronic Databases

BOX 2–6

1. Be a detective. 2. Be organized. 3. Identify keywords you will use to guide your search. Some

articles and online search engines identify keywords associated with particular articles. It may be useful to use these to guide your own search.

4. If possible, start with a manual search by going to the library. If you prefer to begin with an online search, keep track of references you locate so you can find them again when you need them.

5. Consult the reference lists in useful articles. 6. Be flexible and creative. 7. Consider conducting separate searches for key variables. 8. Ask for help from a librarian!

From “Study Backgrounds and Literature Reviews,” by C. E. Fitzgerald. In S. Norwood, Research Essentials: Foundations for Evidence-Based Practice (p. 147), 2010, Upper Saddle River, NJ: Prentice-Hall Health.

Tips for Conducting a Literature Review

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TABLE 2–3 Characteristics of an Ideal Study

Study Element Quality Standard

Research problem Significant, not trivial. Addresses an issue that is important to nursing. Addresses a researchable problem. Is feasible to address in study setting.

Research purpose Is clearly stated. Will generate and refine knowledge. Consistent with current knowledge about problem.

Research subproblems

Clear, flow logically from purpose.

Review of literature Relevant, thorough, current, authoritative. Study framework Appropriate, clearly informs and enhances

study. Research approach Appropriate for problem and purpose.

Consistent with nature of subproblems. Study design Appropriate for study purpose.

Incorporates appropriate control strategies.

Sample Representative of target population or able to represent phenomenon of interest. Sufficient size. Ethical recruitment strategies.

Data collection Appropriate for variables and sample. Yields appropriate level of measure. Reliable and valid. Safe and humane.

Ethical considerations

Protection of human rights. Ethical standards of beneficence, respect for human dignity, and fair treatment upheld. Approved by Institutional Review Board (IRB).

Data analysis Appropriate for data and research questions.

Findings and interpretation

Consistent with study results, address research questions, supported with evidence, logical and reasonable.

From Research Essentials: Foundations for Evidence-Based Practice (p. 268), by S. Norwood, 2010, Upper Saddle River, NJ: Prentice-Hall Health.

RESEARCH TEAM MEMBER In addition to being well-informed research consumers, in today’s evidence-based practice environment, nurses need to be able to function as a member of a research team. This role is particularly important in hospitals that are seeking or wishing to maintain mag- net recognition status. Nurses in hospitals with this designation are expected to be involved in research and EBP activities on an ongoing basis. Research priorities were established by the Magnet National Research Agenda Study and include items in the catego- ries of clinical outcomes, client and nurse satisfaction, practice en- vironment, human resources, and financial and material resources (American Nurses Credentialing Center, 2013). Depending on their individual experience with research, nurses who are working

directly with clients can make particularly valuable contributions to research projects, including:

• Identifying clinically relevant problems that need to be studied • Reviewing the literature to provide background information for

a study • Recruiting study participants • Securing clients’ consent to participate in a study • Designing data collection instruments • Pilot-testing data collection procedures • Collecting research data • Monitoring for adverse effects of study participation • Implementing research interventions • Assisting with interpretation of study findings.

A chief responsibility in all of these activities is serving as a client ad- vocate and protecting the rights of clients who are involved in a re- search study. Unfortunately, there are many historical instances of our failure to advocate for ethical treatment of clients in the conduct of research. Examples of these include the 40-year-long study of Black men in Alabama in the mid-1900s who were allowed to go untreated for syphilis in order to investigate the progression of the disease— commonly referred to as the Tuskegee study, the 1992 Kennedy Krieger Institute study in which young children were knowingly exposed to lead in their homes (Schildmann, Sandow, Rauprich, & Vollmann, 2012), and the Havasupai Arizona Indian tribe study where blood drawn to study diabetes was used for additional research regarding genetic tendencies in the population without their permis- sion (Langford & Young, 2013). The nurse’s responsibility to protect clients’ rights is discussed in more depth in the following section.

PROTECTING THE RIGHTS OF STUDY PARTICIPANTS Because nursing research usually involves humans, a major nursing responsibility is to be aware of and to advocate on behalf of clients’ rights. Before any research on humans can be started, the researcher must obtain approval from the relevant committee designated to protect human subjects’ rights. This includes research that does not require direct involvement of the person, only access to data about the client. This committee is often called the Institutional Review Board (IRB). The IRB ensures that all clients are informed of and understand the consequences of consenting to serve as research participants (Figure 2–3 •). The specific elements that comprise informed consent are listed in Box 2–7.

The client needs to have enough information to be able to assess whether an appropriate balance exists between the risks and inconvenience of participating in a study and the potential benefits, either to the client or to the development of knowledge that may benefit others.

For many years, adults have been the focus of much health care research conducted on human subjects. The American Academy of Pediatrics has identified the need to conduct pediatric research so that children can benefit from advances in medical science. At the same time, because children are so vulnerable, extra precautions must be taken to ensure their rights are upheld and they are not harmed. It is critical to have pediatric expertise on panels that review prospec- tive research studies and in research development. All nurses who practice in settings where research is being conducted with human subjects or who participate in such research play an important role in safeguarding the rights discussed next.

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RIGHT NOT TO BE HARMED The risk of harm to a research subject is exposure to the possibility of injury going beyond everyday situations. The risk can be immediate or delayed and can be physical, emotional, legal, financial, or social in nature. For instance, withhold- ing standard care from a client in labor for the purpose of studying the course of natural childbirth clearly poses a potential physical dan- ger. Risks can also involve psychological factors such as exposure to stress or anxiety, or social factors, such as loss of confidentiality or loss of privacy. Potential risks of participating in a study need to be detailed in informed consent documents.

RIGHT TO FULL DISCLOSURE Even though it may be possible to collect research data about a client as part of everyday care without the client’s particular knowledge or consent, to do so is considered unethical. Full disclosure, the act of making clear the client’s role in a research situation, is a basic right. This means that deception, by ei- ther withholding information about a client’s participation in a study or giving the client false or misleading information about what par- ticipating in the study will involve, must not occur.

RIGHT TO SELF-DETERMINATION Many clients feel pressured to participate in studies. They believe that they must please the phy- sicians and nurses who are responsible for their treatment and care. The right to self-determination means that participants should feel free from constraints, coercion, or any undue influence to participate in a study. Hidden inducements—for instance, suggesting to poten- tial participants that by taking part in the study they might become famous, make an important contribution to science, or receive spe- cial attention—must be strictly avoided.

RIGHT TO PRIVACY Privacy enables a client to participate with- out worrying about later embarrassment. The anonymity of a study participant must be ensured even if the investigator cannot link a specific person to the information reported. Confidentiality means that any information a participant relates will not be made public or available to others without the participant’s consent. Investiga- tors must inform research participants about the laws (such as the Privacy and Security Rules of the Health Insurance Portability and Accountability Act of 1996 [HIPAA]) and measures that provide for these rights. Such measures may include the use of pseudonyms or code numbers or reporting only aggregate or group data in pub- lished research.

Figure 2–3 • It is important for clients to be fully informed before they participate in a research study. Ron Sutherland/Photo Researchers, Inc.

BOX 2–7

Subject status (“You are being asked to participate in a research study.”)

Study purpose Sponsorship (“This study is being paid for by [name of

pharmaceutical company, research grant, hospital].”) Subject selection (“You are being asked to take part in this

study because [identify relevant subject characteristics or eligibility requirements].”)

Study procedures, type of data to be collected Nature of commitment (“Taking part in this study should

take no longer than [period of time].”) Potential risks and costs associated with participation Potential benefits associated with participation Protection of privacy Voluntary consent (“By signing this form, you are indicating

that you are freely agreeing to take part in this study and are indicating that no one is forcing you to take part.”)

Alternatives (If the individual is being asked to take part in a study about an experimental treatment, information must be provided about other ways in which his or her condition could be treated.)

Right to decline to participate or to withdraw from the study; nonprejudicial treatment (“You can refuse to take part in this study and will not be punished or treated dif- ferently in any way. If you agree to take part in this study, you can stop taking part at any time or refuse to answer any questions. If you do this, you will not be punished or treated differently in any way.”)

Comprehension of information (“By signing this form you indicate that you have read and understand the information on the form. You also are indicating that you have had a chance to ask questions.”)

Contact information: whom to contact with questions about the study or complaints about treatment during the course of the study

Adapted from Research Essentials: Foundations for Evidence-Based Practice (p. 82), by S. Norwood, 2010, Upper Saddle River, NJ: Prentice-Hall Health.

Elements of Informed Consent

Critical Thinking Checkpoint

Imagine that you have read a research report that found a new type of mattress overlay reduced the incidence of skin breakdown by 25%. Before you recommend that your agency purchase these overlays: 1. What other aspects of the research study should be carefully

examined? 2. How would other aspects of EBP be brought into this situation? 3. What additional aspects would you take into consideration?

See Critical Thinking Possibilities on student resource website.

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• Evidence-based practice, or evidence-based nursing, involves clinical decision making using a variety of sources of evidence modified for use in specific settings and for individual clients.

• Change in practice requires assessing the need for change; locating and analyzing the best evidence; designing, implementing, and evalu- ating the practice change; and integrating and maintaining the change.

• Some nurses believe that research should not be the sole or pri- mary source of evidence for practice because it may differ greatly from the real world of practice, limits creativity, does not adequately consider meaning and significance to clients, and has not been demonstrated to be cost effective.

• Nursing research began in North America in the early 1900s. Since that time, the concept of research has been introduced into

nursing education programs, research journals in nursing have been developed, and the National Institute for Nursing Research has been established.

• Nurses use both quantitative and qualitative approaches to ad- dress issues of concern for client care. Quantitative studies are reported using descriptive and analytical statistics, and qualitative studies are reported in narrative format.

• In today’s evidence-based practice environment, all nurses need to be well-informed consumers of research and able to serve as effective research team members.

• A key responsibility for nurses who are assisting on a research team is to protect the rights of clients who are participating in the study.

CHAPTER HIGHLIGHTS

1. Which of the following is the lowest level of “best evidence” for evidence-based practice? 1. Clinical experiences 2. Opinions of experts 3. Client values and preferences 4. Trial and error

2. A quantitative research approach is most appropriate for which study? 1. A study measuring the effects of sleep deprivation on wound

healing 2. A study examining the bereavement process in spouses of

clients with terminal cancer 3. A study exploring factors influencing weight control behavior 4. A study examining a client’s feelings before and after a bone

marrow aspiration 3. A qualitative research approach is most appropriate for which

study? 1. A study measuring nutrition and weight loss or gain in clients

with cancer 2. A study examining oxygen levels after endotracheal suctioning 3. A study examining client reactions to stress after open heart

surgery 4. A study measuring differences in blood pressure before,

during, and after a procedure 4. A key function of a study’s methodology is to

1. Determine the hypotheses that will be tested in the study. 2. Exercise control over contaminating factors in the study

environment. 3. Identify grants and other funding sources for conducting the

study. 4. Protect the rights of the study’s participants.

5. In the PICO format for phrasing research questions and identifying key terms for a literature search, what does the “P” stand for? 1. Patterns 2. Population 3. Probability 4. Purpose

6. Which of the following is a nursing responsibility when reading published nursing research? 1. Assume that the research was properly conducted since it

has been published.

2. Evaluate whether the findings are applicable to the nurse’s specific clients.

3. Implement the research findings if at least two studies have shown the same results.

4. Request the raw data from the researchers so that the nurse can analyze the statistics again.

7. A research critique can best be defined as a/an 1. Appraisal of a study’s strengths and weaknesses. 2. Conclusion about the utilization potential of a study’s findings. 3. Criticism of a study’s flaws. 4. Summary of a study’s key points.

8. An 85-year-old client in a nursing home tells a nurse, “Because the doctor was so insistent, I signed the papers for that research study. Also, I was afraid he would not continue taking care of me.” Which client right is being violated? 1. Right not to be harmed 2. Right to full disclosure 3. Right to privacy and confidentiality 4. Right to self-determination

9. Place each of the following steps of evidence-based practice change in their usual sequence. 1. _____ Locate the best evidence. 2. _____ Ask the clinical question. 3. _____ Assess the need for change. 4. _____ Integrate the change with client preferences. 5. _____ Analyze the evidence. 6. _____ Implement and evaluate the change.

10. A nurse proposes that the hospital apply the findings from a re- cent research study that shows that clients appreciate classical orchestra music and playing it frequently lowers clients’ blood pressure. Which aspect of research suggests that it may not be appropriate to implement this as evidence-based practice? 1. All research is flawed. 2. The research would not have taken into consideration the

cost of acquiring and playing the music in a hospital. 3. One study would not be sufficient to show that all clients

would find orchestral music pleasing. 4. Research cannot demonstrate clients’ appreciation of music

since research is only appropriate for physiological problems. See Answers to Test Your Knowledge in Appendix A.

TEST YOUR KNOWLEDGE

35

Chapter 2 Review

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Suggested Reading McCleland, A. (2011). Culturally safe nursing research: Explor-

ing the use of an indigenous research methodology from an indigenous researcher’s perspective. Journal of Transcultural Nursing, 22, 362–367. doi:10.1177/1043659611414141 This article defines cultural safety and the concern that indig- enous students put aside their culture when they commit to study within a Western perspective. It outlines the use of a methodology and method in a project that enabled partici- pants and the researcher to develop a culturally safe process.

Related Research Breimaier, H., Halfens, R., & Lohrmann, C. (2011). Nurses’

wishes, knowledge, attitudes and perceived barriers on implementing research findings into practice among graduate nurses in Austria. Journal of Clinical Nursing, 20, 1744–1756. doi:10.1111/j.1365-2702.2010.03491.x

Majid, S., Foo, S., Luyt, B., Xue, Z., Yin-Leng, T., Yun-Ke, C., & Mokhtar, I. A. (2011). Adopting evidence-based practice in clinical decision making: Nurses’ perceptions, knowledge, and barriers. Journal of the Medical Library Association, 99, 229–236. doi:10.3163/1536-5050.99.3.010

Solomons, N., & Spross, J. (2011). Evidence-based practice barriers and facilitators from a continuous quality improvement perspective: An integrative review. Journal of Nursing Management, 19, 109–120. doi:10.1111/j.1365-2834.2010.01144.x

References American Association of Colleges of Nursing. (2006). AACN posi-

tion statement on nursing research. Washington, DC: Author. American Nurses Association. (2010). Nursing: Scope and

standards of practice (2nd ed.). Silver Spring, MD: Author. American Nurses Credentialing Center. (2013). National

Magnet Research Agenda. Retrieved from http://www .nursecredentialing.org/Magnet/ResourceCenters/ MagnetResearch/NationalMagnetResearchAgenda.html

Cannon, S. (2014). Quantitative research design. In C. Boswell and S. Cannon (Eds.), Introduction to nursing research: Incorporating evidence-based practice (pp. 203–225). Burlington, MA: Jones & Bartlett.

Cronenwett, L., Sherwood, G., Barnsteiner J., Disch, J., Johnson, J., Mitchell, P., . . . Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55, 122–131. doi:10.1016/j.outlook.2007.02.006

Daglas, M., & Antoniou, E. (2012). Cultural views and practices related to breastfeeding. Health Science Journal, 6, 353–361.

Davies, K. S. (2011). Formulating the evidence based practice question: A review of the frameworks. Evidence Based Library and Information Practice, 6(2), 75–80.

Fawcett, J. (2012). Thoughts about evidence-based nurs- ing practice. Nursing Science Quarterly, 25, 199–200. doi:10.1177/0894318412437967

Finfgeld-Connett, D. (2010). Generalizability and trans- ferability of meta-synthesis research findings. Journal of Advanced Nursing, 66, 246–254. doi:10.1111/j.1365-2648.2009.05250.x

Fitzgerald, C. E. (2010). Study backgrounds and literature reviews. In S. Norwood, Research essentials: Foundations for evidence-based practice (pp. 125–162). Upper Saddle River, NJ: Prentice-Hall Health.

Howie, W. O., & Dutton, R. P. (2012). Implementation of an evidence-based extubation checklist to reduce extubation failure in patients with trauma: A pilot study. AANA Journal, 80, 179–184.

Langford, R., & Young, A. (2013). Making a difference with nursing research. Upper Saddle River, NJ: Pearson.

Massey, R. L. (2012). Return of bowel sounds indicating an end of postoperative ileus: Is it time to cease this long-standing nursing tradition? MEDSURG Nursing, 21, 146–150.

Melnyk , B. M., Fineout-Overholt, E., Stillwell, S. B., & Williamson, K. M. (2010). Evidence-based practice: Step by step: The seven steps of evidence-based practice. American Journal of Nursing, 110(1), 51–53. doi:10.1097/01.NAJ.0000366056.06605.d2

National Institute of Nursing Research, National Institutes of Health. (2011). Bringing science to life: NINR strategic plan (NIH Publication No. 11-7783). Retrieved from https:// www.ninr.nih.gov/sites/www.ninr.nih.gov/files/ninr- strategic-plan-2011.pdf

Norwood, S. (2010). Research essentials: Foundations for evidence-based practice. Upper Saddle River, NJ: Prentice-Hall Health.

Pearson A., Jordan, Z., & Munn, Z. (2012). Translational science and evidence-based healthcare: A clarification and reconceptualization of how knowledge is generated and used in healthcare. Nursing Research and Practice, 2012, Article 792519. doi:10.1155/2012/792519

Schildmann, J., Sandow, V., Rauprich, O., & Vollmann, J. (2012). Human medical research: Ethical, legal and socio-cultural aspects. Basel, Switzerland: Springer.

Stepter, C. R. (2012). Maintaining placement of temporary enteral feeding tubes in adults: A critical appraisal of the evidence. MEDSURG Nursing, 21(2), 61–102.

Selected Bibliography Brown, S. J. (2012). Evidence-based nursing: The research-

practice connection (2nd ed.). Sudbury, MA: Jones & Bartlett. Dearholt, S., & Dang, D. (2012). Johns Hopkins nursing

evidence based practice: Model and guidelines (2nd ed.). Indianapolis, IN: Sigma Theta Tau International.

Fineout-Overholt, E., Gallagher-Ford, L., Melnyk, B. M., & Stillwell, S. B. (2011). Evidence-based practice: Step by step: Evaluating and disseminating the impact of an evidence-based intervention: Show and tell. American Journal of Nursing, 111(7), 56–59. doi:10.1097/01 .NAJ.0000399317.21279.47

Fineout-Overholt, E., Melnyk, B. M., Stillwell, S. B., & Williamson, K. M. (2010). Evidence-based practice: Step by step: Critical appraisal of the evidence: Part I. American Journal of Nursing, 110(7), 47–52. doi:10.1097/01 .NAJ.0000383935.22721.9c

Fineout-Overholt, E., Melnyk, B. M., Stillwell, S. B., & Williamson, K. M. (2010). Evidence-based practice: Step

by step: Critical appraisal of the evidence: Part II: Digging deeper—Examining the “keeper” studies. American Journal of Nursing, 110(9), 41–48. doi:10.1097/01.NAJ.0000388264.49427.f9

Fineout-Overholt, E., Melnyk, B. M., Stillwell, S. B., & Williamson, K. M. (2010). Evidence-based practice: Step by step: Critical appraisal of the evidence: Part III. American Journal of Nursing, 110(11), 43–51. doi:10.1097/01.NAJ.0000390523.99066.b5

Fineout-Overholt, E., Williamson, K. M., Gallagher-Ford, L., Melnyk, B. M., & Stillwell, S. B. (2011). Evidence-based practice: Step by step: Following the evidence: Planning for sustainable change. American Journal of Nursing, 111(1), 54–60. doi:10.1097/01.NAJ.0000393062.83761.c0

Gallagher-Ford, L., Fineout-Overholt, E., Melnyk, B. M., & Stillwell, S. B. (2011). Evidence-based practice: Step by step: Rolling out the rapid response team. American Journal of Nursing, 111(5), 42–47. doi:10.1097/01 .NAJ.0000398050.30793.0f

Gallagher-Ford, L., Fineout-Overholt, E., Melnyk, B. M., & Stillwell, S. B. (2011). Evidence-based practice: Step by step: Implementing an evidence-based practice change. American Journal of Nursing, 111(3), 54–60. doi:10.1097/10.1097/01.NAJ.0000395243.14347.7e

Melnyk, B. M., & Fineout-Overholt, B. (2011). Evidence-based practice in nursing and healthcare: A guide to best practice (2nd ed.). Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins.

Melnyk, B. M., Fineout-Overholt, E., Gallagher-Ford, L., & Stillwell, S. B. (2011). Evidence-based practice: Step by step: Sustaining evidence-based practice through organizational policies and an innovative model. American Journal of Nursing, 111(9), 57–60. doi:10.1097/01.NAJ.0000405063.97774.0e

Rebar, C. R., Gersch, C. J., Macnee, C. L., & McCable, S. (2011). Understanding nursing research: Using research in evidence-based practice (3rd ed.). Philadelphia, PA: Wolters Kluwer/Lippincott Wiliams & Wilkins.

Schmidt, N. A., & Brown, J. M. (2012). Evidence-based practice for nurses: Appraisal and application of research (2nd ed.). Sudbury, MA: Jones & Bartlett.

Sherwood, G., & Barnsteiner, J. (Eds.). (2012). Quality and safety in nursing: A competency approach to improving outcomes. Ames, IA: John Wiley & Sons.

Stillwell, S. B., Fineout-Overholt, E., Melnyk, B. M., & Williamson, K. M. (2010). Evidence-based practice: Step by step: Searching for the evidence. American Journal of Nursing, 110(5), 41–47. doi:10.1097/ 01.NAJ.0000372071.24134.7e

Stillwell, S. B., Fineout-Overholt, E., Melnyk, B. M., & Williamson, K. M. (2010). Evidence-based practice: Step by step: Asking the clinical question: A key step in evidence- based practice. American Journal of Nursing, 110(3), 58–61. doi:10.1097/01.NAJ.0000368959.11129.79

Titler, M. G. (2011). Nursing science and evidence-based prac- tice. Western Journal of Nursing Research, 33(3), 291–295. doi:10.1177/0193945910388984

READINGS AND REFERENCES

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LEARNING OUTCOMES

After completing this chapter, you will be able to: 1. Differentiate the terms theory, concept, conceptual framework,

paradigm, and metaparadigm for nursing. 2. Describe the major purpose of theory in the sciences and

practice disciplines. 3. Identify the components of the metaparadigm for nursing.

INTRODUCTION As a profession, nursing is involved in identifying its own unique body of knowledge essential to nursing practice—nursing science. To identify this knowledge base, nurses must develop and recognize concepts and theories specific to nursing. Because theories in some other disciplines were developed and used much before nursing theories, it is helpful to explore briefly how theory has been used by those disciplines before considering theory in nursing.

INTRODUCTION TO THEORIES A theory may be defined as a system of ideas that is presumed to explain a given phenomenon. For now, think of a theory as a major, very well-articulated idea about something important. Theories are used to describe, predict, and control phenomena.

Four influential theories from the 20th century were Marx’s the- ory of alienation, Freud’s theory of the unconscious, Darwin’s theory of evolution, and Einstein’s theory of relativity. Most undergraduate students are introduced to the major theories in their disciplines. Psy- chology majors study Freud and Jung’s theories of the unconscious, Sullivan and Piaget’s theories of development, and Skinner’s theory of behaviorism. Sociology majors study Marx’s theory of alienation and Weber’s theories of modern work. Biology majors are introduced to Darwin’s theory of evolution, but also to Stephen Jay Gould’s critique and modification of evolutionary theory. Physics majors are intro- duced to a historical progression of theorists including Copernicus, Newton, Einstein, and newer theorists in quantum mechanics.

The extent to which theories build on or modify previous theo- ries varies with the discipline, as does the importance of theory in the discipline. Students in nursing, teaching, and management often take some courses in theory, but these students generally focus on learn- ing their practice. Management students study management theories,

but the relationship between the theory of management and the prac- tice of management is not nearly as strong as the relationship between the theory of physics and the practice of physics. This is because the practice of physics is theory and research, whereas the practice of management, teaching, nursing, art, music, law, clinical psychol- ogy, and pastoral care is something else entirely. The term practice discipline is used for fields of study in which the central focus is per- formance of a professional role (e.g., nursing, teaching, management, music). Practice disciplines are differentiated from the disciplines that have research and theory development as their central focus, for example, the natural sciences. In the practice disciplines, the main function of theory (and research) is to provide new possibilities for understanding the discipline’s practice.

Context for Theory Development in American Universities In the 19th century, Florence Nightingale thought that the people of Great Britain needed to know more about how to maintain healthy homes and how to care for sick family members. Nightingale’s Notes on Nursing: What It Is, and What It Is Not (1860/1969) was our first textbook on home care and community health. However, the audi- ence for that text was the public at large, not a separate discipline or profession. To Nightingale, the knowledge needed to provide good nursing was neither unique nor specialized. Rather, Nightingale viewed nursing as a central human activity grounded in observation, reason, and commonsense health practices. Nightingale’s theory is further described on page 40.

In the 20th century, nursing education in the United States took a different path from nursing education in Great Britain and Europe. The drive to establish nursing departments in colleges and universi- ties exposed American nursing to the dominant ideas and pressures

KEY TERMS

clients, 38 conceptual framework, 38 critical theory, 39 environment, 38

grand theories, 38 health, 38 metaparadigm, 38

midlevel (or middle range) theories, 39

nursing, 38 paradigm, 38

philosophy, 40 practice discipline, 37 theory, 37

3 Nursing Theories and Conceptual Frameworks

4. Identify the role of nursing theory in nursing education, research, and clinical practice.

5. Identify one positive and one negative effect of using theory to understand clinical practice.

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in American higher education at the time. During the latter half of the 20th century, disciplines seeking to establish themselves in univer- sities had to demonstrate something that Nightingale had not envi- sioned for nursing: a unique body of theoretical knowledge.

The natural and technologic sciences were often seen as role mod- els in this regard. Theories in the natural sciences provided a founda- tion and direction for research. Research in these disciplines often produced tangible results: knowledge that could be used in our efforts to control nature, disease, and foreign threats. Scientifically produced knowledge resulted in a stronger national security and economy.

The term practice discipline was not in common use until the very end of the 20th century. Disciplines without a strong theory and research base were referred to as “soft,” a negative comparison with the “hard” natural sciences. Many of the soft disciplines attempted to emulate the sciences, so theory and scientific research became a more important part of academic life, both in the practice disciplines and in the humanities.

In practice disciplines, theories work like lenses through which we are invited to interpret things like market forces, industrial effi- ciency, the human mind, pain, and suffering. Their usefulness comes from helping us interpret phenomena from unique perspectives, building new understandings, relationships, and possibilities.

Defining Terms Concepts are often called the building blocks of theories. Concepts are hard to define because the definition has to include everything from the speed of light to the unconscious. Concepts are easier to un- derstand by example. Einstein’s theory of relativity consists of a beau- tiful mathematical relationship between three concepts in physics: mass, energy, and the speed of light. However, theories are not always built like houses out of block-like concepts. Freud’s theory of the un- conscious not only required some new concepts, it required a com- pletely new model. Freud needed a model for the mind that could bring a host of human experiences together under one mental roof: dreams, wishes, decisions, behaviors, feelings, anxieties, and sexual- ity. Freud’s theory of the mind included three new concepts: the ego, the id, and the superego. It would not be right to say that Freud’s the- ory of the unconscious evolved out of these concepts. Rather, these new concepts helped him create a model in which his larger idea, the unconscious, might be understood.

A conceptual framework is a group of related ideas, state- ments, or concepts. Freud’s structure of the mind (id, ego, superego) could be considered a conceptual framework. The term conceptual model is often used interchangeably with conceptual framework, and sometimes with grand theories, those that articulate a broad range of the significant relationships among the concepts of a discipline (Peterson & Bredow, 2013).

No scientific theory is purely objective, because each is devel- oped in cultures and expressed in language. Theories offer ways of looking at or conceptualizing the central interests of a discipline. In the natural sciences, theories are often expressed in mathematical formulas, but Darwin’s Origin of Species theory requires a short book. In the social and behavioral sciences, theories attempt to explain re- lationships among concepts. The conceptualization is often complex. Other authors build on, explain, and critique the original work.

Broadly speaking, a paradigm refers to a pattern of shared un- derstandings and assumptions about reality and the world. Paradigms

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include our notions of reality that are largely unconscious or taken for granted. However, the term paradigm is used in a variety of ways by different authors, and its everyday usage varies considerably.

We become aware of paradigms when realities clash. The para- digm of 16th-century Europe, informed largely by established reli- gious doctrines and practices, clashed with the emerging discoveries in astronomy. The Industrial Revolution clashed with the long- standing feudal order, disrupting social and class relationships. In the 20th century, the ideals of socialism clashed with the ideals of capi- talism, and religious fundamentalism clashed with evolution. The next paradigm clash is likely to be between commonsense notions of space and time and the emerging field of quantum mechanics.

THE METAPARADIGM FOR NURSING In the late 20th century, much of the theoretical work in nursing fo- cused on articulating relationships among four major concepts: per- son, environment, health, and nursing. Because these four concepts can be superimposed on almost any work in nursing, they are collec- tively referred to as the metaparadigm for nursing. The term origi- nates from two Greek words: meta, meaning “with,” and paradigm, meaning “pattern.” Many consider the following four concepts to be central to nursing:

1. The individuals or clients are the recipients of nursing care (in- cludes individuals, families, groups, and communities).

2. The environment is the internal and external surroundings that affect the client. This includes people in the physical environ- ment, such as families, friends, and significant others.

3. Health is the degree of wellness or well-being that the client experiences.

4. Nursing is the attributes, characteristics, and actions of the nurse providing care on behalf of, or in conjunction with, the client.

The work of American nurse theorists reflects a wide range of ideas about people, the world, health, and nursing. Each nurse theorist’s definitions of these four major concepts vary with scientific and philosophical orientation, experience in nursing, and the effects of that experience on the theorist’s view of nursing.

Nursing theorists have built on the metaparadigm and on the work of Nightingale, whether or not they were conscious of doing so. In addition, other theories foundational to many nursing theories in- clude interactive, systems, and developmental theories (Figure 3–1 •).

ROLE OF NURSING THEORY Direct links exist among theory, education, research, and clinical practice. In many cases, nursing theory guides knowledge develop- ment and directs education, research, and practice although each influences the others. The interface between nursing experts in each area helps to ensure that work in the other areas remains relevant, cur- rent, useful, and ultimately influences health. Im and Chang (2012) reviewed the nursing literature from 2001 to 2010 and identified more than 2,000 articles that included key terms related to nursing theory. Of those, almost two thirds used grounded theory, while the remainder involved concept analysis, grand theory, midrange theory, or situation-specific theory. Although the focus of theory develop- ment has changed during the past 70 years, it is apparent that theory remains an important focus of nurses’ work.

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midlevel (or middle range) theories that focus on the explora- tion of concepts such as pain, self-esteem, learning, and hardiness. In qualitative research, theory can be used to help select the phenom- enon, frame the philosophical underpinnings of the study, and guide data analysis and interpretation. Qualitative research in nursing and the social sciences can also be grounded in theories from philosophy or the social sciences. For example, the term critical theory is used in academia to describe theories that help elucidate how social struc- tures affect a wide variety of human experiences from art to social practices. In nursing, critical theory research helps explain how these structures such as race, gender, sexual orientation, and economic class affect client experiences and health outcomes.

Bond et al. (2011) reviewed 2,184 research reports in seven lead- ing nursing journals over 5 years and found that 38% used theory, al- though only slightly more than half of those studied nursing theories. In comparison to previous studies, these percentages have not increased.

In Clinical Practice Where nursing theory has been employed in a clinical setting, its pri- mary contribution has been the facilitation of reflecting, questioning, and thinking about what nurses do. For example, one publication described how practicing school nurses could use Orem’s self-care deficit theory to work with children with special health care needs (Green, 2012).

As described in Chapter 2 , evidence-based practice involves the recognition of which knowledge is appropriate for application

In Education Because nursing theory was used primarily to establish the profes- sion’s place in the university, it is not surprising that nursing theory became more firmly established in academia than in clinical practice. In the 1970s and 1980s, many nursing programs identified the ma- jor concepts in one or two nursing models, organized these concepts into a conceptual framework, and built the entire curriculum around that framework. The unique language in these models was typi- cally introduced into program objectives, course objectives, course descriptions, and clinical performance criteria. The purpose was to elucidate the central meanings of the profession and to improve the status of the profession. Although all nursing programs are organized around concepts, many nursing programs have abandoned theory- driven conceptual frameworks.

In Research Nursing research identifies the philosophical assumptions or con- ceptual frameworks from which it proceeds because all thinking, writing, and speaking is based on previous assumptions about peo- ple and the world. New theoretical perspectives provide an essential service by identifying gaps in the way we approach specific fields of study such as symptom management or quality of life. Different con- ceptual perspectives also help generate new ideas, research questions, and interpretations.

Because of their breadth, grand theories only occasionally di- rect nursing research. Nursing research is more often informed by

Figure 3–1 • The living tree of nursing theories. From “The Living Tree of Nursing Theories,” by C. Tourville & K. Ingalls, 2003, Nursing Forum, 38(3), p. 23. Copyright © 2003 Blackwell Publishers. Reprinted with permission.

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to client care. Practice theories, those that describe the relationships among variables as applied to specific clinical situations (e.g., theory of postpartum depression), are important contributors to effective evidence-based practice. The Magnet Recognition Program (American Nurses Credentialing Center, 2011), which recognizes organizations that demonstrate excellence in nursing practice, requires that the orga- nization use a professional practice model. Although this model could be a nursing theory, it could also be a model from another discipline.

An increasing body of theoretical scholarship in nursing practice has been outside the framework of the formal theories presented in the next section. Philosophy is used to explore both clinical and theoreti- cal issues in the journal Nursing Philosophy. Family theorists and criti- cal theorists have encouraged the profession to move the focus from individuals to families and social structures. In addition, as nurses work increasingly in interprofessional teams, they will need theories that are applicable not only to nurses, but to the other health care pro- fessionals with whom they work (Bond et al., 2011). Debates about the role of theory in nursing practice provide evidence that nursing is maturing, both as an academic discipline and as a clinical profession.

OVERVIEW OF SELECTED NURSING THEORIES The nursing theories discussed in this chapter vary considerably in their (a) level of abstraction; (b) conceptualization of the client, health/illness, environment, and nursing; and (c) ability to describe, explain, or predict phenomena. Some theories are broad in scope; others are limited. The works presented may be classified as philoso- phies, nursing models, or nursing theories using the categorizations of Alligood and Tomey (2010). A philosophy is a belief system, of- ten an early effort to define nursing phenomena, and serves as the basis for later theoretical formulations. Examples of philosophies are those of Nightingale, Henderson, and Watson. Nursing models include those of Neuman, Orem, Rogers, Roy, and King, whereas nursing theories are those of Peplau, Leininger, and Parse. Only brief summaries of the authors’ central themes and basic assumptions are included here (and presented in chronologic order).

Nightingale’s Environmental Theory Florence Nightingale, often considered the first nurse theorist, de- scribed nursing 150 years ago as establishing an environment that allows persons to recover from illness (Nightingale, 1860/1969). She linked health with five environmental factors: (1) pure or fresh air, (2) pure water, (3) efficient drainage, (4) cleanliness, and (5) light, especially direct sunlight. Deficiencies in these five factors produced lack of health or illness.

These environmental factors attain significance when one con- siders that sanitation conditions in the hospitals of the mid-1800s were extremely poor and that women working in the hospitals were often unreliable, uneducated, and incompetent to care for the ill. In addition to those factors, Nightingale also stressed the importance of keeping the client warm, maintaining a noise-free environment, and attending to the client’s diet in terms of assessing intake, timeliness of the food, and its effect on the person.

Nightingale set the stage for further work in the development of nursing theories. Her general concepts about ventilation, cleanliness, quiet, warmth, and diet remain integral parts of nursing and health care today.

Peplau’s Interpersonal Relations Model Hildegard Peplau, a psychiatric nurse, introduced her interpersonal concepts in 1952. Central to Peplau’s theory is the existence of a ther- apeutic relationship between the nurse and the client. Nurses enter into a personal relationship with an individual when a need is pres- ent. The nurse–client relationship evolves in four phases:

1. Orientation. The client seeks help and the nurse assists the client to understand the problem and the extent of the need for help.

2. Identification. The client assumes a posture of dependence, interdependence, or independence in relation to the nurse (re- latedness). The nurse’s focus is on ensuring the individual that the nurse understands the interpersonal meaning of the client’s situation.

3. Exploitation. The client derives full value from what the nurse offers through the relationship. The client uses available services based on self-interest and needs. Power shifts from the nurse to the client.

4. Resolution. In the final phase, old needs and goals are put aside and new ones adopted. Once older needs are resolved, newer and more mature ones emerge.

To help clients fulfill their needs, nurses assume many roles: stranger, teacher, resource person, surrogate, leader, and counselor. Peplau’s model continues to be used by clinicians when working with individuals who have psychological problems (see, for example, Draucker, Cook, Martsolf, & Stephenson, 2012).

Henderson’s Definition of Nursing In 1966, Virginia Henderson’s definition of the unique function of nursing was a major stepping stone in the emergence of nursing as a discipline separate from medicine. Like Nightingale, Henderson de- scribes nursing in relation to the client and the client’s environment. Unlike Nightingale, Henderson sees the nurse as concerned with both healthy and ill individuals, acknowledges that nurses interact with clients even when recovery may not be feasible, and mentions the teaching and advocacy roles of the nurse. Henderson’s emphasis on the importance of nursing’s independence from, and interdepen- dence with, other health care disciplines is well recognized.

Henderson (1966) conceptualizes the nurse’s role as assisting sick or healthy individuals to gain independence in meeting 14 fun- damental needs:

1. Breathing normally 2. Eating and drinking adequately 3. Eliminating body wastes 4. Moving and maintaining a desirable position 5. Sleeping and resting 6. Selecting suitable clothes 7. Maintaining body temperature within normal range by adjusting

clothing and modifying the environment 8. Keeping the body clean and well groomed to protect the

integument 9. Avoiding dangers in the environment and avoiding injuring others

10. Communicating with others in expressing emotions, needs, fears, or opinions

11. Worshipping according to one’s faith 12. Working in such a way that one feels a sense of accomplishment 13. Playing or participating in various forms of recreation

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hazards to life and well-being; and promoting normal human functioning.

2. Developmental requisites result from maturation or are associ- ated with conditions or events, such as adjusting to a change in body image or to the loss of a spouse.

3. Health deviation requisites result from illness, injury, or disease or its treatment. They include actions such as seeking health care assistance, carrying out prescribed therapies, and learning to live with the effects of illness or treatment.

Therapeutic self-care demand refers to all self-care activities required to meet existing self-care requisites, or in other words, actions to maintain health and well-being.

Self-care deficit results when self-care agency is not adequate to meet the known self-care demand. Orem’s self-care deficit theory ex- plains not only when nursing is needed but also how people can be assisted through five methods of helping: acting or doing for, guiding, teaching, supporting, and providing an environment that promotes the individual’s abilities to meet current and future demands.

Orem identifies three types of nursing systems. The five meth- ods of helping discussed for self-care deficit can be used in each of the three nursing systems:

1. Wholly compensatory systems are required for individuals who are unable to control and monitor their environment and pro- cess information.

2. Partly compensatory systems are designed for individuals who are unable to perform some, but not all, self-care activities.

3. Supportive-educative (developmental) systems are designed for persons who need to learn to perform self-care measures and need assistance to do so.

Self-Care, Dependent Care & Nursing is the official journal of the International Orem Society. The society holds an international con- ference approximately every 4 years. Many research and theoretical articles are published every year using Orem’s theory (see, for example, Sürücü & Kizilci, 2012).

King’s Goal Attainment Theory Imogene King’s theory of goal attainment (1981) was derived from her conceptual framework (Figure 3–2 •). King’s framework shows

14. Learning, discovering, or satisfying the curiosity that leads to normal development and health, and using available health facilities.

Rogers’ Science of Unitary Human Beings Martha Rogers first presented her theory of unitary human beings in 1970. It contains complex conceptualizations related to multiple sci- entific disciplines (e.g., Einstein’s theory of relativity, von Bertalanffy’s general systems theory, and many other disciplines, such as anthro- pology, psychology, sociology, astronomy, religion, philosophy, his- tory, biology, and literature).

Rogers views the person as an irreducible whole, the whole being greater than the sum of its parts. She states that humans are dynamic energy fields in continuous exchange with environmental fields, both of which are infinite. The “human field image” perspective surpasses that of the physical body. Both human and environmental fields are characterized by pattern, a universe of open systems, and four dimensionality. According to Rogers, unitary man:

• Is an irreducible, four-dimensional energy field identified by pattern. • Manifests characteristics different from the sum of the parts. • Interacts continuously and creatively with the environment. • Behaves as a totality. • As a sentient being, participates creatively in change.

Nurses applying Rogers’ theory in practice (a) focus on the person’s wholeness, (b) seek to promote symphonic interaction be- tween the two energy fields (human and environment) to strengthen the coherence and integrity of the person, (c) coordinate the human field with the rhythmicities of the environmental field, and (d) direct and redirect patterns of interaction between the two energy fields to promote maximum health potential.

Nurses’ use of noncontact therapeutic touch is based on the concept of human energy fields. The qualities of the field vary from person to person and are affected by pain and illness. Nurses trained in noncontact therapeutic touch claim they can assess and feel the en- ergy field and manipulate it to enhance the healing process of people who are ill or injured.

Orem’s General Theory of Nursing Dorothea Orem’s theory, first published in 1971, includes three related concepts: self-care, self-care deficit, and nursing systems. Self-care the- ory is based on four concepts: self-care, self-care agency, self-care requi- sites, and therapeutic self-care demand. Self-care refers to those activities an individual performs independently throughout life to promote and maintain personal well-being. Self-care agency is the individual’s ability to perform self-care activities. It consists of two agents: a self-care agent (an individual who performs self-care independently) and a dependent care agent (a person other than the individual who provides the care). Most adults care for themselves, whereas infants and people weakened by illness or disability require assistance with self-care activities.

Self-care requisites, also called self-care needs, are measures or actions taken to provide self-care. There are three categories of self- care requisites:

1. Universal requisites are common to all people. They include maintaining intake and elimination of air, water, and food; balancing rest, solitude, and social interaction; preventing

Figure 3–2 • King’s conceptual framework for nursing: dynamic interacting systems. From A Theory for Nursing: Systems, Concepts, Process (p. 11), by I. M. King, 1981, Albany, NY: Delmar. Copyright Imogene M. King. Reprinted with permission.

Social Systems (Society)

Interpersonal Systems (Groups)

Personal Systems (Individual)

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depicted as a solid line, represents the person’s state of equilibrium or the state of adaptation developed and maintained over time and con- sidered normal for that person. The flexible line of defense, depicted as a broken line, is dynamic and can be rapidly altered over a short period of time. It is a protective buffer that prevents stressors from penetrating the normal line of defense. Certain variables (e.g., sleep deprivation) can create rapid changes in the flexible line of defense.

Neuman categorizes stressors as intrapersonal stressors, those that occur within the individual (e.g., an infection); interpersonal stressors, those that occur among individuals (e.g., unrealistic role expectations); and extrapersonal stressors, those that occur outside the person (e.g., financial concerns). The individual’s reaction to stressors depends on the strength of the lines of defense. When the lines of defense fail, the resulting reaction depends on the strength of the lines of resistance. As part of the reaction, a person’s system can adapt to a stressor, an effect known as reconstitution. Nursing interventions focus on retaining or maintaining system stability. These interventions are carried out on three preventive levels: primary, secondary, and tertiary.

1. Primary prevention focuses on protecting the normal line of de- fense and strengthening the flexible line of defense.

2. Secondary prevention focuses on strengthening internal lines of resistance, reducing the reaction, and increasing resistance factors.

3. Tertiary prevention focuses on readaptation and stability and protects reconstitution or return to wellness following treatment.

Betty Neuman’s model of nursing is applicable to a variety of nursing practice settings involving individuals, families, groups, and communities. The model is used in many countries and to direct nursing administration and research programs. It is also used in a variety of nursing education programs at the associate degree and higher levels (Beckman, Boxley-Harges, & Kaskel, 2012).

Roy’s Adaptation Model Sister Callista Roy (2009) defines adaptation as “the process and out- come whereby the thinking and feeling person uses conscious aware- ness and choice to create human and environmental integration” (p. 26). Roy’s work focuses on the increasing complexity of person and environment self-organization, and on the relationship between and among persons, universe, and what can be considered a supreme being or God.

the relationship of personal systems (individuals), interpersonal sys- tems (groups such as nurse–client), and social systems (such as edu- cational system, health care system). She selected 15 concepts from the nursing literature (self, role, perception, communication, inter- action, transaction, growth and development, stress, time, personal space, organization, status, power, authority, and decision making) as essential knowledge for use by nurses.

Ten of the concepts in the framework were selected (self, role, perception, communication, interaction, transaction, growth and de- velopment, stress, time, and personal space) as essential knowledge for use by nurses in concrete nursing situations. Within this theory, a transaction process model was designed (Figure 3–3 •). This process describes the nature of and standard for nurse–client interactions that lead to goal attainment—that nurses purposefully interact and mutually set, explore, and agree to means to achieve goals. Goal attainment repre- sents outcomes. When this information is recorded in the client record, nurses have data that represent evidence-based nursing practice.

King’s theory offers insight into nurses’ interactions with individ- uals and groups within the environment. It highlights the importance of a client’s participation in decisions that influence care and focuses on both the process of nurse–client interaction and the outcomes of care. King believes that her theory, used in evidence theory-based practice, blends the art and the science of nursing. In India, one re- search study used King’s work as the theoretical framework for a study of perceptions of nursing practice (Andrade, George, & Roach, 2013).

Neuman’s Systems Model Betty Neuman (Neuman & Fawcett, 2002), a community health nurse and clinical psychologist, developed a model based on the in- dividual’s relationship to stress, the reaction to it, and reconstitution factors that are dynamic in nature. Reconstitution is the state of adap- tation to stressors.

Neuman views the client as an open system consisting of a basic structure or central core of energy resources (physiologic, psychologic, sociocultural, developmental, and spiritual) surrounded by two  concentric boundaries or rings referred to as lines of resistance (Figure 3–4 •). The lines of resistance represent internal factors that help the client defend against a stressor; one example is an increase in the body’s leukocyte count to combat an infection. Outside the lines of resistance are two lines of defense. The inner or normal line of defense,

Figure 3–3 • King’s model of transactions. From A Theory for Nursing: Systems, Concepts, Process (p. 145), by I. M. King, 1981, Albany, NY: Delmar. Copyright Imogene M. King. Reprinted with permission.

Nurse

Client

Judgment

Feedback

Judgment

Perception

Feedback

Perception

TransactionInteraction

Action

Action

Reaction

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Leininger’s Cultural Care Diversity and Universality Theory Madeleine Leininger, a nurse anthropologist, put her views on transcultural nursing in print in the 1970s, established the Journal of Transcultural Nursing in 1986, and then in 1991 published her book Culture Care Diversity and Universality: A Theory of Nursing. Leininger states that care is the essence of nursing and the dominant, distinctive, and unifying feature of nursing. She emphasizes that hu- man caring, although a universal phenomenon, varies among cul- tures in its expressions, processes, and patterns; it is largely culturally derived. Leininger produced the Sunrise model to depict her theory of cultural care diversity and universality. This model emphasizes that health and care are influenced by elements of the social struc- ture, such as technology, religious and philosophical factors, kinship and social systems, cultural values, political and legal factors, eco- nomic factors, and educational factors. These social factors are ad- dressed within environmental contexts, language expressions, and ethnohistory. Each of these systems is part of the social structure of any society; health care expressions, patterns, and practices are also integral parts of these aspects of social structure. In order for nurses to assist people of diverse cultures, Leininger presents three inter- vention modes:

• Culture care preservation and maintenance • Culture care accommodation, negotiation, or both • Culture care restructuring and repatterning.

Leininger states that her theory is the only one focused unequivocally on culture care, examining what is universal among cultures and what varies (Leininger & McFarland, 2010).

Roy focuses on the individual as a biopsychosocial adaptive system that employs a feedback cycle of input (stimuli), throughput (control processes), and output (behaviors or adaptive responses). Both the individual and the environment are sources of stimuli that require modification to promote adaptation, an ongoing purposive response. Adaptive responses contribute to health, which she defines as the process of being and becoming integrated; ineffective or mal- adaptive responses do not contribute to health. Each person’s adapta- tion level is unique and constantly changing.

The goal of Roy’s model is to enhance life processes through adaptation in four adaptive modes. Individuals respond to needs (stimuli) in one of the four modes:

1. The physiological mode involves the body’s basic physiological needs and ways of adapting with regard to fluids and electrolytes, activity and rest, circulation and oxygen, nutrition and elimination, protection, the senses, and neurologic and endocrine function.

2. The self-concept mode includes two components: the physical self, which involves sensation and body image, and the personal self, which involves self-ideal, self-consistency, and the moral- ethical self.

3. The role function mode is determined by the need for social in- tegrity and refers to the performance of duties based on given positions within society.

4. The interdependence mode involves one’s relations with signifi- cant others and support systems that provide help, affection, and attention.

In evolving her work since the early 1980s, Roy has expanded the model for application with families and clients in relationships.

Figure 3–4 • Neuman’s client system. From The Neuman Systems Model, 4th ed. (p. 15), by B. Neuman and J. Fawcett, 2002, Upper Saddle River, NJ: Prentice Hall. Reprinted with permission.

Basic structure energy

resources

Note: Physiologic, psychologic, sociological, developmental, and spiritual variables occur and are considered simultaneously in each client concentric circle.

Flexible l ine of defense

Norm al line of defense

Lines of resistance

Basic structure

Basic factors common to all organisms, e.g.,

• Normal temperature range • Genetic structure • Response pattern • Organ strength or weakness • Ego structure • Knowns or commonalities

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• Rhythmicity is the movement toward greater diversity. • Cotranscendence is the process of reaching out beyond the self.

Parse’s model of humanbecoming emphasizes how individu- als choose and bear responsibility for patterns of personal health. Parse contends that the client, not the nurse, is the authority figure and decision maker. The nurse’s role involves helping individuals and families in choosing the possibilities for changing the health process. Specifically, the nurse’s role consists of using “true presence” in illumi- nating meaning (uncovering what was and what will be), synchroniz- ing rhythms (leading through discussion to recognize harmony), and mobilizing transcendence (dreaming of possibilities and planning to reach them). The goal of nursing from the humanbecoming perspec- tive is quality of life (Parse, 2010).

CRITIQUE OF NURSING THEORY There are several arguments opposing the use of nursing models. Five discussed by McCrae (2011) are:

1. There is not a single global, commonly accepted definition of nursing and, thus, how can there be a theory of nursing?

2. The existing theories and models are too vague or too complex to clearly guide practice.

3. Because many theories are untested, they cannot be considered to provide evidence-based practice.

4. Interprofessional teamwork and overlapping of health care pro- fessional roles suggest that a theory guiding nursing practice cannot be unique to nursing.

5. Science and the world in general have changed so much that historically fundamental theories or models do not fit with 21st-century nursing practice.

Most things in the world have both positive and negative impli- cations. Theory can be used to broaden our perspectives in nursing and facilitate the altruistic and humanistic values of the profession. At the same time, rational and predictive theory can produce language and social practices that are superimposed onto the lives of vulner- able clients and do violence to the fragility of human dignity. As a lens, theory can either illuminate or obscure. As a tool, theory can either liberate or enslave. Work is still needed—even to reach agree- ment on the meaning of the terminology used in the discussion of theory (Webber, 2010).

Watson’s Human Caring Theory Jean Watson believes the practice of caring is central to nursing; it is the unifying focus for practice. Nursing interventions related to human care originally referred to as carative factors have now been translated into 10 clinical caritas processes (Watson, 2013):

1. Embrace altruistic values and practice loving kindness with self and others.

2. Instill faith and hope and honor others. 3. Be sensitive to self and others by nurturing individual beliefs and

practices. 4. Develop helping–trusting, human caring relationships. 5. Promote and accept positive and negative feelings as you authen-

tically listen to another’s story. 6. Use creative scientific problem-solving methods for caring deci-

sion making. 7. Share teaching and learning that addresses the individual needs

and comprehension styles. 8. Create a healing environment for the physical and spiritual self

which respects human dignity. 9. Assist with basic physical, emotional, and spiritual human needs.

10. Open to mystery and allow miracles to enter.

A survey has been created and tested that measures these processes used by nurses in caring for clients (DiNapoli, Nelson, Turkel, & Watson, 2010).

Parse’s Humanbecoming Theory Parse (2010) proposes three assumptions about humanbecoming:

1. Humanbecoming is freely choosing personal meaning in situ- ations in the intersubjective process of relating value priorities.

2. Humanbecoming is cocreating rhythmic patterns or relating in mutual process with the universe.

3. Humanbecoming is cotranscending multidimensionally with the emerging possibles.

These three assumptions focus on meaning, rhythmicity, and cotranscendence:

• Meaning arises from a person’s interrelationship with the world and refers to happenings to which the person attaches varying degrees of significance.

Preterm infants face unique challenges due to immaturities in many major organ systems. Because neonatal nurses play an essential role in supporting preterm infants and their families through their criti- cal postnatal transition, theoretical frameworks to guide planning and delivery of holistic neonatal nursing care need refinement and testing. The purpose of the study by Mefford and Alligood (2011) was to per- form an exploratory test of a middle range theory of health promotion for preterm infants based on Levine’s conservation model of nursing.

More than 130 babies who met the criteria were included in the study. Analysis of the data supported the applicability of the theory to this population, which, in turn, supports the assumption that the role of the nurse is essential in facilitating infant survival. One of the

most central findings indicated that consistency of the nurse was an essential component in infant improvement.

IMPLICATIONS Mathematical models such as those used in the analysis of the data in this study can be useful in determining the interrelationships between the variables of preterm infant characteristics, nursing roles and ac- tions, and infant health outcomes. The study demonstrates the value of nursing, which may have previously only been known intuitively to nurses and their clients. Using a theoretical model or framework such as that of Levine’s conservation model of nursing anchors the study and the knowledge it provides in a broader context.

Evidence-Based Practice How Well Does a Levine-Based Theory Apply to the Care of Preterm Infants? EVIDENCE-BASED PRACTICE

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Critical Thinking Checkpoint

Tony is a 32-year-old man with HIV. His first AIDS-defining illness caused his weight to drop from 175 to 116 pounds due to intrac- table diarrhea. The physician thought caloric intake was of primary importance and urged Tony to eat whatever he wanted. The physi- cian also prescribed tincture of opium for the diarrhea, but Tony hated the tincture of opium because it made him feel out of con- trol. Because Tony was getting worse, his nurse argued that he needed intravenous nutrition and should eat only bananas, rice, applesauce, and weak tea until the diarrhea stopped. The nurse suggested adding other foods one at a time and only as toler- ated. Tony’s family and friends offered to take control of Tony’s food preparation.

The physician compared AIDS to advanced cancer and argued he would not prescribe intravenous nutrition for advanced cancer.

The nurse argued that this was Tony’s first AIDS infection and that his prognosis was better than someone with advanced cancer. The nurse’s primary focus was on stopping the diarrhea, and supplement- ing nutrition with IVs. Tony’s friends preferred the nurse’s approach, but Tony was not as easily convinced. 1. What concepts are present in this case? 2. What appear to be the perspectives or views represented by the

physician and the nurse (how might you say they are defining the metaparadigm)?

3. How might Florence Nightingale analyze this situation? 4. Which of the nursing models in this chapter best supports the

nurse’s plan of care? See Critical Thinking Possibilities on student resource website.

• In the natural sciences, the main function of theory is to guide re- search. In the practice disciplines, the main function of theory (and research) is to provide new possibilities for understanding the dis- cipline’s focus (music, art, management, nursing).

• To Florence Nightingale, the knowledge required to provide good nursing was neither unique nor specialized. Rather, Nightingale viewed nursing as a central human activity grounded in observa- tion, reason, and commonsense health practices.

• During the latter half of the 20th century, disciplines seeking to establish themselves in universities had to demonstrate something that Nightingale had not envisioned for nursing—a unique body of theoretical knowledge.

• Theories articulate significant relationships between concepts in order to point to something larger, such as gravity, the uncon- scious, or the experience of pain.

• Paradigms include our notions of reality that are largely uncon- scious or taken for granted. Most theories reflect the dominant

paradigm of a culture, although some may grow out of a develop- ing rival paradigm.

• In the late 20th century, much of the theoretical work in nursing focused on articulating relationships between four major concepts: person, environment, health, and nursing. Because these four concepts can be superimposed on almost any work in nursing, they are sometimes collectively referred to as a metaparadigm for nursing.

• Nursing theories vary considerably in their (a) level of abstraction; (b) conceptualization of the client, health/illness, environment, and nursing; and (c) ability to describe, explain, or predict phenomena. Some theories are broad in scope; others are limited.

• Debates about the role of theory in nursing practice provide evi- dence that nursing is maturing, as both an academic discipline and a clinical profession.

CHAPTER HIGHLIGHTS

1. “A supposition or system of ideas that is proposed to explain a given phenomenon” best defines which of the following? 1. A concept 2. A conceptual framework 3. A theory 4. A paradigm

2. “A group of related ideas or statements” best defines which of the following? 1. A philosophy 2. A conceptual framework 3. A theory 4. A paradigm

3. “A set of shared understandings and assumptions about reality and the world” is a definition for which of the following? 1. A concept 2. A conceptual framework 3. A practice discipline 4. A paradigm

4. Which provides the best explanation for describing nursing as a practice discipline? 1. Nursing focuses on performing the professional role. 2. It takes time and experience to become a competent nurse. 3. Research and theory development is a central focus. 4. Nurses function as members of a team who form a practice

group.

TEST YOUR KNOWLEDGE

Chapter 3 Review

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7. The purpose of theory in science is to 1. Build a rationale for programs of research. 2. Explain why scientists do what they do. 3. Help scientists interpret phenomena. 4. Distinguish science from art.

See Answers to Test Your Knowledge in Appendix A.

5. Person, environment, health, and nursing constitute the metaparadigm for nursing because they do which of the following? 1. Provide a framework for implementing the nursing process. 2. Can be utilized in any setting when caring for a client. 3. Can be utilized to determine applicability of a research study. 4. Focus on the needs of a group of clients.

6. Which is an accurate statement about the role of nursing theory? 1. Practice theories assist nurses to reflect on the effectiveness

of what they do. 2. Midlevel theories, describing the interrelationships among

a broad range of concepts within nursing, have been well tested through nursing research.

3. All schools of nursing in the United States are organized around one of the conceptual models described in this chapter.

4. Nursing theory guides the direction of research but not that of education or practice.

Suggested Reading Burdette, L. (2012). Relationship between self-care agency,

self-care practices and obesity among rural midlife women. Self-Care, Dependent Care & Nursing, 19(1), 5–14. This article provides an example of applying the Orem self- care deficit theory to 224 overweight women in rural South Dakota. Facilitators, barriers, and practices were identified.

Related Research Alligood, M. (2011). Theory-based practice in a major medical

centre. Journal of Nursing Management, 19(8), 981–988. doi:10.1111/j.1365-2834.2011.01327.x

Häggström, M., Asplund, K., & Kristiansen, L. (2012). How can nurses facilitate patient’s transitions from intensive care?: A grounded theory of nursing. Intensive & Critical Care Nursing, 28(4), 224–233. doi:10.1016/J.ICCN.2012.01.002

References Alligood, M. R., & Tomey, A. M. (2010). Nursing theorists and

their work (7th ed.). St. Louis, MO: Mosby. American Nurses Credentialing Center. (2011). Magnet model

components and sources of evidence (2nd ed.). Silver Spring, MD: Author.

Andrade, M., George, A., & Roach, E. J. (2013). Perceptions of health care consumers, deliverers and nurse educa- tors on nursing practice. Nitte University Journal of Health Science, 3(1), 11–16.

Beckman, S. J., Boxley-Harges, S. L., & Kaskel, B. L. (2012). Experience informs: Spanning three decades with the Neuman systems model. Nursing Science Quarterly, 25, 341–346. doi:10.1177/0894318412457053

Bond, A. E., Eshah, N. F., Bani-Khaled, M., Hamad, A. O., Habashneh, S., Kataua, H., . . . Maabreh, R. (2011). Who uses nursing theory? A univariate descriptive analysis of five years of research articles. Scandi- navian Journal of Caring Science, 25, 404–409. doi:10.1111/j.1471-6712.2010.00835.x

DiNapoli, P. P., Nelson, J., Turkel, M., & Watson, J. (2010). Measuring the caritas processes: Caring factor survey. International Journal for Human Caring, 14(3), 16–21.

Draucker, C. B., Cook, C. B., Martsolf, D. S., & Stephenson, P. S. (2012). Adolescent dating violence and Peplau’s dimensions of the self. Journal of the American Psychiatric Nurses Association, 18, 175–188. doi:10.1177/1078390312442743

Green, R. (2012). Application of the self care deficit nursing theory to the care of children with special health care

needs in the school setting. Self-Care & Dependent-Care & Nursing, 19(1), 35–40.

Henderson, V. A. (1966). The nature of nursing: A definition and its implications for practice, research, and education. Riverside, NJ: Macmillan.

Im, E.-O., & Chang, S. J. (2012). Current trends in nursing theories. Journal of Nursing Scholarship, 44, 156–164. doi:10.1111/j.1547-5069.2012.01440.x

King, I. M. (1981). A theory for nursing: Systems, concepts, process. Albany, NY: Delmar.

Leininger, M. M. (Ed.). (1991). Culture care diversity and univer- sality: A theory of nursing. New York, NY: National League for Nursing Press.

Leininger, M., & McFarland, M. R. (2010). Madeleine Leininger’s theory of culture care diversity and universality. In M. E. Parker & M. C. Smith (Eds.), Nursing theories & nursing practice (3rd ed., pp. 317–336). Philadelphia, PA: F.A. Davis.

McCrae, N. (2011). Whither nursing models? The value of nurs- ing theory in the context of evidence-based practice and multidisciplinary health care. Journal of Advanced Nursing, 68(1), 222–229. doi:10.1111/j.1365-2648.2011.05821.x

Mefford, L. C., & Alligood, M. (2011). Testing a theory of health promotion for preterm infants based on Levine’s conserva- tion model of nursing. Journal of Theory Construction and Testing, 15(2), 41–47.

Neuman, B., & Fawcett, J. (2002). The Neuman systems model (4th ed.). Upper Saddle River, NJ: Prentice Hall.

Nightingale, F. (1969). Notes on nursing: What it is, and what it is not. New York, NY: Dover. (Original work published 1860)

Orem, D. E. (1971). Nursing: Concepts of practice. Hightstown, NJ: McGraw-Hill.

Parse, R. R. (2010). Rosemarie Rizzo Parse’s humanbecoming school of thought. In M. E. Parker & M. C. Smith (Eds.), Nursing theories and nursing practice (3rd ed., pp. 277–289). Philadelphia, PA: F.A. Davis.

Peplau, H. E. (1952). Interpersonal relations in nursing. New York, NY: Putnam.

Peterson, S. J., & Bredow, T. S. (2013). Middle range theories (3rd ed.). Philadelphia, PA: Wolters Kluwer Health/ Lippincott Williams & Wilkins.

Rogers, M. E. (1970). An introduction to the theoretical basis of nursing. Philadelphia, PA: F.A. Davis.

Roy, C. (2009). The Roy adaptation model (3rd ed.). Upper Saddle River, NJ: Prentice Hall.

Sürücü, H., & Kizilci, S. (2012). Use of Orem’s self- care deficit nursing theory in the self-management

education of patients with type 2: A case study. Self-Care & Dependent-Care Nursing, 19(1), 53–59.

Tourville, C., & Ingalls, K. (2003). The living tree of nurs- ing theories. Nursing Forum, 38(3), 21–30, 36. doi:10.1111/j.0029-6473.2003.t01-1-00021.x

Watson, J. (2013). Ten caritas processes. Retrieved from http://watsoncaringscience.org/about-us/ caring-science-definitions-processes-theory/#

Webber, P. (2010). Language consistency: A missing link in the- ory, research, and reasoning? Journal of Advanced Nursing, 66, 218–227. doi:10.1111/j.1365-2648.2009.05176.x

Selected Bibliography Chinn, P. L., & Kramer, M. K. (2010). Integrated theory and

knowledge development in nursing (8th ed.). St. Louis, MO: Mosby Elsevier.

Fawcett, J., & DeSanto-Madeya, S. (2012). Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories (3rd ed.). Philadelphia, PA: F.A. Davis.

George, J. B. (Ed.). (2011). Nursing theories: The base for professional nursing practice (6th ed.). Upper Saddle River, NJ: Pearson.

Hanna, D. R. (2013). Roy’s specific life values and the philosophical assumption of humanism. Nursing Science Quarterly, 26, 53–58. doi:10.1177/0894318412467070

Henderson, V. A. (1991). The nature of nursing: Reflections after 25 years. New York, NY: National League for Nursing Press.

Malinski, V. (2010). Celebrating nursing theory. Nursing Sci- ence Quarterly, 23, 5–6. doi:10.1177/0894318409353798

Meleis, A. I. (2011). Theoretical nursing: Development and progress (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Orem, D. E., Taylor, S. G., & Renpenning, K. M. (2001). Nursing: Concepts of practice (6th ed.). St. Louis, MO: Mosby.

Riegel, B., Jaarsma, T., & Strömberg, A. (2012). A middle- range theory of self-care of chronic illness. Advances in Nursing Science, 35, 194 –204.

Rogers, M. E. (1994). The science of unitary human beings: Current perspectives. Nursing Science Quarterly, 7, 33–35. doi:10.1177/089431849400700111

Watson, J. (2008). Nursing: The philosophy and science of caring. Norman, OK: University of Oklahoma Press.

READINGS AND REFERENCES

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LEARNING OUTCOMES

After completing this chapter, you will be able to: 1. List sources of law and types of laws. 2. Describe ways nurse practice acts, credentialing, standards

of care, and agency policies and procedures affect the scope of nursing practice.

3. Compare and contrast the state-based licensure model and the mutual recognition model for multistate licensure.

4. Describe the purpose and essential elements of informed consent.

5. Describe the purpose of the Americans with Disabilities Act. 6. Discuss the impaired nurse and available diversion or peer

assistance programs. 7. Recognize the nurse’s legal responsibilities with selected

aspects of nursing practice.

INTRODUCTION Nursing practice is governed by many legal concepts. It is important for nurses to know the basics of legal concepts, because nurses are ac- countable for their professional judgments and actions. Accountabil- ity is an essential concept of professional nursing practice and the law. Knowledge of laws that regulate and affect nursing practice is needed for two reasons:

1. To ensure that the nurse’s decisions and actions are consistent with current legal principles.

2. To protect the nurse from liability.

GENERAL LEGAL CONCEPTS Law can be defined as “the sum total of rules and regulations by which a society is governed. As such, law is created by people and exists to regulate all persons” (Guido, 2014, p. 2).

Functions of the Law in Nursing The law serves a number of functions in nursing:

• It provides a framework for establishing which nursing actions in the care of clients are legal.

KEY TERMS

advance health care directives, 59

answer, 49 assault, 64 autopsy, 59 battery, 64 breach of duty, 62 burden of proof, 49 causation, 62 civil actions, 48 civil law, 48 common law, 48 complaint, 49 contract, 52 contract law, 48 contractual obligations, 52 contractual relationships, 52 coroner, 61 credentialing, 49 crime, 62

criminal actions, 48 criminal law, 48 damages, 62 decision, 49 defamation, 65 defendants, 49 delegation, 56 discovery, 49 do not resuscitate (DNR), 59 duty, 62 euthanasia, 61 expert witness, 49 express consent, 54 false imprisonment, 64 felony, 62 foreseeability, 62 gross negligence, 62 harm, 62 health care proxy, 59 impaired nurse, 57

implied consent, 54 implied contract, 52 informed consent, 53 injury, 62 inquest, 61 interstate compact, 51 invasion of privacy, 64 law, 47 liability, 52 libel, 65 license, 49 litigation, 49 living will, 59 malpractice, 62 mandated reporters, 57 manslaughter, 62 medical examiner, 61 misdemeanor, 62 mutual recognition model, 51 negligence, 62

plaintiff, 49 postmortem examination, 59 private law, 48 public law, 48 res ipsa loquitur, 62 respondeat superior, 52 responsibility, 53 right, 53 slander, 65 standards of care, 51 statutory laws, 48 strike, 53 tort, 62 tort law, 48 trial, 49 unprofessional conduct, 67 verdict, 49

4 Legal Aspects of Nursing

8. Discriminate between negligence and professional negligence/ malpractice.

9. Delineate the elements of professional negligence. 10. Compare and contrast intentional torts (assault/battery, false

imprisonment, invasion of privacy, defamation) and uninten- tional torts (professional negligence).

11. Describe the four specific areas of the Health Insurance Por- tability and Accountability Act and their impact on nursing practice.

12. Describe the laws and strategies that protect the nurse from litigation.

13. Discuss the legal responsibilities of nursing students.

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• It differentiates the nurse’s responsibilities from those of other health professionals.

• It helps establish the boundaries of independent nursing action. • It assists in maintaining a standard of nursing practice by making

nurses accountable under the law.

Sources of Law The legal system in the United States has its origin in the English common law system. Figure 4–1 • provides an overview of the pri- mary sources of law (i.e., how laws are created): constitutions, statutes, administrative agencies, and decisions of courts (common law).

CONSTITUTIONAL LAW The Constitution of the United States is the supreme law of the coun- try. It establishes the general organization of the federal government, grants certain powers to the government, and places limits on what federal and state governments may do. A constitution creates legal rights and responsibilities and is the foundation for a system of jus- tice. For example, the U.S. Constitution ensures each U.S. citizen the right to due process of law.

LEGISLATION (STATUTORY LAW) Laws enacted by any legislative body are called statutory laws. When federal and state laws conflict, federal law supersedes. Like- wise, state laws supersede local laws.

The regulation of nursing is a function of state law. State legisla- tures pass statutes that define and regulate nursing, that is, nurse prac- tice acts. These acts, however, must be consistent with constitutional and federal provisions.

CLINICAL ALERT!

It is important for nurses to keep their legislators informed about nurs- ing because it is the legislature that passes laws that affect nursing practice.

ADMINISTRATIVE LAW When a state legislature passes a statute, an administrative agency is given the authority to create rules and regulations to enforce the statutory laws. For example, state boards of nursing write rules and regulations to implement and enforce a nurse practice act, which was created through statutory law.

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Figure 4–1 • Overview of sources of law.

Administrative Law

Legislation (Statutes)

Nurse Practice Acts

Constitution Common Law

Sources of Law

COMMON LAW Laws evolving from court decisions are referred to as common law. In addition to interpreting and applying constitutional or statutory law, courts also are asked to resolve disputes between two parties. Common law is continually being adapted and expanded. In decid- ing specific controversies, courts generally adhere to the doctrine of stare decisis— “to stand by things decided”—usually referred to as “ following precedent.” In other words, to arrive at a ruling in a par- ticular case, the court applies the same rules and principles applied in previous, similar cases.

Types of Laws Laws can be further classified into different types. The two main types are public law and private or civil law.

Public law refers to the body of law that deals with relation- ships between individuals and the government and governmen- tal agencies. An important segment of public law is criminal law, which deals with actions against the safety and welfare of the pub- lic. Examples are homicide, manslaughter, and theft. Crimes can be classified as either felonies or misdemeanors, which are described in more detail later in this chapter.

Private law, or civil law, is the body of law that deals with relationships among private individuals. It can be categorized into a variety of legal specialties such as contract law and tort law. Contract law involves the enforcement of agreements among private individu- als or the payment of compensation for failure to fulfill agreements. Tort law defines and enforces duties and rights among private indi- viduals that are not based on contractual agreements. Some examples of tort laws applicable to nurses are professional negligence, invasion of privacy, and assault and battery, which are discussed in more de- tail later in this chapter. See Table 4–1 for selected categories of law affecting nurses.

Kinds of Legal Actions There are two kinds of legal actions: civil or private actions and crimi- nal actions. Civil actions deal with the relationships among indi- viduals in society; for example, a man may file a suit against a person who he believes cheated him. Civil actions that are of concern to nurses include the torts and contracts listed in Table 4–1. Criminal actions deal with disputes between an individual and society as a whole; for example, if a man shoots a person, society brings him to

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called the burden of proof. See Figure 4–2 • for a diagram of the judicial process.

Nurses as Witnesses A nurse may be called to testify in a legal action. It is advisable that any nurse who is asked to testify in such a situation seek the advice of an attorney before providing testimony. In most cases, the attorney for the nurse’s employer will provide support and counsel during the legal case. If the nurse is the defendant, however, the nurse should retain his or her own attorney to protect the nurse’s interests.

A nurse may also be asked to provide testimony as an expert witness. An expert witness has special training, experience, or skill in a relevant area and is allowed by the court to offer an opinion on some issue within his or her area of expertise. The nurse’s creden- tials and expertise help a judge or jury understand the appropriate standard of care. The nurse expert, thus, has the ability to analyze the facts or evidence and draw inferences. For example, the nurse expert may offer an opinion on whether or not a particular standard of care was met.

REGULATION OF NURSING PRACTICE Protection of the public is the legal purpose for defining the scope of nursing practice, licensing requirements, and standards of care. Nurses who know and follow their nurse practice act and standards of care provide safe, competent nursing care.

Nurse Practice Acts Each state has a nurse practice act, which protects the public by le- gally defining and describing the scope of nursing practice. State nurse practice acts also legally control nursing practice through licensing requirements. For advanced nursing practice, many states require a different license or have an additional clause that pertains to ac- tions that may be performed only by nurses with advanced educa- tion. For example, an additional license may be required to practice as a nurse midwife, nurse anesthetist, or nurse practitioner. The advanced practice nurse also requires a license to prescribe medi- cation or order treatments from physical therapists or other health professionals.

Nurse practice acts, although similar, do differ from state to state. For example, they may differ in their scope of practice definition and in licensing and license renewal requirements. It is the nurse’s respon- sibility to know the nurse practice act of the state in which he or she practices nursing. A state’s nurse practice act is easily accessed at the specific state board of nursing’s website.

Credentialing Credentialing is the process of determining and maintaining com- petence in nursing practice. The credentialing process is one way in which the nursing profession maintains standards of practice and ac- countability for the educational preparation of its members. Creden- tialing includes licensure, certification, and accreditation.

LICENSURE A license is a legal permit that a government agency grants to indi- viduals to engage in the practice of a profession and to use a particular title. Nursing licensure is mandatory in all states. For a profession or

trial. The major difference between civil and criminal law is the po- tential outcome for the defendant. If found guilty in a civil action, such as professional negligence, the defendant will have to pay a sum of money. If found guilty in a criminal action, the defendant may lose money, be jailed, or be executed and, if a nurse, could lose his or her license. The action of a lawsuit is called litigation, and lawyers who participate in lawsuits may be referred to as litigators.

The Civil Judicial Process The judicial process primarily functions to settle disputes peacefully and in accordance with the law. A lawsuit has strict procedural rules. There are generally five steps:

1. A document, called a complaint, is filed by a person referred to as the plaintiff, who claims that his or her legal rights have been infringed on by one or more other persons or entities, referred to as defendants.

2. A written response, called an answer, is made by the defendants. 3. Both parties engage in pretrial activities, referred to as discovery,

in an effort to obtain all the facts of the situation. 4. In the trial of the case, all relevant facts are presented to a judge

or to a jury. 5. The judge renders a decision, or the jury renders a verdict. If

the outcome is not acceptable to one of the parties, an appeal can be made for another trial.

During a trial, a plaintiff must offer evidence of the defendant’s wrongdoing. This duty to prove an assertion of wrongdoing is

Category Examples

Constitutional Due process Equal protection

Statutory (legislative) Nurse practice acts Good Samaritan acts Child and adult abuse laws Living wills Sexual harassment laws Americans with Disabilities Act

Criminal (public) Homicide, manslaughter Theft Arson Active euthanasia Sexual assault Illegal possession of controlled drugs

Contracts (private/civil) Nurse and client Nurse and employer Nurse and insurance Client and agency

Torts (private/civil) Professional negligence/malpractice Libel and slander Invasion of privacy Assault and battery False imprisonment Abandonment

Selected Categories of Laws Affecting NursesTABLE 4–1

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Figure 4–2 • Anatomy of a lawsuit. Adapted from Legal and Ethical Issues in Nursing, 6th ed. (pp. 15–29), by G. W. Guido, 2014, Upper Saddle River, NJ: Pearson Education, Inc.

Anatomy of a Lawsuit

Initiation and Pleadings [written statements of facts as perceived by both parties]

Discovery of Evidence [Each side gathers information about the other]

complaint filed by plaintiff

served on defendant

answer or response filed by defendant

health care provider contacts employer and/or insurance provider

Methods of pretrial questioning

May result in a settlement. This is not considered an admission

of liability but allows party to settle upon a dollar figure and

not have to go to trial.

Trial

Interrogatories – questions served on opposing parties,

requiring written responses

Depositions – Oral questions are asked of witnesses, under oath, by attorney from opposing side. Information is recorded by court reporter and admissible as evidence.

Request to produce documents – Each side can request and receive

documents (e.g., medical record, x-ray films, consultation reports).

Jury selection

Opening statements as to what each side intends to show by the evidence

Plaintiffs case presented with cross-examination by defendant

Defendant’s case presented with cross-examination by plaintiff

Closing statements

Jury deliberates to reach a verdict

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occupation to obtain the right to license its members, three criteria must generally be met:

1. There is a need to protect the public’s safety or welfare. 2. The occupation is clearly delineated as a separate, distinct area

of work. 3. A proper authority has been established to assume the obliga-

tions of the licensing process, for example, in nursing, state boards of nursing.

The government agency issuing the RN license views the hold- ing of that license to be a privilege, not a right. Nurse attorney Brous (2012) states that “nurses don’t have the right to practice nursing or to hold themselves out as nurses unless their nursing licenses are in good standing” (p. 59). Each state has a mechanism by which licenses can be revoked for just cause (e.g., incompetent nursing practice, pro- fessional misconduct, or conviction of a crime such as using illegal drugs or selling drugs illegally). In each situation, a committee at a hearing reviews all the facts. Nurses are entitled to be represented by legal counsel at such a hearing. If a nurse’s license is revoked as a result of the hearing, either the nurse can appeal the decision to a court of law or, in some states, an agency is designated to review the decision before any court action is initiated.

MUTUAL RECOGNITION MODEL Historically, licensure for nurses has been state based; that is, the state’s board of nursing has licensed all nurses practicing in the state. Changes, however, in health care delivery and telecommunication technology advances (e.g., telehealth) have raised questions about the state-based model. Telehealth is the “use of medical information exchanged from one site to another via electronic communications to improve the patient’s health status” (Institute of Medicine, 2012, p. 134). Thus, according to the state-based model, a nurse who electronically interacts with a client in another state to provide health information or intervention is practicing across state lines without a license in the other state.

In response, the National Council of State Boards of Nursing (NCSBN) developed a new regulatory model named the mutual recognition model, which allows for multistate licensure. With mutual recognition, a nurse who is not under any disciplinary action can practice in person or electronically across state lines under one license. For example, a nurse who lives on the border of a state can practice in both states under one license if the adjoining states have an interstate compact. A nurse who practices nursing in a state other than his or her primary state of residence must still contact the other state’s board of nursing and provide proof of licensure.

An interstate compact called the Nurse Licensure Compact (NLC) (an agreement between two or more states) is the mechanism used to create mutual recognition among states. Each state’s legislature initiates and decides on the establishment of an interstate compact or NLC. As of 2014, 24 states had implemented the Nurse Licensure Compact for RNs and LVN/LPNs (National Licensure Compact Administrators [NLCA], 2010, 2011; NCSBN, 2014b). Only those states who have adopted the RN and LPN/LVN Nurse Licensure Compact may implement a compact for advanced practice registered nurses (APRNs). Utah, Iowa, and Texas have passed laws authorizing APRN compacts. Since 2010, these states have been discussing the implementation of the APRN compact and the anticipated date of implementation is 2016 (NLCA, 2010, 2012). The NCSBN website

provides current information about the number of states that have passed NLC legislation. See Box 4–1 for additional information about the mutual recognition model.

CERTIFICATION Certification is the voluntary practice of validating that an individual nurse has met minimum standards of nursing competence in spe- cialty areas such as maternal–child health, pediatrics, mental health, gerontology, and school nursing. National certification may be re- quired to become licensed as an advanced practice nurse. Certifica- tion programs are conducted by the American Nurses Association (ANA) and by specialty nursing organizations.

ACCREDITATION/APPROVAL OF BASIC NURSING EDUCATION PROGRAMS One of the functions of a state board of nursing is to ensure that schools preparing nurses maintain minimum standards of education. Depending on the state, a state board of nursing must either approve or accredit a nursing program. This is a legal requirement.

Nursing programs can also choose to seek voluntary accredi- tation from a private organization such as the Accreditation Com- mission for Education in Nursing (ACEN) and the Commission on Collegiate Nursing Education (CCNE). Maintaining voluntary accreditation is a means of informing the public and prospective stu- dents that the nursing program has met certain criteria.

All states require approval/accreditation by the state board of nursing. Some states require that nursing programs be both state approved/accredited and accredited by a national accrediting agency such as ACEN or CCNE.

Standards of Care The purpose of standards of care is to protect the public. Standards of care are the skills and learning commonly possessed by members

BOX 4–1 Mutual Recognition Model

• Each state has to enter into an interstate compact, called the Nurse Licensure Compact (NLC), that allows nurses to practice in more than one state.

• Multistate licensure privilege means the authority to practice nursing in another state that has signed an interstate compact. It is not an additional license.

• A nurse must have a license in his or her primary state of legal residency, if it is an NLC state.

• The states continue to have authority in determining licensure requirements and disciplinary actions.

• The nurse is held accountable for knowing and practicing the nursing practice laws and regulations in the state where the client is located at the time of care.

• Enactment does not change a state’s nurse practice act. • Complaints and/or violations would be addressed by the

home state (place of residence) and the remote (practice) state.

• RNs and LPNs/LVNs are included in the interstate compact or NLC. There is now a separate APRN compact. A state must be a member of the NLC for RNs and LPNs before entering into the APRN compact. A state must adopt both compacts to cover LPNs/RNs and APRNs for mutual recognition.

From “Nurse Licensure Compact Frequently Asked Questions” by National Council State Boards of Nursing, 2014a. Retrieved from https://www.ncsbn.org/2002.htm.

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of a profession (Guido, 2014). These standards are used to evaluate the quality of care nurses provide and, therefore, become legal guide- lines for nursing practice.

Nursing standards of care can be classified into two categories: internal and external standards. Internal standards of care include “the nurse’s job description, education, and expertise as well as indi- vidual institutional policies and procedures” (Guido, 2014, p. 55).

External standards consist of the following:

• Nurse practice acts • Professional organizations (e.g., ANA) • Nursing specialty-practice organizations (e.g., Emergency Nurses

Association, Oncology Nursing Society) • Federal organizations and federal guidelines (e.g., The Joint

Commission and Medicare).

It is important, therefore, for nurses to know their institution’s poli- cies and procedures and nurse practice act. They also need to remain competent through reading professional journals and attending con- tinuing education and in-service programs. Again, the purpose of knowing and practicing nursing’s standards of care is to protect the client/consumer.

CONTRACTUAL ARRANGEMENTS IN NURSING A contract is the basis of the relationship between a nurse and an employer—for example, a nurse and a hospital or a nurse and a pri- mary care provider. A contract is an agreement between two or more competent persons, on sufficient consideration (remunera- tion), to do or not to do some lawful act. A contract may be written or oral. An oral contract is as equally binding as a written contract. The terms of the oral contract, however, may be more difficult to prove in a court of law. A written contract cannot be changed le- gally by an oral agreement. If two people wish to change some aspect of a written contract, the change must be written into the contract, because one party cannot hold the other to an oral agreement that differs from the written one.

A contract is considered to be expressed when the two parties discuss and agree, orally or in writing, to terms and conditions dur- ing the creation of the contract. For example, a nurse will work at a hospital for a stated length of time and under stated conditions. An implied contract is one that has not been explicitly agreed to by the parties but that the law nevertheless considers to exist. For ex- ample, the nurse is expected to be competent and to follow hospital policies and procedures even though these expectations were not written or discussed. Likewise, the hospital is expected to provide the necessary supplies and equipment needed to provide competent nursing care.

A lawful contract requires the following four features (Guido, 2014):

1. Promise or agreement between two or more persons for the per- formance of an action or restraint from certain actions

2. Mutual understanding of the terms and meaning of the contract by all

3. A lawful purpose (i.e., the activity must be legal) 4. Compensation in the form of something of value—in most

cases, compensation is monetary.

Legal Roles of Nurses Nurses have three separate, interdependent legal roles, each with rights and associated responsibilities: provider of service, employee or contractor for service, and citizen.

PROVIDER OF SERVICE The nurse is expected to provide safe and competent care. Implicit in this role are several legal concepts: liability, standards of care, and contractual obligations.

Liability is the quality or state of being legally responsible for one’s obligations and actions and for making financial restitution for wrongful acts. A nurse, for example, has an obligation to prac- tice and direct the practice of others under the nurse’s supervision so that harm or injury to the client is prevented and standards of care are maintained. Even when a nurse carries out treatments ordered by the primary care provider, the responsibility for the nursing activity belongs to the nurse. When a nurse is asked to carry out an activity that the nurse believes will be injurious to the client, the nurse’s re- sponsibility is to refuse to carry out the order and report this to the nurse’s supervisor.

The standards of care by which a nurse acts or fails to act are legally defined by nurse practice acts and by the rule of reasonable and prudent action—what a reasonable and prudent professional with similar preparation and experience would do in similar cir- cumstances. Contractual obligations refer to the nurse’s duty of care, that is, duty to render care, established by the presence of an expressed or implied contract.

EMPLOYEE OR CONTRACTOR FOR SERVICE A nurse who is employed by an agency works as a representative of the agency, and the nurse’s contract with clients is an implied one. However, a nurse who is employed directly by a client, for example, a private nurse, may have a written contract with that client in which the nurse agrees to provide professional services for a certain fee. A nurse might be prevented from carrying out the terms of the contract because of illness or death. However, personal inconvenience and personal problems, such as the nurse’s car failure, are not legitimate reasons for failing to fulfill a contract.

Contractual relationships vary among practice settings. An independent nurse practitioner is a contractor for service whose con- tractual relationship with the client is an independent one. The nurse employed by a hospital functions within an employer–employee re- lationship in which the nurse represents and acts for the hospital and therefore must function within the policies of the employing agency. This type of legal relationship creates the ancient legal doctrine known as respondeat superior (“let the master answer”). In other words, the master (employer) assumes responsibility for the conduct of the servant (employee) and can also be held responsible for pro- fessional negligence by the employee. By virtue of the employee role, therefore, the nurse’s conduct is the hospital’s responsibility.

This doctrine does not imply that the nurse cannot be held liable as an individual. Nor does it imply that the doctrine will prevail if the employee’s actions are extraordinarily inappropriate, that is, beyond those expected or foreseen by the employer. For example, if the nurse hits a client, the employer could disclaim responsibility because this behavior is beyond the bounds of expected behavior. Criminal acts, such as assisting with criminal abortions or taking tranquilizers from

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of employment, including work hours, working environment, and fringe benefits of employment (e.g., vacation time, sick leave, and personal leave). Through a written agreement, both management and employees legally commit themselves to observe the terms and conditions of employment.

The collective bargaining process involves the recognition of a certified bargaining agent for the employees. This agent can be a union, a trade association, or a professional organization. The agent represents the employees in negotiating a contract with management. The ANA, through its state constituent associations (e.g., MSNA— Michigan State Nurses Association), has represented the interests of nurses within individual states.

When collective bargaining breaks down because an agreement cannot be reached, the employees usually call a strike. A strike is an organized work stoppage by a group of employees to express a griev- ance, enforce a demand for changes in conditions of employment, or solve a dispute with management.

Because nursing practice is a service to people who are often ill or vulnerable, striking presents a moral dilemma to many nurses. Actions taken by nurses can affect the safety of people. When faced with a strike, each nurse must make an individual decision to cross or not to cross a picket line. Nursing students may also be faced with decisions about crossing picket lines in the event of a strike at a clini- cal agency used for learning experiences. The ANA supports striking as a means of achieving economic and general welfare.

SELECTED LEGAL ASPECTS OF NURSING PRACTICE Nurses need to know and apply legal aspects in their many different roles. For example, as client advocates, nurses ensure the client’s right to informed consent or refusal, and they identify and report violent behavior and neglect of vulnerable clients. Legal aspects also include the duty to report the nurse suspected of chemical impairment.

Informed Consent Informed consent is an agreement by a client to accept a course of treatment or a procedure after being provided complete informa- tion, including the benefits and risks of treatment, alternatives to

a client’s supply for personal use, would also be considered extraordi- narily inappropriate behavior. Nurses can be held liable for failure to act as well. For example, a nurse who sees another nurse consistently performing in an incompetent manner and fails to do anything to protect the client may be considered negligent.

The nurse in the role of employee or contractor for service has obligations to the employer, the client, and other personnel. The nurs- ing care provided must be within the limitations and terms specified. The nurse has an obligation to contract only for those responsibilities that the nurse is competent to discharge. For example, the nurse must practice according to the state’s nurse practice act and the policies and procedures of the facility or organization.

The nurse is expected to respect the rights and responsibilities of other health care participants. For example, although the nurse has a responsibility to explain nursing activities to a client, the nurse does not have the right to comment on medical practice in a way that dis- turbs the client or denounces the primary care provider. At the same time, the nurse has the right to expect reasonable and prudent con- duct from other health professionals.

CITIZEN The rights and responsibilities of the nurse in the role of citizen are the same as those of any individual under the legal system. Rights of citi- zenship protect clients from harm and ensure consideration for their personal property rights, rights to privacy, confidentiality, and other rights discussed later in this chapter. These same rights apply to nurses.

Nurses move in and out of these roles when carrying out profes- sional and personal responsibilities. An understanding of these roles and the rights and responsibilities associated with them promotes legally responsible conduct and practice by nurses. A right is a privi- lege or fundamental power to which an individual is entitled unless it is revoked by law or given up voluntarily; a responsibility is the obligation associated with a right. See Table 4–2 for examples of the responsibilities and rights associated with each role.

Collective Bargaining Collective bargaining is the formalized decision-making process between representatives of management (employer) and repre- sentatives of labor (employee) to negotiate wages and conditions

TABLE 4–2 Legal Roles, Responsibilities, and Rights

Role Responsibilities Rights Provider of service

To provide safe and competent care commensurate with the nurse’s preparation, experience, and circumstances To inform clients of the consequences of various alternatives and outcomes of care To provide adequate supervision and evaluation of others for whom the nurse is responsible To remain competent

Right to adequate and qualified assistance as necessary Right to reasonable and prudent conduct from clients (e.g., provision of accurate information as required)

Employee or contractor for service

To fulfill the obligations of contracted service with the employer To respect the employer To respect the rights and responsibilities of other health care providers

Right to adequate working conditions (e.g., safe equipment and facilities) Right to compensation for services rendered Right to reasonable and prudent conduct by other health care providers

Citizen To protect the rights of the recipients of care Right to respect by others of the nurse’s own rights and responsibilities Right to physical safety

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Cultural perspective also needs to be considered when clients are asked to make decisions about a procedure or treatment. For ex- ample, informed consent in the United States is based on the prin- ciple of autonomy. That is, each person has the right to decide what can or cannot be done to his or her person. The competent adult cli- ent is expected to have the autonomy to make his or her own health care decisions. In contrast to this individual perspective, people from other cultures (e.g., Southeast Asia, Native American) may apply a group perspective to decision making. They may believe that another member of their family or group or tribe should make the decision. The nurse can provide culturally responsive care by asking clients if there is someone they would like to be present when information or discussion of their health care treatment occurs.

It is also important for the client to understand the written mate- rial. Illiteracy in the United States continues to present a challenge as it pertains to recognizing and understanding words commonly used in consent forms. According to Koh et al. (2012), only 12% of U.S. adults are proficient enough to understand and use health informa- tion effectively, and more than 33% of adults have low literacy, which means they do not understand important warnings on the label of an over-the-counter medication. Additionally, 24 million Americans are not proficient in English (p. 435). Technical words and language bar- riers inhibit understanding and may encourage a signature without discussion of its actual meaning when the client has a lower literacy level. A person with low or limited literacy skills is not illiterate. See Box 4–2 for literacy definitions.

CLINICAL ALERT!

Consent forms often consist of language that exceeds the average reading level of clients. As a result, many clients do not read the form before signing it.

There is a link between literacy, health, and client safety. For example, adverse and even potentially life-threatening errors can occur if a client cannot read a pill bottle label or an educational brochure. Communication is critical for client safety and qual- ity nursing care. The increasing diversity of the client population means that nurses are treating individuals with limited English pro- ficiency (LEP) because of language, literacy, and/or cultural barri- ers. Recent federal policy initiatives, including the Affordable Care Act of 2010, the U.S. Department of Health and Human Services’

the treatment, and prognosis if not treated by a health care provider. Richardson (2013) reminds us that the goal of informed consent is “mutual decision making between both professional and patient over the treatment option that the patient wishes to receive or not to re- ceive” (p. 27). However, little research has been conducted to deter- mine if clients realize this purpose of consent. A review of literature by Leclercq, Keulers, Scheltinga, Spauwen, and Van der Will (2010) found that neither health care providers nor clients are well prepared for the informed consent process. Usually the client signs a form pro- vided by the agency. The form is a record of the informed consent, not the informed consent itself.

There are two types of consent: express and implied. Express consent may take the form of either an oral or written agreement. Usually, the more invasive a procedure or the greater the potential for risk to the client, the greater the need for written permission. Implied consent exists when the individual’s nonverbal behavior indicates agreement. For example, clients who position their bodies for an injec- tion or cooperate with the taking of vital signs infer implied consent. Consent is also implied in a medical emergency when an individual cannot provide express consent because of physical condition.

Obtaining informed consent for specific medical and surgical treatments is the responsibility of the person who is going to perform the procedure. Generally this person is the primary care provider; however, it could also be a nurse practitioner, nurse anesthetist, nurse midwife, clinical nurse specialist, or physician assistant who is per- forming procedures in their advanced practices.

Informed consent also applies to nurses who are not indepen- dent practitioners and are performing direct nursing care for such procedures as nasogastric tube insertion or medication administra- tion. The nurse relies on orally expressed consent or implied consent for most nursing interventions. It is imperative to remember the im- portance of communicating with the client by explaining nursing pro- cedures, ensuring the client understands, and obtaining permission.

The law says that a “reasonable amount” of information required for the client to make an informed decision is what any other reason- able health care practitioner would disclose under similar circum- stances. General guidelines include the following:

• The diagnosis or condition that requires treatment • The purposes of the treatment • What the client can expect to feel or experience • The intended benefits of the treatment • Possible risks or negative outcomes of the treatment • Advantages and disadvantages of possible alternatives to the

treatment (including no treatment).

Informed consent has three major elements:

1. The consent must be given voluntarily. 2. The consent must be given by a client or individual with the

capacity and competence to understand. 3. The client or individual must be given enough information to be

the ultimate decision maker.

To give informed consent voluntarily, the client must not feel coerced. Sometimes fear of disapproval by a health professional can be the motivation for giving consent; such consent is not voluntarily given. Coercion invalidates the consent. It is important, therefore, for the person obtaining the consent to invite and answer client questions.

BOX 4–2

• Literacy: an individual’s ability to read, write, and speak in English, and compute and solve problems at levels of proficiency necessary to function on the job and in society, to achieve one’s goals, and develop one’s knowledge and potential

• Low literacy: a limited ability to do what is defined above • Illiteracy: being unable to read or write • Health literacy: the degree to which individuals have the

capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions

From “Plain Language: A Promising Strategy for Clearly Communicating Health Information and Improving Health Literacy,” by U.S. Department of Health and Human Services. Retrieved from http://www.health.gov/communication/literacy/plainlanguage/PlainLanguage .htm#top.

Literacy Definitions

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National Action Plan to Improve Health Literacy, and the Plain Writing Act of 2010 have made health literacy a priority in im- proving health care and health for all Americans (Koh et al., 2012). Health organizations need to address the communication needs of clients who have language and cultural barriers. For example, if a client cannot read, the consent form must be read to the client and the client must state understanding before the form is signed. If the client does not speak the same language as the health professional who is providing the information, an interpreter must be present. However, even with an interpreter, it is important to remember that potential interpretation errors can occur (see the Culturally Responsive Care features).

CLINICAL ALERT!

You cannot tell someone’s literacy level by looking at the person. In addition, some people may read at a lower level than their educational level. Many clients are embarrassed about their reading level and will conceal that they cannot read. Instead, they may say things like “I forgot my glasses,” “The form is too long,” “I want my family to read it first,” or “There are too many medical and legal terms.”

If given sufficient information, a competent adult can make decisions regarding health. A competent adult is a person over 18  years of age who is conscious and oriented. A client who is confused, disoriented, or sedated is not considered functionally

competent. A legal guardian or representative can provide or refuse consent for the incompetent adult.

Informed consent regulations were originally written with acute care settings in mind. Nonetheless, ensuring informed consent is equally important in providing nursing care in the home. Because the provision of home care often occurs over an extended period of time, the nurse has multiple opportunities to ensure that the client agrees to the plan of treatment. A challenge to informed consent in the home, however, is that the plan may affect other members of the family and, if so, they need to be consulted.

EXCEPTIONS Three groups of people cannot provide consent. The first is minors. In most areas, a parent or guardian must give consent before minors can obtain treatment. The same is true of an adult who has the men- tal capacity of a child and who has an appointed guardian. In some states, however, minors are allowed to give consent for such proce- dures as blood donations, treatment for substance abuse, treatment for mental health problems, and treatment for reproductive health concerns such as sexually transmitted infections or pregnancy. In ad- dition, certain groups of minors are often legally permitted to provide their own consent. These include those who are married, pregnant, parents, members of the military, or emancipated (living on their own). These statutes may vary by state.

The second group is individuals who are unconscious or injured in such a way that they are unable to give consent. In these situations, consent is usually obtained from the closest adult relative if existing statutes permit. In a life-threatening emergency, if consent cannot be obtained from the client or a relative, then the law generally agrees that consent is implied to provide necessary care for the client’s emer- gency condition.

The third group is people with mental illnesses who have been judged by professionals to be incompetent. State mental health acts or similar statutes generally provide definitions of mental illness and specify the rights of those who have mental illnesses under the law as well as the rights of the staff caring for such clients.

NURSE’S ROLE Nurses are often asked to obtain a signed consent form. The nurse is not responsible for explaining the procedure but for witnessing the client’s signature on the form (Figure 4–3 •). The nurse’s signature confirms three things:

• The client gave consent voluntarily. • The signature is authentic. • The client appears competent to give consent.

The nurse advocates for the client by verifying that the client received enough information to give consent. Therefore, it is impor- tant for the nurse to assess the client’s understanding and identify any misconceptions. If a client is just asked if she or he understands, most will answer “yes” (Richardson, 2013, p. 28). To prevent this, the nurse can ask clients to explain in their own words what the person who is going to perform the procedure explained to them. If the client has questions or if the nurse has doubts about the client’s understanding, the nurse must notify the health care provider. Again, the nurse is not responsible for explaining the medical or surgical procedure. In fact, the nurse could be liable for giving incorrect or incomplete informa- tion or interfering with the client–provider relationship.

Providing Culturally and Linguistically Appropriate Services

Health institutions have a legal and ethical responsibility to pro- vide language access services to clients who have limited ability to speak, read, write, or understand the English language (limited English proficiency). Appropriate communication between provider and client is essential for ensuring quality and safety in health care. The Office of Minority Health has developed 14 national standards for culturally and linguistically appropriate services (CLAS) orga- nized by three themes: culturally competent care, language access services, and organizational supports for cultural competence. Fol- lowing are the mandated language access services: Standard 4: Health care organizations must offer and provide

language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation.

Standard 5: Health care organizations must provide to patients/ consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services.

Standard 6: Health care organizations must assure the com- petence of language assistance provided to limited English proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer).

Standard 7: Health care organizations must make available easily understood patient-related materials and post signage in the languages of the commonly encountered groups or groups represented in the service area.

From “National Standards on Culturally and Linguistically Appropriate Services (CLAS),” by U.S. Department of Health & Human Services, Office of Minority Health, 2007. Retrieved from http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=15.

PATIENT-CENTERED CARECulturally Responsive Care

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Figure 4–3 • Obtaining informed consent is the responsibility of the individual performing the procedure. The nurse may be asked to witness the client’s signature on the consent form.

The right of consent also involves the right of refusal (Guido, 2014). Remind clients that they can change their minds and cancel the procedure at any time because the right to refuse continues even after signing the consent. Similar to informed consent, it is important to verify that the client is aware of the pros and cons of refusal and is mak- ing an informed decision. The nurse needs to notify the health care provider of the client’s refusal and document the refusal in the chart.

Documentation is an important aspect of informed consent. A cli- ent’s concerns or questions must be documented along with the noti- fication of the health care provider. Equally important is documenting when the client states understanding. Record any teaching as a result of nursing-related questions by the client. Any special circumstances, such as use of an interpreter, should be documented. When document- ing the use of an interpreter, include the interpreter’s full name and title.

Delegation In 2005, the ANA and the NCSBN both defined delegation as “the process for a nurse to direct another person to perform nursing tasks and activities” (NCSBN, n.d.). Competent unlicensed assistive personnel (UAP) can be of assistance to the nurse, which allows the nurse to perform those functions appropriate to the nurse’s scope of practice. From a legal perspective, however, the nurse’s authority to delegate is based on laws and regulations. Therefore, nurses must be familiar with their nurse practice act (NPA).

Nurses must know not only their own scope of practice but also the scope of practice of the UAP, which may vary depending on a facil- ity’s policies and procedures. Thus, the nurse must know the employer’s

Working with a Health Care Interpreter

The interpreter’s primary task is the transformation of a message ex- pressed in a source language into its equivalent in a target language, so that the interpreted message has the potential to elicit the same response in the listener as the original message. This encounter is a highly interactive process in which the nurse uses language that can be understood and provides teaching. The interpreter serves as a cultural broker and engages both the health care provider and the client effectively and efficiently in accessing the nuances and hid- den sociocultural assumptions embedded in each other’s language (International Medical Interpreters Association, 2013). The following are helpful guidelines (Minnesota Department of Health Refugee Health Program, 2010): • Use qualified interpreters. Have access to an experienced

and qualified interpreter who knows his or her role, limitations, and responsibilities. Refrain from using children, relatives, and friends of clients, because they are not qualified for health- related interpretation and may compromise the client’s health outcomes and right to confidentiality.

• Have a brief pre-interview meeting with the interpreter to explain the situation and determine the best place for the interpreter to be seated.

• Plan sufficient time for the interpreted session. Interpretation is time consuming, because every statement must be repeated.

• Talk to the client directly, not the interpreter. • State only what you want interpreted; expect that everything

you utter will be interpreted. • Use words, not gestures, to convey your meaning. This makes

it easier for the interpreter. • Speak in a normal voice, clearly, and not too fast. There is

no need to speak louder, or very slowly; it is easier for the

interpreter to interpret speech at normal speed, with normal rhythms.

• Avoid jargon and technical terms, particularly idiomatic expressions (such as “I’m pulling your leg”) or cultural expres- sions (“for all the tea in China”) that either the interpreter might not understand or may have difficulty translating.

• Keep your sentences short, pausing to permit time for interpre- tation. After a long sentence, or three or four short sentences, you should pause at a natural place. Avoid taxing your inter- preter’s memory, particularly for complex explanations. Do not pause in the middle of the sentence, because the interpreter may need to hear the whole sentence before being able to translate. Remember that grammatical structure of sentences varies across languages.

• Ask only one question at a time. • Expect the interpreter to interrupt when necessary for

clarification. • Expect the interpreter to take notes if things get complicated.

This will help the interpreter remember the concepts during the interpretation.

• Be prepared to repeat yourself in different words if your message is not understood.

• Have a brief post-interview meeting with the interpreter to address any questions or concerns about the process of communication.

• Document in the client’s chart that the client gave consent to use an interpreter, the process used, the client’s verbal and nonverbal responses, the full name and title of the profes- sional medical language interpreter, the translation service, and the names of all those present during the interaction. If a professional interpreter is not available, document if the interpreter is a family member or a nonprofessional.

PATIENT-CENTERED CARE Culturally Responsive Care

SAFETY ALERT!

Ask clients to state in their own words what they have been told about the procedure or treatment.

SAFETY

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criteria for ADA eligibility. The ADA also enables individuals of nor- mal intelligence who have a physical or learning disability to pursue a nursing curriculum through alternative learning methods.

Court cases have challenged the definition of a qualified indi- vidual with a disability. For example, early challenges to the ADA concerned individuals with an HIV infection. A landmark 1998 Su- preme Court decision, Bragdon v. Abbott, ruled that an asymptomatic HIV-positive individual is considered to have a disability and is pro- tected by the ADA (Guido, 2014). In contrast, courts have also held that a variety of conditions do not constitute a disability under ADA. Examples include a lifting disability, depression and anxiety, inability to handle the stress of a specific job, migraine headaches, nonlatex allergies, and pregnancy (Guido, 2014).

It is the employer’s responsibility to provide reasonable accom- modations that would allow the person with a disability to perform the job satisfactorily. The employer, however, can claim undue hardship if the accommodation is extremely expensive or difficult to implement.

Controlled Substances U.S. laws regulate the distribution and use of controlled substances such as narcotics, depressants, stimulants, and hallucinogens. Misuse of con- trolled substances leads to criminal penalties (see Chapter 35 ).

The Impaired Nurse The term impaired nurse refers to a nurse’s inability to perform es- sential job functions because of chemical dependency on drugs or alcohol or mental illness. Darbro and Malliarakis (2012) report that the top four risk factors that make nurses susceptible to substance use disorders in the workplace are access, stress, lack of education, and attitude (p. 45). Nurses administer medications for all purposes (e.g., to relieve pain, prevent infections, decrease anxiety and depression). The ready availability of drugs is an occupational hazard, especially if the administration of controlled substances in the health care agency is poorly managed. Stress can be caused by increased workloads, de- creased staffing, fatigue, and isolation. Substance abuse may be a way of coping with the stress. An overlooked risk factor is the lack of edu- cation on the addictive process and its signs and symptoms. Finally, there are five attitudes that can increase nurses’ chances of having a problem with substance abuse: (1) viewing substance abuse as an acceptable means of coping with problems; (2) developing a faith in drugs as a means of promoting healing; (3) having a sense of entitle- ment that it is important to keep working along with the view that it is okay to use drugs to keep working; (4) feeling invulnerable to the illnesses of their clients (e.g., it won’t happen to them); and (5) hav- ing the attitude that their knowledge about addictive substances serves as a barrier against becoming addicted themselves (Darbro & Malliarakis, 2012, p. 46).

policies and procedures for delegation, the UAP’s job description, and the UAP’s skill level. Is the UAP competent to perform the delegated task? The NCSBN has provided “five rights of delegation” to help nurses make delegation decisions (see Chapter 28 ). It is important to remember that the nurse may delegate a task to a UAP; however, the responsibility for action or inaction on the part of the nurse or UAP remains with the nurse.

Violence, Abuse, and Neglect Violent behavior can include domestic violence, child abuse, abuse of older adults, and sexual abuse. Neglect is the absence of care necessary to maintain the health and safety of a vulnerable individual such as a child or older adult. Nurses, in their many roles (e.g., home health nurse, pediatric nurse, emergency department nurse), can often identify and assess cases of violence against others. As a result, they are often considered mandated reporters, meaning that they are required, by law, to report suspected abuse, neglect, or exploitation. Mandated reporting is designed to detect cases of abuse and neglect at an early stage, protect children, and facilitate the provision of ser- vices to children and families. Health care providers are protected when they, in good faith, report suspected abuse even if subsequent investigation shows the report to be groundless (Guido, 2014). See Chapter 21 for additional information about child abuse and Chapter 23 for information about abuse of older adults.

The Americans with Disabilities Act The Americans with Disabilities Act (ADA), passed by the U.S. Con- gress in 1990 and fully implemented in 1994, prohibits discrimina- tion on the basis of disability in employment, public services, and public accommodations. The purposes of the act are as follows:

• To provide a clear and comprehensive national mandate for elimi- nating discrimination against individuals with disabilities.

• To provide clear, strong, consistent, enforceable standards address- ing discrimination against individuals with disabilities.

• To ensure that the federal government plays a central role in enforcing standards established under the act.

The ADA is about productivity, economic independence, and the ability to move about freely in society. The nurse plays a key part in helping individuals with disabilities comprehend the opportuni- ties provided by the law. For example, nurses working in a variety of settings may be involved in educating clients with disabilities about accessing and using public transportation, communicating through telecommunications devices for individuals with speech and hearing impairments, and patronizing public accommodations such as gro- cery stores, restaurants, and theaters. Furthermore, an employer may not refuse to hire a nurse with disabilities if the nurse is qualified and able to fulfill the essential functions of the work role. Box 4–3 lists the

BOX 4–3

The employee or applicant for employment must show: • A physical or mental impairment that substantially limits one

or more major life activities of such individual; • A record of such an impairment; or • Being regarded as having such an impairment. From Legal and Ethical Issues in Nursing, 6th ed. (p. 276), by G. W. Guido, 2014, Upper Saddle River, NJ: Pearson Education, Inc. Reprinted with permission.

Meeting ADA Eligibility SELF-CARE ALERT

Nurses have a high level of compassion and empathy for their clients. Giving of yourself, however, all day at work along with caring for your family may result in compassion fatigue. It is important for nurses to be as compassionate, understanding, and forgiving of themselves as they are of their clients and loved ones.

The prevalence of alcohol and drug abuse in the nursing pop- ulation is approximately 10%, which is comparable to that of the

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problems. Reporting a nurse may save the nurse’s license and possibly his or her life. The only wrong thing to do about a fellow nurse who is impaired is to do nothing (Servodidio, 2011, p. 144). The Practice Guidelines on page 69 can be used to report the nurse suspected of chemical impairment.

CLINICAL ALERT!

It is important for student nurses and nurses to become knowledge- able about the risk factors of chemical abuse and its early identifica- tion and interventions.

A variety of programs have been developed to assist impaired nurses to recover. The Intervention Project for Nurses (IPN), an affiliate of the Florida Nurses Association, is the oldest and most comprehensive program. It provides swift interventions and close monitoring and advocacy for impaired nurses (IPN, 2013). In many states, impaired nurses who voluntarily enter a diversion program (sometimes called a peer assistance program) do not have their nursing license revoked if they follow treatment requirements. Their practice, however, is closely supervised within specific guide- lines (e.g., working on a general nursing unit versus critical care area, no overtime, work only day shift, not allowed to administer or have access to narcotics). The programs require counseling and ongoing participation in support groups with periodic progress reports that may include random drug screening. The nurse may petition the state board of nursing for reinstatement of full licensure after a specified amount of time and evidence of recovery as deter- mined by the state board. Diversion programs allow for rehabilita- tion of the nurse while still being able to work in the profession. They also allow the state board to protect the public while comply- ing with the ADA.

Sexual Harassment Sexual harassment is a violation of an individual’s rights and a form of discrimination. In 1987, the law prohibiting sexual discrimination was clarified to apply to all educational and employing institutions re- ceiving federal funding. The Equal Employment Opportunity Com- mission (EEOC) defines sexual harassment as “unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature” occurring in the following circumstances (EEOC, 2000, section 1604.11):

• When submission to such conduct is considered, either explicitly or implicitly, a condition of an individual’s employment

• When submission to or rejection of such conduct is used as the basis for employment decisions affecting the individual

• When such conduct interferes with an individual’s work perfor- mance or creates an “intimidating, hostile, or offensive working environment.”

The victim or the harasser may be male or female. The victim does not have to be of the opposite sex. Nurses must develop skills of assertiveness to deter sexual harassment in the workplace. In ad- dition, nurses must be familiar with the sexual harassment policies and procedures that must be in place in every institution. These will include information regarding the reporting procedure, to whom in- cidents should be reported, the investigative process, and how confi- dentiality will be protected to the extent possible.

general population (Darbro & Malliarakis, 2012; Servodidio, 2011). As a result, professional organizations have passed resolutions to ensure that nurses and student nurses with chemical dependencies receive treatment and support, not discipline and derision.

Employers must have sound policies and procedures for iden- tifying and intervening in situations involving a possibly impaired nurse. The primary concern is for the protection of clients, but it is also critically important that the nurse’s problem be identified quickly so that appropriate treatment may be instituted. Box 4–4 lists behav- iors that may be seen in the impaired nurse.

Nurses usually avoid dealing with impaired colleagues. Nurses work as a team and the friendships that develop can be barriers to reporting problems. Another reason is that the nurse who observes suspicious behavior may fear retribution in the work environment or being called a whistle-blower. Although the reporting of unsafe or suspicious behavior may be difficult, it is important to remem- ber that nurses are client advocates. The ANA (2010) Code of Ethics for Nurses states that the “nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.” Additionally, nurses need to advocate for their colleagues who have substance

BOX 4–4

NURSE WITH ALCOHOLISM • Irritability, mood swings • Elaborate excuses for behavior; unkempt appearance • Blackouts (periods of temporary amnesia) • Impaired motor coordination, slurred speech, flushed face,

bloodshot eyes • Numerous injuries, burns, bruises, etc., with vague

explanations • Smell of alcohol on breath, or excessive use of mouthwash,

mints, etc. • Increased isolation from others

NURSE WITH A SUBSTANCE ABUSE PROBLEM • Rapid mood and/or performance changes • Frequent absence from unit; frequent use of restroom • May work a lot of overtime, usually arriving early and staying

late • Increased somatic complaints necessitating prescriptions of

pain medications • Consistently signs out more or larger amounts of controlled

drugs than anyone else; excessive wasting of drugs • Often medicates others’ clients; may wear long sleeves all of

the time • Increased isolation from others • Client complaints that pain medication is not effective or that

they did not receive medication • Excessive discrepancies in signing and documentation

procedures of controlled substances

NURSE WHO IS MENTALLY ILL • Depressed, lethargic, unable to focus or concentrate,

apathetic • Makes many mistakes at work • Erratic behavior or mood swings • Inappropriate or bizarre behavior or speech • May also exhibit some of the same or similar characteristics

as chemically dependent nurses Note: It is most important to look for patterns or changes in behavior. Not all characteristics need to be present to indicate that a problem exists. From “Texas Peer Assistance Program for Nurses. Warning Signs: Clues to Nurses with Problems,” 2013, by Texas Nurses Association. Retrieved from http://www.texasnurses.org/ displaycommon.cfm?an=1&subarticlenbr=103. Reprinted with permission.

Warning Signs of Impairment

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need to incorporate teaching in this area and continue to be support- ive of clients’ decisions.

The two types of advance health care directives are the living will and the health care proxy or surrogate. The living will provides spe- cific instructions about what medical treatment the client chooses to omit or refuse (e.g., ventilatory support) in the event that the client is unable to make those decisions.

The health care proxy, also referred to as a durable power of at- torney for health care, is a notarized or witnessed statement appointing someone else (e.g., a relative or trusted friend) to manage health care treatment decisions when the client is unable to do so. Figure 4–4 • shows an example of an advance health care directive that combines a living will declaration and a durable power of attorney for health care. A form specific to the state in which you live can be obtained from the National Hospice and Palliative Care Organization.

Nurses should learn the law regarding client self-determination for the state in which they practice, as well as the policies and pro- cedures for implementation in the institution where they work. The legally binding nature and specific requirements of advance medi- cal directives are determined by individual state legislation. In most states, advance directives must be witnessed by two people but do not require review by an attorney. Some states do not permit relatives, heirs, or primary care providers to witness advance directives. As a client advocate, it is important for the nurse to facilitate family discus- sion about end-of-life concerns and decisions.

AUTOPSY An autopsy or postmortem examination is an examination of the body after death. It is performed only in certain cases. The law de- scribes under what circumstances an autopsy must be performed, for example, when death is sudden or occurs within 48 hours of admis- sion to a hospital. The organs and tissues of the body are examined to establish the exact cause of death, to learn more about a disease, and to assist in the accumulation of statistical data.

The primary care provider or, in some instances, a designated individual in the hospital is responsible for obtaining consent for an autopsy. Consent must be given by the decedent (before death) or by the next of kin. Laws in many states and provinces prioritize the fam- ily members who can provide consent as follows: surviving spouse, adult children, parents, and siblings. After an autopsy, hospitals can- not retain any tissues or organs without the permission of the indi- vidual who consented to the autopsy.

CERTIFICATION OF DEATH The formal determination of death, or pronouncement, must be per- formed by a primary care provider, a coroner, or a nurse. The grant- ing of the authority to nurses to pronounce death is regulated by the state. It may be limited to nurses in long-term care, home health, and hospice agencies or to advanced practice nurses. By law, a death cer- tificate must be made out when an individual dies. It is usually signed by the attending primary care provider and filed with a local health or other government office. The family is usually given a copy to use for legal matters, such as insurance claims.

DO-NOT-RESUSCITATE ORDERS Primary care providers may order “no code” or “do not resuscitate” (DNR) for clients who are in a stage of terminal, irreversible illness or expected death. A DNR order is generally written when the cli- ent or proxy has expressed the wish for no resuscitation in the event

Abortions Abortion laws provide specific guidelines for nurses about what is legally permissible. In 1973, when the Roe v. Wade and Doe v. Bolton cases were decided, the Supreme Court of the United States held that the constitutional rights of privacy give a woman the right to control her own body to the extent that she can abort her fetus in the early stages of pregnancy.

In 1989, the Supreme Court’s decision in Webster v. Reproductive Health Services upheld a Missouri law banning the use of public funds or facilities for performing or assisting with abortions. In 1992, Presi- dent Clinton rescinded the 1991 Rust v. Sullivan decision, dubbed the “gag rule,” that prevented health care providers from discussing abor- tion services with clients in nonprofit agencies. The Supreme Court and state legislatures continue to struggle with the issue of abortion.

Many statutes also include conscience clauses, upheld by the Su- preme Court, designed to protect nurses and hospitals. These clauses give hospitals the right to deny admission to abortion clients and give health care personnel, including nurses, the right to refuse to partici- pate in abortions. When these rights are exercised, the statutes also protect the agency and employee from discrimination or retaliation.

Death and Related Issues The nurse’s role in legal issues related to death is prescribed by the laws of the region and the policies of the health care institution. For example, in some states, a feeding tube cannot be removed from a person in a persistent vegetative state without a prior directive from the client, but in other states the removal is allowed at the family’s re- quest or a primary care provider’s order. Some facilities permit do- not-resuscitate orders or protocols that specify the extent of invasive life-sustaining measures. Caring for dying clients who have agreed to organ donation can also be complex in terms of determining which medications, treatments, or equipment must be continued until the time for harvesting the organs has arrived. Many of these legal issues stimulate strong ethical concerns. It is important for the nurse to have support from other team members in understanding and providing appropriate care to clients facing death.

ADVANCE HEALTH CARE DIRECTIVES Advance health care directives include a variety of legal and lay documents that allow persons to specify aspects of care they wish to receive should they become unable to make or communicate their preferences. The Patient Self-Determination Act implemented in 1991 requires all health care facilities receiving Medicare and Medic- aid reimbursement to (a) recognize advance directives, (b) ask clients whether they have advance directives, and (c) provide educational materials advising clients of their rights to declare their personal wishes regarding treatment decisions, including the right to refuse medical treatment. Clients and families often have difficulty making advance treatment decisions for end-of-life matters. They need to be reassured that even if they make a decision and have an advance di- rective, they will always have the option to change their decision. For example, clients who are terminally ill may have decided not to have ventilator support, but if and when the actual situation occurs, they have the right to change their mind or take more time to make the decision.

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Figure 4–4 • Sample advance health care directive.

POWER OF ATTORNEY FOR HEALTH CARE (1) DESIGNATION OF AGENT: I designate the following individual as my agent to make health care decisions for me: ________________________________________ __________________________________________________________________________________________________________________________________________________ (Name of individual you choose as agent) __________________________________________________________________________________________________________________________________________________ (address) (city) (state) (zip code) __________________________________________________________________________________________________________________________________________________ (home phone) (work phone)

OPTIONAL: If I revoke my agent’s authority or if my agent is not willing, able, or reasonably available to make a healthcare decision for me, I designate as my first alternate agent: __________________________________________________________________________________________________________________________________________________ (Name of individual you choose as first alternate agent) __________________________________________________________________________________________________________________________________________________ (address) (city) (state) (zip code) __________________________________________________________________________________________________________________________________________________ (home phone) (work phone)

OPTIONAL: If I revoke the authority of my agent and first alternate agent or if neither is willing, able, or reasonably available to make a health care decision for me, I designate as my second alternate agent: __________________________________________________________________________________________________________________________________________________ (Name of individual you choose as second alternate agent) __________________________________________________________________________________________________________________________________________________ (address) (city) (state) (zip code) __________________________________________________________________________________________________________________________________________________ (home phone) (work phone)

(2) AGENT’S AUTHORITY: My agent is authorized to make all health care decisions for me, including decisions to provide, withhold, or withdraw artificial nutrition and hydration, and all other forms of health care to keep me alive, except as I state here:

(3) WHEN AGENT’S AUTHORITY BECOMES EFFECTIVE: My agent’s authority becomes effective when my primary physician determines that I am unable to make my own health care decisions unless I mark the following box. If I mark this box [ ], my agent’s authority to make health care decisions for me takes effect immediately.

(4) AGENT’S OBLIGATION: My agent shall make health care decisions for me in accordance with this power of attorney for health care, any instructions I give below, and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent shall make health care decisions for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent shall consider my personal values to the extent known to my agent.

(5) AGENT’S POSTDEATH AUTHORITY: My agent is authorized to make anatomical gifts, authorize an autopsy, and direct disposition of my remains, except as I state here or elsewhere in this form:

INSTRUCTIONS FOR HEALTH CARE Strike any wording you do not want.

(6) END-OF-LIFE DECISIONS: I direct that my health care providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the choice I have marked below: (Initial only one box) [ ] (a) Choice NOT to Prolong Life I do not want my life to be prolonged if (1) I have an incurable and irreversible condition that will result in my death within a relatively short time, (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (3) the likely risks and burdens of treatment would outweigh the expected benefits, OR [ ] (b) Choice to Prolong Life I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.

(7) RELIEF FROM PAIN: Except as I state in the following space, I direct that treatment for alleviation of pain or discomfort should be provided at all times even if it hastens my death: DONATION OF ORGANS AT DEATH (8) Upon my death: (mark applicable box) [ ] (a) I give any needed organs, tissues, or parts, OR [ ] (b) I give the following organs, tissues, or parts only: ___________________________________________________________________________ [ ] (c) My gift is for the following purposes: (strike any of the following you do not want) (1) Transplant (2) Therapy (3) Research (4) Education (9) EFFECT OF COPY: A copy of this form has the same effect as the original.

(10) SIGNATURE: Sign and date the form here: ______________________________________________________ _______________________________________________________ (date) (sign your name) ______________________________________________________ _______________________________________________________ (address) (print your name) ______________________________________________________ _______________________________________________________ (city) (state)

(11) WITNESSES: This advance health care directive will not be valid for making health care decisions unless it is either: (1) signed by two (2) qualified adult witnesses who are personally known to you and who are present when you sign or acknowledge your signature; or (2) acknowledged before a notary public.

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of a respiratory or cardiac arrest. Many primary care providers are reluctant to write such an order if there is any conflict between the client and family members or among family members. A DNR or- der is written to indicate that the goal of treatment is a comfortable, dignified death and that further life-sustaining measures are not in- dicated. If it is contrary to the nurse’s personal beliefs to carry out a DNR order, the nurse should consult the nurse manager for a change in assignment. Family members may think that DNR means giving permission to terminate an individual’s life. The term allow natural death (AND) is clear, more descriptive, and perhaps less threatening (ANA, 2012, p. 8).

The ANA (2012) makes the following recommendations for clinical nurses:

• Clinical nurses actively participate in timely and frequent discus- sions on changing goals of care and initiate DNR/AND discus- sions with patients and their families and significant others.

• Clinical nurses ensure that DNR orders are clearly documented, reviewed, and updated periodically to reflect changes in the pa- tient’s condition.

• All nurses ensure that, whenever possible, the DNR decision is a subject of explicit discussion between the health care team, patient, and family (or designated surrogate), and that actions taken are in accordance with the patient’s wishes.

• All nurses facilitate and participate in interdisciplinary mecha- nisms for the resolution of disputes among patients, families, and clinicians’ DNR orders.

• All nurses actively participate in developing DNR policies within the institutions where they work (pp. 9–10).

Many states (but not all) permit clients living at home to arrange special orders so that emergency technicians called to the home in the event of a cardiopulmonary arrest will respect the client’s wish not to be resuscitated. Some emergency medical services have writ- ten policies specifying that staff may withhold CPR if the client has a signed order or approved form or wears a medical alert DNR medal- lion. Nurses should be familiar with the federal and state laws and the policies of their agency concerning withholding life-sustaining measures.

EUTHANASIA Euthanasia is the act of painlessly putting to death people suffer- ing from incurable or distressing disease. It is sometimes referred to as “mercy killing.” Regardless of compassion and good intentions or moral convictions, euthanasia is legally wrong in the United States and can lead to criminal charges of homicide or to a civil lawsuit for withholding treatment or providing an unacceptable standard of care. Because advanced technology has enabled the medical profes- sion to sustain life almost indefinitely, people are increasingly consid- ering the meaning of quality of life. For some people, the withholding of artificial life-support measures or even the withdrawal of life sup- port is a desired and acceptable practice for clients who are terminally ill or who are incurably disabled and believed unable to live their lives with some happiness and meaning.

Voluntary euthanasia refers to situations in which the dying individual desires some control over the time and manner of death. All forms of euthanasia are illegal except in states where right-to-die statutes and living wills exist. In 1994, the state of Oregon approved

the first U.S. physician-assisted suicide law, the Death with Dignity Act (DWDA), which permits primary care providers to prescribe le- thal doses of medications. Since the law was passed in 1997, and as of January 2013, a total of 1,050 people have had DWDA prescrip- tions written, and 673 clients have died from ingesting medications prescribed under the DWDA (Oregon Public Health Division, 2012, p. 2). Since Oregon’s action, a number of states have proposed right- to-die laws. Right-to-die statutes legally recognize the client’s right to refuse treatment.

INQUEST An inquest is a legal inquiry into the cause or manner of a death. When a death is the result of an accident, for example, an inquest is held into the circumstances of the accident to determine any blame. The inquest is conducted under the jurisdiction of a coroner or medical examiner. A coroner is a public official, not necessarily a physician, appointed or elected to inquire into the causes of death, when appropriate. A medical examiner is a physician and usually has advanced education in pathology or forensic medicine. Agency policy dictates who is responsible for reporting deaths to the coroner or medical examiner.

ORGAN DONATION Under the Uniform Anatomical Gift Act and the National Organ Transplant Act in the United States, people 18 years or older and of sound mind may make a gift of all or any part of their own bodies for the following purposes: for medical or dental education, research, advancement of medical or dental science, therapy, or transplanta- tion. The donation can be made by a provision in a will or by signing a card-like form. This card is usually carried at all times by the person who signed it. In some states, the driver’s license will indicate if the in- dividual is an organ donor. In most states, the person can revoke the gift, either by destroying the card or by revoking the gift orally in the presence of two witnesses. Nurses may serve as witnesses for people consenting to donate organs.

In early 2004, the Organ Donation and Recovery Improvement Act was signed by the U.S. Congress, authorizing funds through 2009 for projects and activities to increase public awareness of and will- ingness to participate in organ donation. In almost every case, there is a greater need for transplantation than there are available organs. Thus, in many states, if there is no valid donor document, health care workers are required to discuss with survivors of a potential organ donor the option to make an anatomic gift. Survivors are obliged to grant or withhold donation in accordance with their knowledge of the donor’s views on anatomic gifts. The details regarding this process of requesting donation from family members and other legal aspects of organ donation vary by state. The nurse needs to be familiar with the appropriate legislation.

AREAS OF POTENTIAL LIABILITY IN NURSING Nursing liability is usually involved with tort law. It is important for the nurse to know the differences between professional negligence (an unintentional tort) and intentional torts. Nurses must also rec- ognize those nursing situations in which negligent actions are most likely to occur, and take measures to prevent them.

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The standard can come from documents published by national or professional organizations, boards of nursing, institutional poli- cies and procedures, or textbooks or journals, or it may be stated by expert witnesses.

• Foreseeability. A link must exist between the nurse’s act and the injury suffered.

• Causation. It must be proved that the harm occurred as a direct result of the nurse’s failure to follow the standard of care and that the nurse could have (or should have) known that failure to follow the standard of care could result in such harm.

• Harm or injury. The client or plaintiff must demonstrate some type of harm or injury (physical, financial, or emotional) as a result of the breach of duty owed the client. The plaintiff will be asked to document physical injury, medical costs, loss of wages, “pain and suffering,” and any other damages.

• Damages. If professional negligence caused the injury, the nurse is held liable for damages that may be compensated. The goal of awarding damages is to assist the injured party to his or her origi- nal position as far as financially possible (Guido, 2014).

CLINICAL ALERT!

The best defense against a professional negligence claim is to know your nursing responsibilities and the scope of practice of members of your health team (e.g., LPN/LVN, UAP).

Several legal doctrines or principles are related to negligence. One such doctrine is respondeat superior. A lawsuit for a negligent act performed by a nurse will also name the nurse’s employer. In addi- tion, employers may be held liable for negligence if they fail to pro- vide adequate human and material resources for nursing care, fail to properly educate nurses on the use of new equipment or procedures, or fail to orient nurses to the facility. Another doctrine or principle is res ipsa loquitur (“the thing speaks for itself ”). In some cases, the harm cannot be traced to a specific health care provider or standard but does not normally occur unless there has been a negligent act. An example is harm that results when surgical instruments or bandages are accidentally left in a client during surgery.

To defend against a professional negligence lawsuit, the nurse must prove that one or more of the six required elements is not met. There is also a limit to the amount of time that can pass between recognition of harm and the bringing of a suit. This is referred to as the statute of limitations. The exact time limitation varies by type of suit and state.

To avoid charges of professional negligence, nurses must rec- ognize those nursing situations in which negligent actions are most likely to occur, and take measures to prevent them (Box 4–5). The most common situation is the medication error. Because of the large number of medications on the market today and the variety of meth- ods of administration, these errors may be on the increase. Nursing errors include failing to read the medication label, misreading or in- correctly calculating the dosage, failing to correctly identify the client, preparing the wrong concentration, or administering a medication by the wrong route (e.g., intravenously instead of intramuscularly). Some medication errors are very serious and can result in death. For example, administering dicumarol, an anticoagulant, to a client re- cently returned from surgery could cause the client to hemorrhage.

Crimes and Torts A crime is an act committed in violation of public (criminal) law and punishable by a fine or imprisonment. A crime does not have to be intentional in order to be a crime. For example, a nurse may acciden- tally give a client an additional and lethal dose of a narcotic to relieve discomfort.

Crimes are classified as either felonies or misdemeanors. A felony is a crime of a serious nature, such as murder, punishable by a term in prison. In some areas, second-degree murder is called manslaughter. A nurse who accidentally gives an additional and lethal dose of a narcotic can be accused of manslaughter.

Crimes are punished through criminal action by the state against an individual. A misdemeanor is an offense of a less serious nature and is usually punishable by a fine or short-term jail sentence, or both.

A tort is a civil wrong committed against a person or a person’s property. Torts are usually litigated in court by civil action between individuals. In other words, the person or persons claimed to be responsible for the tort are sued for damages. Tort liability almost always is based on fault, which is something that was done incorrectly (an unreasonable act of commission) or something that should have been done but was not (an act of omission).

Torts are classified as unintentional or intentional.

UNINTENTIONAL TORTS Negligence and professional negligence are examples of uninten- tional torts that may occur in the health care setting. Negligence is misconduct or practice that is below the standard expected of an ordinary, reasonable, and prudent person. Such conduct places an- other person at risk for harm. Both nonmedical and professional individuals can be liable for negligent acts. Gross negligence in- volves extreme lack of knowledge, skill, or decision making that the person clearly should have known would put others at risk for harm. Malpractice is “professional negligence,” that is, negligence that oc- curred while the person was performing as a professional. Malprac- tice applies to primary care providers, dentists, lawyers, and generally includes nurses. In some states nurses cannot be sued for malpractice, only professional negligence. The terms malpractice and professional negligence are often used interchangeably. Six elements must be pres- ent for a case of nursing professional negligence to be proven:

• Duty. The nurse must have (or should have had) a relationship with the client that involves providing care and following an ac- ceptable standard of care. Such duty, for example, is evident when the nurse has been assigned to care for a client in the home or hos- pital. A nurse also has a general duty of care, even if not specifi- cally assigned to a client, if the client needs help.

CLINICAL ALERT!

It is a nurse’s duty to respond to all clients’ call lights, not just those of assigned clients.

• Breach of duty. There must be a standard of care that is expected in the specific situation but that the nurse did not observe. For ex- ample, something was done that should not have been done or nothing was done when it should have been done. This is the fail- ure to act as a reasonable, prudent nurse under the circumstances.

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appendix ruptures and death occurs. By failing to take the blood pres- sure and pulse and to check the dressing of a client who has just had abdominal surgery, a nurse omits important assessments. If the cli- ent hemorrhages and dies, the nurse may be held responsible for the death as a result of this professional negligence.

CLINICAL ALERT!

Monitor both the physical and psychosocial status of the client. Document observations and interventions.

Incorrectly identifying clients is a problem, particularly in busy hospital units. Unfortunate occurrences, such as removal of a healthy gallbladder from the wrong person, have resulted from nurses preparing the wrong client for surgery. Cases of mistaken identity are costly to the client and render the nurse liable for profes- sional negligence.

The number of nurses being named in professional negligence suits is increasing. The most common causes of nursing profes- sional negligence include failure to monitor, failure to perform as- sessment and notify health care provider, and failure to document and report a deteriorating condition (Painter & Dudjak, 2010, p. 534). See Practice Guidelines later in this chapter for steps to help nurses reduce potential liability.

INTENTIONAL TORTS Several differences distinguish unintentional torts from intentional torts. Unintentional torts (e.g., professional negligence) do not re- quire intent but do require the element of harm. In contrast, with intentional torts, the defendant executed the act on purpose or with intent. No harm need be caused by intentional torts for liability to exist. Also, since no standard is involved, no expert witnesses are

Nurses always must check medications very carefully. Even after checking, the nurse is wise to recheck the medication order and the medication before administering it if the client states, for example, “I did not have a green pill before.”

CLINICAL ALERT!

To be a client advocate, you must know about the medications be- ing administered. Know why the client is receiving the medication, the dosage range, possible adverse effects, toxicity levels, and contraindications.

Clients often fall accidentally, sometimes with resultant injury. Some falls can be prevented by elevating the side rails on the cribs, beds, and stretchers of babies and small children and, when neces- sary, of adults. If a nurse leaves the rails down or leaves a baby unat- tended on a bath table, that nurse is guilty of professional negligence if the client falls and is injured as a direct result. Most hospitals and nursing homes have policies regarding the use of safety devices. The nurse needs to be familiar with these policies and to take indicated precautions to prevent injuries (see Chapter 32 ).

BOX 4–5

Failure to follow standards of care, including failure to: • Perform a complete admission assessment or design a plan of

care. • Institute a fall protocol. • Adhere to standardized protocols or institutional policies and

procedures (e.g., using an improper injection site). • Follow a primary care provider’s verbal or written orders. Failure to use equipment in a responsible manner, including failure to: • Follow the manufacturer’s recommendations for operating the

equipment. • Check equipment for safety prior to use. • Place equipment properly during treatment. • Learn how equipment functions. Failure to communicate, including failure to: • Notify a primary care provider in a timely manner when

conditions warrant it. • Listen to a client’s complaints and act on them. • Communicate effectively with a client (e.g., inadequate or

ineffective communication of discharge instructions). • Communicate important assessment findings to the nurse for

the oncoming shift. • Seek higher medical authorization for a treatment.

Failure to document, including failure to follow the facility’s documentation policies and procedures and/or failure to note in the client’s medical record: • A client’s progress and response to treatment. • A client’s injuries. • Pertinent nursing assessment information (e.g., drug allergies). • A primary care provider’s medical orders. • Information on telephone conversations with primary care

providers, including time, content of communication between nurse and primary care provider, and actions taken.

Failure to assess and monitor, including failure to: • Complete a shift assessment. • Implement a plan of care. • Observe a client’s ongoing progress. • Interpret a client’s signs and symptoms. • Recognize significant changes in a client’s condition and

communicate them promptly. Failure to act as a client advocate, including failure to: • Question discharge orders when a client’s condition warrants it. • Question incomplete or illegible medical orders. • Provide a safe environment. From “Make Your Nursing Care Malpractice-Proof,” by D. L. Reising, 2012, American Nurse Today, 7(1), pp. 24–28; “How to Avoid the Top Seven Nursing Errors,” by A. Delamont, 2013, Nursing Made Incredibly Easy!, 11(2), pp. 8–10.

Categories of Negligence That Result in Professional Negligence Lawsuits

SAFETY ALERT!

Assess clients for fall potential. Document all nursing measures taken to protect the client (e.g., “Instructed client how to use the call light”).

SAFETY

In some instances, ignoring a client’s complaints can consti- tute professional negligence. This type of professional negligence is termed failure to observe and take appropriate action. The nurse who does not report a client’s complaint of acute abdominal pain is neg- ligent and may be found guilty of professional negligence if ensuing

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False imprisonment is the “unjustifiable detention of a per- son without legal warrant to confine the person” (Guido, 2014, p. 88). False imprisonment accompanied by forceful restraint or threat of restraint is battery.

Although nurses may suggest under certain circumstances that a client remain in the hospital room or in bed, the client must not be detained against the client’s will. The client has a right to insist on leaving even though it may be detrimental to health. In this instance, the client can leave by signing an AWA (absence without authority) or AMA (against medical advice) form. As with assault or battery, cli- ent competency is a factor in determining whether there is a case of false imprisonment or a situation of protecting a client from injury. To guide nurses in such dilemmas, agencies usually have clear poli- cies regarding the application of restraints (see Chapter 32 ).

Invasion of privacy is a direct wrong of a personal nature. It injures the feelings of the person and does not take into account the effect of revealed information on the reputation of the person in the community. The right to privacy is the right of individuals to with- hold themselves and their lives from public scrutiny. It can also be described as the right to be left alone. Liability can result if the nurse breaches confidentiality by passing along confidential client informa- tion to others or intrudes into the client’s private domain.

In this context, a delicate balance must be maintained between the need of a number of people to contribute to the diagnosis and treatment of a client and the client’s right to confidentiality. In most situations, necessary discussion about a client’s medical condition is considered appropriate, but unnecessary discussions and gossip are considered breaches of confidentiality. Necessary discussion involves only those people engaged in the client’s care.

CLINICAL ALERT!

Never discuss client situations in the elevator, cafeteria, or other public areas.

needed. Four intentional torts related to nursing are discussed here: assault/battery, false imprisonment, invasion of privacy, and defa- mation (libel/ slander). Figure 4–5 • provides an overview of the types of law in nursing.

The terms assault and battery are often heard together, but each has its own meaning. Assault can be described as an attempt or threat to touch another person unjustifiably. Assault precedes bat- tery; it is the act that causes the person to believe a battery is about to occur. For example, the person who threatens someone by making a menacing gesture with a club or a closed fist is guilty of assault. A nurse who threatens a client with an injection after the client refuses to take the medication orally would be committing assault.

Battery is the willful touching of a person (or the person’s clothes or even something the person is carrying) that may or may not cause harm. To be actionable at law, however, the touching must be wrong in some way; for example, touching done without permission, that is em- barrassing, or that causes injury. In the previous example, if the nurse followed through on the threat and gave the injection without the cli- ent’s consent, the nurse would be committing battery. Liability applies even though the primary care provider ordered the medication or the activity and even if the client benefits from the nurse’s action.

Consent is required before procedures are performed. Battery exists when there is no consent, even if the plaintiff was not asked for consent. Unless there is implied consent, such as in life-threatening emergencies, a procedure performed on an unconscious client with- out informed consent is battery. Another requirement for consent is that the client be competent to give consent. It can be very difficult to determine if clients who are older, who have specific mental dis- orders, or who take particular medications are competent to agree to treatments. If the nurse is uncertain whether a client refusing a treat- ment is competent, the supervisor and primary care provider should be consulted so that ethical treatment that does not constitute battery can be provided. Determination of competency is not a medical deci- sion; it is one made through court hearings.

Analysis of professional negligence claims can contribute to cor- recting deficiencies that contribute to practice errors. Little research has investigated the relationships among the nursing characteris- tics, actions, or behaviors of nurses whose actions contributed to professional negligence suits providing monetary compensation. Painter and Dudjak (2010) conducted a retrospective chart review of claims from a professional liability insurance program managed internally by a large health care system. The claims were limited to adult clients receiving care in acute care hospitals located in a single state. These cases were then further limited to those that involved nursing care during medication administration, IV therapy, and/or monitoring of physiological changes because these events were considered preventable. As a result the authors reviewed 16 professional negligence claims that involved 19 RNs. Data were col- lected on client, environment, and nurse. There were 8 men and 8 women clients with an average age of 55. The environment of the events included a postoperative surgical unit, general medicine unit, intensive care unit, and the emergency department. The actions of the nurses that contributed to the events included failure to respond or set audible monitor alarms (15.7%), failure to follow the five rights of medication administration (15.7%), failure to escalate commu- nication with a nonresponsive clinical provider (10.5%), and failure to perform timely assessment and intervention in a clinical situation

with the majority of these cases related to opioid administration and monitoring (42%). Fifty-three percent of the nursing behaviors were related to failure to follow the policies and procedures of the facility, and 47% were associated with nurses not performing their duty. The nurse characteristics included an average age of 41 years with the majority of nurses involved being non-BSN prepared. The probabil- ity of client death was substantially greater for nurses with less than 48 months of nursing experience. One third of the nurses involved in the events were not working in their regularly assigned unit, and 50% of the deaths involved nurses from this subgroup.

IMPLICATIONS Although this study is small, it is important and worthy of attention. That 89% of the nurses had less than a BSN supports previous research of the direct relationship between nurse education and fa- vorable client outcomes. The finding that 50% of the client deaths involved nurses who were reassigned to a unit other than their usual nursing unit raises concerns about this staffing practice. There is a need for nurse leaders to provide processes that promote a safe work environment for nurses and clients. As the authors stated, “Nurse leaders should encourage active involvement of direct-care nurses in quality forums not only within the unit, but across all levels of the organization” (p. 538).

Evidence-Based Practice What Are the Actions, Behaviors, and Characteristics of RNs Involved in Professional Negligence Claims? EVIDENCE-BASED PRACTICE

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Figure 4–5 • An overview of the types of law in nursing practice.

Negligence/ Malpractice

Failure to meet

standard of care

Duty Breach of duty Foreseeability

Causation Harm/Injury

Damage

Assault/battery

False imprisonment

Invasion of privacy

Private/Civil

Contract Law Torts

Unintentional

Public

Criminal Law

Felony Misdemeanor

Types of Law

Intentional

Willful action

Causation

Intended to bring about

consequence

Defamation

Libel Slander

Must be present

Common elements

Most jurisdictions of the country have a variety of statutes that impose a duty to report certain confidential client information. Four major categories are (a) vital statistics, such as births and deaths; (b) infections and communicable diseases, such as diphtheria, syphi- lis, and typhoid fever; (c) child or abuse of older adults; and (d) vio- lent incidents, such as gunshot wounds and knife wounds.

The client must be protected from four types of invasion:

• Use of the client’s name or likeness for profit, without consent. This refers to use of identifiable photographs or names such as ad- vertising for the health care agency or provider without the client’s permission.

• Unreasonable intrusion. This involves observation of client care (such as by nursing students) or taking of photographs for any purpose without the client’s consent.

• Public disclosure of private facts. This occurs when private in- formation is given to others who have no legitimate need for that information.

• Putting a person in a false light. This type of invasion involves publishing information that is normally considered offensive but which is not true.

Defamation is communication that is false, or made with a careless disregard for the truth, and results in injury to the reputation of a person. Both libel and slander are wrongful actions that come un- der the heading of defamation. Libel is defamation by means of print, writing, or pictures. Writing in the nurse’s notes that a primary care provider is incompetent because he did not respond immediately to a call is an example of libel. Slander is defamation by the spoken word, stating unprivileged (not legally protected) or false words by which a

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reputation is damaged. An example of slander would be for the nurse to tell a client that another nurse is incompetent.

Only the person defamed may bring the lawsuit. The defama- tory material must be communicated to a third party such that the person’s reputation may be harmed. For example, a comment made in private criticizing that person’s competence is not defamation since a third party did not hear it.

Nurses have a qualified privilege to make statements that could be considered defamatory, but only as a part of nursing practice and only to a primary care provider or another health team member car- ing directly for the client. The communication must be made in good faith with the intent to protect the quality of client care—for example, when a nurse manager provides a prospective employer with infor- mation about a nurse’s professional practice.

Privacy of Clients’ Health Information Protecting clients’ confidentiality has always been an important re- sponsibility of nursing. Recent changes in the laws regarding privacy have implications for health care providers and organizations. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is the first nationwide legislation to protect privacy for health infor- mation. It is important to be aware of identifying information that is protected under HIPAA but may not be initially perceived as health information. Examples include Social Security number, name, ad- dress, phone number, e-mail address, and fingerprints. Age should also be a consideration because age can become an identifier in the population older than age 89.

HIPAA includes four specific areas:

1. Electronic transfer of information among organizations. Instead of each health provider using its own electronic format to transact claims, etc., HIPAA implements a national uniform standard to simplify such transactions.

2. Standardized numbers for identifying providers, employers, and health plans. Instead of each health care organization us- ing different formats for identification, HIPAA published stan- dard identifiers. For example, an employer’s tax ID number or employer identification number is the standard for electronic transactions.

3. The security rule provides for a uniform level of protection of all health information. This rule requires health care organizations and providers to ensure the confidentiality, integrity, and avail- ability of all electronic protected health information (ePHI).

4. The privacy rule sets standards defining appropriate disclosure of protected health information. This rule also gives clients new rights to understand and control how their health information is used (i.e., how to access their medical records, restrict access by others, request changes, and learn how they have been accessed).

See Box 4–6 for examples of how HIPAA compliance affects nursing practice.

Social Media The use of social media and other types of electronic communication is rapidly growing. Social media is a valuable tool when used wisely. Nurses and nursing students must understand the benefits and con- sequences of participating in social networking of all types. Inappro- priate use of social networking by nurses has resulted in nurses losing

Examples of HIPAA Compliance and Nursing PracticeBOX 4–6

• Store charts in a secure, nonpublic location to prevent the public from viewing or accessing confidential health information.

• Place clipboards face down. • Do not leave printed copies of protected health information

unattended at a printer or fax machine. • Verify the number dialed before faxing personal health

information. • Encrypt personal health information when transmitting by

e-mail. • Limit access to protected health information to those

authorized to obtain the information. • Require health care providers to have passwords to access

a client’s electronic chart. • Post or provide a notice informing clients of their rights to

privacy regarding their health information. • Lower voice levels to minimize disclosure of information

when, for example, discussing a client’s condition over the telephone, giving a report, or reading information aloud from a computer screen or chart.

• Ensure that health care providers stay current with HIPAA regulations.

their jobs and being disciplined by the board of nursing. Both the NCSBN and ANA have published social media guidelines for nurses.

Health care organizations have policies about the use of elec- tronic and social media in the workplace. Therefore, it is usually the nurse’s use of social media outside of the workplace where the nurse may face serious consequences for inappropriate use of social media. Here are guidelines from the ANA (2011) and NCSBN (2011) for avoiding the inappropriate use of social media:

• Remember that the standards of professionalism (e.g., an ethical and legal obligation to maintain client privacy and confidentiality at all times) are the same online as in any other circumstance.

• Do not take photos or videos of clients on personal devices, in- cluding cell phones.

• Maintain professional boundaries when using electronic media. • Do not transmit or place online individually identifiable client

information. • Report any identified breach of confidentiality or privacy.

Loss of Client Property Loss of client property, such as jewelry, money, eyeglasses, and den- tures, is a constant concern to hospital personnel. Today, agencies are taking less responsibility for property and are generally requesting clients to sign a waiver on admission relieving the hospital and its employees of any responsibility for property. Situations arise, how- ever, in which the client cannot sign a waiver and the nursing staff must follow prescribed policies for safeguarding the client’s property. Nurses are expected to take reasonable precautions to safeguard a cli- ent’s property, and they can be held liable for its loss or damage if they do not exercise reasonable care.

Unprofessional Conduct According to most nurse practice acts, unprofessional conduct is considered one of the grounds for action against a nurse’s license.

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The same reasoning applies to nurses, who are among the people best prepared to help at the scene of an accident. If the level of care a nurse provides is of the caliber that would have been provided by any other nurse, then the nurse will not be held liable.

Guidelines for nurses who choose to render emergency care are as follows:

• Limit actions to those normally considered first aid, if possible. • Do not perform actions that you do not know how to do. • Offer assistance, but do not insist. • Have someone call or go for additional help. • Do not leave the scene until the injured person leaves or another

qualified person takes over. • Do not accept any compensation.

Professional Liability Insurance Because of the increase in the number of professional negligence lawsuits against health professionals, nurses are advised to carry their own liability insurance. Most hospitals have liability insurance that covers all employees, including all nurses. However, some smaller facilities, such as walk-in clinics, may not. Thus, the nurse should al- ways check with the employer at the time of hiring to see what cover- age the facility provides. A primary care provider or a hospital can be sued because of the negligent conduct of a nurse, and the nurse can also be sued and held liable for professional negligence. Because hospitals have been known to countersue nurses when they have been found negligent and the hospital was required to pay, nurses are advised to provide their own insurance coverage and not rely on hospital-provided insurance.

Additionally, nurses often provide nursing services outside of employment-related activities, such as being available for first aid at children’s sport or social activities or providing health screening and education at health fairs. Neighbors or friends may seek advice about illnesses or treatment for themselves or family members. In the lat- ter situation, the nurse may be tempted to give advice; however, it is always advisable for the nurse to refer the friend or neighbor to their family primary care provider. The nurse may be protected from li- ability under Good Samaritan acts when nursing service is volun- teered; however, if the nurse receives any compensation or if there is a written or verbal agreement outlining the nurse’s responsibility to the group, the nurse needs liability coverage for legal expenses in the event that the nurse is sued.

Liability insurance coverage usually defrays all costs of defend- ing a nurse, including the costs of retaining an attorney. The insur- ance also covers all costs incurred by the nurse up to the face value of the policy, including a settlement made out of court. In return, the insurance company may have the right to make the decisions about the claim and the settlement.

Nursing faculty and nursing students are also vulnerable to law- suits. Students and teachers of nursing employed by community col- leges and universities are not likely to be covered by the insurance carried by hospitals and health agencies. It is advisable for nursing students to check with their school about the coverage that applies to them. Increasingly, faculty carry their own professional liability insurance. Liability insurance can be obtained through the ANA or private insurance companies. Nursing students can also obtain in- surance through the National Student Nurses Association. In some states, hospitals do not allow nursing students to provide nursing

Unprofessional conduct includes incompetence or gross negli- gence, conviction for practicing without a license, falsification of cli- ent records, and illegally obtaining, using, or possessing controlled substances. Having a personal relationship with a client, especially a vulnerable client, may be considered unprofessional conduct be- cause the Code of Ethics for Nurses states that nurses are responsible for maintaining their professional boundaries (ANA, 2010, p.151). Certain acts may constitute a tort or crime in addition to being un- professional conduct.

Unethical conduct may also be addressed in nurse practice acts. Unethical conduct includes violation of professional ethical codes, breach of confidentiality, fraud, or refusing to care for clients of spe- cific socioeconomic or cultural origins (see Chapter 5 ).

Nurses at all levels of nursing practice, can be reported to na- tional data banks. The Healthcare Integrity and Protection Data Bank (HIPDB) was created for the reporting of civil judgments or criminal convictions related to health care and licensure or certifica- tion actions. Another data bank, the National Practitioner Data Bank (NPDB), was established to identify incompetent and unprofessional health care practitioners. The information in these two data banks is not accessible by the public. It can be accessed, however, by state licensing boards, HMOs, hospitals, and professional organizations. The data banks are examples of a nationwide effort to protect the public and to identify and track professionals found liable of profes- sional negligence or actions taken against their license. NPDB annual reports of group data are available at their website.

LEGAL PROTECTIONS IN NURSING PRACTICE Laws and strategies are in place to protect the nurse against litigation. Good Samaritan acts are an example of laws designed to help protect nurses when assisting at the scene of an emergency. Providing safe, competent practice by following the nurse practice act and standards of practice is a major legal safeguard for nurses. Accurate and com- plete documentation is also a critical component of legal protection for the nurse.

Good Samaritan Acts Good Samaritan acts are laws designed to protect health care pro- viders who provide assistance at the scene of an emergency against claims of professional negligence unless it can be shown that there was a gross departure from the normal standard of care or willful wrongdoing on their part. Gross negligence usually involves further injury or harm to the person. For example, an automobile may strike an injured child left on the side of the road when the nurse leaves to obtain help.

Most state statutes do not require citizens to render aid to people in distress. Such assistance is considered more of an ethical than a le- gal duty. To encourage citizens to be Good Samaritans, most states have now enacted legislation releasing a Good Samaritan from legal liability for injuries caused under such circumstances, even if the in- juries resulted from negligence of the person offering emergency aid. It is important, however, to check your state’s statute since some states (e.g., Vermont) require people to stop and aid persons in danger.

It is generally believed that a person who renders help in an emergency, at a level that would be provided by any reasonably prudent person under similar circumstances, cannot be held liable.

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Application of the nursing process is another essential aspect of providing safe and effective client care. Clients need to be as- sessed and monitored appropriately and involved in care decisions. All assessments and care must be documented accurately. Effec- tive communication can also protect the nurse from negligence claims. Nurses need to approach every client with sincere concern and include the client in conversations. In addition, nurses should always acknowledge when they do not know the answer to a client’s questions, telling the client they will find out the answer and then follow through.

Methods of legal protection are summarized in the accompany- ing Practice Guidelines.

Documentation The client’s medical chart is a legal document and can be produced in court as evidence. Often, the chart is used to remind a witness of events surrounding a lawsuit, because several months or years usu- ally elapse before a suit goes to trial. The effectiveness of a witness’s testimony can depend on the accuracy of the nurse’s documentation of nursing care. Nurses, therefore, need to provide accurate and com- plete documentation of the nursing care provided to clients. Failure to properly document can constitute negligence and be the basis for tort liability. Insufficient or inaccurate assessments and documenta- tion can hinder proper diagnosis and treatment and result in injury to the client (Figure 4–6 •). See Chapter 15 for types of records and facts about recording.

The Incident Report An incident report (also called an unusual occurrence report) is an agency record of an accident or unusual occurrence. Incident reports are used to make all facts available to agency personnel, to contrib- ute to statistical data about accidents or incidents, and to help health personnel prevent future incidents or accidents. All accidents are usually reported on incident forms. Some agencies also report other incidents, such as the occurrence of client infection or the loss of per- sonal effects.

care without liability insurance or a signed disclaimer placing the responsibility of the student’s actions while in the clinical setting on the student.

Carrying Out a Physician’s Orders Nurses are expected to analyze procedures and medications ordered by the physician or primary care provider. It is the nurse’s responsibil- ity to seek clarification of ambiguous or seemingly erroneous orders from the prescriber. Clarification from any other source is unaccept- able and regarded as a departure from competent nursing practice.

If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out. For example, if the order is for oxygen to be administered at 4 liters per minute, the nurse must ad- minister oxygen at that rate, and not at 2 or 6 liters per minute. If the orders state that the client is not to have solid food after a bowel resec- tion, the nurse must ensure that no solid food is given to the client.

There are several categories of orders that nurses must question to protect themselves legally:

• Question any order a client questions. For example, if a client who has been receiving an intramuscular injection tells the nurse that the health care provider changed the order from an injectable to an oral medication, the nurse must recheck the order before giv- ing the medication.

• Question any order if the client’s condition has changed. The nurse is considered responsible for notifying the primary care provider of any significant changes in the client’s condition, whether the pri- mary care provider requests notification or not. For example, if a client who is receiving an intravenous infusion suddenly develops a rapid pulse, chest pain, and a cough, the nurse must notify the primary care provider immediately and question continuance of the ordered rate of infusion. If a client who is receiving morphine for pain develops severely depressed respirations, the nurse must withhold the medication and notify the primary care provider.

• Question and record verbal orders to avoid miscommunications. In addition to recording the time, the date, the primary care provider’s name, and the orders, the nurse documents the circumstances that occasioned the call to the primary care provider, reads the orders back to the primary care provider, and documents that the primary care provider confirmed the orders as the nurse read them back.

• Question any order that is illegible, unclear, or incomplete. Mis- interpretations in the name of a drug or in dose, for example, can easily occur with handwritten orders. The nurse is responsible for ensuring that the order is interpreted the way it was intended and that it is a safe and appropriate order.

Providing Competent Nursing Care Competent practice is a major legal safeguard for nurses. Nurses need to provide care that is within the legal boundaries of their practice and within the boundaries of agency policies and procedures. Nurses therefore must be familiar with their various job descriptions, which may differ from agency to agency. Every nurse is responsible for en- suring that his or her education and experience are adequate to meet the responsibilities delineated in the job description.

Competency also involves care that protects clients from harm. Nurses need to anticipate sources of client injury, educate clients about hazards, and implement measures to prevent injury.

Figure 4–6 • Clear and accurate documentation is the nurse’s best defense against potential liability. Ryan McVay/Getty Images.

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PRACTICE GUIDELINES

Legal Protection for Nurses

• Function within the scope of your education, job description, and nurse practice act.

• Follow the policies and procedures of the employing agency. • Build and maintain good rapport with clients. • Always check the identity of a client to make sure it is the

right client. • Observe and monitor the client accurately. Communicate

and record significant changes in the client’s condition to the primary care provider.

• Promptly and accurately document all assessments and care given.

• Be alert when implementing nursing interventions, and give each task your full attention and skill.

• Perform procedures correctly and appropriately. • Make sure the correct medications are given in the correct dose,

by the right route, at the scheduled time, and to the right client.

• When delegating nursing responsibilities, make sure that the person who is delegated a task understands what to do and that the person has the required knowledge and skill.

• Protect clients from injury. • Report all incidents involving clients. • Always check any order that a client questions. • Know your own strengths and weaknesses. Ask for assistance

and supervision in situations for which you feel inadequately prepared.

• Maintain your clinical competence. For students, this demands study and practice before caring for clients. For graduate nurses, it means continued study to maintain and update clinical knowledge and skills.

The nurse completes the following tasks when completing an incident report:

• Identify the client by name, initials, and hospital or identification number.

• Give the date, time, and place of the incident. • Describe the facts of the incident. Avoid any conclusions or blame.

Describe the incident as you saw it even if your impressions differ from those of others.

• Incorporate the client’s account of the incident. State the client’s comments by using direct quotes.

• Identify all witnesses to the incident. • Identify any equipment by number and any medication by name

and dosage.

The report should be completed as soon as possible and filed according to agency policy. Because incident reports are not part of the client’s medical record, the facts of the incident should also be noted in the medical record. Do not record in the client record that an incident report has been completed because the facts are already documented in the chart. The purpose of the report form is to alert the risk manager to the event.

The person who identifies that the incident occurred should complete the incident report. This may not be the same person actu- ally involved with the incident. For example, the nurse who discovers that an incorrect medication has been administered completes the form even if it was another nurse who administered the medication. In addition, all witnesses to an incident, such as a client fall, are listed on the incident form even if they were not directly involved.

Incident reports are often reviewed by an agency risk manage- ment committee, which decides whether to investigate the incident further. Nurses may be required to answer such questions as what they believe precipitated the accident, how it could have been pre- vented, and whether any equipment should be adjusted.

When an accident occurs, the nurse should first assess the client and intervene to prevent injury. If a client is injured, nurses must take steps to protect the client, themselves, and their employer. Most agen- cies have policies regarding accidents. It is important to follow these policies and not to assume one is negligent. Although negligence may

be involved, accidents can and do happen even when every precau- tion has been taken to prevent them.

REPORTING CRIMES, TORTS, AND UNSAFE PRACTICES Nurses may need to report nursing colleagues or other health profes- sionals for practices that endanger the health and safety of clients. For instance, alcohol and drug use, theft from a client or agency, and un- safe nursing practice should be reported. Reporting a colleague is not easy. The person reporting may feel disloyal, incur the disapproval of others, or perceive that chances for promotion are endangered. When reporting an incident or series of incidents, the nurse must be care- ful to describe observed behavior only and not make inferences as to what might be happening. The accompanying Practice Guidelines can be used for reporting a crime, tort, or unsafe practice.

Reporting these events is referred to as whistle-blowing. Many states have laws that prevent wrongful termination of whistle-blowers by employers. In some states, it is mandatory for a nurse with knowledge of unprofessional conduct to report that behavior to the state board of nursing. In addition, reporting illegal, unethical, or incompetent performance is an expectation found in the ANA Code of Ethics.

PRACTICE GUIDELINES

Reporting a Crime, Tort, or Unsafe Practice

• Write a clear description of the situation you believe you should report.

• Make sure that your statements are factual and complete. • Make sure you are credible. • Obtain support from at least one trustworthy person before

filing the report. • Report the matter starting at the lowest possible level in the

agency hierarchy. • Assume responsibility for reporting the individual by being

open about it. Sign your name to the letter. • See the problem through once you have reported it.

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LEGAL RESPONSIBILITIES OF STUDENTS Nursing students are responsible for their own actions and liable for their own acts of negligence committed during the course of clinical ex- periences. When they perform duties that are within the scope of profes- sional nursing, such as administering an injection, they are legally held to the same standard of skill and competence as a registered professional nurse. Lower standards are not applied to the actions of nursing students.

CLINICAL ALERT!

Each nurse and nursing student is responsible and accountable for providing safe client care.

Nursing students are not considered employees of the agencies in which they receive clinical experience because these nursing programs contract with agencies to provide clinical experiences for students. In cases of negligence involving such students, the hospital or agency (e.g., public health agency) and the educational institution will be held po- tentially liable for negligent actions by students. Some nursing schools require students to carry individual professional liability insurance.

Nursing students need to be aware that most state boards of nursing require a reporting of prior criminal history when applying for licensure. A person with past felony and some misdemeanor of- fenses may be denied licensure even though that individual gradu- ated from an approved nursing program. Nursing students who are unsure of their personal situation are advised to contact their state board of nursing for more information. Many nursing schools

currently require a background check of students before they can at- tend their clinical practicum. The purpose of this requirement is to protect the public.

Students in clinical situations must be assigned learning experi- ences within their capabilities and be given reasonable guidance and supervision. Nursing instructors are responsible for assigning students to the care of clients and for providing reasonable supervision. Failure to provide reasonable supervision or the assignment of a client to a student who is not prepared and competent can be a basis for liability.

To fulfill responsibilities to clients and to minimize chances for liability, nursing students need to:

• Make sure they are prepared to carry out the necessary care for assigned clients.

• Ask for additional help or supervision in situations for which they feel inadequately prepared.

• Comply with the policies of the agency in which they obtain their clinical experience.

• Comply with the policies and definitions of responsibility sup- plied by the school of nursing.

Students who work as part-time or temporary nursing assistants or aides must also remember that legally they can perform only those tasks that appear in the job description of a nurse’s aide or assistant. Even though a student may have received instruction and acquired competence in administering injections or suctioning a tracheostomy tube, the student cannot legally perform these tasks while employed as an aide or assistant. While acting as a paid employee, the student is covered for negligent acts by the employer, not the school of nursing.

Critical Thinking Checkpoint

A female adult client who has been blind since birth is admitted to the surgical unit. She is to have surgery the next morning. The primary care provider has written an order for the client to sign the surgical consent form. The husband is in the client’s room when the nurse ap- proaches the client to sign the consent form. The husband says that he will sign for his wife. 1. What question(s) should the nurse ask before addressing the

signing of the form?

2. Can someone who is blind give consent? 3. How can the nurse ensure that the client is aware of what she is

signing? 4. What else should the nurse consider when obtaining a

signature? 5. What would the nurse include in the documentation?

See Critical Thinking Possibilities on student resource website.

• Accountability is an essential concept of professional nursing prac- tice under the law.

• Nurses need to understand laws that regulate and affect nursing practice to ensure that nurses’ actions are consistent with current legal principles and to protect themselves from liability.

• Nurse practice acts legally define and describe the scope of nurs- ing practice that the law seeks to regulate.

• Competence in nursing practice is determined and maintained by various credentialing methods, such as licensure, certification, and accreditation, that protect the public’s welfare and safety.

• Standards of practice published by national and state nursing as- sociations, agency policies and procedures, and job descriptions further delineate the scope of a nurse’s practice.

• The nurse has specific legal obligations and responsibilities to cli- ents and employers. As a citizen, the nurse has the rights and responsibilities shared by all individuals in the society.

• Collective bargaining is one way nurses can improve their working conditions and economic welfare.

• Informed consent implies that (a) the consent was given voluntarily, (b) the client was of age and had the capacity and competency to

CHAPTER HIGHLIGHTS

Chapter 4 Review

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• Nurses can be held liable for intentional torts, such as assault and battery, false imprisonment, invasion of privacy, and defamation.

• The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was the first nationwide legislation to protect the privacy of health information. HIPAA includes four specific areas: a uniform standard for electronic transfer of information among organiza- tions; standardized numbers for identifying providers, employers, and health plans; a security rule; and a privacy rule.

• Good Samaritan acts protect health professionals from claims of professional negligence when they offer assistance at the scene of an emergency, provided that there is no willful wrongdoing or gross departure from normal standards of care.

• Nursing students and practicing nurses can obtain professional liability insurance through professional nursing associations.

• When a client is accidentally injured or involved in an unusual situ- ation, the nurse’s first responsibility is to take steps to protect the client and then to notify appropriate agency personnel.

• Nursing students are held to the same standard as licensed nurses and, therefore, need to make certain that they are prepared to pro- vide the necessary care to assigned clients. It is important that students ask for help or supervision in situations for which they feel inadequately prepared.

understand, and (c) the client was given enough information on which to make an informed decision.

• The Americans with Disabilities Act of 1990 prohibits discrimi- nation on the basis of disability in employment, public services, and public accommodations. Nurses need to know how the ADA affects nursing practice.

• Chemical dependence in health care workers is a problem, in part, because of the high levels of stress involved in many health care settings and the easy access to addictive drugs. Chemical impairment includes abuse of alcohol and addictive drugs. The nurse needs to know the proper reporting procedures for nursing colleagues whose practice is chemically impaired.

• Nurses must be knowledgeable of their responsibilities about legal issues surrounding death: advance directives, autopsies, certification of death, DNR orders, euthanasia, inquests, and or- gan donation.

• Nurse professional negligence, an unintentional tort, can be estab- lished when the following criteria are met: (a) the nurse (defendant) owed a duty to the client, (b) the nurse failed to carry out that duty according to standards, (c) there was foreseeability of harm, (d) the client’s injury was caused by the nurse’s failure to follow the stan- dard, and (e) the client (plaintiff) was injured. The nurse is liable for damages that may be compensated.

1. A primary care provider’s orders indicate that a surgical consent form needs to be signed. Because the nurse was not present when the primary care provider discussed the surgical proce- dure, which statement best illustrates the nurse fulfilling the client advocate role? 1. “The doctor has asked that you sign this consent form.” 2. “Do you have any questions about the procedure?” 3. “What were you told about the procedure you are going to

have?” 4. “Remember that you can change your mind and cancel the

procedure.” 2. Although the client refused the procedure, the nurse insisted and

inserted a nasogastric tube in the right nostril. The administrator of the hospital decides to settle the lawsuit because the nurse is most likely to be found guilty of which of the following? 1. An unintentional tort 2. Assault 3. Invasion of privacy 4. Battery

3. A nurse discovers that a primary care provider has prescribed an unusually large dosage of a medication. Which is the most appropriate action? 1. Administer the medication. 2. Notify the prescriber. 3. Call the pharmacist. 4. Refuse to administer the medication.

4. A primary care provider prescribes one tablet, but the nurse accidently administers two. After notifying the primary care pro- vider, the nurse monitors the client carefully for untoward effects of which there are none. Is the client likely to be successful in suing the nurse for professional negligence? 1. No, the client was not harmed. 2. No, the nurse notified the primary care provider. 3. Yes, a breach of duty exists. 4. Yes, foreseeability is present.

5. A nursing student is employed and working as an unlicensed as- sistive personnel (UAP) on a busy surgical unit. The nurses know that the UAP is enrolled in a nursing program and will be gradu- ating soon. A nurse asks the UAP if he has performed a urinary catheterization on clients while in the nursing program. When the UAP says “Yes,” the nurse asks him to help her out by doing a urinary catheterization on a postsurgical client. What is the best response by the UAP? 1. “Let me get permission from the client first.” 2. “Sure. Which client is it?” 3. “I can’t do it unless you supervise me.” 4. “I can’t do it. Is there something else I can help you with?”

6. The primary care provider wrote a do-not-resuscitate (DNR) order. The nurse recognizes that which applies in the planning of nursing care for this client? 1. The client may no longer make decisions regarding his or her

own health care. 2. The client and family know that the client will most likely die

within the next 48 hours. 3. The nurses will continue to implement all treatments focused

on comfort and symptom management. 4. A DNR order from a previous admission is valid for the

current admission. 7. The nurse’s partner/spouse undergoes exploratory surgery at

the hospital where the nurse is employed. Which practice is most appropriate? 1. Because the nurse is an employee, access to the chart is

allowed. 2. The relationship with the client provides the nurse special

access to the chart. 3. Access to the chart requires a signed release form. 4. The nurse can ask the surgeon to discuss the outcome of

the surgery.

TEST YOUR KNOWLEDGE

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3. “Forgets” to sign out for administration of controlled substances.

4. Offers to administer prn opioids for other nurses’ clients. 5. Is able to say “no” to requests to work more shifts.

10. Which nursing actions could result in professional negligence? Select all that apply. 1. Learns about a new piece of equipment. 2. Forgets to complete the assessment of a client. 3. Does not follow up on client’s complaints. 4. Charts client’s drug allergies. 5. Questions primary care provider about an illegible order.

See Answers to Test Your Knowledge in Appendix A.

8. Following a motor vehicle crash, a nurse stops and offers assistance. Which of the following actions is/are most appropriate? Select all that apply. 1. The nurse needs to know the Good Samaritan Act for the state. 2. The nurse is not held liable unless there is gross negligence. 3. After assessing the situation, the nurse can leave to obtain help. 4. The nurse can expect compensation for helping. 5. The nurse offers to help but cannot insist on helping.

9. The nurse notices that a colleague’s behaviors have changed during the past month. Which behaviors could indicate signs of impairment? Select all that apply. 1. Is increasingly absent from the nursing unit during the shift. 2. Interacts well with others.

Suggested Readings Brous, E. A. (2012). Common misconceptions about profes-

sional licensure. American Journal of Nursing,112(10), 55–59. doi:10.1097/01.NAJ.0000421027.92789.95

Brous, E. A. (2012). Professional licensure: Investigation and disciplinary action. American Journal of Nursing,112(11), 53–60. doi:10.1097/01.NAJ.0000422256.95706.9b

Brous, E. A. (2012). Professional licensure protection strategies. American Journal of Nursing,112(12), 43–47. doi:10.1097/01.NAJ.0000423512.68887.8d The author of this three-part series is a nurse attorney. Part 1 discusses misconceptions nurses commonly have about licensure; Part 2 discusses common reasons boards of nursing conduct investigations and take disciplinary action; and Part 3 reviews strategies for protecting the nursing license.

Koh, H. K., Berwick, D. M., Clancy, C. M., Baur, C., Brach, C., Harris, L. M., & Zerhusen, E. G. (2012). New federal policy initiatives to boost health literacy can help the nation move beyond the cycle of costly “crisis care.” Health Affairs, 31(2), 434–443. doi:10.1377/hlthaff.2011.1169 The authors provide a comprehensive review of the current status of health literacy among U.S. adults and the needed priority for improving health literacy to promote better health and health care for the nation.

Related Research Cole, C. A. (2012). Implied consent and nursing practice:

Ethical or convenient? Nursing Ethics, 19, 550–557. doi:10.1177/0969733011436028

Tschurtz, B. A., Koss, R. G., Kupka, N. J., & Williams, S. C. (2011). Language services in hospitals: Discordance in availability and staff use. Journal of Healthcare Manage- ment, 56(6), 403–418.

References American Nurses Association. (2010). Guide to the code of

ethics for nurses interpretation and application. Silver Spring, MD: Author.

American Nurses Association. (2011). Principles for social networking and the nurse. Silver Spring, MD: Author.

American Nurses Association. (2012). Nursing care and do not resuscitate (DNR) and allow natural death (AND) deci- sions. Revised position statement. Retrieved from http:// nursingworld.org/dnrposition

Brous, E. (2012). Common misconceptions about professional licensure. American Journal of Nursing, 112(10), 55–59. doi:10.1097/01.NAJ.0000421027.92789.95

Darbro, N., & Malliarakis, K. D. (2012). Substance abuse: Risk factors and protective factors. Journal of Nursing Regulation, 3(1), 44–48.

Delamont, A. (2013). How to avoid the top seven nursing errors. Nursing Made Incredibly Easy!, 11(2), 8–10. doi:10.1097/01.NME.0000426302.88109.4e

Equal Employment Opportunity Commission. (2000). Guidelines on discrimination because of sex (Section

1604.11, Sexual harassment. Code of Federal Regula- tions, Title 29, Vol. 4). Retrieved from http://www.ecfr.gov/ cgi-bin/text-idx?c=ecfr&SID=08e7cb0e14fbc6fa1607e54 c8b77db5b&rgn=div8&view=text&node=29:4.1.4.1.5.0.2 1.11&idno=29

Guido, G. W. (2014). Legal and ethical issues in nursing (6th ed.). Upper Saddle River, NJ: Pearson.

Institute of Medicine. (2012). The role of telehealth in an evolving health care environment: Workshop summary. Washington, DC: National Academies Press.

International Medical Interpreters Association. (2013). Standards of practice. Retrieved from http://www.imiaweb .org/standards/standards.asp

Intervention Project for Nurses. (2013). Intervention project for nurses. Retrieved from http://www.ipnfl.org

Leclercq, W. K., Keulers, B. J., Scheltinga, M. R., Spauwen, P. H., & Van der Will, G. J. (2010). A review of surgical informed consent: Past, present, and future. A quest to help patients make better decisions. World Journal of Surgery, 34, 1406–1415. doi:10.1007/s00268-010-0542-0

Minnesota Department of Health Refugee Health Program. (2010). Minnesota refugee health provider guide— Chapter 11—Working with medical interpreters. Retrieved from http://www.health.state.mn.us/divs/idepc/refugee/ guide/11interpreters.html

National Council of State Boards of Nursing. (n.d.). Joint state- ment on delegation. Retrieved from https://www.ncsbn .org/Delegation_joint_statement_NCSBN-ANA.pdf

National Council of State Boards of Nursing. (2011). White paper: A nurse’s guide to the use of social media. Chicago, IL: Author.

National Council of State Boards of Nursing. (2014a). Nurse Licensure Compact frequently asked questions. Retrieved from https://www.ncsbn.org/2002.htm

National Council of State Boards of Nursing. (2014b). Nurse licen- sure compact. Retrieved from https://www.ncsbn.org/nlc.htm

National Licensure Compact Administrators. (2010). NLCA annual report: Oct. 1, 2009–Sept. 30, 2010. Retrieved from https://www.ncsbn.org/NLCA_AnnualReport_2010.pdf

National Licensure Compact Administrators. (2011). NLCA 2011 annual report. Retrieved from https://www.ncsbn .org/NLCA_AnnualReport_2011_web.pdf

National Licensure Compact Administrators. (2012). APRN (advanced practice nurse) licensure compact. Retrieved from https://www.ncsbn.org/APRN_Compact_hx_ timeline_April_2012_(2).pdf

Oregon Public Health Division. (2012). Oregon’s death with dignity act—2012. Retrieved from http://public.health .oregon.gov/ProviderPartnerResources/EvaluationResearch/ DeathwithDignityAct/Documents/year15.pdf

Painter, L. M., & Dudjak, L. A. (2010). Actions, behaviors, and characteristics of RNs involved in compensable injury. Jour- nal of Nursing Administration, 40, 534–539. doi:10.1097/ NNA.0b013e3181fc19eb

Reising, D. L. (2012). Make your nursing care malpractice- proof. American Nurse Today, 7(1), 24–28.

Richardson, V. (2013). Patient comprehension of informed consent. Journal of Perioperative Practice, 23(1), 26–30.

Servodidio, C. A. (2011). Alcohol abuse in the workplace and patient safety. Clinical Journal of Oncology Nursing, 15(2), 143–145. doi:10.1188/11.CJON.143-145

Texas Nurses Association. (2013). Warning sign: Clues to nurses with problems. Retrieved from http://www .texasnurses.org/displaycommon.cfm?an= 1&subarticlenbr=103

U.S. Department of Health and Human Services. (n.d.). Plain language: A promising strategy for clearly communicating health information and improving health literacy. Retrieved from http://www.health.gov/communication/literacy/ plainlanguage/PlainLanguage.htm#top

U.S. Department of Health and Human Services, Office of Minority Health. (2007). National standards on culturally and linguistically appropriate services (CLAS). Retrieved from http://minorityhealth.hhs.gov/templates/browse .aspx?lvl=2&lvlID=15

Selected Bibliography Arizona State Board of Nursing Regulatory Journal. (2010).

Nurse licensure compact—Sharing the realities. Retrieved from https://ncsbn.org/AZBN_Journal_NLC_ edition_12_1_10.pdf

Buppert, C. (2012). When does a nurse need a lawyer? Medscape. Retrieved from http://www.medscape.com/ viewarticle/760437

Buppert, C. (2012). When is gossip a HIPAA violation? Medscape. Retrieved from http://www.medscape.com/ viewarticle/766976

Cook, L. (2013). Can nurses trust nurses in recovery reentering the workplace? Nursing, 43(3), 21–24. doi:10.1097/01 .NURSE.0000427092.87990.86

Cummings, S. (2012). How to tell whether patients can make decisions about their care. Emergency Nurse, 20(5), 22–26.

Hicks, D. (2012). Cultural competence and the Hispanic population. Medsurg Nursing, 21, 314–315.

Mitchell, M. (2011). An analysis of common arguments against advance directives. Nursing Ethics, 19(2), 245–251. doi:10.1177/0969733011416398

Monroe, T., & Kenaga, H. (2010). Don’t ask don’t tell: Substance abuse and addiction among nurses. Journal of Clinical Nursing, 20, 504–509. doi:10.1111/j.1365-2702.2010.03518.x

Orozco, E. (2012). Understanding the culturally and linguisti- cally appropriate services (CLAS) standards. Migrant Health, 29(1), 1–2.

Ward-Smith, P. (2012). Health literacy. Urologic Nursing, 32(3), 168–170.

READINGS AND REFERENCES

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LEARNING OUTCOMES

After completing this chapter, you will be able to: 1. Explain how values, moral frameworks, and codes of ethics

affect moral decisions. 2. Explain how nurses use knowledge of values to make ethical

decisions and to assist clients in clarifying their values. 3. When presented with an ethical situation, identify the moral

issues and principles involved.

INTRODUCTION In their daily work, nurses deal with intimate and fundamental human events such as birth, death, and suffering. They must decide the moral- ity of their own actions when they face the many ethical issues that surround such sensitive areas. Because of the special nurse– client rela- tionship, nurses are the ones who are there to support and advocate for clients and families who are facing difficult choices, and for those who are living the results of choices that others make for and about them.

The present environment of cost containment and the nursing shortage tends to emphasize business values. This creates new moral problems and intensifies old ones, making it more critical than ever for nurses to make sound moral decisions. Therefore, nurses need to (a) develop sensitivity to the ethical dimensions of nursing prac- tice, (b) examine their own and clients’ values, (c) understand how values influence their decisions, and (d) think ahead about the kinds of moral problems they are likely to face. This chapter explores the influences of values and moral frameworks on the ethical dimensions of nursing practice and on the nurse’s role as a client advocate.

VALUES Values are enduring beliefs or attitudes about the worth of a person, object, idea, or action. Values are important because they influence decisions and actions, including nurses’ ethical decision making. Even though they may be unspoken and perhaps even unconsciously held, questions of value underlie all moral dilemmas. Of course, not all values are moral values. For example, people hold values about work, family, religion, politics, money, and relationships. Values are often taken for granted. In the same way that people are not aware

of their breathing, they usually do not think about their values; they simply accept them and act on them.

People organize their values internally along a continuum from most important to least important, forming a value system. Value systems are basic to a way of life, give direction to life, and form the basis of behavior—especially behavior that is based on decisions or choices.

Beliefs and attitudes are related, but not identical, to values. Peo- ple have many different beliefs and attitudes, but a smaller number of values. Beliefs (or opinions) are interpretations or conclusions that people accept as true. They are based more on faith than fact. Beliefs do not necessarily involve values. For example, the statement “If I study hard I will get a good grade” expresses a belief that does not involve a value. By contrast, the statement “Good grades are really important to me. I must study hard to obtain good grades” involves both a value and a belief.

Attitudes are mental positions or feelings toward a person, ob- ject, or idea (e.g., acceptance, compassion, openness). Typically, an at- titude lasts over time, whereas a belief may last only briefly. Attitudes are often judged as bad or good, positive or negative, whereas beliefs are judged as correct or incorrect. Attitudes have thinking and behav- ioral aspects. Attitudes vary greatly among individuals. For example, some clients may feel strongly about their need for privacy, whereas others may dismiss it as unimportant.

Values Transmission Values are learned through observation and experience. As a result, they are heavily influenced by a person’s sociocultural environment— that is, by societal traditions; by cultural, ethnic, and religious groups; and by family and peer groups. For example, if a parent consistently

KEY TERMS

accountability, 77 active euthanasia, 82 advocate, 83 assisted suicide, 82 attitudes, 73 autonomy, 76 beliefs, 73 beneficence, 76 bioethics, 75

code of ethics, 78 consequence-based

(teleological) theories, 76

ethics, 75 fidelity, 77 justice, 77 moral development, 76 moral distress, 79

moral rules, 76 morality, 75 nonmaleficence, 76 nursing ethics, 75 passive euthanasia, 82 personal values, 74 principles-based

(deontological) theories, 76 professional values, 74

relationships-based (caring) theories, 76

responsibility, 77 utilitarianism, 76 utility, 76 value system, 73 values, 73 values clarification, 74 veracity, 77

5 Values, Ethics, and Advocacy

4. Discuss common ethical issues currently facing health care professionals.

5. Discuss the advocacy role of the nurse.

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One widely used theory of values clarification was developed by Raths, Harmin, and Simon (1978). They described a “valuing pro- cess” of thinking, feeling, and behavior that they termed “choosing,” “prizing,” and “acting” (Box 5–2). In some cases, a values clarification exercise can be useful in helping individuals or groups to become more aware of their values and how they may influence their actions. For example, asking a client to agree or disagree with a list of state- ments or to rank in order of importance a list of beliefs can assist the nurse and client to make the client’s values more open so they can be considered in planning the client’s care.

CLARIFYING THE NURSE’S VALUES Nurses and nursing students need to reflect on the values they hold about life, death, health, and illness. Nurses hold both per- sonal and professional values. One strategy for gaining awareness of personal values is to consider attitudes about specific issues such as abortion or euthanasia, asking: “Can I accept this, or live with this?” “What would I do or want done in this situation?” As is true with all people, nurses’ values are influenced by culture, education, and age. However, research shows that fundamental professional nursing values of human dignity, equality, and pre- vention of suffering have not varied over time or across groups (Snellman & Gedda, 2012).

CLARIFYING CLIENT VALUES To plan effective client-centered care, nurses need to identify clients’ values as they influence and relate to a particular health problem. For example, a client with failing eyesight will probably place a high value on the ability to see, and a client with chronic pain will value comfort. Normally, people take such things for granted. For informa- tion about health beliefs and practices, see Chapter 17 . The nurse should never assume that the client has any particular values. Rather,

demonstrates honesty in dealing with others, the child will probably begin to value honesty. Historically, American values reflected the influence of original settlers, who originated from a limited number of countries. In a classic essay, members of the Washington Interna- tional Center identified 13 U.S. values that differed significantly from the traditional values of residents from other countries (Kohls, 1984). For example, Americans place less value on the past than on the fu- ture, whereas in other countries, the past and present are the most important perspectives.

Nurses should keep in mind the influence of values on health (see Chapter 17 ). For example, some cultures value treatment by a folk healer over that by a physician. For additional information about cultural values related to health and illness, see Chapter 18 .

PERSONAL VALUES Although people derive values from society and their individual subgroups, they internalize some or all of these values as personal values. People need societal values to feel accepted, and they need personal values to have a sense of individuality.

PROFESSIONAL VALUES Nurses’ professional values are acquired during socialization into nursing from codes of ethics, nursing experiences, teachers, and peers. The American Association of Colleges of Nursing (2008) iden- tified five values essential for the professional nurse: altruism, auton- omy, human dignity, integrity, and social justice (Box 5–1).

Values Clarification Values clarification is a process by which people identify, examine, and develop their own individual values. A principle of values clarifi- cation is that no one set of values is right for everyone. When people can identify their values, they can retain or change them and thus act based on freely chosen, rather than unconscious, values. Values clari- fication promotes personal growth by fostering awareness, empathy, and insight. Therefore, it is an important step for nurses to take in dealing with ethical problems.

BOX 5–1

Altruism is a concern for the welfare and well-being of others. In professional practice, altruism is reflected by the nurse’s concern for the welfare of patients, other nurses, and other health care providers.

Autonomy is the right to self-determination. Professional practice reflects autonomy when the nurse respects patients’ rights to make decisions about their health care.

Human dignity is respect for the inherent worth and uniqueness of individuals and populations. In professional practice, human dignity is reflected when the nurse values and respects all patients and colleagues.

Integrity is acting in accordance with an appropriate code of ethics and accepted standards of practice. Integrity is re- flected in professional practice when the nurse is honest and provides care based on an ethical framework that is accepted within the profession.

Social justice is acting in accordance with fair treatment regardless of economic status, race, ethnicity, age, citizenship, disability, or sexual orientation.

From The Essentials of Baccalaureate Education for Professional Nursing Practice (pp. 27–28), American Association of Colleges of Nursing, 2008, Washington, DC: Author. Reprinted with permission.

Essential Nursing Values BOX 5–2

Choosing (Cognitive) Beliefs are chosen • Freely, without outside pressure • From among alternatives • After reflecting and considering

consequences. Example: A person learns about energy resources, production, and consumption; the greenhouse effect; and other environmental issues, including ways to minimize use of and to recycle limited resources.

Prizing (Affective) Chosen beliefs are prized and cherished.

Example: The person is proud of the belief that he or she has an obligation to participate in some way in reducing environmental waste.

Acting (Behavioral) Chosen beliefs are • Affirmed to others • Incorporated into one’s behavior • Repeated consistently in one’s life.

Example: The person participates in the city recycling program for household waste, uses public transportation rather than driving a personal car when possible, helps organize recycling in the work- place, and is active in legislative and political activities related to environmental issues. From Values and Teaching: Working with Values in the Classroom, 2E, by L. Raths, J. Harmin, and S. Simon. Published by C. E. Merrill Publishing Company, 1978. Used by permission of James Raths.

Values Clarification

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TABLE 5–1 Behaviors That May Indicate Unclear Values

Behavior Example

Ignoring a health professional’s advice A client with heart disease who values hard work ignores advice to exercise regularly.

Inconsistent communication or behavior A pregnant woman says she wants a healthy baby, but continues to drink alcohol and smoke tobacco.

Numerous admissions to a health agency for the same problem

A middle-aged obese woman repeatedly seeks help for back pain but does not lose weight.

Confusion or uncertainty about which course of action to take

A woman wants to obtain a job to meet financial obligations, but also wants to stay at home to care for an ailing husband.

the nurse explores client values through discussion. As described in the QSEN competencies, the client’s values, and thus their prefer- ences, are assessed and used in each step of nursing care, including the communication of these values to other members of the health care team (Cronenwett et al., 2007). When it seems as if clients hold unclear or conflicting values that are detrimental to their health, the nurse should use values clarification as an intervention. Examples of behaviors that may indicate the need for clarification of health values are listed in Table 5–1.

The following process may help clients clarify their values:

1. List alternatives. Make sure that the client is aware of all alterna- tive actions. Ask “Are you considering other courses of action?” “Tell me about them.”

2. Examine possible consequences of choices. Make sure the client has thought about possible results of each action. Ask “What do you think you will gain from doing that?” “What benefits do you foresee from doing that?”

3. Choose freely. To determine whether the client chose freely, ask “Did you have any say in that decision?” “Do you have a choice?”

4. Feeling about the choice. Some clients may not feel satisfied with their decision. A sensitive question may be “Some people feel good after a decision is made; others feel bad. How do you feel?”

5. Affirm the choice. Ask “How will you discuss this with others (family, friends)?”

6. Act with a pattern. To determine whether the client consistently behaves in a certain way, ask “How many times have you done that before?” or “Would you act that way again?”

When implementing these steps to clarify values, the nurse assists the client to think each question through, but does not impose personal values. The nurse rarely, if ever, offers an opinion when the client asks for it—and then only with great care or when the nurse is an expert in the content area. Because each situation is different, what the nurse would choose in his or her own life may not be relevant to the client’s circumstances. Thus, if the client asks the nurse “What would you have done in my situation?” it is best to redirect the question back to the client rather than answering from the nurse’s personal view.

ETHICS AND MORALITY The term ethics has several meanings in common use. It refers to (a) a method of inquiry that helps people to understand the morality of human behavior (i.e., it is the study of morality), (b) the practices or beliefs of a certain group (e.g., medical ethics, nursing ethics), and (c) the expected standards of moral behavior of a particular group as described in the group’s formal code of professional ethics. Nurses

have been viewed as the most honest and ethical professionals in U.S. Gallup polls every year since 1999 except when firefighters ranked first shortly after the September 11, 2001, terrorist attacks (Newport, 2012). Bioethics is ethics as applied to human life or health (e.g., to deci- sions about abortion or euthanasia). Nursing ethics refers to ethical issues that occur in nursing practice. The American Nurses Associa- tion (ANA) has updated its Nursing: Scope and Standards of Practice (2010) publication, which holds nurses accountable for their ethical conduct. Professional Performance Standard 7 relates to ethics. The current edition of this standard was significantly expanded to include greater emphasis on nurse advocacy and professional responsibility.

Morality (or morals) is similar to ethics, and many people use the terms interchangeably. Morality usually refers to private, per- sonal standards of what is right and wrong in conduct, character, and attitude. Sometimes the first clue to the moral nature of a situation is an active conscience or an awareness of feelings such as guilt, hope, or shame. Another indicator is the tendency to respond to the situation with words such as ought, should, right, wrong, good, and bad. Moral issues are concerned with important social values and norms; they are not about trivial things.

Nurses should distinguish between morality and law. Laws re- flect the moral values of a society, and they offer guidance in deter- mining what is moral. However, an action can be legal but not moral. For example, an order for full resuscitation of a dying client is legal, but one could still question whether the act is moral. On the other hand, an action can be moral but illegal. For example, if a child at home stops breathing, it is moral but not legal to exceed the speed limit when driving to the hospital. Legal aspects of nursing practice are covered in Chapter 4 .

Nurses should also distinguish between morality and religion as they relate to health practices, although the two concepts are related. For example, according to some religious beliefs, women should un- dergo procedures such as female circumcision that may cause physi- cal mutilation. Other religions or groups may consider this practice to be an ethical violation of the human right to self-determination. Additional common instances of differences in moral perspectives on health involving religious beliefs include blood transfusions, abortion, sterilization, and contraceptive and safer sex counseling.

CLINICAL ALERT!

Many Chinese people are members of either the Confucian or the Buddhist religion. Confucian religious beliefs do not consider a fetus a human being. However, Buddhists believe the fetus is a form of human life. As a result, Chinese people may vary in their views on abortion, depending on their religious affiliation.

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even feel guilty later.” Using principles-based reasoning, Nurse B thinks, “This violates the principle of autonomy. This man has a right to decide what happens to his body.” Using caring-based reasoning, Nurse C thinks, “My relationship to this client commits me to protect- ing him and meeting his needs, and I feel such compassion for him. I must try to help the family understand that he needs their support.” Each of these perspectives is based on the nurse’s moral framework.

Moral Principles Moral principles are statements about broad, general, philosophical concepts such as autonomy and justice. They provide the foundation for moral rules, which are specific prescriptions for actions. For ex- ample, the rule “Do not lie” is based on the moral principle of respect for persons (autonomy). Principles are useful in ethical discussions because even if people disagree about which action is right in a situ- ation, they may be able to agree on the principles that apply. Such an agreement can serve as the basis for a solution that is acceptable to all parties. For example, most people would agree to the principle that nurses are obligated to respect their clients, even if they disagree as to whether the nurse should deceive a particular client about his or her prognosis.

Autonomy refers to the right to make one’s own decisions. Nurses who follow this principle recognize that each client is unique, has the right to be who that individual is, and has the right to choose personal goals. People have “inward autonomy” if they have the abil- ity to make choices; they have “outward autonomy” if their choices are not limited or imposed by others.

Honoring the principle of autonomy means that the nurse re- spects a client’s right to make decisions even when those choices seem to the nurse not to be in the client’s best interest. It also means treat- ing others with consideration. In a health care setting, this principle is violated, for example, when a nurse disregards clients’ subjective ac- counts of their symptoms (e.g., pain). Finally, respect for autonomy means that people should not be treated as impersonal sources of knowledge or training. This principle comes into play, for example, in the requirement that clients provide informed consent before tests, procedures, or participation in a research project can be carried out. See the discussion of informed consent in Chapter 4 .

Nonmaleficence is the duty to “do no harm.” Although this would seem to be a simple principle to follow, in reality it is complex. Harm can mean intentionally causing harm, placing someone at risk of harm, and unintentionally causing harm. In nursing, intentional harm is never acceptable. However, placing a person at risk of harm has many facets. A client may be at risk of harm as a known conse- quence of a nursing intervention that is intended to be helpful. For example, a client may react adversely to a medication. Unintentional harm occurs when the risk could not have been anticipated. For ex- ample, while catching a client who is falling, the nurse grips the client tightly enough to cause bruises to the client’s arm. Caregivers do not always agree on the degree of risk that is morally permissible in order to attempt the beneficial result.

Beneficence means “doing good.” Nurses are obligated to do good, that is, to implement actions that benefit clients and their support persons. However, doing good can also pose a risk of doing harm. For example, a nurse may advise a client about a strenuous ex- ercise program to improve general health, but should not do so if the client is at risk of a heart attack.

Moral Development Ethical decisions require persons to think and reason. Reason- ing is a cognitive function and is, therefore, developmental. Moral development is the process of learning to tell the difference be- tween right and wrong and of learning what ought and ought not to be done. It is a complex process that begins in childhood and con- tinues throughout life.

Theories of moral development attempt to answer questions such as these: How does a person become moral? What factors influ- ence the way a person behaves in a moral situation? Two well-known theorists of moral development are Lawrence Kohlberg (1969) and Carol Gilligan (1982). Kohlberg’s theory emphasizes rights and for- mal reasoning; Gilligan’s theory emphasizes care and responsibility, although it points out that people use the concepts of both theorists in their moral reasoning. For a full discussion of these two theories, see Chapter 20 .

Moral Frameworks Moral theories provide different frameworks through which nurses can view and clarify disturbing client care situations. Nurses can use moral theories in developing explanations for their ethical decisions and actions and in discussing problem situations with others. Three types of moral theories are widely used, and they can be differentiated by their emphasis on (a) consequences, (b) principles and duties, or (c) relationships.

Consequence-based (teleological) theories look to the outcomes (consequences) of an action in judging whether that ac- tion is right or wrong. Utilitarianism, one form of consequentialist theory, views a good act as one that is the most useful—that is, one that brings the most good and the least harm to the greatest number of people. This is called the principle of utility. This approach is often used in making decisions about the funding and delivery of health care. Teleological theories focus on issues of fairness.

Principles-based (deontological) theories involve logical and formal processes and emphasize individual rights, duties, and obligations. The morality of an action is determined not by its conse- quences but by whether it is done according to an impartial, objective principle. For example, following the rule “Do not lie,” a nurse might believe he or she should tell the truth to a dying client, even though the physician has given instructions not to do so. There are many deontological theories; each justifies the rules of acceptable behavior differently.

Relationships-based (caring) theories stress courage, gen- erosity, commitment, and the need to nurture and maintain relation- ships. Unlike the two preceding theories, which frame problems in terms of justice (fairness) and formal reasoning, caring theories (see Chapter 25 ) judge actions according to a perspective of caring and responsibility. Principles-based theories stress individual rights, but caring theories promote the common good or the welfare of the group.

A moral framework guides moral decisions, but it does not de- termine the outcome. Imagine a situation in which a frail, older adult client has made it clear that he does not want further surgery, but the family and surgeon insist. Three nurses have each decided that they will not help with preparations for surgery and that they will work through proper channels to try to prevent it. Using consequence- based reasoning, Nurse A thinks, “Surgery will cause him more suf- fering; he probably will not survive it anyway, and the family may

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accountability means “answerable to oneself and others for one’s own actions” (p. 157), whereas responsibility refers to “the specific accountability or liability associated with the performance of duties of a particular role” (p. 157). Thus, the ethical nurse is able to explain the rationale behind every action and recognize the standards to which he or she will be held.

NURSING ETHICS In the past, nurses looked on ethical decision making as the physi- cian’s responsibility. However, no one profession is responsible for ethical decisions, nor does expertise in one discipline such as medi- cine or nursing necessarily make a person an expert in ethics. As situations become more complex, input from all caregivers becomes increasingly important.

Ethical standards of The Joint Commission (2013) mandate that health care institutions provide ethics committees or a similar structure to write guidelines and policies and to provide education, counseling, and support on ethical issues. These multidisciplinary committees include nurses and can be asked to review a case and provide guidance to a competent client, an incompetent client’s fam- ily, or health care providers. They ensure that the relevant facts of a case are brought out, provide a forum in which diverse views can be

Justice is frequently referred to as fairness. Nurses often face de- cisions in which a sense of justice should prevail. For example, a nurse making home visits finds one client tearful and depressed, and knows she could help by staying for 30 more minutes to talk. However, that would take time from her next client, who has diabetes and needs a great deal of teaching and observation. The nurse will need to weigh the facts carefully in order to divide her time justly among her clients.

Fidelity means to be faithful to agreements and promises. By virtue of their standing as professional caregivers, nurses have re- sponsibilities to clients, employers, government, and society, as well as to themselves. Nurses often make promises such as “I’ll be right back with your pain medication” or “I’ll find out for you.” Clients take such promises seriously, and so should nurses.

Veracity refers to telling the truth. Although this seems straight- forward, in practice, choices are not always clear. Should a nurse tell the truth when it is known that it will cause harm? Does a nurse tell a lie when it is known that the lie will relieve anxiety and fear? Lying to sick or dying people is rarely justified. The loss of trust in the nurse and the anxiety caused by not knowing the truth, for example, usually outweigh any benefits derived from lying.

Nurses must also have professional accountability and respon- sibility. According to the Code of Ethics for Nurses (Fowler, 2010),

Decision support involves helping the client choose among two or more health care options. In this study, Llewellyn-Thomas and Crump (2013) identified the roles that values clarification and prefer- ence elicitation play in the process of clients’ decision support, em- phasizing the importance of effective communication between client and care provider. The authors describe various approaches to val- ues clarification, including direct and indirect, interactive and passive strategies. Decision aids are tools that assist in the clarification and preferences processes. These aids may vary in effectiveness based on the particular kind of decision and on the skill of the health care provider using the aid.

IMPLICATIONS It is the nurse’s responsibility to assist the client in making informed decisions about health care that are consistent with the clients’ values and preferences. Even the most motivated nurse, however, may not have the skills needed to elicit these opinions from the cli- ent. This study presents the breadth of tools available to guide the nurse and also emphasizes the usefulness of such tools in ensur- ing that the result is the client, and not the health care provider’s, decision.

Evidence-Based Practice What Is the Best Way to Determine Clients’ Values and Preferences When Assisting in Health Care Decision Making? EVIDENCE-BASED PRACTICE

Moral Principles

Moral principles are commonly accepted as universal. However, the principles that guide bioethics are rooted in a secular Western European perspective. Thus, there is often conflict in creating a fit between these principles and the guiding moral principles of vari- ous cultural groups. Religious groups (such as Catholics, Jehovah’s

Principle Examples of Ethnic/Cultural Variations

Autonomy The client/family may expect the healthcare provider to respect their right to refuse a treatment. Primary responsibility for decision making may rest with others, such as the family, elders, or religious community. The family and community are viewed as affected by the client’s condition and decisions as much as the individual is affected.

Veracity Clients may not value truth-telling for life-threatening conditions, because this may eliminate hope and, therefore, hasten death. Family members may request that the client not be told of his or her diagnosis.

Nonmaleficence Discussion of advance directives and issues such as cardiopulmonary resuscitation may be viewed as physically and emotionally harmful to the client. Withdrawal of life support or withdrawal of futile or damaging treatments may be seen as decreasing length of life or hastening death.

Beneficence The client/family may expect health care providers to promote client well-being and hope, and provide treatment that will help prolong life.

PATIENT-CENTERED CARECulturally Responsive Care

Witnesses, and Muslims) and ethnic groups (such as African, Asian, and Latin American) may hold different views from those of health care providers. Nurses must be familiar with each of these principles as it relates to ethical decision making, in addition to gaining an understanding of the client’s moral principles.

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expressed, provide support for caregivers, and can reduce the insti- tution’s legal risks. In some settings, ethics rounds are held. In these meetings, ethical dilemmas from real or simulated cases are presented from a theoretical perspective, introducing those present to the issues and processes used in analyzing such dilemmas (Figure 5–1 •).

Nursing Codes of Ethics A code of ethics is a formal statement of a group’s ideals and values. It is a set of ethical principles that (a) is shared by members of the group, (b) reflects their moral judgments over time, and (c) serves as a standard for their professional actions. Codes of ethics usually have higher requirements than legal standards, and they are never lower than the legal standards of the profession. Nurses are responsible for being familiar with the code that governs their practice.

International, national, and state nursing associations have es- tablished codes of ethics. The International Council of Nurses (ICN) first adopted a code of ethics in 1953, and the most recent revi- sion (2012) is shown in Box 5–3. The ANA first adopted a Code for

Figure 5–1 • An ethics committee contemplates all aspects of the case being considered. Ghislain & Marie David de Lossy/Alamy.

BOX 5–3 International Council of Nurses Code of Ethics

PREAMBLE Nurses have four fundamental responsibilities: to promote health,

to prevent illness, to restore health and to alleviate suffering. The need for nursing is universal.

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, colour, creed, culture, disability or illness, gender, sexual orientation, nationality, politics, race or social status.

Nurses render health services to the individual, the family and the community and coordinate their services with those of related groups.

THE ICN CODE The ICN Code of Ethics for Nurses has four principal elements that outline the standards of ethical conduct.

ELEMENTS OF THE CODE 1. Nurses and People

The nurse’s primary professional responsibility is to people requiring nursing care.

In providing care, the nurse promotes an environment in which the human rights, values, customs and spiri- tual beliefs of the individual, family and community are respected.

The nurse ensures that the individual receives accurate, sufficient and timely information in a culturally appropriate manner on which to base consent for care and related treatment. The nurse holds in confidence personal information and uses judgement in sharing this information.

The nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations.

The nurse advocates for equity and social justice in resource allocation, access to health care, and other social and economic services.

The nurse demonstrates professional values such as respectfulness, responsiveness, compassion, trustworthiness, and integrity.

2. Nurses and Practice The nurse carries personal responsibility and accountability

for nursing practice, and for maintaining competence by continual learning.

The nurse maintains a standard of personal health such that the ability to provide care is not compromised.

The nurse uses judgement regarding individual competence when accepting and delegating responsibility.

The nurse at all times maintains standards of personal conduct which reflect well on the profession and enhance public confidence.

The nurse, in providing care, ensures that use of technology and scientific advances are compatible with the safety, dignity and rights of people.

The nurse strives to foster and maintain a practice culture promoting ethical behaviour and open dialogue.

3. Nurses and the Profession The nurse assumes the major role in determining and

implementing acceptable standards of clinical nursing practice, management, research and education.

The nurse is active in developing a core of research-based professional knowledge.

The nurse is active in developing and sustaining a core of professional values.

The nurse, acting through the professional organization, participates in creating and maintaining safe, equitable social and economic working conditions in nursing.

The nurse practices to sustain and protect the natural environment and is aware of its consequences on health.

The nurse contributes to an ethical organisational environment and challenges unethical practices and settings.

4. Nurses and Co-workers The nurse sustains a co-operative relationship with coworkers

in nursing and other fields. The nurse takes appropriate action to safeguard individuals,

families and communities when their health is endangered by a coworker or any other person.

The nurse takes appropriate action to support and guide coworkers to advance ethical conduct.

From The ICN Code of Ethics for Nurses, International Council of Nurses, 2012, Geneva, Switzerland: Imprimerie Fornara. Reprinted with permission.

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ensure clients receive care and are not abandoned, and feeling loyalty to the hospital employer.

Making Ethical Decisions Many nursing problems are not moral problems at all, but simply questions of good nursing practice. An important first step in ethical decision making is to determine whether a moral situation exists. The following criteria may be used:

• A difficult choice exists between actions that conflict with the needs of one or more persons.

• Moral principles or frameworks exist that can be used to provide some justification for the action.

• The choice is guided by a process of weighing reasons. • The decision must be freely and consciously chosen. • The choice is affected by personal feelings and by the particular

context of the situation.

Responsible ethical reasoning is rational and systematic. It should be based on ethical principles and codes rather than on emo- tions, intuition, fixed policies, or precedent (that is, an earlier similar occurrence). A variety of decision-making models are available that are compatible with the nursing process. Each institution adopts its own set of steps for making formal ethical decisions, but each nurse also benefits from having an organizing framework for analyzing ethical issues.

A good decision is one that is in the client’s best interest and at the same time preserves the integrity of all involved. Nurses have ethical obligations to their clients, to the agency that employs them, and to primary care providers. Therefore, nurses must weigh competing factors when making ethical decisions. See Box 5–4 for examples.

Although ethical reasoning is principle based and has the client’s well-being at center, being involved in ethical problems and dilemmas is stressful for the nurse. The nurse may feel torn between obligations to the client, the family, and the employer. What is in the client’s best interest may be contrary to the nurse’s personal belief system. This conflict is referred to as moral distress and is considered a serious issue in the workplace. Wocial and Weaver (2012) created an easy- to-use instrument that measures hospital nurses’ level of moral dis- tress. Another method to assist nurses in coping with moral distress is using the four steps of The 4A’s to Rise Above Moral Distress: ask, af- firm, assess, act (American Association of Critical-Care Nurses, n.d.). Using this model, the nurse asks whether signs of moral distress are present, affirms a commitment to addressing the distress, assesses the sources and severity of the distress plus readiness to act, and acts to

Nurses in 1950. The current version reflects several major changes in the code (now called the Code of Ethics for Nurses). A statement on compassion has been added, and the duty to protect clients has been broadened to include all client rights.

Nursing codes of ethics have the following purposes:

1. Inform the public about the minimum standards of the profes- sion and help them understand professional nursing conduct.

2. Provide a sign of the profession’s commitment to the public it serves.

3. Outline the major ethical considerations of the profession. 4. Provide ethical standards for professional behavior. 5. Guide the profession in self-regulation. 6. Remind nurses of the special responsibility they assume when

caring for the sick.

Origins of Ethical Problems in Nursing Nurses’ growing awareness of ethical problems has occurred largely because of (a) social and technologic changes and (b) nurses’ conflict- ing loyalties and obligations.

SOCIAL AND TECHNOLOGIC CHANGES Social changes, such as the women’s movement and a growing con- sumerism, also expose problems. The large number of people with- out health insurance, the high cost of health care, and workplace redesign under managed care all raise issues of fairness and allocation of resources.

Technology creates new issues that did not exist in earlier times. Before monitors, respirators, and parenteral feedings, there was no question about whether to “allow” an 800-gram premature infant to die. Before organ transplantation, death did not require a legal defi- nition that permits viable tissues to be removed and given to other living persons. Advances in the ability to decode and control the growth of tissues through gene manipulation present new poten- tial ethical dilemmas related to cloning organisms and altering the course of hereditary diseases and biologic characteristics. Today, with treatments that can prolong and enhance biologic life, these questions arise: Should we do what we know we can? Who should be treated—everyone, only those who can pay, only those who have a chance to improve?

CONFLICTING LOYALTIES AND OBLIGATIONS Because of their unique position in the health care system, nurses experience conflicts among their loyalties and obligations to clients, families, primary care providers, employing institutions, and licens- ing bodies. Client needs may conflict with institutional policies, pri- mary care provider preferences, needs of the client’s family, or even laws of the state. According to the nursing code of ethics, the nurse’s first loyalty is to the client. However, it is not always easy to deter- mine which action best serves the client’s needs. For instance, the nurse may be aware that marijuana has been shown to be effective for a condition a client has that has not responded to mainstream therapies. Although legal issues are involved, the nurse must deter- mine if, ethically, the client should be made aware of a potentially effective alternative. Another example is individual nurses’ decisions regarding honoring picket lines during employee strikes. The nurse may experience conflict among feeling the need to support cowork- ers in their efforts to improve working conditions, feeling the need to

Examples of Nurses’ Obligations in Ethical Decision MakingBOX 5–4

• Maximize the client’s well-being. • Balance the client’s need for autonomy with family members’

responsibilities for the client’s well-being. • Support each family member and enhance the family support

system. • Carry out hospital policies. • Protect other clients’ well-being. • Protect the nurse’s own standards of care.

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Strategies to Enhance Ethical Decisions and Practice Several strategies help nurses overcome possible organizational and social constraints that may hinder the ethical practice of nursing and create moral distress for nurses. You as a nurse should do the following:

• Become aware of your own values and the ethical aspects of nursing.

• Be familiar with nursing codes of ethics. • Seek continuing education opportunities to stay knowledgeable

about ethical issues in nursing. • Respect the values, opinions, and responsibilities of other health

care professionals that may be different from your own. • Participate in or establish ethics rounds. Ethics rounds use hypo-

thetical or real cases that focus on the ethical dimensions of client care rather than the client’s clinical diagnosis and treatment.

• Serve on institutional ethics committees. • Strive for collaborative practice in which nurses function effec-

tively in cooperation with other health care professionals.

SPECIFIC ETHICAL ISSUES Some of the ethical problems nurses encounter most frequently are issues in the care of clients with HIV/AIDS, abortion, organ or tis- sue transplantation, end-of-life decisions, cost-containment issues that jeopardize client welfare and access to health care (resource al- location), and breaches of client confidentiality (e.g., computerized information management).

Acquired Immunodeficiency Syndrome (AIDS) Because of its association with sexual behavior, illicit drug use, and physical decline and death, AIDS bears a social stigma. According to an ANA position statement, the moral obligation to care for a client with HIV infection cannot be set aside unless the risk exceeds the re- sponsibility (ANA, 2006).

Other ethical issues center on testing for HIV status and for the presence of AIDS in health professionals and clients. Questions arise as to whether testing of all providers and clients should be mandatory or voluntary and whether test results should be released to insurance companies, sexual partners, or caregivers. As with all ethical dilem- mas, each possibility has both positive and negative implications for specific individuals.

Abortion Abortion is a highly publicized issue about which many people feel very strongly. Debate continues, pitting the principle of sanctity of life against the principle of autonomy and a woman’s right to control her own body. This is an especially volatile issue because no public con- sensus has yet been reached.

Most state laws have provisions known as conscience clauses that permit individual primary care providers and nurses, as well as institutions, to refuse to assist with an abortion if doing so vio- lates their religious or moral principles. However, nurses have no right to impose their values on a client. Nursing codes of ethics support clients’ rights to information and counseling in making decisions.

implement a plan to reduce the distress. In settings in which ethical issues arise frequently, nurses should establish support systems such as team conferences and use of counseling professionals to allow ex- pression of their feelings.

One structure that may be useful to nurses in ethical decision making is the Four Topic or Four Box method (Jonsen, Siegler, & Winslade, 2010). This structure provides questions that guide the nurse in gathering all relevant information in the four topics/boxes: medical indications, patient preferences, quality of life, and contex- tual features. Once the data have been collected, ethical principles such as autonomy, nonmaleficence, beneficence, and justice are re- viewed against the data to reach a decision or resolution (Butts & Rich, 2013).

Although the nurse’s input is important, in reality several people are usually involved in making an ethical decision. The client, family, spiritual support persons, and other members of the health care team work together in reaching ethical decisions (Figure 5–2 •). There- fore, collaboration, communication, and compromise are important skills for health professionals. When nurses do not have the auton- omy to act on their moral or ethical choices, compromise becomes essential.

CLINICAL ALERT!

Ethical behavior is contextual—what is an ethical action or decision in one situation may not be ethical in a different situation.

Box 5–5 presents an example of an approach to ethical decision making for a specific clinical case.

Addressing moral distress is consistent with the Quality and Safety Education for Nurses patient-centered care attitude competencies: “Acknowledge the tension that may exist between patient rights and the organizational responsibility for professional, ethical care. Appre- ciate shared decision making with empowered patients and families, even when conflicts occur” (Cronenwett et al., 2007, p. 124).

Figure 5–2 • When there is a need for ethical decisions or client advocacy, many different individuals contribute to the final outcome. Photo Network/Alamy.

SAFETY ALERT! SAFETY

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BOX 5–5

SITUATION Mrs. L., a 67-year-old woman, is hospitalized with multiple fractures and lacerations caused by an automobile collision. Her husband, who was killed in the collision, was taken to the same hospital. Mrs. L., who had been driving the automobile, constantly questions her nurse about her husband. The surgeon has told the nurse not to

tell Mrs. L. about the death of her husband; however, the surgeon does not give the nurse any reason for these instructions. The nurse expresses concern to the charge nurse, who says the surgeon’s orders must be followed—that the surgeon will decide when Mrs. L. should be told. However, the nurse is not comfortable with this and wonders what should be done.

Application of a Bioethical Decision-Making Model

Nursing Actions Considerations

1. Identify the moral aspects. See the criteria provided on page 79 to determine whether a moral situation exists.

Alternative actions are to tell the truth or withhold it. The moral principles involved are honesty and loyalty. These principles conflict because the nurse wants to be honest with Mrs. L. without being disloyal to the surgeon and the charge nurse. The nurse weighs reasons in making a freely and consciously chosen choice. The choice will be affected by feelings of concern for Mrs. L. and a context that includes the surgeon’s incomplete communication with the client and the nurse.

2. Gather relevant facts that relate to the issue.

Data should include information about the client’s health problems. Determine who is involved, the nature of their involvement, and their motives for acting. In this case, the people involved are the client (who is concerned about her husband), the husband (who is deceased), the surgeon, the charge nurse, and the primary nurse. Motives are not known. Perhaps the nurse wishes to protect the therapeutic relationship with Mrs. L.; possibly the surgeon believes this action protects Mrs. L. from psychological trauma and consequent physical deterioration.

3. Determine ownership of the decision. For example, for whom is the decision being made? Who should decide and why?

In this case, the decision is being made for Mrs. L. The surgeon obviously believes that a physician should be the one to decide, and the charge nurse agrees. It would be helpful if caregivers agreed on criteria for deciding who the decision maker should be.

4. Clarify and apply personal values. We can infer from this situation that Mrs. L. values her husband’s welfare, that the charge nurse values policy and procedure, and that the nurse seems to value a client’s right to have information. The nurse needs to clarify his or her own and the surgeon’s values, as well as confirm the values of Mrs. L. and the charge nurse.

5. Identify ethical theories and principles.

For example, failing to tell Mrs. L. the truth can negate her autonomy. The nurse would uphold the principle of honesty by telling Mrs. L. The principles of beneficence and nonmaleficence are also involved because of the possible effects of the alternative actions on Mrs. L.’s physical and psychological well-being.

6. Identify applicable laws or agency policies.

Because the surgeon simply “gave instructions” rather than an actual order, agency policies might not require the nurse to follow the instructions. The nurse should clarify this with the charge nurse and be familiar with the nurse practice act in that state.

7. Use competent interdisciplinary resources.

In this case, the nurse might consult the literature to find out whether clients are harmed by receiving bad news when they are injured and might also consult with the chaplain.

8. Develop alternative actions and project their outcomes on the client and family. Possibly because of the limited time available for ethical deliberations in the clinical setting, nurses tend to identify two opposing, either–or alternatives (e.g., to tell or not to tell) instead of generating multiple options. This creates a dilemma even when none exists.

Two alternative actions, with possible outcomes, follow (others may also be appropriate): 1. Follow the charge nurse’s advice and do as the surgeon says. Possible outcomes:

(a) Mrs. L. might become anxious and angry when she finds out that information has been withheld from her; or (b) by waiting until Mrs. L. is stronger to give her the bad news, the health care team may avoid harming Mrs. L.’s health.

2. Discuss the situation further with the charge nurse and surgeon, pointing out Mrs. L.’s right to autonomy and information. Possible outcomes: (a) The surgeon acknowledges Mrs. L.’s right to be informed, or (b) the surgeon states that Mrs. L.’s health is at risk and insists that she not be informed until a later time. Regardless of whether the action is congruent with the nurse’s personal value system, Mrs. L.’s best interests take precedence.

9. Apply nursing codes of ethics to help guide actions. (Codes of nursing usually support autonomy and nursing advocacy.)

If the nurse believes strongly that Mrs. L. should hear the truth, then as a client advocate, the nurse should choose to confer again with the charge nurse and surgeon.

10. For each alternative action, iden- tify the risk and seriousness of consequences for the nurse. (Some employers may not support nursing autonomy and advocacy in ethical situations.)

If the nurse tells Mrs. L. the truth without the agreement of the charge nurse and surgeon, the nurse risks the surgeon’s anger and a reprimand from the charge nurse. If the nurse follows the charge nurse’s advice, the nurse will receive approval from the charge nurse and surgeon; however, the nurse risks being seen as unassertive, and the nurse violates a personal value of truthfulness. If the nurse requests a conference, the nurse may gain respect for assertiveness and professionalism, but the nurse risks the surgeon’s annoyance at having the instructions questioned.

Continued on page 82

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BOX 5–5 Application of a Bioethical Decision-Making Model—continued

Nursing Actions Considerations

11. Participate actively in resolving the issue. Recommend actions that can be ethically supported, recognizing that all actions have positive and negative aspects.

The appropriate degree of nursing input varies with the situation. Sometimes nurses participate in choosing what will be done; sometimes they merely support a client who is making the decision. In this situation, if an action cannot be agreed on, the nurse must decide whether this issue is important enough to merit the personal risks involved.

12. Implement the action. The nurse will carry out one of the actions developed in step 8.

13. Evaluate the action taken. Involve the client, family, and other healthcare members in the evaluation, if possible.

The nurse can begin by asking, “Did I do the right thing?” Would the nurse make the same decisions again if the situation were repeated? If the nurse is not satisfied, the nurse can review other alternatives and work through the process again.

Organ and Tissue Transplantation Organs or tissue for transplantation may come from living donors or from donors who have just died. Many living people choose to be- come donors by giving consent under the Uniform Anatomical Gift Act (see Chapter 43 ). Ethical issues related to organ transplanta- tion include allocation of organs, selling of body parts, involvement of children as potential donors, consent, clear definition of death, and conflicts of interest between potential donors and recipients. In some situations, a person’s religious belief may also present conflict. For ex- ample, certain religions forbid the mutilation of the body, even for the benefit of another person.

Individuals’ spiritual beliefs and views on when human life be- gins have an impact on their opinions about stem cell research. The ANA (2007) supports the ethical use of stem cells for research and therapeutic purposes that impact health. This position is slightly different from a previous position statement regarding cloning (ex- act duplication of cells or organisms). Stem cell research is the foun- dation for cell-based therapies in which stem cells are induced to differentiate into the specific cell type required to repair damaged or destroyed cells or tissues. Both embryonic and adult cells are used in this research. Embryonic cells are derived from a 5-day pre- implantation embryo. Adult cells are undifferentiated cells found in differentiated tissue.

End-of-Life Issues The increase in technologic advances and the growing number of older adults have expanded ethical dilemmas. Providing infor- mation and professional assistance, as well as the highest qual- ity of care and caring, is of the utmost importance during the end-of-life period. Some of the most frequent disturbing ethical problems for nurses involve issues that arise around death and dying. These include euthanasia, assisted suicide, termination of life-sustaining treatment, and withdrawing or withholding of food and fluids.

ADVANCE DIRECTIVES Many moral problems surrounding the end of life can be resolved if clients complete advance directives. Presently, all 50 of the United States have enacted advance directive legislation. Advance directives direct caregivers as to the client’s wishes about treatments, providing an ongoing voice for clients when they have lost the capacity to make or communicate their decisions. See Chapter 43 for a full discus- sion of advance directives.

EUTHANASIA AND ASSISTED SUICIDE Euthanasia, a Greek word meaning “good death,” is popularly known as “mercy killing.” Active euthanasia involves actions to bring about the client’s death directly, with or without client consent. An example of this would be the administration of a lethal medication to end the client’s suffering. Regardless of the caregiver’s intent, active euthanasia is forbidden by law and can result in criminal charges of murder.

A variation of active euthanasia is assisted suicide, or giving cli- ents the means to kill themselves if they request it (e.g., providing lethal doses of pills). Some countries or states have laws permitting assisted suicide for clients who are severely ill, who are near death, and who wish to commit suicide. Although some people may disagree with the con- cept, assisted suicide is currently legal in the states of Montana, Oregon, Vermont, and Washington and several countries. In any case, the nurse should recall that legality and morality are not the same thing. Deter- mining whether an action is legal is only one aspect of deciding whether it is ethical. The questions of suicide and assisted suicide are still con- troversial in Western society. The ANA’s position statement on assisted suicide and active euthanasia (2013) states that both active euthanasia and assisted suicide are in violation of the Code of Ethics for Nurses.

Passive euthanasia, more commonly referred to now as with- drawing or withholding life-sustaining therapy (WWLST), involves the withdrawal of extraordinary means of life support, such as re- moving a ventilator or withholding special attempts to revive a client (e.g., giving the client “no code” status) and allowing the client to die of the underlying medical condition. WWLST may be both legally and ethically more acceptable to most people than assisted suicide.

TERMINATION OF LIFE-SUSTAINING TREATMENT Antibiotics, organ transplants, and technologic advances (e.g., ventila- tors) help to prolong life, but not necessarily to restore health. Clients may specify that they wish to have life-sustaining measures withdrawn, they may have advance directives on this matter, or they may appoint a surrogate decision maker. However, it is usually more troubling for health care professionals to withdraw a treatment than to decide ini- tially not to begin it. Nurses must understand that a decision to with- draw treatment is not a decision to withdraw care. Nurses must ensure that sensitive care and comfort measures are given as the client’s illness progresses. When the client is at home, nurses often provide this type of education and support through hospice services (see Chapter 43 for more information regarding hospice and end-of-life care).

It is difficult for families to withdraw treatment, which makes it very important that they fully understand the treatment. They often

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ADVOCACY When people are ill, they are frequently unable to assert their rights as they would if they were healthy. An advocate is one who expresses and defends the cause of another. The health care system is complex, and many clients are too ill to deal with it. If they are to keep from “falling through the cracks,” clients need an advocate to cut through the layers of bureaucracy and help them get what they require. Values basic to client advocacy are shown in Box 5–6. Clients may also advocate for themselves. Today, clients are seeking more self- determination and control over their own bodies.

If a client lacks decision-making capacity, is legally incompe- tent, or is a minor, these rights can be exercised on the client’s behalf by a designated surrogate or proxy decision maker. It is important, however, for the nurse to remember that client control over health decisions is a Western view. In other societies, such decisions may normally be made by the head of the family or another member of the community. The nurse must ascertain the client’s and family’s views and honor their traditions regarding the locus of decision making.

To help make clients’ rights more explicit to both the client and the health care provider, several versions of a patient’s bill of rights have been published by consumer organizations. The most com- monly used was last revised in 2003 by the American Hospital Association into the Patient Care Partnership: Understanding Expec- tations, Rights, and Responsibilities.

The Advocate’s Role The overall goal of the client advocate is to protect clients’ rights. An advocate informs clients about their rights and provides them with the information they need to make informed decisions.

An advocate supports clients in their decisions, giving them full or at least mutual responsibility in decision making when they are capable of it. The advocate must be careful to remain objective and not convey approval or disapproval of the client’s choices. Advocacy requires accepting and respecting the client’s right to decide, even if the nurse believes the decision to be wrong.

In mediating, the advocate directly intervenes on the client’s be- half, often by influencing others. An example of acting on behalf of a client is asking a primary care provider to review with the client the reasons for and the expected duration of therapy because the client says he always forgets to ask the primary care provider.

ADVOCACY IN HOME CARE Although the goals of advocacy remain the same, home care poses unique concerns for the nurse advocate. For example, while in the hospital, people may operate from the values of the nurses and pri- mary care providers. When they are at home, they tend to operate

have misunderstandings about which treatments are life sustaining. Keeping clients and families well informed is an ongoing process, al- lowing them time to ask questions and discuss the situation. It is also essential that they understand that they can reevaluate and change their decision if they wish.

WITHDRAWING OR WITHHOLDING FOOD AND FLUIDS It is generally accepted that providing food and fluids is part of ordi- nary nursing practice and, therefore, a moral duty. However, when food and fluids are administered by tube to a dying client, or are given over a long period to an unconscious client who is not expected to improve, then some consider it to be an extraordinary, or heroic, measure. A nurse is morally obligated to withhold food and fluids (or any treatment) if it is determined to be more harmful to administer them than to withhold them. The nurse must also honor competent and informed clients’ refusal of food and fluids. The ANA Code of Ethics for Nurses (2010) supports this position through the nurse’s role as a client advocate and through the moral principle of autonomy. However, the debate on ethical, legal, personal, and religious grounds continues—especially as it relates to the care of children who are un- able to speak for themselves. In addition, client views on the accept- ability of these actions vary according to culture (Preedy, 2011).

Allocation of Scarce Health Resources Allocation of limited supplies of health care goods and services, including organ transplants, artificial joints, and the services of specialists, has become an especially urgent issue as medical costs continue to rise and more stringent cost-containment measures are implemented. The moral principle of autonomy cannot be applied if it is not possible to give each client what he or she chooses. In this situation, health care providers may use the principle of justice— attempting to choose what is most fair to all.

Nursing care is also a health resource. Most institutions have been implementing “workplace redesign” to cut costs. Some nurses are concerned that staffing in their institutions is not adequate to give the level of care they value. California is the first state to enact legisla- tion mandating specific nurse-to-client ratios in hospitals and other health care settings. With a nationwide shortage of nurses, an ethical dilemma arises when, in order to provide adequate staffing, facilities must turn away needy clients. Nurses must continue to look for ways to balance economics and caring in the allocation of health resources.

Management of Personal Health Information In keeping with the principle of autonomy, nurses are obligated to re- spect clients’ privacy and confidentiality. Privacy is both a legal and ethical mandate. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) includes standards protecting the confidential- ity, integrity, and availability of data, and standards defining appro- priate disclosures of identifiable health information and client rights protection. Clients must be able to trust that nurses will reveal details of their situations only as appropriate and will communicate only the information necessary to provide for their health care. Computerized client records make sensitive data accessible to more people and ac- cent issues of confidentiality. Nurses should help develop and follow security measures and policies to ensure appropriate use of client data.

BOX 5–6

• The client is a holistic, autonomous being who has the right to make choices and decisions.

• Clients have the right to expect a nurse–client relationship that is based on shared respect, trust, collaboration in solving problems related to health and health care needs, and consideration of their thoughts and feelings.

• It is the nurse’s responsibility to ensure the client has access to health care services that meet health needs.

Values Basic to Client Advocacy

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arena, the nurse needs an understanding of the ethical issues in nursing and health care, as well as knowledge of the laws and regulations that affect nursing practice and the health of society (see Chapter 4 ).

Being an effective client advocate involves the following:

• Being assertive • Recognizing that the rights and values of clients and families must

take precedence when they conflict with those of health care providers

• Being aware that conflicts may arise over issues that require consul- tation, confrontation, or negotiation between the nurse and admin- istrative personnel or between the nurse and a primary care provider

• Working with community agencies and lay practitioners • Knowing that advocacy may require political action—

communicating a client’s health care needs to government and other officials who have the authority to do something about these needs.

from their own personal values and may revert to old habits and ways of doing things that may not be beneficial to their health. The nurse may see this as noncompliance; nevertheless, client autonomy must be respected.

In home care, limited resources and a lack of client care ser- vices may shift the focus from client welfare to concerns about re- source allocation. Financial considerations can limit the availability of services and materials, making it difficult to ensure that client needs are met.

PROFESSIONAL AND PUBLIC ADVOCACY Advocacy is needed for the nursing profession as well as for the pub- lic. Gains that nursing makes in developing and improving health policy at the institutional and government levels help to achieve bet- ter health care for the public.

Nurses who function responsibly as professional and public ad- vocates are in a position to effect change. To act as an advocate in this

Critical Thinking Checkpoint

A 79-year-old man with severe peripheral vascular disease has been told that a nonhealing lesion on his foot must be treated with either vascular bypass surgery or amputation of the foot. Although the sur- geon believes the foot can be saved with bypass, the man elects to have the amputation. His main reason is that the site will heal more quickly and allow him to resume normal activities sooner. He asks for the nurse’s opinion. 1. What values and beliefs does the client seem to embrace?

2. What additional information might the nurse need to gather from the client or the surgeon?

3. What is the nurse’s ethical/moral responsibility in this instance? 4. What conflicting loyalties and obligations does the nurse face? 5. Of what value is the Code of Ethics for Nurses to the nurse in

solving this dilemma? See Critical Thinking Possibilities on student resource website.

• Values are enduring beliefs that give direction and meaning to life and guide a person’s behavior.

• Values clarification is a process in which people identify, examine, and develop their own values.

• Nursing ethics refers to the ethical problems that occur in nursing practice and to ethical decisions that nurses make.

• Morality refers to private, personal standards of what is right and wrong in conduct, character, and attitude.

• Moral issues are those that arouse the conscience or awareness of feelings such as guilt, hope, or shame; are concerned with im- portant social values and norms; and evoke words such as good, bad, right, wrong, should, and ought.

• Three common moral frameworks (approaches) are consequence- based (teleological), principles-based (deontological), and relationships-based (caring-based) theories.

• Moral principles (e.g., autonomy, nonmaleficence, beneficence, justice, fidelity, and veracity) are broad, general philosophical con- cepts that can be used to make and explain moral choices.

• A professional code of ethics is a formal statement of a group’s ideals and values that serves as a standard and guideline for

the group’s professional actions and informs the public of its commitment.

• Ethical problems are created as a result of changes in society, ad- vances in technology, conflicts within nursing itself, and nurses’ conflicting loyalties and obligations (e.g., to clients, families, em- ployers, primary care providers, and other nurses).

• The goal of ethical reasoning, in the context of nursing, is to reach a mutual, peaceful agreement that is in the best interests of the client; reaching the agreement may require compromise.

• Nurses are responsible for determining their own actions and for supporting clients who are making moral decisions or for whom decisions are being made by others.

• Nurses can enhance their ethical practice and client advocacy by clarifying their own values, understanding the values of other health care professionals, becoming familiar with nursing codes of ethics, and participating in ethics committees and rounds.

• Client advocacy involves concern for and actions on behalf of another person or organization in order to bring about change.

• The functions of the advocacy role are to inform, support, and mediate.

CHAPTER HIGHLIGHTS

Chapter 5 Review

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1. When an ethical issue arises, one of the most important nursing responsibilities in managing client care situations is which of the following? 1. Be able to defend the morality of one’s own actions. 2. Remain neutral and detached when making ethical

decisions. 3. Ensure that a team is responsible for deciding ethical

questions. 4. Follow the client and family’s wishes exactly.

2. Which of the following situations is most clearly a violation of the underlying principles associated with professional nursing ethics? 1. A hospital’s policy permits use of internal fetal monitoring

during labor. However, there is literature to both support and refute the value of this practice.

2. When asked about the purpose of a medication, a nurse colleague responds, “Oh, I never look them up. I just give what is prescribed.”

3. The nurses on the unit agree to sponsor a fund-raising event to support a labor strike proposed by fellow nurses at another facility.

4. A client reports that he didn’t quite tell the doctor the truth when asked if he was following his therapeutic diet at home.

3. Following a motor vehicle crash, the parents of a child with no apparent brain function refuse to permit withdrawal of life support from the child. Although the nurse believes the child should be allowed to die and organ donation considered, the nurse supports their decision. Which moral principle provides the basis for the nurse’s actions? 1. Respect for autonomy 2. Nonmaleficence 3. Beneficence 4. Justice

4. Which of the following statements would be most helpful when a nurse is assisting clients in clarifying their values? 1. “That was not a good decision. Why did you think it

would work?” 2. “The most important thing is to follow the plan of care. Did

you follow all your doctor’s orders?” 3. “Some people might have made a different decision. What

led you to make your decision?” 4. “If you had asked me, I would have given you my opinion

about what to do. Now, how do you feel about your choice?”

5. After recovering from her hip replacement, an older adult client wants to go home. The family wants the client to go to a nursing home. If the nurse were acting as a client advocate, the nurse would perform which of the following actions? 1. Inform the family that the client has a right to decide on

her own. 2. Ask the primary care provider to discharge the client

to home. 3. Suggest the client hire a lawyer to protect her rights. 4. Help the client and family communicate their views to

each other. 6. Values, moral frameworks, and codes of ethics influence

the professional nurse’s moral decisions in which of the following ways? 1. The nurse will provide direct client care that is consistent

with the nurse’s personal values. 2. The nurse will seek to ensure that the client’s values and the

nurse’s are the same. 3. The choice of moral framework determines what the client

outcome will be. 4. The nurse is bound to act according to the nurses’ code of

ethics even if the nurse’s values are different. See Answers to Test Your Knowledge in Appendix A.

TEST YOUR KNOWLEDGE

Suggested Reading Huffman, D., & Rittenmeyer, L. (2012). How professional

nurses working in hospital environments experience moral distress: A systematic review. Critical Care Nursing Clinics of North America, 24(1), 91–100. A systematic review is a formal survey of the literature and research about one particular topic. The overall objective of this systematic review was to appraise and synthesize the best available evidence published between 1995 and 2008 on how professional nurses working in hospital environ- ments experience ethical/moral distress. The context was professional nurses experiencing ethical/moral distress as a result of their client care responsibilities. The 101 articles revealed four themes: “1. Human Reactivity: Nurses who experience moral distress respond with a myriad of biologi- cal, psychological, and stress reactions. 2. Institutional Culpability: Moral distress is experienced when nurses feel the need to advocate for clients’ well-being while coping with institutional constraints. 3. Client Pain and Suffering: The perception of client pain and suffering as a result of medical decisions, of which the nurse has little power to influence, contribute to the experience. 4. Unequal Power Hierarchies: Unequal power structures, prevalent in institu- tions, exacerbate the problem” (p. 96).

Related Research Davis, S., Schrader, V., & Belcheir, M. (2012). Influencers

of ethical beliefs and the impact on moral distress and conscientious objection. Nursing Ethics, 19(6), 738–749. doi:10.1177/0969733011423409

Dekeyser Ganz, F., & Berkovitz, K. (2012). Surgical nurses’ perceptions of ethical dilemmas, moral distress and quality of care. Journal of Advanced Nursing, 68(7), 1516–1525. doi:10.1111/J.1365-2648.2011.05897.x

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

essentials of baccalaureate education for professional nursing practice. Washington, DC: Author.

American Association of Critical-Care Nurses. (n.d.). The 4 A’s to Rise Above Moral Distress. Aliso Viejo, CA: Author. Retrieved from http://www.aacn.org/WD/Practice/ Docs/4As_to_Rise_Above_Moral_Distress.pdf

American Hospital Association. (2003). The patient care partnership: Understanding expectations, rights and responsibilities. Washington, DC: Author. Retrieved from http://www.aha.org/aha/issues/Communicating- With-Patients/pt-care-partnership.html

American Nurses Association (ANA). (2006). Position statement: Risk and responsibility in providing nursing care. Retrieved from http://nursingworld.org/ MainMenuCategories/Policy-Advocacy/Positions-and- Resolutions/ANAPositionStatements/Position-Statements- Alphabetically/RiskandResponsibility.pdf

American Nurses Association (ANA). (2007). Position statement on stem cell research. Retrieved from http://nursingworld.org/MainMenuCategories/ Policy-Advocacy/Positions-and-Resolutions/ ANAPositionStatements/Position-Statements-Alphabetically/ StemCellResearch.txt

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

American Nurses Association (ANA). (2013). Position statement: Euthanasia, assisted suicide, and aid in dying. Retrieved from http://www.nursingworld.org/ euthanasiaanddying

Butts, J. B., & Rich, K. L. (2013). Nursing ethics: Across the curriculum and into practice (3rd ed.). Burlington, MA: Jones & Bartlett.

Cronenwett, L., Sherwood, G., Barnsteiner J., Disch, J., Johnson, J., Mitchell, P., . . . Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55, 122–131. doi:10.1016/j.outlook.2007.02.006

Fowler, M. D. M. (Ed.). (2010). Guide to the code of ethics for nurses: Interpretation and application. Silver Spring, MD: American Nurses Association.

Gilligan, C. (1982). In a different voice. Cambridge, MA: Harvard University Press.

International Council of Nurses. (2012). The ICN code of ethics for nurses. Geneva, Switzerland: Imprimerie Fornara.

The Joint Commission. (2013). Joint Commission International accreditation standards for hospitals (4th ed.). Oakbrook Terrace, IL: Author.

Jonsen, A. R., Siegler, M., & Winslade, W. J. (2010). Clinical ethics: A practical approach to ethical decisions in clinical medicine (7th ed.). New York, NY: McGraw-Hill.

Kohlberg, L. (1969). Stage and sequence: The cognitive- developmental approach to socialization. In D. A. Goslin (Ed.), Handbook of socialization theory and research (pp. 347–480). Chicago, IL: Rand McNally.

READINGS AND REFERENCES

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Kohls, L. R. (1984). The values Americans live by. Washington, DC: Meridian House International.

Llewellyn-Thomas, H. A., & Crump, R. T. (2013). Decision support for patients: Values clarification and preference elicitation. Medical Care Research Review, 70, 50s –79s. doi:10.1177/1077558712461182

Newport, F. (2012). Congress retains low honesty rating: Nurses have highest honesty rating; car salespeople, lowest. Retrieved from http://www.gallup.com/ poll/159035/congress-retains-low-honesty-rating.aspx

Preedy, V. R. (Ed.). (2011). Diet and nutrition in palliative care. Boca Raton, FL: Taylor & Francis.

Raths, L., Harmin, M., & Simon, S. (1978). Values and teaching: Working with values in the classroom (2nd ed.). Columbus, OH: Merrill.

Snellman, I., & Gedda, K. M. (2012). The value ground of nursing. Nursing Ethics, 19, 714 –726. doi:10.1177/0969733011420195.

Wocial, L. D., & Weaver, M. T. (2012). Development and psychometric testing of a new tool for detecting moral distress: The Moral Distress Thermom- eter. Journal of Advanced Nursing, 69(1), 167–174. doi:10.1111/j.1365-2648.2012.06036.x

Selected Bibliography Beauchamp, T., & Childress, J. (1979). Principles of biomedical

ethics. New York, NY: Oxford University Press.

Burkhardt, M. A., & Nathaniel, A. K. (2013). Ethics and issues in contemporary nursing (4th ed.). Albany, NY: Delmar.

Carter, S. M., Rychetnik, L., Lloyd, B., Kerridge, I. H., Baur, L., Bauman, A., … Zask, A. (2011). Evidence, ethics, and values: A framework for health promotion. American Journal of Public Health, 101, 465–472. doi:10.2105/ AJPH.2010.195545

Guido, G. W. (2014). Legal and ethical issues in nursing (6th ed.). Upper Saddle River, NJ: Prentice Hall.

Hamric, A., Borchers, C., & Epstein, E. (2012). Development and testing of an instrument to measure moral distress in healthcare professionals. AJOB Primary Research, 3(2), 1–9. doi:10.1080/21507716.2011.652337

Johns Hopkins University Bloomberg School of Public Health, Center for Communication Programs. (2002). Question- naire for values clarification. Retrieved from http://www .jhuccp.org/research/download/Valuesinstrument.pdf

Pieterse, A. H., de Vries, M., Kunneman, M., Stiggelbout, A. M., & Feldman-Stewart, D. (2013). Theory-informed design of values clarification methods: A cognitive psychological perspective on patient health-related decision making. Social Science & Medicine, 77, 156–163. doi:10.1016/ j.socscimed.2012.11.020

Pignone, M. P., Brenner, A. T., Hawley, S., Sheridan, S. L., Lewis, C. L., Jonas, D. E., & Howard, K. (2012). Conjoint analysis versus rating and ranking for values elicitation and clarification in colorectal cancer screening. Journal

of General Internal Medicine, 27, 45–50. doi:10.1007/ s11606-011-1837-z

Redman, B. K., & Fry, S. T. (1998). Ethical conflicts reported by certified registered rehabilitation nurses. Rehabilitation Nursing, 23, 179–184. doi:10.1002/j.2048-7940.1998 .tb01777.x

Shepard, A. (2010). Moral distress: A consequence of caring. Clinical Journal of Oncology Nursing,14, 25–27. doi:10.1188/10.CJON.25-27

Snellman, D. (2011). Professional values and nursing. Medicine, Health Care and Philosophy, 14, 203–208. doi:10.1007/s11019-010-9295-7

Ulrich, C. M., Hamric, A. B., & Grady, C. (2010). Moral distress: A growing problem in the health professions? Hastings Center Report,40(1), 20–22. doi:10.1353/hcr.0.0222

Veatch, R. M. (2012). Hippocratic, religious, and secular medical ethics: The points of conflict. Washington, DC: Georgetown University Press.

Wiegand, D., & Funk, M. (2012). Consequences of clinical situations that cause critical care nurses to experience moral distress. Nursing Ethics, 19, 479–487. doi:10.1177/0969733011429342

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CLIENT: Megan AGE: 19 CURRENT MEDICAL DIAGNOSIS: Cystic Fibrosis, Pneumonia Medical History: Megan was diagnosed with cystic fibrosis when she was 3 months old. Her parents were very protective and home schooled her during cold and flu seasons to reduce her exposure to viruses. She has been hospitalized several times throughout her life, mostly for pulmonary infections, but has remained fairly healthy compared to others with cystic fibrosis. This is largely due to her parent’s vigilance in meeting her health care needs. Megan con- tracted influenza approximately 5 days ago and became increasingly short of breath. She has been unable to adequately clear pulmonary secretions, and has not been able to meet her caloric needs due to severe coughing episodes that cause vomiting, resulting in a 3.6-kg (8-lb) weight loss. Her temperature is 38.8°C (101.8°F) tympanically. Breath sounds reveal course crackles throughout, and her x-ray shows dense concentrations of fluid in the bases of both lungs.

Personal and Social History: After graduating from high school last year, Megan entered a college located approximately 100 miles from her parents, and is currently living in the dormitory. She has relished her independence, but recognizes her parents’ concerns. Her mother calls frequently to make sure she is eating properly, taking her medications, and doing her breathing exercises as prescribed. In order not to worry her mother, Megan did not tell her when her roommate contracted the flu. Then Megan dreaded having to call and tell her parents she herself had the flu and had been admitted to the hospital near her college. Her parents arrived at the hospital within 2 hours of learning their daughter had been admitted, and her mother seeks out the nurse assigned to her care shortly after greeting her daughter.

Questions American Nurses Association Standard of Professional Performance #7 is Ethics: The registered nurse delivers care in a manner that preserves and protects health care consumer au- tonomy, dignity, rights, values, and beliefs while upholding the client’s confidentiality within legal and regulatory parameters. 1. Megan’s mother asks the nurse to call Megan’s doctor so she

can speak with him and asks what the x-ray and diagnostic studies have indicated about her daughter’s condition. What information can the nurse legally share with Megan’s mother about Megan’s condition?

2. Megan’s doctor explains to Megan and her parents that her condition has worsened, and recommends intubation and place- ment on a mechanical ventilator. Megan says “No, I do not want to be placed on a ventilator,” but her mother urges compliance with the recommended treatment. Megan’s mother turns to the nurse and says, “Tell her she must agree to follow the doctor’s recommendations!” What is the nurse’s best response?

3. The doctor suggests Megan be included in a research study for people with cystic fibrosis who want to avoid mechanical ventila- tion. What are the nurse’s responsibilities in protecting Megan’s rights based on your reading in Chapter 2 ?

American Nurses Association Standard of Practice #1 is Assessment: The registered nurse collects comprehensive data pertinent to the client’s health and/or the situation by using appropri- ate evidence-based assessment techniques, instruments, and tools. 4. What is the nurse’s responsibility when caring for Megan once

she is enrolled in the research study? 5. If the nurse questions the currency of an assessment technique

found in the hospital’s policy and procedure manual, what steps can the nurse take to ensure that evidence-based practice is used?

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

See Suggested Answers to End-of-Unit Meeting the Standards Questions on student resource website.

UNIT

1 Meeting the StandardsIn this unit we have explored the profession of nursing, moving from the history of nursing to the contemporary issues facing nurses today. Nurses must consider legal and ethical issues, theories and conceptual frameworks that guide nursing practice, and the increasing need to develop and maintain an evidence-based practice to provide optimal care to clients. This is occurring at a time when there is a rapidly evolving body of knowledge resulting from research both within nursing as well as other disciplines included in nursing practice. In the case study described below, you will explore how the nurse responds to client and family needs while upholding the standards essential to the nursing profession.

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UNIT

2 Contemporary Health Care

6 Health Care Delivery Systems 89

7 Community Nursing and Care Continuity 105

8 Home Care 118

9 Electronic Health Records and Information Technology 129

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INTRODUCTION A health care system is the totality of services offered by all health disciplines. It is one of the largest industries in the United States. Pre- viously, the major purpose of a health care system was to provide care to people who were ill or injured. However, with increasing awareness of health promotion, illness prevention, and levels of wellness, health care systems are changing, as are the roles of nurses in these areas. The services provided by a health care system are commonly categorized according to type and level.

TYPES OF HEALTH CARE SERVICES Health care services are often described in terms of how they are correlated with levels of disease prevention: (a) primary prevention, which consists of health promotion and illness prevention; (b) sec- ondary prevention, which consists of diagnosis and treatment; and (c) tertiary prevention, which consists of rehabilitation, health resto- ration, and palliative care.

Primary Prevention: Health Promotion and Illness Prevention Based on the notion of maintaining an optimum level of wellness, the World Health Organization (WHO) developed a project called Healthy People. The current U.S. Department of Health and Human Services (2010) project that evolved from the original work is called Healthy People 2020 and has four overarching goals: (1) Increase qual- ity and years of healthy life, (2) achieve health equity and eliminate health disparities, (3) create healthy environments for everyone, and (4) promote health and quality life across the life span.

Health promotion was slow to develop until the 1980s. Since that time, more and more people have recognized the advantages of

staying healthy and avoiding illness. Primary prevention programs address areas such as adequate and proper nutrition, weight con- trol and exercise, and stress reduction. Health promotion activities emphasize the important role clients play in maintaining their own health and encourage them to maintain the highest level of wellness they can achieve.

CLINICAL ALERT!

As insurance companies have realized that keeping people healthy is less expensive than treating illnesses, their insurance plans have begun to pay for preventive health care activities.

Illness prevention programs may be directed at the client or the community and involve such practices as providing immunizations, identifying risk factors for illnesses, and helping people take measures to prevent these illnesses from occurring. Significant examples are the smoking cessation campaigns that both assist individuals to stop smoking and protect the public from ill effects of secondhand smoke by regulating where people are permitted to smoke. Illness preven- tion also includes environmental programs that can reduce the inci- dence of illness or disability. For example, to decrease air pollution, automobile exhaust systems are inspected to ensure acceptable levels of fumes. Environmental protective measures are frequently legis- lated by governments and lobbied for by citizens groups.

Secondary Prevention: Diagnosis and Treatment In the past, the largest segment of health care services was dedicated to the diagnosis and treatment of illness. Hospitals and physicians’ of- fices have been the major agencies offering these complex secondary

LEARNING OUTCOMES

After completing this chapter, you will be able to: 1. Differentiate health care services based on primary, second-

ary, and tertiary disease prevention categories. 2. Describe the functions and purposes of the health care agen-

cies outlined in this chapter.

3. Identify the roles of various health care professionals. 4. Describe the factors that affect health care delivery. 5. Describe frameworks for the delivery of nursing care. 6. Compare various systems of payment for health care services.

KEY TERMS

accountable care organizations (ACOs), 102

case management, 99 coinsurance, 100 critical pathways, 99 diagnosis-related groups

(DRGs), 101 differentiated practice, 99

health care system, 89 health maintenance organization

(HMO), 102 independent practice associations

(IPAs), 102 integrated delivery system

(IDS), 102

licensed practical nurse (LPN), 94

licensed vocational nurse (LVN), 94

managed care, 98 Medicaid, 101 Medicare, 100

preferred provider arrangements (PPAs), 102

preferred provider organization (PPO), 102

safety-net hospitals, 92 Supplemental Security Income

(SSI) benefits, 101 team nursing, 99

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in the hospital, in the home, or in another agency within the commu- nity. Because the array of health care agencies and services is so great, nurses often need to help clients choose that which best suits their needs. Clients may be seen by any number and type of nurses and other providers, depending on their care requirements and ability to pay for the services.

Public Health Government (official) agencies are established at the local, state, and federal levels to provide public health services. Health agencies at the state, county, or city level vary according to the needs of the area. Their funds, usually generated from taxes, are administered by elected or appointed officials. Local health departments are respon- sible for developing programs to meet the health needs of the people, providing the necessary nursing and other staff and facilities to carry out these programs, continually evaluating the effectiveness of the programs, and monitoring changing needs (Figure 6–1 •). State health organizations are responsible for assisting the local health departments. In some remote areas, state departments also provide direct services to people.

The Public Health Service (PHS) of the U.S. Department of Health and Human Services is an official agency at the federal level. Its functions include conducting research and providing training in the health field, assisting communities in planning and developing health facilities, and assisting states and local communities through financing and provision of trained personnel. Also at the national level in the United States are research institutions such as the Na- tional Institutes of Health (NIH). The National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism, and the National Institute of Mental Health work with federal, regional, and state agencies. The Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, administers a broad program related to surveillance of diseases and behaviors that lead to disease and dis- ability. By means of laboratory and epidemiologic investigations, data are made available to the appropriate authorities. The CDC also publishes recommendations about the prevention and control of in- fections and administers a national health program. The federal gov- ernment also administers a number of Veterans Affairs (VA) services in the United States.

prevention services. Hospitals continue to focus significant resources on clients who require emergency, intensive, and around-the-clock acute care.

Freestanding diagnostic and treatment facilities have also evolved and serve ever-growing numbers of clients. For example, magnetic resonance imaging (MRI) and related radiologic diagnos- tic procedures are commonly performed at physician- or corporate- owned centers. Similar structures exist in outpatient surgical units (surgi-centers).

Also included as a health promotion service is early detection of disease. This is accomplished through routine screening of the popu- lation and focused screening of those at increased risk of developing certain conditions. Examples of early detection services include regu- lar dental exams from childhood throughout life and bone density studies for women at menopause to evaluate for early osteoporosis. Community-based agencies have become instrumental in provid- ing these services. For example, clinics in some communities provide mammograms and education regarding the early detection of cancer of the breast. Voluntary HIV testing and counseling is another exam- ple of the shift in services to community-based agencies. Some malls and shopping centers have walk-in clinics that provide diagnostic tests, such as screening for cholesterol and high blood pressure.

Tertiary Prevention: Rehabilitation, Health Restoration, and Palliative Care The goal of tertiary prevention is to help people move to their previous level of health (i.e., to their previous capabilities) or to the highest level they are capable of given their current health status. Rehabilitative care emphasizes the importance of assisting clients to function adequately in the physical, mental, social, economic, and vocational areas of their lives. For example, someone with an injured neck or back from an au- tomobile crash may have restrictions in the ability to perform work or daily activities. If the injury is temporary, rehabilitation can assist in return to former function. If the injury is permanent, rehabilitation assists the client in adjusting the way activities are performed in or- der to maximize the client’s abilities. Rehabilitation may begin in the hospital, but will eventually lead clients back into the community for further treatment and follow-up once health has been restored.

An example of tertiary mental health prevention is an outreach program that follows individuals with mental disorders in the com- munity to ensure that they adhere to their medication regimens. These programs can reduce acute psychiatric hospital admissions and long-term institutionalization and enable individuals with men- tal disorders to live independently.

Sometimes, people cannot be returned to health. A growing field of nursing and tertiary prevention services is that of palliative care—providing comfort and treatment for symptoms. End-of-life care may be conducted in many settings, including the home.

TYPES OF HEALTH CARE AGENCIES AND SERVICES Health care agencies and services in the United States are both varied and numerous. Some health care agencies or systems provide ser- vices in different settings; for example, a hospital may provide acute inpatient services, outpatient clinic or ambulatory care services, and emergency department services. Hospice services may be provided

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Figure 6–1 • Health departments may provide screening services for all age groups. Michelle Bridwell/PhotoEdit.

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families. Private hospitals are often operated by churches, companies, communities, and charitable organizations. Private hospitals may be for-profit or not-for-profit institutions. Although hospitals are chiefly viewed as institutions that provide care, they have other functions, such as providing sources for health-related research and teaching.

Hospitals are also classified by the services they provide. General hospitals admit clients requiring a variety of services, such as medical, surgical, obstetric, pediatric, and psychiatric services (Figure 6–3 •). Other hospitals offer only specialty services, such as psychiatric or pediatric care. An acute care hospital provides assistance to clients whose illness and need for hospitalization are relatively short term, for example, several days.

The variety of health care services hospitals provide usually de- pends on their size and location. Large urban hospitals usually have inpatient beds, emergency services, diagnostic facilities, ambulatory surgery centers, pharmacy services, intensive and coronary care ser- vices, and multiple outpatient services provided by clinics. Some large hospitals have other specialized services such as spinal cord injury

Physicians’ Offices In North America, the physician’s office is a significant care setting. The majority of physicians either have their own offices or work with several other physicians in a group practice. Clients usually go to a physician’s office for routine health screening, illness diagnosis, and treatment. People seek consultation from physicians when they are experiencing symptoms of illness or when a significant other consid- ers the person to be ill.

In some medical office practices, such as those of family practice physicians or specialists such as dermatologists or surgeons, nurse practitioners (NPs) practice alongside physicians. Often, physicians’ offices do not require the expertise of registered nurses (RNs). In of- fices that do have RNs, the RNs have a variety of roles and respon- sibilities, including client registration, preparing the client for an examination, obtaining health information, and providing informa- tion. Other functions may include obtaining specimens, assisting with procedures, and providing some treatments. In offices without RNs, these tasks may be performed by medical assistants.

Ambulatory Care Centers Ambulatory care centers are used in many communities. Most am- bulatory care centers have diagnostic and treatment facilities that provide medical, nursing, laboratory, and radiologic services, and they may or may not be associated with an acute care hospital. Some ambulatory care centers provide services to people who require mi- nor surgical procedures that can be performed outside the hospital. After surgery, the client returns home, often the same day. These cen- ters offer two advantages: They permit the client to live at home while obtaining necessary health care, and they free up costly hospital beds for seriously ill clients. The term ambulatory care center has replaced the term clinic in many places.

Occupational Health Clinics The industrial (occupational) clinic is gaining importance as a setting for employee health care. The importance of employee health to pro- ductivity has long been recognized. Today, more companies recog- nize the value of healthy employees and encourage healthy lifestyles by providing exercise facilities and coordinating health promotion activities.

Community health nurses in the occupational setting have a variety of roles. Worker safety has always been a concern of occu- pational nurses. Today, nursing functions in industrial health care include work safety and health education, annual employee health screening for tuberculosis, and maintaining immunization informa- tion. Other functions may include screening for such health prob- lems as hypertension and obesity, caring for employees following injury, and counseling (Figure 6–2 •).

Hospitals Hospitals vary in size from the 12-bed rural hospital to the 1,500-bed metropolitan hospital. Hospitals can be classified according to their ownership or control as governmental (public) or nongovernmental (private). In the United States, governmental hospitals are either fed- eral, state, county, or city hospitals. The federal government provides hospital facilities for veterans and merchant mariners (VA hospi- tals). Military hospitals provide care to military personnel and their

Figure 6–2 • In occupational health clinics, primary care providers may examine clients with occasional symptoms. Hero Images/Getty Images.

Figure 6–3 • Most acute care hospitals have active operating room services. Chris Ryan/Getty Images.

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or custodial care. Because clients are being discharged earlier from acute care hospitals, some clients may still require supplemental care in a skilled nursing or extended care facility before they return home.

Because chronic illness occurs most often in older adults, long- term care facilities have programs that are oriented to the needs of this age group. Facilities are intended for people who require not only personal services (bathing, hygiene, eating) but also some regular nursing care and occasional medical attention. However, the type of care provided varies considerably. Some facilities admit and retain only residents who are able to dress themselves and are ambulatory. Other extended care facilities provide bed care for clients who are more incapacitated. These facilities can, in effect, become the client’s home, and consequently the people who live there are frequently re- ferred to as residents rather than patients or clients.

Specific guidelines govern the admission procedures for clients admitted to an extended care facility. Insurance criteria, treatment needs, and nursing care requirements must all be assessed beforehand. Extended care and skilled nursing facilities are becoming increasingly popular means for managing the health care needs of clients who do not meet the criteria for remaining in the hospital. Nurses in ex- tended care facilities assist clients with their daily activities, provide care when necessary, and coordinate rehabilitation activities.

CLINICAL ALERT!

Older adults may move among levels of care several times—from in- dependent living, to a hospital, to a rehabilitation center, to long-term care, and hopefully back to independent or assisted living. The se- quence varies as will the length of time in each setting.

Retirement and Assisted Living Centers Retirement or assisted living centers consist of separate houses, con- dominiums, or apartments for residents. Residents live relatively in- dependently; however, many of these facilities offer meals, laundry services, nursing care, transportation, and social activities. Some cen- ters have an affiliated hospital to care for residents with short-term or long-term illnesses. Often these centers also work collaboratively with other community services including case managers, social ser- vices, and a hospice agency to meet the needs of the residents who live there. The retirement or assisted living center is intended to meet the needs of people who are unable to remain at home but do not require hospital or nursing home care. Nurses in retirement and assisted liv- ing centers provide limited care to residents, usually related to the administration of medications and minor treatments, but conduct significant care coordination and health promotion activities.

Rehabilitation Centers Rehabilitation centers usually are independent community centers or special units. However, because rehabilitation ideally starts the moment the client enters the health care system, nurses who are em- ployed on pediatric, psychiatric, or surgical units of hospitals also help to rehabilitate clients. Rehabilitation centers play an important role in assisting clients to restore their health and recuperate. Drug and alcohol rehabilitation centers, for example, help free clients of drug and alcohol dependence and assist them to reenter the com- munity and function to the best of their ability. Today, the concept of rehabilitation is applied to all illness and injury (physical and

and burn units, oncology services, and infusion and dialysis units. In addition, some hospitals have substance abuse treatment units and health promotion units. Small rural hospitals often are limited to in- patient beds, radiology and laboratory services, and basic emergency services. The number of services a rural hospital provides is usually directly related to its size and its distance from an urban center.

Hospitals in the United States have undergone organizational changes in order to contain costs or to attract clients. Some hospitals have merged with other hospitals or have been purchased by large multihospital for-profit corporations (e.g., Hospital Corporation of America, Community Health Systems, and Tenet Healthcare). Other hospitals are providing innovative outpatient services, such as fit- ness classes, day care for older adults, nutrition classes, and alterna- tive birth centers. Hospitals that provide a significant level of care to low-income, uninsured, and vulnerable populations are referred to as safety-net hospitals.

Subacute Care Facilities Subacute care is a variation of inpatient care designed for someone who has an acute illness, injury, or exacerbation of a disease process. Clients may be admitted after, or instead of, acute hospitalization or to administer one or more technically complex treatments. Gener- ally, the individual’s condition is such that the care does not depend heavily on high-technology monitoring or complex diagnostic pro- cedures. Subacute care requires the coordinated services of an inter- professional team including physicians, nurses, and other relevant professional disciplines. Subacute care is generally more intensive than long-term care and less intensive than acute care.

Extended (Long-Term) Care Facilities Extended care facilities, formerly called nursing homes, are now often multilevel campuses that include independent living quarters for se- niors, assisted living facilities, skilled nursing facilities (intermediate care), and extended care (long-term care) facilities that provide lev- els of personal care for those who are chronically ill or are unable to care for themselves without assistance (Figure 6–4 •). Traditionally, extended care facilities only provided care for older adult clients, but they now provide care to clients of all ages who require rehabilitation

Figure 6–4 • Nurses in long-term care facilities develop strong relationships with clients. fstop123/Getty Images.

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in rural areas. In 1997, the Balanced Budget Act authorized the Medi- care Rural Hospital Flexibility Program in order to continue to make available primary care access and improve emergency care for rural residents. This program established a new classification called critical access hospitals, which receive federal funding to remain open and provide the breadth of services needed for rural residents, including interfaces with regional tertiary care centers. Each state has an Office of Rural Health Programs that assesses and identifies interventions for the health care needs of the local population. Nurses in rural set- tings must be generalists who are able to manage a wide variety of clients and health care problems. Due to their training in providing comprehensive primary care across the life span, NPs are particularly suited to these roles.

Hospice Services Originally, a hospice was a place for travelers to rest. Recently the term has come to mean interprofessional health care service for the dying, provided in the home or another health care setting. The hospice movement subsumes a variety of services given to clients who are ter- minally ill, their families, and support persons. The central concept of the hospice movement, as distinct from the acute care model, is not saving life but improving or maintaining the quality of life until death. Hospice nurses serve primarily as case managers and super- vise the delivery of direct care by other members of the team. Clients in hospice programs are cared for at home, in hospitals, in freestand- ing hospice facilities, or in skilled nursing facilities. The place of health care delivery may vary as the client’s condition declines or as the ability of the family to care for the client changes. The hospice nurse performs ongoing assessments of needs of the client and family and helps to find the appropriate resources and additional services for them as needed.

Crisis Centers Crisis centers provide emergency services to clients experiencing life crises. These centers may operate out of a hospital or in the com- munity, and most provide 24-hour telephone service. Some also provide direct counseling to people at the center or in their homes. The primary purpose of the center is to help people cope with an immediate crisis and then provide guidance and support for long- term therapy.

Nurses working in crisis centers need well-developed communi- cation and counseling skills. The nurse must immediately identify the individual’s problem, offer assistance to help the individual cope, and perhaps later direct the individual to resources for long-term support.

Mutual Support and Self-Help Groups In North America today, there are more than 500 mutual support or self-help groups that focus on nearly every major health problem or life crisis people experience. These groups may be for the client or for the friends and family of the client, who also need education, guid- ance, and support. Such groups arose largely because people felt their needs were not being met by the existing health care system. Alcohol- ics Anonymous, which formed in 1935, served as the model for many of these groups. The American Self-Help Group Clearinghouse pro- vides information on current support groups and guidelines about how to start a self-help group. The nurse’s role in self-help groups is discussed in Chapter 27 .

mental) (Figure 6–5 •). Nurses in the rehabilitation setting coordi- nate client activities and ensure that clients are complying with their treatments. This type of nursing often requires specialized skills and knowledge.

Home Health Care Agencies The implementation of prospective payment programs (discussed later in this chapter) and the resulting earlier discharge of clients from hospitals have made home care an essential aspect of the health care delivery system. As concerns about the cost of health care have es- calated, the use of the home as a care delivery site has increased. In addition, the scope of services offered in the home has broadened. Home health care nurses and other staff offer education to clients and families and also provide comprehensive care to clients who are acutely, chronically, or terminally ill.

Day Care Centers Day care centers serve many functions and many age groups. Some day care centers provide care for infants and children while parents work. Other centers provide care and nutrition for adults who cannot be left at home alone but do not need to be in an institution. Older adult care centers often provide care involving socializing, exercise programs, and stimulation. Some centers provide counseling and physical therapy. Nurses who are employed in day care centers may provide medications, treatments, and counseling, thereby facilitating continuity between day care and home care.

Rural Care Rural primary care hospitals were created as a result of the 1987 Om- nibus Budget Reconciliation Act to provide emergency care to clients

Figure 6–5 • Physical therapy services are an integral service in rehabilitation centers. Ingram Publishing/Alamy.

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Alternative (Complementary) Care Provider Alternative or complementary health care refers to those practices not commonly considered part of Western medicine. See Chapter 19 for detailed descriptions of these. Chiropractors, herbalists, acupunc- turists, massage therapists, reflexologists, holistic health healers, and other health care providers are playing increasing roles in the con- temporary health care system. These providers may practice along- side Western health care providers, or clients may use their services in conjunction with, or in lieu of, Western therapies.

Case Manager The case manager’s role is to ensure that clients receive fiscally sound, appropriate care in the best setting. This role is often filled by the member of the health care team who is most involved in the client’s care. Depending on the nature of the client’s concerns, the case man- ager may be a nurse, a social worker, an occupational therapist, a physical therapist, or any other member of the health care team.

Dentist Dentists diagnose and treat mouth, jaw, and dental problems. Dentists (and their dental hygienists) are also actively involved in preventive measures to maintain healthy oral structures (e.g., teeth and gums).

Dietitian or Nutritionist A dietitian has special knowledge about the diets required to main- tain health and to treat disease. Dietitians in hospitals generally are concerned with therapeutic diets, supervise the preparation of meals to ensure that clients receive the proper diet, and may design special diets to meet the nutritional needs of individual clients.

A nutritionist is a person who has special knowledge about nutrition and food. The nutritionist in a community setting recom- mends healthy diets and provides broad advisory services about the purchase and preparation of foods. Community nutritionists often function at the preventive level. They promote health and prevent disease, for example, by advising families about balanced diets for growing children and pregnant women.

Emergency Medical Personnel Several different categories of providers are associated with ambu- lance or emergency medical services agencies (e.g., fire departments) that provide first-responder care in the community. Titles, education, and certification vary for emergency medical technicians (EMTs) and paramedics. In general, however, these personnel are trained to as- sess, treat, and transport clients experiencing a medical emergency, accident, or trauma.

Occupational Therapist An occupational therapist (OT) assists clients with impaired func- tion to gain the skills to perform activities of daily living (ADLs). For example, an OT might teach a man with severe arthritis in his arms and hands how to adjust his kitchen utensils so that he can continue to cook. The OT teaches skills that are therapeutic and at the same time provide some fulfillment. For example, weaving is a recreational activity but also exercises the arthritic man’s arms and hands.

PROVIDERS OF HEALTH CARE The providers of health care, also referred to as the health care team or health professionals, are nurses and health personnel from differ- ent disciplines who coordinate their skills to assist clients and their support people. Their mutual goal is to restore a client’s health and promote wellness. The choice of personnel for a particular client de- pends on the needs of the client. Health teams commonly include the nurse and several different personnel (Figure 6–6 •). Nurses’ roles are described in Chapter 1 and throughout this textbook. The fol- lowing sections on the nonnurse providers are in alphabetical order and do not represent an all-inclusive list of possible providers. The scope of practice, qualifications, education, licensure, certification, and/or accreditation of these providers is determined by the regula- tions of the state in which they practice.

Nurse The role of the nurse varies with the needs of the client, the nurse’s credentials, and the type of employment setting. An RN assesses a client’s health status, identifies health problems, and develops and co- ordinates care. A licensed vocational nurse (LVN), in some states known as a licensed practical nurse (LPN), provides direct cli- ent care under the direction of an RN, physician, or other licensed practitioner. As nursing roles have expanded, new dimensions for nursing practice have been established. Nurses can pursue a variety of practice specialties (e.g., critical care, mental health, oncology). Advanced practice registered nurses (APRNs) provide direct client care as NPs, nurse midwives, certified registered nurse anesthetists, and clinical nurse specialists. These nurses have education and cer- tifications that—depending on state regulations—may allow them to provide primary care, prescribe medications, and receive third-party (insurance) reimbursement directly for their services.

Figure 6–6 • Although all members of the health care team individualize care for the client based on the expertise of their own discipline, there are areas of overlap facilitated through teamwork.

73-year old with heart

failure, short of breath

Occupational therapist designs self-care activities

that reserve client’s energy

MD develops medical care plan,

prescribes medications and

treatments

Physical therapist designs

strengthening and balance exercise plan

Dietitian creates

low-salt diet

RN develops nursing

care plan

Pharmacist supplies and

teaches about medications

Case manager

communicates care plan to

family and other providers

Respiratory therapist provides breathing treatments

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of osteopathy (DOs), a branch of medicine traditionally focused on primary care. Differences between allopathic and osteopathic physi- cians are becoming fewer (Walkowski, 2011).

Physician Assistant Physician assistants (PAs) perform certain tasks under the direction of a physician and are increasingly positioned to provide primary care. They treat various diseases, conditions, and injuries. In many states, nurses are not legally permitted to follow a PA’s orders unless they are co-signed by a physician. In some settings, PAs and NPs have similar job descriptions.

Podiatrist Doctors of podiatric medicine (DPM) diagnose and treat foot and ankle conditions. They are licensed to perform surgery and prescribe medications.

Respiratory Therapist A respiratory therapist is skilled in therapeutic measures used in the care of clients with respiratory problems. These therapists are knowl- edgeable about oxygen therapy devices, respirators, mechanical ven- tilators, and accessory devices used in inhalation therapy. Respiratory therapists administer many of the pulmonary function tests.

Social Worker A social worker counsels clients and their support persons regard- ing problems such as finances, marital difficulties, and adoption of children. They are particularly familiar with both public and pri- vate resources available to clients according to their socioeconomic qualifications. It is not unusual for health problems to produce problems in day-to-day living and vice versa. For example, an el- derly woman who lives alone and has a stroke resulting in impaired walking may find it impossible to continue to live in her third-floor apartment. Finding a more suitable living arrangement can be the responsibility of the social worker if the client has no support network in place.

Spiritual Support Personnel Chaplains, pastors, rabbis, priests, and other religious or spiritual advisers serve as part of the health care team by attending to the spiritual needs of clients. In most facilities, local clergy volunteer their services on a regular or on-call basis. Hospitals affiliated with specific religions, as well as many large medical centers, have full- time chaplains on staff. The nurse is often instrumental in iden- tifying the client’s desire for spiritual support and notifying the appropriate person.

Unlicensed Assistive Personnel Unlicensed assistive personnel (UAPs) are health care staff who assume delegated aspects of basic client care. These tasks include bathing, assisting with feeding, and collecting specimens. UAP titles include nurse’s aides, hospital attendants, nurse technicians, patient care technicians, and orderlies. Some of these categories of provider may have standardized education and job duties (e.g., certified nurse assistants), whereas others do not. The parameters regarding when a nurse can delegate to UAPs are delineated by state boards of nursing.

Paramedical Technologist Laboratory technologists, radiologic technologists, and nuclear med- icine technologists are just three kinds of paramedical technologists in the expanding field of medical technology. Paramedical means having some connection with medicine. Laboratory technologists examine specimens such as urine, feces, blood, and discharges from wounds to provide exact information that facilitates the medical di- agnosis and the prescription of a therapeutic regimen. The radiologic technologist assists with a wide variety of x-ray film procedures, from simple chest radiography to more complex fluoroscopy. The nuclear medicine technologist uses radioactive substances to provide diag- nostic information and can administer radioactive materials as part of a therapeutic regimen.

Pharmacist A pharmacist prepares and dispenses pharmaceuticals in hospital and community settings. The role of the pharmacist in monitoring and evaluating the actions and effects of medications on clients is becoming increasingly prominent. A clinical pharmacist is a special- ist who guides primary care providers in prescribing medications. Pharmacists also work directly with clients and with other health care team members to ensure safe integration of medications into the cli- ent’s comprehensive health plan.

CLINICAL ALERT!

Significant overlap may occur among those providers who can per- form certain health care activities. For example, an anesthesiologist (MD), a neonatal care nurse, or a respiratory therapist may be respon- sible for assisting a newborn baby with breathing problems. All provid- ers perform client teaching.

Physical Therapist The licensed physical therapist (PT) assists clients with musculo- skeletal problems. Physical therapists treat movement dysfunctions by means of heat, water, exercise, massage, and electric current. The functions of a PT include assessing client mobility and strength, pro- viding therapeutic measures (e.g., exercises and heat applications to improve mobility and strength), and teaching new skills (e.g., how to walk with an artificial leg). Some PTs provide their services in hospi- tals; however, independent practitioners establish offices in commu- nities and serve clients either at the office or in the home.

Physician The physician is responsible for medical diagnosis and for determin- ing the therapy required by a person who has a disease or injury. The physician’s role has traditionally been the treatment of disease and trauma (injury); however, many physicians include health promo- tion and disease prevention in their practice. Some physicians are primary care practitioners (also known as general or family practi- tioners); others are specialists such as dermatologists, neurologists, oncologists, orthopedists, pediatricians, psychiatrists, radiologists, or surgeons—to name a few. Physicians who specialize in the care of clients in hospitals are referred to as hospitalists and hospitalists who specialize in critical care are intensivists. Primary care physicians are those who provide the first point of contact for most clients and can include allopathic (Western) medical doctors (MDs) trained in areas such as internal medicine, gynecology, and geriatrics, and doctors

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plus the expense of training specialized personnel to perform the tests, each procedure can cost consumers hundreds or thousands of dollars.

Economics Paying for health care services is becoming a greater problem. The health care delivery system is very much affected by a country’s total economic status. According to the Centers for Medicaid and Medicare Services (2009), health spending in 2011 was estimated at $2.7 trillion in the United States and projected to reach $4.5 trillion by 2020, increasing substantially after 2014 with the implementation of the Affordable Care Act (ACA). This is currently equal to over $9,000 per year for every man, woman, and child and will increase to over $13,000 by 2020. About 29% are inpatient hospital expenses, 34% physician office and clinic expenses, 20% prescription drug expenses, and the remainder emergency department, home care, dental, and related services. The amount for hospital expenses has decreased, whereas outpatient and prescriptions costs doubled from 2007 to 2011. Approximately 40% of these costs are paid through pri- vate insurance, 36% through public programs, and 14% out of pocket (paid directly by the person) (Carper & Machlin, 2013).

The major reasons for cost increases are as follows:

• Existing equipment and facilities are continually becoming obso- lete as research uncovers new and better methods in health care. Health care providers and clients want the newest and the best, and replacing equipment costs more each year.

• Inflation increases all costs. • The total population is growing, especially the segment of older

adults who tend to have greater health care needs than younger people. Expenses for people over age 65 are more than 2.5 times as much as for those under age 65 (Carper & Machlin, 2013).

• In 2011, 63% of hospital costs were billed to Medicare and Medic- aid (Pfuntner, Wier, & Steiner, 2013).

• As more people recognize that health is everyone’s right, large numbers of people are seeking assistance in health matters. The average American sees a doctor three times per year, and the number of visits to specialist physicians is increasing (Hing & Shappert, 2012).

• The relative number of people who provide health care services has increased.

• The numbers of uninsured individuals are changing. The exact number changes daily, especially with implementation of the ACA. Fewer Americans were uninsured in 2011 than 2012, but the percentage of people covered by government health insur- ance, including Medicare, increased. More young adults gained coverage from a provision of the ACA that allows parents to keep their children on their policies longer. For adults between 26 and 64 years old, the major parts of ACA coverage expansion went into effect in 2014.

• The cost of prescription drugs is increasing. Medicare recipients are eligible for prescription drug coverage to help cover some basic and catastrophic medication costs.

Women’s Health The women’s movement has been instrumental in changing health care practices. Examples are the provision of childbirth services in more relaxed settings such as birthing centers, and the provision of

FACTORS AFFECTING HEALTH CARE DELIVERY Today’s health care consumers have greater knowledge about their health than in previous years, and they are increasingly influencing health care delivery. Formerly, people expected a primary care pro- vider to make decisions about their care; today, however, consumers expect to be involved in making any decisions. Consumers have also become aware of how lifestyle affects health. As a result, they desire more information and services related to health promotion and ill- ness prevention. A number of other factors affect the ability of the health care delivery system to meet the needs of the population.

Increasing Number of Older Adults By the year 2020, it is estimated that the number of U.S. adults over the age of 65 years will be more than 62 million (U.S. Census Bureau, 2012). Long-term illnesses are prevalent among this group, and they frequently require special housing, treatment services, financial sup- port, and social networks. The frail elderly, considered to be people over age 85, are projected to be the fastest growing population in the United States and will number almost 7 million by 2020 and 9 million by 2030 (U.S. Census Bureau, 2012). Because less than 5% of older adults are institutionalized with health problems, substantial home management and nursing support services are required to assist those living in their homes and communities.

Older adults also need to feel they are part of a community even though they are approaching the end of their lives. The feeling of being a useful, wanted, and productive citizen is essential to every person’s health. Special programs are being designed in communities so that the talents and skills of this group will be used and not lost to society.

Advances in Technology Scientific knowledge and technology related to health care are rap- idly increasing. Improved diagnostic procedures and sophisticated equipment permit early recognition of diseases that might otherwise have remained undetected. New medications are continually being manufactured to treat infections and multidrug-resistant organisms. Surgical procedures involving the heart, lungs, and liver that were nonexistent years ago are common today. Laser and microscopic procedures streamline the less invasive treatment of diseases that re- quired surgery in the past.

Computers, bedside charting, and the ability to store and retrieve large volumes of information in databases are becoming required of health care organizations. In addition, as a result of the availability of Internet access from numerous public and private locations, clients now have access to medical information similar to that of health care providers (although not all websites provide accurate information). One example of a reliable source of health care information for clients is the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ) website.

Clients are increasingly likely to be treated in the community, utilizing resources, technology, and treatments outside the hospital. For example, years ago a person having cataract surgery had to re- main in bed in the hospital for 10 days; today, most cataract removals are performed in outpatient surgery centers.

Technological advances and specialized treatments and proce- dures may come, unfortunately, with a high price tag. Some diagnos- tic equipment may cost millions of dollars. Due to this expenditure

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the most (National Center for Health Statistics, 2012). One response to insufficient numbers of physicians qualified to provide hospital ser- vices has been the creation of hospitalist and intensivist specialties.

An increasing number of health care personnel provide special- ized services. Specialization can lead to fragmentation of care and, often, increased cost of care. To clients, it may mean receiving care from 5 to 30 people during their hospital experience. This seemingly endless stream of personnel and required paperwork is often confus- ing and frightening.

Access to Health Insurance Another problem plaguing individuals is access to health insurance. Without health insurance, people receive less preventive care, delay or avoid care and medications, are diagnosed later in their illnesses, and have higher mortality. In addition, because of low or absent re- imbursement for services, primary care providers may hesitate to provide care.

Lack of health insurance is related to income. Low income has been associated with relatively higher rates of infectious diseases (e.g., tuberculosis, AIDS), problems with substance abuse, rape, violence, and chronic diseases. Thus, those with the greatest need for health care are often those least able to pay for it.

Governmental sources of health insurance cover individuals at both ends of the age spectrum. Medicare covers those who are

overnight facilities for parents in children’s hospitals. Until recently, women’s health issues focused on the reproductive aspects of health, disregarding many health care concerns that are unique to women. Investigators are beginning to recognize the need for research that examines women equally to men in health issues such as osteopo- rosis, heart disease, and responses to various treatment modalities. Current provision of health care shows an increased emphasis on the psychosocial aspects of women’s health, including the impact of ca- reer, delayed childbearing, role of caregiver to older family members, and extended life span.

Uneven Distribution of Services Serious problems in the distribution of health services exist in the United States. Two facets of this problem are (a) uneven distribution and (b) increased specialization. In some areas, particularly remote and rural locations, the number of health care professionals and services available to meet the health care needs of individuals is insufficient. Rural clients may need to drive large distances to obtain the services they require. Uneven distribution is evidenced by the relatively higher number of nurses per capita in some of the New England and Midwest states and the lowest number in the Southwest (Figure 6–7 •). Phy- sicians are also unevenly distributed: In 2010, Mississippi, Idaho, and Wyoming had the fewest physicians per 100,000 people, whereas the District of Columbia, Massachusetts, Rhode Island, and Maryland had

Figure 6–7 • Registered nurses per 100,000 population, 2011. From the Kaiser Family Foundation StateHealthFacts.org., n.d. Retrieved from http://kff.org/other/state-indicator/registered-nurses-per-100000-population

581–780

791–891

893–1,001

1,005–1,561

ALASKA HAWAII

MAINE

VT. N.H.

MASS.

R.I. New York

CT. N.Y.

PA. N.J.

DEL.

MD. D.C.

VA.

NORTH CAROLINA

SOUTH CAROLINA

OHIO

M I C H

I G A

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WISCONSIN

ILLINOIS IN DI

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W. VA.

KENTUCKY

TENNESSEE

MINNESOTA NORTH DAKOTA

SOUTH DAKOTA

NEBRASKA

KANSAS

IOWA

MISSOURI

ARKANSASOKLAHOMA

MONTANA

WYOMING

COLORADO

CALIFORNIA

WASHINGTON

OREGON

IDAHO

NEVADA UTAH

ARIZONA NEW MEXICO

MISS. ALABAMA GEORGIA

FLORIDA

LOUISIANA TEXAS

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practices for each type of health care provider. These notices clearly state how and under what conditions individual health care records will be shared with other persons or agencies. Violation of HIPAA regulations by health care providers or agencies can result in heavy fines for this breach of trust.

SELF-CARE ALERT

Nurses must protect their own health and private information just as clients do. Be sure your personal health care team provides you with the appropriate HIPAA documents and safeguards your privacy. And remember, privacy regulations apply to care of all clients—even those who happen to be friends, family, or coworkers.

Demographic Changes The characteristics of the North American family have changed con- siderably in the past few decades. The numbers of single-parent fami- lies and alternative family structures have increased markedly. Most of the single-parent families are headed by women, many of whom work and require assistance with child care or when a child is sick at home.

Recognition of the cultural and ethnic diversity of the United States is also increasing. Health care professionals and agencies are aware of this diversity and are employing means to meet the chal- lenges it presents. For example, more agencies are employing nurses who are bilingual and who can communicate with clients whose pri- mary language is not English.

FRAMEWORKS FOR CARE A number of configurations for the delivery of nursing care support continuity of care and cost effectiveness. These include managed care, case management, differentiated practice, the case method, the functional method, team nursing, and primary nursing. These have evolved, some from each other, for reasons such as the need to decrease health care costs and to improve the utilization of limited human and physical resources. Some configurations are more suited for inpatient (hospital and long-term care) settings, whereas others are better suited to community or ambulatory settings. A particular agency may use more than one configuration—for example, a hos- pital may have team nursing on the medical—surgical units and pri- mary nursing on the cardiac surgery unit.

Managed Care Managed care describes a health care system whose goals are to provide cost-effective, quality care that focuses on decreased costs and improved outcomes for groups of clients. In managed care,

disabled or over age 65, and Medicaid and public children’s insurance programs cover those under age 18. Even though some government assistance is available, eligibility for government insurance programs and benefits varies considerably from state to state and is continually being reevaluated.

The Homeless and the Poor Because of the conditions in which homeless people live (in shelters, on the streets, in parks, in tents, under temporary covers and dwell- ings, in transportation terminals, or in cars), their health problems are often exacerbated and sometimes become chronic. Physical, mental, social, and emotional factors create health care challenges for the homeless and the poor (Box 6–1). These individuals may lack convenient or timely transportation to health care facilities, es- pecially if repeated visits are necessary. Limited access to health care services significantly contributes to the general poor health of people who are homeless and poor in the United States. However, low in- come does not always mean below-average access, quality, or health outcomes. In one study, for some U.S. states, many of the health care benchmarks for low-income populations were better than average and better than those for higher income or more educated individu- als in other states (Shoen et al., 2013). With the ACA, states will have an opportunity to greatly improve health and health care for vulner- able populations across the country.

Health Insurance Portability and Accountability Act One of the major alterations in how health care is practiced in this country may be attributed to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The HIPAA regulations were instituted to protect the privacy of individuals by safeguarding indi- vidually identifiable health care records, including those housed in electronic media (Box 6–2). Protection of individual medical records extends not only to clinical health care sites but also to all ancillary health care providers such as pharmacies, laboratories, and third- party payers. Each health care provider dealing with client health care information must, by HIPAA regulations, provide for secure. limited access to that information. This is accomplished by restricting access to only those individuals who truly need to possess the information to aid the client, by locking documents in file cabinets, and by limit- ing access to computerized health care files.

The regulated privacy has altered the way health care provid- ers share information. Each client is provided a notice of privacy

Factors Contributing to Health Problems of the Homeless and the PoorBOX 6–1

• Poor physical environment resulting in increased susceptibility to infections

• Inadequate rest and privacy • Improper nutrition • Poor access to facilities for personal hygiene • Exposure to the elements • Lack of social support • Few personal resources • Questionable personal safety (physical assault is a constant

threat for the homeless) • Inconsistent health care • Difficulty with adherence to treatment plans

BOX 6–2

• Provides individuals with more control over their health information.

• Establishes limits for appropriate use and release of health care information.

• Requires health care providers and their agents to comply with safeguards to protect individual privacy related to health care information.

• Delineates a set of civil and criminal penalties holding HIPAA regulation transgressors accountable for actions if a client’s health care privacy is violated.

Intent of HIPAA Regulation

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resultant skill sets. Thus, differentiated practice models consist of specific job descriptions for nurses according to their education or training, for example, LVN, associate degree RN, BSN RN, MSN RN, or APRN. The model is customized within each health care institu- tion by the nurses employed there. The institution must first identify the nursing competencies required by the clients within the specific practice environment. This model further requires the delineation of roles between both licensed nursing personnel and UAPs. This en- ables nurses to progress and assume roles and responsibilities appro- priate to their level of experience, capability, and education. As with managed care and case management, differentiated nursing practice seeks to provide quality care at an affordable cost.

Case Method The case method, also referred to as total care, is one of the earliest nursing models developed. In this client-centered method, one nurse is assigned to and is responsible for the comprehensive care of a group of clients during an 8- or 12-hour shift. For each client, the nurse as- sesses needs, makes nursing plans, formulates nursing diagnoses, im- plements care, and evaluates the effectiveness of care. In this method, a client has consistent contact with one nurse during a shift but may have different nurses on other shifts. The case method, considered the precursor of primary nursing, continues to be used in a variety of practice settings such as intensive care nursing.

Functional Method The functional nursing method focuses on the jobs to be completed (e.g., bed making, temperature measurement). In this task-oriented approach, personnel with less preparation than the professional nurse perform less complex care requirements. It is based on a pro- duction and efficiency model that gives authority and responsibility to the person assigning the work, for example, the head nurse. Clearly defined job descriptions, procedures, policies, and lines of communi- cation are required. The functional approach to nursing is economi- cal and efficient and permits centralized direction and control. Its disadvantages are fragmentation of care and the possibility that non- quantifiable aspects of care, such as meeting the client’s emotional needs, may be overlooked.

Team Nursing Team nursing is the delivery of nursing care to individual clients by a group of providers led by a professional nurse. A nursing team

health care providers and agencies collaborate to render the most ap- propriate, fiscally responsible care possible. Managed care denotes an emphasis on cost controls, customer satisfaction, health promotion, and preventive services. Health maintenance organizations and pre- ferred provider organizations are examples of provider systems com- mitted to managed care.

Managed care can be used with primary, team, functional, and alternative nursing care delivery systems. Although managed care has been embraced as a model for health care reform, many question the application of this business approach to a commodity as precious as health.

Case Management Case management describes a range of models for integrating health care services for individuals or groups. Generally, case man- agement involves multidisciplinary teams that assume collaborative responsibility for planning, assessing needs, and coordinating, imple- menting, and evaluating care for groups of clients from preadmission to discharge or transfer and recuperation. A case manager, however, may be a nurse, social worker, or other appropriate professional. In some areas of the United States, case managers may be referred to as discharge planners. Key responsibilities for case managers/discharge planners are shown in Box 6–3.

Case management may be used as a cost-containment strategy in managed care. Both case management and managed care systems often use critical pathways to track the client’s progress. A critical pathway is a plan or tool that specifies interprofessional assessments, interventions, treatments, and outcomes for health-related condi- tions across a time line. Critical pathways are also called critical paths, interprofessional plans, anticipated recovery plans, and action plans.

Differentiated Practice Differentiated practice is a system in which the best possible use of nursing personnel is based on their educational preparation and

Among the greatest challenges in health care is meeting the needs of those with multiple chronic conditions. In this study, Gulley, Rasch, and Chan (2011) used the Medical Expenditure Panel Sur- vey data to examine differences in health status, service use, and access to care among and between working-age adults reporting disabilities and/or one or more chronic conditions. More than half of working-age people with disabilities reported having more than one chronic condition. Among those with ADL or instrumental ADL limitations, 35% reported four or more chronic conditions at a time. They found considerable variability in access problems and service use. However, disability consistently predicted higher emergency department use, higher hospitalization rates, and greater access problems.

IMPLICATIONS The overall prevalence of chronic conditions among the U.S. working- age population, coupled with the high concentration of multiple chronic conditions among those with disabilities, underscores the importance of reforming health care delivery systems to provide person-centered care over time. New policy-relevant measures that transcend diag- nosis are required to track the ongoing needs for health services that these populations present. Nurses are often the health care provid- ers who have the most contact with clients who have disabilities and chronic health conditions. Knowledge of the interface between these two characteristics and the complexity of the health care delivery sys- tem places nurses in an ideal position to assist clients in obtaining the care they need at the most appropriate facilities and cost.

Responsibilities of Case Managers/ Discharge PlannersBOX 6–3

• Assessing clients and their homes and communities • Coordinating and planning cost-effective client care • Collaborating with other health professionals • Monitoring clients’ progress • Evaluating client outcomes

Evidence-Based Practice How Do Chronic Conditions and Disabilities Interact in Clients Accessing Health Care Services? EVIDENCE-BASED PRACTICE

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organization, through which individuals and small businesses can purchase insurance.

• Modified private health insurance plans allow extended coverage for children and options for individuals with preexisting health problems.

• Established a nonprofit Patient-Centered Outcomes Research Institute to identify research priorities and conduct research that compares the clinical effectiveness of medical treatments

• Established the National Prevention, Health Promotion, and Pub- lic Health Council to coordinate federal prevention, wellness, and public health activities.

Payment Sources in the United States In most situations, a health care agency receives funding from sev- eral of the available payment sources. For example, an older adult client may have Medicare coverage and supplement Medicare with private insurance plus the need to pay some out-of-pocket expenses (Figure 6–8 •). Almost all insurance plans include a per-visit or per-prescription copayment.

MEDICARE AND MEDICAID In the United States, the 1965 Medicare amendments (Title 18) to the Social Security Act provided a national and state health insurance program for older adults. By the mid-1970s, virtually everyone over 65 years of age was protected by hospital insurance under Part A, which also includes post-hospital extended care and home health benefits. In 1972, its coverage was broadened to include workers with permanent disabilities and their dependents who are eligible for dis- ability insurance under Social Security. In 1988, Congress expanded Medicare to include extremely expensive hospital care, “catastrophic care,” and expensive drugs.

The Medicare plan is divided into parts: Part A is available to people with disabilities and people ages 65 years and older. It provides insurance toward hospitalization, home care, and hospice care. Part B is voluntary and provides partial coverage of outpatient and physician services to people eligible for Part A. Part D is the voluntary prescrip- tion drug plan begun in January 2006. Most clients pay a monthly premium for Parts B and D coverage.

All Medicare clients pay a deductible and coinsurance. Coinsurance is the percentage share (usually 20%) of a government-

consists of RNs, LPNs, and UAPs. This team is responsible for provid- ing coordinated nursing care to a set of clients for a specific period of time, for example, one shift.

The RN retains responsibility and authority for client care but delegates appropriate tasks to the other team members. Proponents of this model believe the team approach increases the efficiency of the RN. Opponents state that clients’ high acuity of illness leaves little to be delegated to non-RNs.

Primary Nursing Primary nursing is a system in which one nurse is responsible for overseeing the total care of a number of hospitalized clients 24 hours a day, 7 days a week, even if he or she does not deliver all of the care personally. It is a method of providing comprehensive, individual- ized, and consistent care.

Primary nursing uses the nurse’s technical knowledge and man- agement skills. The primary nurse assesses and prioritizes each client’s needs, identifies nursing diagnoses, develops a plan of care with the client, and evaluates the effectiveness of care. Associates provide some care, but the primary nurse coordinates it and communicates informa- tion about the client’s health to other nurses and other health profes- sionals. Primary nursing encompasses all aspects of the professional role, including teaching, advocacy, decision making, and continuity of care. The primary nurse is the first-line manager of the client’s care with all its inherent accountabilities and responsibilities. Primary nurses should be those who work consistently on the nursing unit. Thus, one of the challenges with primary nursing is the variable number of part- time nurses who may not be appropriate for the primary nurse role.

FINANCING HEALTH CARE Although efforts have been made to control the costs of health care, these costs continue to increase. Employers, legislators, insurers, and health care providers continue to collaborate in efforts to resolve is- sues surrounding how to best finance health care costs. Among these efforts, the United States has implemented some cost-containment strategies including health promotion and illness prevention activi- ties, managed care systems, and alternative insurance delivery sys- tems. The U.S. Center for Outcomes and Evidence (COE) conducts and supports studies on the outcomes and effectiveness of diagnostic, therapeutic, and preventive health care services and procedures, in- cluding cost.

On March 23, 2010, President Obama signed comprehensive U.S. health care reform, the Patient Protection and Affordable Care Act (commonly referred to as the ACA), into law. The primary pur- pose of the ACA is to require most Americans and legal residents to have some form of health insurance. The legalities and practicalities of the ACA have caused much controversy, and its full impact will not be known for many years. Some key features of the very complex ACA are as follows:

• Individuals will be fined if they do not have health insurance (the individual mandate).

• Employers must offer insurance coverage if they meet specific requirements.

• Eligibility for Medicaid is significantly expanded (see below). • State-based American Health Benefit Exchanges and Small Busi-

ness Health Options Program (SHOP) Exchanges were created. They are administered by a governmental agency or nonprofit

Figure 6–8 • Medicare helps defray the costs of health care. Photo Researchers/Getty Images.

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This legislation limits the amount paid to hospitals that are reimbursed by Medicare. Reimbursement is made according to a classification system known as diagnosis-related groups (DRGs). The system has categories that establish pretreatment diagnosis billing categories.

Under this system, the hospital is paid a predetermined amount for clients with a specific diagnosis. For example, a hospital that ad- mits a client with a diagnosis of uncomplicated asthma is reimbursed a specified amount, such as $1,300, regardless of the cost of services, the length of stay, or the acuity or complexity of the client’s illness. Prospective payment or billing is formulated before the client is even admitted to the hospital; thus, the record of admission, rather than the record of treatment, now governs payment. DRG rates are set in advance of the prospective year during which they apply and are con- sidered fixed except for major, uncontrollable occurrences.

In efforts to decrease costs and encourage attention to prevent- able conditions, for discharges occurring after October 1, 2008, hos- pitals no longer receive additional payment for cases in which one of several identified preventable conditions was not present on admis- sion. That is, the case would be paid as though the secondary diagnosis were not present. Examples of hospital-acquired conditions (HACs) are pressure ulcers and urinary tract infections following catheteriza- tion. In addition, certain HAC “never events” have been identified that can result in fines to the health care provider on top of the missed re- imbursement. Examples of never events are objects accidentally left in the body during surgery or incorrect blood type transfusions.

Insurance Plans A variety of plans have come into existence to finance health care in the United States. These include private insurance and group insur- ance. Each individual and group plan offers different options for con- sumers to consider.

Commonly, health care providers bill the insurance company directly for their services and the consumer may be responsible for a copayment or deductible. In some situations, the consumer must pay the provider fees and then submit a claim to the insurance company for eligible reimbursements. Another type of insurance that is usually a reimbursed plan is long-term care insurance. This covers a portion of the cost of care in the home or at assisted living, adult day care, re- spite care, hospice care, nursing home, and Alzheimer’s facilities.

PRIVATE INSURANCE In the United States, numerous commercial health insurance carriers offer a wide range of coverage plans. The two types of private insur- ance are not-for-profit (e.g., Blue Shield) and for-profit (e.g., Metro- politan Life, Travelers, and Aetna) insurance. Private health insurance pays either the entire bill or, more often, 80% of the costs of health care services. With private insurance health plans, the insurance company reimburses the health care provider a fee for each service provided (fee-for-service). The term third-party reimbursement refers to the in- surance company that pays the client’s (first party) bill to the provider (second party).

These insurance plans may be purchased either as an individual plan or as part of a group plan through an individual’s employer, union, student association, or similar organization. For private insurance not covered by an employer, the individual usually pays a monthly pre- mium for health care insurance. Group plans offer lower premiums that may be paid for completely by the employer, completely by group members, or by some combination of the two.

approved charge that is paid by the client; the remaining percent is paid by the plan.

Medicare does not cover dental care, dentures, eyeglasses, hear- ing aids, or examinations to prescribe and fit hearing aids. Most pre- ventive care, including routine physical examinations and associated diagnostic tests, is also not included. However, as part of the 1997 Bal- anced Budget Act, annual screening mammograms for women over age 40 are a fully covered cost under Medicare.

Medicaid was also established in 1965 under Title 19 of the So- cial Security Act. Medicaid is a federal public assistance program paid out of general taxes to people who require financial assistance, such as people with low incomes. Medicaid is paid by federal and state gov- ernments. Each state program is distinct. Some states provide very limited coverage, whereas others pay for dental care, eyeglasses, and prescription drugs.

In 1972, Congress directed the U.S. Department of Health, Education, and Welfare to create professional standards review or- ganizations to monitor the appropriateness of hospital use under the Medicare and Medicaid programs. In 1974, the National Health Planning and Resources Development Act established health sys- tems agencies throughout the United States for comprehensive health planning. In 1978, the Rural Health Clinics Act provided for the de- velopment of health care in medically underserved rural areas. This act opened the door for NPs to provide primary care.

SUPPLEMENTAL SECURITY INCOME People with disabilities or those who are blind may be eligible for special payments called Supplemental Security Income (SSI) benefits. These benefits are also available to people not eligible for Social Security, and payments are not restricted to health care costs. Clients often use this money to purchase medicines or to cover costs of extended health care.

CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP) The CHIP was established by the U.S. government in 1997 to provide insurance coverage for poor and working-class children. The pro- gram expands coverage for children under Medicaid and subsidizes low-cost state insurance alternatives. Coverage includes visits to pri- mary health care providers, prescription medicines, and hospitaliza- tion. In early 2009, President Obama signed the Children’s Health Insurance Program Reauthorization Act (CHIPRA), which renews and expands coverage of CHIP from 7 million children to 11 million children. State eligibility requirements vary, but generally, those with family incomes of less than twice the federal poverty line are eligible.

WOMEN, INFANTS, AND CHILDREN PROGRAM The Special Supplemental Nutrition Program for Women, Infants, and Children, popularly known as WIC, provides nutritious foods to supplement diets, information on healthy eating, and referrals to health care for mothers and for children up to age 5. WIC provides federal grants to states for low-income pregnant, breast-feeding, and non–breast-feeding postpartum women, and to infants and children who are found to be at nutritional risk. It is administered by the Food and Nutrition Service of the U.S. Department of Agriculture.

PROSPECTIVE PAYMENT SYSTEM To curtail health care costs in the United States, Congress in 1983 passed legislation putting the prospective payment system into effect.

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PREFERRED PROVIDER ORGANIZATIONS The preferred provider organization (PPO) consists of a group of providers and perhaps a health care agency (often a hospital) that provide an insurance company or employer with health services at a discounted rate. One advantage of the PPO is that it provides clients with a choice of health care providers and services. Providers can belong to one or several PPOs, and the client can choose among the providers belonging to the PPO. A disadvantage of PPOs is that they tend to be more expensive than HMO plans, and if individuals wish to join a PPO, they might have to pay more for the additional choices.

PREFERRED PROVIDER ARRANGEMENTS Preferred pro- vider arrangements (PPAs) are similar to PPOs. The main difference is that the PPAs can be contracted with individual health care providers, whereas PPOs involve an organization of health care providers. A PPA plan can be limited or unlimited. A limited PPA restricts the client to using only preferred providers of health care; an unlimited PPA permits the client to use any health care provider in the area who accepts the contractual agreement of the plan. Again, with PPAs, more choices in health care providers may mean more cost to the enrollee.

INDEPENDENT PRACTICE ASSOCIATIONS Independent pra- ctice associations (IPAs) are somewhat like HMOs and PPOs. The IPA provides care in offices, just as the providers belonging to a PPO do. The difference is that clients pay a fixed prospective payment to the IPA, and the IPA pays the provider. In some instances, the health care provider bills the IPA for services; in others, the provider receives a fixed fee for services given. At the end of the fiscal year, any surplus money is divided among the providers; any loss is assumed by the IPA.

PHYSICIAN/HOSPITAL ORGANIZATIONS Physician/hospital organizations (PHOs) are joint ventures between a group of private practice physicians and a hospital. PHOs combine both resources and personnel to provide managed care alternatives and medical services. PHOs work with a variety of insurers to provide services. A typical PHO will include primary care providers and specialists.

A PHO may be part of an integrated delivery system (IDS). Such a system incorporates acute care services, home health care, extended and skilled care facilities, and outpatient services. Most in- tegrated delivery systems provide care throughout the life span. Insur- ers can contract with IDSs to provide all required services, rather than the insurer contracting with multiple agencies for the same services. Ideally, an IDS enhances continuity of care and communication be- tween professionals and various agencies providing managed care.

GROUP PLANS Health care group plans provide blanket medical service in exchange for a predetermined monthly payment. A variety of group plans have come into existence to finance health care in the United States. These include health maintenance organizations, accountable care organizations, preferred provider organizations, preferred provider arrangements, independent practice associations, and physician/ hospital organizations. Each group plan offers different options for consumers to consider when choosing a prepaid health care program.

HEALTH MAINTENANCE ORGANIZATIONS A health mainte- nance organization (HMO) is a group health care agency that provides health maintenance and treatment services to voluntary enrollees. A fee is set without regard to the amount or kind of services provided.

The HMO plan emphasizes client wellness; the better the health of the person, the fewer the HMO services that are needed and the greater the agency’s profit. Members of HMOs choose a primary care provider (PCP) such as an internal medicine physician, general prac- titioner, or NP who evaluates their health status and coordinates their care. If the primary care provider cannot treat a particular problem because of its special nature, he or she may make a referral to a spe- cialist provider. To reduce costs, HMOs will pay for specialty services only if the PCP has made a referral to the specialist. It is an expec- tation between the HMO and PCPs being reimbursed under their plans that PCPs will treat clients and reduce costs whenever possible.

Thus, under HMO plans, clients are limited in their ability to select health care providers and services, but available services are at a reduced and predetermined cost to the client. Because health promotion and illness prevention are highly emphasized in HMOs, nurses in HMOs focus on these aspects of care. Companies that pro- vide HMO plans such as Kaiser Permanente, United Healthcare, and Aetna have been established across the United States, although not in every community.

ACCOUNTABLE CARE ORGANIZATIONS Accountable care organizations (ACOs) are characterized by a payment and care delivery model that ties provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients. In many ways, they are similar to HMOs. There are incentives to hospitals, physicians, post–acute care facilities, and other providers to facilitate coordination of care delivery. Beginning in 2012, ACOs were able to contract to provide services for persons covered under Medicare.

LIFESPAN CONSIDERATIONS Assessing Older Adults’ Functional Levels

Assessing the functional levels of older adults on an ongoing ba- sis will provide guidelines for detecting needs for special care, resources, and services. It helps to determine their level of inde- pendence and changes as they occur. The two most common as- sessments are to evaluate the following activities of daily living and instrumental activities of daily living:

ACTIVITIES OF DAILY LIVING • Bathing • Dressing • Toileting • Transferring • Continence • Feeding

INSTRUMENTAL ACTIVITIES OF DAILY LIVING • Ability to use the telephone • Shopping • Food preparation • Housekeeping • Laundry • Mode of transportation • Responsibility for own medication • Ability to handle finances The case study in this chapter’s Critical Thinking Checkpoint is an example of how these assessments and needs might change for older adults. Mobilizing appropriate resources to help maintain older adults’ functioning ability is important in providing nursing care.

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Critical Thinking Checkpoint

Mr. Mendel is an 83-year-old married man. He has a history of severe osteoarthritis leading to bilateral hip replacements and one knee re- placement. He has mild hypertension controlled by oral medication. His last orthopedic surgery was done to replace a hip component that failed due to repeated dislocations. At that time, he developed a severe urinary tract infection resulting in weight loss, fatigue, and weakness. After stabilizing, he was sent to the skilled nursing unit of the hospital for 2 weeks until ready to go back home. Occupational therapists consulted with him and his wife during his hospitalization.

He lives in a three-story house with the bedrooms on the top floor, kitchen and living room on the middle/main floor, and family room on the bottom floor. He has not driven since the last operation, but would like to. He has smoked cigars for years and sits on the front porch to smoke. Physical therapists have come to the house three times a

week for several months. A home health nurse has also been con- sulted periodically to assist with nutrition and elimination difficulties. 1. In what ways has Mr. Mendel used (a) health promotion and

illness prevention (primary prevention), (b) diagnosis and treat- ment (secondary prevention), and (c) rehabilitation and health restoration (tertiary prevention) health care services?

2. Name three types of health care agencies he has used. What are the strengths of each of these?

3. Mr. Mendel’s insurance company has assigned him a case manager. What would this person’s responsibilities be in his particular case?

4. What other members of the health care profession would most likely be on the case manager’s team and why?

See Critical Thinking Possibilities on student resource website.

• Health care delivery services can be categorized by the type of service: (a) primary prevention: health promotion and illness pre- vention, (b) secondary prevention: diagnosis and treatment, and (c) tertiary prevention: rehabilitation, health restoration, and pallia- tive care.

• Hospitals provide a wide variety of services on an inpatient and outpatient basis. Hospitals can be categorized as public or private, for-profit or not-for-profit, and acute care or long-term care. Many other settings, such as clinics, offices, and day care centers, also provide care.

• Various providers of health care coordinate their skills to assist a client. Their mutual goal is to restore a client’s health and promote wellness.

• The role of the nurse in providing care to clients will vary depending on the employment setting, the nurse’s credentials, and the needs of the client.

• The many factors affecting health care delivery include the increas- ing number of older adults, advances in knowledge and technol- ogy, economics, increased emphasis on women’s health, uneven distribution of health services, access to health insurance, health care for the homeless and poor, HIPAA, and demographic changes.

• Delivery of nursing care that supports continuity of client-focused care and is cost effective may be implemented by any of the fol- lowing methods: managed care, case management, differentiated practice, the case method, the functional method, team nursing, and primary nursing.

• In the United States, health care is financed largely through gov- ernment agencies and private organizations that provide health care insurance, prepaid plans, and federally funded programs. Government-financed plans include Medicare and Medicaid. Private plans include Blue Cross and Blue Shield. Prepaid group plans include HMOs, ACOs, PPOs, PPAs, IPAs, and PHOs.

CHAPTER HIGHLIGHTS

1. Which of the following is an example of a primary prevention activity? 1. Antibiotic treatment of a suspected urinary tract infection 2. Occupational therapy to assist a client in adapting his or her

home environment following a stroke 3. Nutrition counseling for young adults with a strong family

history of high cholesterol 4. Removal of tonsils for a client with recurrent tonsillitis

2. Which of the following statements is true regarding types of health care agencies? 1. Hospitals provide only acute, inpatient services. 2. Public health agencies are funded by governments to

investigate and provide health programs. 3. Surgery can only be performed inside a hospital setting. 4. Skilled nursing, extended care, and long-term care facilities

provide care for older adults whose insurance no longer covers hospital stays.

TEST YOUR KNOWLEDGE

Chapter 6 Review

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5. A client is seeking to control health care costs for both preventive and illness care. Although no system guarantees exact out-of-pocket expenditures, the most prepaid and predictable client contribution would be seen with 1. Medicare. 2. An individual fee-for-service insurance. 3. A preferred provider organization (PPO). 4. A health maintenance organization (HMO).

See Answers to Test Your Knowledge in Appendix A.

3. In most cases, clients must have a primary care provider in order to receive health insurance benefits. If a client is in need of a primary care provider, it is most appropriate for the nurse to recommend which of the following? 1. Family practice physician 2. Physical therapist 3. Case manager/discharge planner 4. Pharmacist

4. The most significant method for reducing the ongoing increase in the cost of health care in the United States includes controlling which of the following? 1. Number of children according to the family’s income 2. Numbers of uninsured and underinsured persons 3. Number of physicians and nurses nationwide 4. Competition among drug and medical equipment

manufacturers

Suggested Reading Grabowski, D. C., Huckfeldt, P. J., Sood, N., Escarce, J. J., &

Newhouse, J. P. (2012). Medicare postacute care pay- ment reforms have potential to improve efficiency of care, but may need changes to cut costs. Health Affairs, 31, 1941–1950. The Affordable Care Act mandates changes in payment policies for Medicare postacute care services. In addition to reducing annual payment increases to providers under the existing prospective payment systems, the act calls for demonstration projects of bundled payment, account- able care organizations, and other strategies to promote care coordination and reduce spending. Experience with the adoption of Medicare prospective payment systems in postacute care settings suggests that current reforms could produce undesirable effects such as decreased access for less profitable clients, poorer client outcomes, and only short-lived curbs on spending. Policy makers will need to be vigilant in monitoring the impact of the Afford- able Care Act reforms and be prepared to amend policies as necessary to ensure that the reforms exert persistent controls on spending without compromising the delivery of client-appropriate postacute services.

Related Research Li, Y., Glance, L. G., Yin, J., & Mukamel, D. B. (2011). Racial

disparities in rehospitalization among Medicare patients in skilled nursing facilities. American Journal of Public Health,101, 875–882. doi:10.2105/AJPH.2010.300055

References Carper, K., & Machlin, S. R. (2013). National health care

expenses in the U.S. civilian noninstitutionalized population, 2010 (Medical Expenditure Panel Survey Statistical Brief #396). Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from http://www.meps.ahrq.gov/ mepsweb/data_files/publications/st396/stat396.pdf

Centers for Medicaid and Medicare Services. (2009). National health expenditure projections 2011–2021. Retrieved from http://www.cms.gov/Research-Statistics- Data-and-Systems/Statistics-Trends-and-Reports/ NationalHealthExpendData/Downloads/Proj2011PDF.pdf

Gulley, S. P., Rasch, E. K., & Chan, L. (2011). The complex web of health: Relationships among chronic conditions, disability, and health services. Public Health Reports, 126, 495–507.

Hing, E., & Shappert, M. S. (2012). Generalist and specialty physicians: Supply and access, 2009–2010 (NCHS Data Brief No. 105). Hyattsville, MD: National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/data/ databriefs/db105.pdf

Kaiser Family Foundation StateHealthFacts.org. (n.d.). Registered nurses per 100,000 population, 2011. Retrieved from http://www.statehealthfacts.org/comparemaptable .jsp?ind=439&cat=8

National Center for Health Statistics. (2012). Health: United States, 2012. Hyattsville, MD: Author. Retrieved from http://www.cdc.gov/nchs/data/hus/hus12.pdf

Pfuntner, A., Wier, L. M., & Steiner, C. (2013, December). Costs for hospital stays in the United States, 2011 (HCUP Statistical Brief #168). Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from http:// www.hcup-us.ahrq.gov/reports/statbriefs/sb168-Hospital- Costs-United-States-2011.jsp

Shoen, C., Radley, D., Riley, P., Lippa, J., Berenson, J., Dermody, C., & Shih, S. (2013). Health care in the two Americas: Findings from the scorecard on state health system performance for low-income populations, 2013. New York, NY: The Commonwealth Fund. Retrieved from http://www.commonwealthfund.org/~/media/Files/ Publications/Fund%20Report/2013/Sep/1700_Schoen_ low_income_scorecard_FULL_REPORT_FINAL_v4.pdf

U.S. Census Bureau. (2012). Table 2. Projections of the population by selected age groups and sex for the United States: 2015 to 2060. Retrieved from http://www .census.gov/population/projections/data/national/2012/ summarytables.html

U.S. Department of Health and Human Services. (2010). Healthy people 2020. Retrieved from http://healthypeople .gov/2020/about/default.aspx

Walkowski, S. A. (2011). Current and distinctive terminology: Osteopath and physician. Journal of the American Osteopathic Association, 111,141–142.

Selected Bibliography American Association of Colleges of Nursing. (1995). A

model for differentiated nursing practice. Washington, DC: Author.

Chin, M. H., Clarke, A. R., Nocon, R. S., Casey, A. A., Goddu, A. P., Keesecker, N. M., & Cook, S. C. (2012). A roadmap and best practices for organizations to reduce racial and ethnic disparities in health care. Journal of General Internal Medicine, 27, 992–1000. doi:10.1007/ s11606-012-2082-9

Hagland, M. (2012). Readmissions and the mechanics of care transitions. Healthcare Informatics, 29(5), 38–40.

Health Resources and Services Administration, Bureau of Health Professions, National Center for Health Workforce Analysis. (2013). Compendium of federal data sources to support health workforce analysis. Retrieved from http://bhpr.hrsa.gov/healthworkforce/data/ compendiumfederaldatasources.pdf

Institute of Medicine. (2009). America’s uninsured crisis: Consequences for health and health care. Washington, DC: National Academies Press.

Kaiser Commission on Medicaid and the Uninsured and the Health Care Marketplace Project. (2011). Summary of new health reform law. Retrieved from http://www.kff.org/ healthreform/8061.cfm

Kirch, D. G., Henderson, M. K., & Dill, M. J. (2012). Physician workforce projections in an era of health care reform. Annual Review of Medicine, 63, 435–445. doi:10.1146/annurev-med-050310-134634

Kongstvedt, P. R. (2013). Essentials of managed health care (6th ed.). Boston, MA: Jones & Bartlett.

Kovner, A. R., & Knickman, J. R. (2011). Jonas & Kovner’s health care delivery in the United States (10th ed.). New York, NY: Springer.

Sredl, D., Melnyk, B., Hsueh, K., Jenkins, R., Ding, C., & Durham, J. (2011). Health care in crisis! Can nurse executives’ beliefs about and implementation of evidence- based practice be key solutions in health care reform? Teaching and Learning in Nursing, 6, 73–79. doi:10.1016/j. teln.2010.06.001

READINGS AND REFERENCES

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INTRODUCTION The health care system is continuously undergoing change. Escalating health care costs, advancements in technology, chang- ing patterns of demographics, shorter hospital stays, increased cli- ent acuity, and limited access to health care are some of the factors motivating change. The location of client care is expanding out of traditional settings into the community and neighborhoods. For example, health care activities such as intravenous fluid admin- istration or mechanical ventilation, once considered safe only in hospital settings, are now available for clients in their homes (see Chapter 8 ) and in ambulatory surgical, rehabilitation, and dialysis centers.

It is difficult to document the shifting of care from hospitals to the community. One resource to track changes is the annual survey of health care dollar expenditures conducted by the U.S. government. The most recent data show that the percentage of total health care dollars spent for hospital care continues to decrease (National Center for Health Statistics, 2013). Although hospitals and other health care institutions remain key components of the health care system, the trend is toward an integrated health care system—one that is commu- nity based. The shift from institutional to community care also brings changes in the roles and responsibilities of health care professionals.

Many things influence whether clients select to have their care in hospitals or in community settings. Some variables include clients’ knowledge and awareness of community resources, cost, availability of home care, and perceived safety of home care. More research is needed to show differences in health outcomes based on location of care.

THE MOVEMENT OF HEALTH CARE TO THE COMMUNITY Health care professionals, consumers, and legislators have expressed major dissatisfaction with the current health care system, which fo- cuses on expensive, acute, hospital-based care. Nurses, professional organizations, and consumers influence health care reform. Nurses provide a unique perspective on the health care system because of their constant presence in a variety of settings and their contact both with consumers who receive the benefits of the system’s most com- plex services and with those who have problems with the system’s inefficiencies. The larger numbers of advanced practice nurses in recent years have resulted in the provision of primary care to many consumers who had previously been neglected—those living in rural areas, the poor, undocumented immigrants, older adults, and women and infants.

Through nurses’ major organizations, nursing has presented a strong voice in describing what a new system should include and what nursing’s contributions should be. In 1991, the American Nurses Association (ANA) published Nursing’s Agenda for Health Care Reform, which set forth the ANA’s recommendations for health care reform. Although the agenda called for “immediate” changes, the majority of the recommendations have still not been implemented more than 20 years later. In 2008, the ANA published a revision of its 2005 Health System Reform Agenda. The revision reiterated the need to move to a balance between providing care in hospitals with their high-technology equipment and providing care via community-based and preventive care programs, with an em- phasis on the latter.

LEARNING OUTCOMES

After completing this chapter, you will be able to: 1. Discuss factors influencing health care reform. 2. Describe various community-based health care frameworks,

including integrated health care systems, community initia- tives and conditions, and case management.

3. Differentiate community health care settings from traditional settings.

4. Differentiate community-based nursing from traditional institutional-based nursing.

KEY TERMS

collaboration, 112 community, 108 community-based health care

(CBHC), 107

community-based nursing (CBN), 111

community health nursing, 108 community nursing centers, 110

continuity of care, 113 discharge planning, 114 integrated health care

system, 109

population, 108 primary care (PC), 107 primary health care (PHC), 106

7 Community Nursing and Care Continuity

5. Discuss competencies community-based nurses need for practice, including the Pew Health Professions Commission recommendations for health competencies for future health practitioners.

6. Explain essential aspects of collaborative health care: defini- tions, objectives, benefits, and the nurse’s role.

7. Describe the role of the nurse in providing continuity of care.

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• Grants to programs preparing nurses to work with older adults and in long-term care settings

• A grant program for states to establish community-based inter- professional teams to support primary care practices

• Grants for nurse-managed clinics and school-based health centers • A Public Health Workforce Loan Repayment Program to ensure

an adequate supply of public health professionals. Under this program, the U.S. Department of Health and Human Services (USDHHS) will repay up to one-third of loans incurred by a public health or health professions student in exchange for that student’s agreement to accept employment with a public health agency for at least 3 years.

Primary Health Care and Primary Care Another major influence promoting health care reform has been the work on Healthy People (USDHHS, 2010). This project pre- sents health-related objectives that provide a framework for national health promotion, health protection, and disease prevention. Details of Healthy People 2020 are discussed in Chapter 16 .

The forerunner of Healthy People and Nursing’s Agenda for Health Care Reform was the 1978 World Health Organization (WHO) report Primary Health Care. The term primary health care (PHC) was coined in the World Health Assembly by WHO and the United Nations In- ternational Children’s Emergency Fund (UNICEF). Primary health care (PHC) is defined as follows:

. . . essential health care based on practical, scientifically sound and socially acceptable methods and technology made univer- sally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their de- velopment in the spirit of self-reliance and self-determination. (WHO, 1978, p. 35)

Primary health care incorporates five principles:

• Equitable distribution • Appropriate technology • A focus on health promotion and disease prevention • Community participation • A multisectoral approach.

Deep concern about health care for the majority of the world’s population, specifically low life expectancies and high mortality rates among children, led to the global health strategy of primary health care. The WHO declaration emphasized health or well-being as a fun- damental right and a worldwide social goal. It attempted to address inequality in health status of individuals in all countries and to target government responsibility for policies that would promote economic, social, and health development. Both economic and social develop- ment were considered basic to the achievement of health for all. Thus, PHC extends beyond the boundaries of traditional health care ser- vices. It involves issues of the environment, agriculture, housing, and other social, economic, and political issues such as poverty, transporta- tion, unemployment, and economic development to sustain the popu- lation. A major feature of PHC is that consumers, governments, and public institutions such as public health departments and city councils should be involved in the planning and delivery of health care.

Consumers are also effecting major changes in health care delivery systems. Consumers are adopting health-related values that include the following:

• Health means more than the absence of disease; it encompasses well-being and quality of life.

• Quality of life is related to a healthy community, which includes healthy families and a healthy environment.

• Individuals can actively participate in promoting and maintaining their health through behavior and lifestyle changes.

• Disease prevention is important.

These values indicate that consumers support an increased emphasis on health care services and programs that promote wellness and res- toration and prevent disease.

After significant debate and negotiation, President Obama signed the most significant change in health care legislation in American history on March 23, 2010: the Patient Protection and Affordable Care Act (Public Law 111-148) (ACA). The ANA (2012c), in response to the ACA, stated:

As the largest single group of clinical health care professionals within the health system, registered nurses are educated and practice within a holistic framework that views the individual, family and community as an interconnected system that can keep us well and help us heal. Registered nurses are fundamen- tal to the critical shift needed in health services delivery, with the goal of transforming the current “sick care” system into a true “health care” system. The ANA is actively engaging with federal policymakers and regulators to advocate for system transformation that includes the valuable contributions of nursing and nurses. (p. 1)

Two of the key components of the ACA are preventing insur- ance companies from denying coverage to persons with previous health conditions and expansion of the criteria for persons to be eli- gible for federal and state health insurance.

This legislation will assist the Health Resources and Services Administration (HRSA), administered by registered nurse Mary Wakefield, PhD (appointed by President Obama in 2009), to meet its goals. The HRSA focuses on uninsured, underserved, and special needs populations and aims to:

1. Improve access to health care. 2. Improve health outcomes. 3. Improve the quality of health care. 4. Eliminate health disparities. 5. Improve the public health and health care systems. 6. Enhance the ability of the health care system to respond to public

health emergencies. 7. Achieve excellence in management practices.

For nurses, the ACA means

• Expanded scholarships and loan forgiveness programs for nurses at both entry-level and advance practice levels who are willing to work with underserved populations

• Increased funding for nurses wishing to become faculty • Support for programs that allow diploma and associate-degree

nurses to obtain their BSN degrees

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PHC differs from primary care (PC). Primary care addresses personal health services and not population-based public health services. Primary care (PC), according to the Institute of Medicine (IOM), is “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health services, developing a sustained partnership with clients, and practicing in the context of family and community” (Donaldson, Yordy, Lohr, & Vanselow, 1996, p. 1). The constituents of PC are shown in Figure 7–1 •.

PHC is community based and driven and requires active com- munity involvement in making decisions to improve health. PC, on the other hand, is expert driven and involves health professionals who advise individuals and communities about what is best for their health. Other differences are shown in Table 7–1.

PHC and PC also have similarities. Both acknowledge the pre- vention and promotion components of health and well-being. Both strive for universal access to and affordability of health care, support empowerment of the client, and target those at risk for preventable health problems.

COMMUNITY-BASED HEALTH CARE Community-based health care (CBHC) is a PHC system that provides health-related services within the context of people’s daily lives—that is, in places where people spend their time, for example, in the home, in shelters, in long-term care residences, at work, in

Figure 7–1 • The interdependence of the constituents of primary care showing the centrality of the clinician–patient relationship in the context of family and community and as furthered by teams and integrated delivery systems. From Primary Care: America’s Health in a New Era (p. 34), by M. S. Donaldson, K. D. Yordy, K. N. Lohr, & N. A. Vanselow (Eds.), 1996, Washington, DC: National Academy Press. Retrieved from http://books.nap.edu/catalog.php?record_id=5152.

Clinician

Integrated Delivery

System Community

Team

Patient

Family

schools, in senior citizens’ centers, in ambulatory settings, and in hos- pitals. The care is directed toward a specific group within the geo- graphic neighborhood (Figure 7–2 •). The group may be established by a physical boundary, an employer, a school district, a managed care insurance provider, or a specific medical need or category. In contrast to the traditional health care system that focuses primarily on those who are ill or injured, community-based care is holistic. It involves a

Figure 7–2 • Communities may consist of several types of neighborhoods. Porterfield-Chickering/Getty Images.

TABLE 7–1 Differences Between Primary Care and Primary Health Care

Primary Care Primary Health Care • Community participation is provider directed. • The professional’s role is expert, provider, authority,

and team leader. • Collaboration occurs among members of the health care team. • The individual or family is the focus. • Access is limited. • Health care is available within given health care institutions. • Empowerment is a provider-assisted process.

• Community participation is client directed. • The professional’s role is that of facilitator, consultant,

and resource. • Collaboration goes beyond the health care sector. • The community or some aggregate is the focus. • Access is universal. • Health care is available where people live and work. • Empowerment is a collaborative, enabling process.

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broad range of services designed not only to restore health but also to promote health, prevent illness, and protect the public.

To be truly effective, a CBHC system needs to (a) provide easy access to care, (b) be flexible in responding to the care needs that in- dividuals and families identify, (c) promote care between and among health care agencies through improved communication mechanisms, (d) provide appropriate support for family caregivers, and (e) be af- fordable. With the ACA, a key task is to create sustainable implemen- tation of community-based models of primary care integrated with public health (IOM, 2012).

COMMUNITY HEALTH A community is a collection of people who share some attribute of their lives and interact with each other in some way. They may live in the same locale, attend a particular church, or even share a particu- lar interest such as art. Groups that constitute a community because of common member interests are often referred to as communities of interest (e.g., religious and cultural groups). A community can also be defined as a social system in which the members interact formally or informally and form networks that operate for the benefit of all people in the community. Five of the main functions of a commu- nity are described in Box 7–1. In community health, the community may be viewed as having a common health problem, such as a high incidence of infant mortality or of tuberculosis, HIV infection, or another communicable disease. Box 7–2 lists the characteristics of a healthy community. A population is composed of people who share some common characteristic but who do not necessarily interact with each other. Community health nursing focuses on promot- ing and preserving the health of population groups.

BOX 7–1

1. Production, distribution, and consumption of goods and services. These are the means by which the community provides for the economic needs of its members. This function includes not only the supplying of food and clothing but also the provision of water, electricity, and police and fire protection and the disposal of refuse.

2. Socialization. Socialization refers to the process of trans- mitting values, knowledge, culture, and skills to others. Communities usually contain a number of established institu- tions for socialization: families, churches, schools, media, voluntary and social organizations, and so on.

3. Social control. Social control refers to the way in which order is maintained in a community. Laws are enforced by the police; public health regulations are implemented to protect people from certain diseases. Social control is also exerted through the family, church, and schools.

4. Social interparticipation. Social interparticipation refers to community activities that are designed to meet people’s needs for companionship. Families and churches have traditionally met this need; however, many public and private organizations also serve this function.

5. Mutual support. Mutual support refers to the community’s ability to provide resources at a time of illness or disaster. Although the family is usually relied on to fulfill this function, health and social services may be necessary to augment the family’s assistance if help is required over an extended period.

Five Main Functions of a Community

Ten Characteristics of a Healthy CommunityBOX 7–2

A HEALTHY COMMUNITY • Is one in which members have a high degree of awareness

of being a community. • Uses its natural resources while taking steps to conserve

them for future generations. • Openly recognizes the existence of subgroups and welcomes

their participation in community affairs. • Is prepared to meet crises. • Is a problem-solving community; it identifies, analyzes, and

organizes to meet its own needs. • Possesses open channels of communication that allow

information to flow among all subgroups of citizens in all directions.

• Seeks to make each of its systems’ resources available to all members.

• Has legitimate and effective ways to settle disputes that arise within the community.

• Encourages maximum citizen participation in decision making.

• Promotes a high level of wellness among all its members.

Communities, like individuals and families, are living entities. As such, the nurse will need to carry out an assessment of this com- munity as the client. Several community assessment frameworks have been devised. Students who enroll in a community health nursing course will study these in some detail. In one framework, Anderson and McFarlane (2011) identified eight subsystems of the community for analysis. The subsystems are illustrated around a core, which consists of the people and their characteristics, values, history, and beliefs. The first stage in assessment is to learn about the people in the community. These community-level subsystems may be thought of as analogous to the physiological subsystems of an individual. Box 7–3 shows major aspects of a community sub- systems assessment. Box 7–4 shows sources of community data that the nurse may draw on to help identify health care concerns and to aid in intervention planning for any acknowledged community health issues.

Planning community health may be oriented toward im- proved crisis management, disease prevention, health mainte- nance, or health promotion. The responsibility for planning at the community level is usually broadly based and needs to in- clude as many of the community partners as possible. The exact resources and skills of members of the community often depend on the size of the community. A broadly based planning group is most likely to create a plan that is acceptable to members of the community. Also, people who are involved in planning become educated about the problems, the resources, and the interrelation- ships within the system.

When setting priorities, health planners must work with con- sumers, interest groups, or other involved persons to prioritize health problems. It is important to take into consideration the values and interests of community members, the severity of the problems, and the resources available to identify and act on the problems. Because any plan is likely to result in change, members of the planning group should understand and use planned change theory.

In community health, evaluation determines whether the planned interventions have led to the achievement of the established goals and

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Sources of Community Assessment DataBOX 7–4

• City maps to locate community boundaries, roads, churches, schools, parks, hospitals, and so on

• State census data for population composition and characteristics

• Chamber of commerce for employment statistics, major in- dustries, and primary occupations

• County or state health departments for location of health fa- cilities, occupational health programs, numbers of health pro- fessionals, numbers of welfare recipients, and so on

• City or regional health planning boards for health needs and practices

• Telephone book for location of social, recreational, and health organizations, committees, and facilities

• Public and university libraries for district social and cultural research reports

• Health facility administrators for information about employee caseloads, prevalent types of problems, and dominant needs

• Recreational directors for programs provided and participation levels

• Police department for incidence of crime, vandalism, and drug addiction

• Teachers and school nurses for incidence of children’s health problems and information on facilities and services to maintain and promote health

• Local newspapers for community activities related to health and wellness, such as health lectures or health fairs

• Online computer services that may provide access to public documents related to community health

BOX 7–3

PHYSICAL ENVIRONMENT Consider the natural boundaries, size, and population density; types of dwellings; and incidence of crime, vandalism, and substance abuse.

EDUCATION Consider educational facilities; existing school health facilities; type and amount of health services handled by the school; school lunch programs; extracurricular sports, libraries, and counseling services; continuing education or extended education programs; and extent of parental involvement in the schools.

SAFETY AND TRANSPORTATION Consider fire, police, and sanitation services; sources of water and its treatment; quality of the air; garbage disposal service; availability and safety of public transportation; and availability of ambulance services.

POLITICS AND GOVERNMENT Consider kind of government; organizations active in the commu- nity; influential people in the community; issues that have recently appeared on local ballots; and the average election turnout.

HEALTH AND SOCIAL SERVICES Consider existing hospitals, health care facilities, and health care services; number, type, and routine caseloads of community health

professionals; geographic, economic, and cultural accessibility to health care services; sources of health information; level of immuni- zation among children and adults; life expectancy in the community; availability of home health care and long-term care services; and availability of transportation service to all major health facilities.

COMMUNICATION Consider local newspapers; radio and TV stations, postal services, Internet access, and telephone services; frequency of public forums; and presence of informal bulletin boards.

ECONOMICS Consider the main industries and occupations; percentage of the population employed or attending school; income levels and qual- ity and type of housing; occupational health programs; and major employers in the community.

RECREATION Consider recreational facilities in the community and outside the community; theaters and movie houses; number and types of church and religious services; number and utilization of playgrounds, pools, parks, and sports facilities; level of participation in various church programs; and number and types of social committees, organiza- tions, and clubs available. From Community as Partner: Theory and Practice in Nursing (6th ed., pp. 186–213), by E. T. Anderson and J. McFarlane, 2011, Philadelphia, PA: Lippincott Williams & Wilkins.

Major Aspects of a Community Subsystems Assessment

objectives; for example, was the immunization rate of preschool children improved? Because community health is usually a collaborative process among health providers, community leaders, politicians, and consum- ers, all may be involved in the evaluation process. Often the community health nurse is the agent of evaluation, collecting and assessing the data that determine the effectiveness of implemented programs.

Community-Based Frameworks Various approaches are emerging to address community health. Some of these are an integrated health care system, community ini- tiatives, community coalitions, managed care, case management, and outreach programs using lay health workers.

An integrated health care system makes all levels of care available in an integrated form—primary care, secondary care, and tertiary care (Figure 7–3 •). Its goals are to facilitate care across set- tings, recovery, positive health outcomes, and the long-term benefits of modifying harmful lifestyles through health promotion and dis- ease prevention. In many parts of the country, hospitals are reflecting this concept by changing their names to health care organization or in- tegrated health care system. This type of system is sometimes referred to as seamless care.

Community initiatives are being sponsored by some hospitals or local community agencies. These initiatives, called healthy cities and healthier communities, involve members of the community in es- tablishing health priorities, setting measurable goals, and determin- ing actions to reach these goals. If a community agency is initiating this project, the associated hospital generally contributes human re- sources to assist in this endeavor.

Community coalitions bring together individuals and groups for the shared purpose of improving the community’s health. Nurses are major participants and contributors in these coalitions and often assume leadership positions. Community coalitions may focus on a single or multifaceted problem. Examples include establishment of an abuse program, a gang prevention program, an older adult assess- ment program, or an immunization program for a high-risk group.

In managed care, which is a common model in health care restructuring, health care providers (hospitals, physicians, nurse practitioners, insurance carriers, and so on) join to meet health needs across the care continuum. The managed care organization serves as a “go-between” or “gatekeeper” with the client, provider, and payer. Providers are organized into groups, and the client must

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COMMUNITY NURSING CENTERS Community nursing centers provide primary care to specific populations and are staffed by nurse practitioners and community health nurses. Although the nurses are the primary providers of care to clients visiting the center, a physician’s consultation is available as needed. Nursing centers may be located in schools, workplaces, or other community agencies, or be freestanding. Nursing centers must interface with nurse-managed services in other settings across the health care continuum, that is, services being provided to clients in their home, hospital, or long-term care facility. There are various cat- egories of community nursing centers:

• Community outreach centers. Relatively small freestanding clinics providing services similar to those traditionally pro- vided by large public health clinics but focused on a narrower population.

• Institution-based centers. Associated with a large parent organi- zation such as a hospital, corporation, or university or college.

• School-based centers. Placed within school facilities from kin- dergarten through college level to provide services such as emer- gency first aid, diagnosis of acute illnesses, health promotion and maintenance programs, as well as health education of school-age populations.

• Wellness centers. Provide services such as health promotion, health maintenance, education, counseling, and screening. In some settings, wellness centers are staffed by members of the health care team other than nurses (e.g., physical therapists or oc- cupational therapists).

PARISH NURSING Parish nursing was founded in the United States in Illinois in the mid-1980s by Reverend Granger Westberg (Church Health Center, n.d.) and became a specialty recognized by the ANA in 1998. The

select one from the group to which he or she belongs. Managed care aims in this way to enhance the quality and cost effectiveness of health care.

Case management is an integrative health care model that tracks clients’ needs and services through a variety of care settings to ensure continuity. The case manager is familiar with the clients’ health needs and resources available through their insurance coverage so they can receive cost-effective care. Another important aspect of case man- agement is assisting the client and family to understand and navigate their way through the health care system.

Outreach programs using lay health workers are one method of linking underserved or high-risk populations with the formal health care system. They can minimize or reduce barriers to health care, in- crease access to services, and thus improve the health status of the community. They involve partnerships between nurses and mem- bers of the community. Interested and committed lay health workers are identified who will assist their neighbors through outreach net- works. Nurses provide training, consultation, and support to these individuals.

Community-Based Settings Traditionally, community nursing services have been provided in county and state health departments (public health nursing), in schools (school nursing), in workplaces (occupational nurs- ing), and in homes (home health care and hospice nursing). Over the years, numerous other settings have been established, includ- ing day care centers, senior centers, storefront clinics, homeless shelters, mental health centers, crisis centers, drug rehabilitation programs, and ambulatory care centers. More recent settings for community nursing practice include nurse-managed community nursing centers, parish nursing, corrections nursing, and tele- health projects.

Figure 7–3 • Model of an integrated health care delivery system.

primary care providers

technicians specialists

clinic

pharmacy

extended care facilityhospital

insurance company

laboratory

client/family

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Church Health Center (2013) describes the roles of the parish nurse as follows:

• Personal health counselor who discusses health issues and prob- lems with individuals and makes home, hospital, and nursing home visits as needed

• Health educator who educates and supports individuals through health education activities that promote an understanding of the relationship between values, attitudes, lifestyle, faith, and well-being

• Referral source who acts as a liaison to other congregational and community resources

• Facilitator who recruits and coordinates volunteers within the congregation and develops support groups

• Integrator of faith and health.

An estimated 15,000 parish nurses serve churches, synagogues, and temples in the United States. The role of a parish nurse is governed by the ANA publication Faith Community Nursing: Scope and Stan- dards of Practice (2012b). Most parish nurses are volunteers, but about one third are employees paid by the congregation or an affiliated insti- tution such as a health system or community agency. Parish nursing is nondenominational and includes nurses of all religious faiths. Parish nursing is one of the few community-based nursing roles found with a similar structure and focus in nations around the world.

CORRECTIONS NURSING Corrections nursing includes the care of clients placed in jails, pris- ons, group homes, detention centers, and other correctional facilities. Corrections nursing is a subset of the broader category of forensic nursing, which encompasses criminal investigations (including that for assault, rape, or suspected abuse), death investigations, and expert legal testimony. Corrections nursing is the “practice of nursing and the delivery of patient care within the unique and distinct environ- ment of the criminal justice system” (ANA, 2007, p. 1). One example of the work of corrections nurses is to assist with implementation of the standards for compliance with the Prison Rape Elimination Act of 2003. In addition to this example of work specific to the care of incarcerated clients, the more than 18,000 corrections nurses encom- pass the full range of nursing—from health promotion through ill- ness and end-of-life care (Trossman, 2011).

TELEHEALTH Telehealth projects use communication and information technol- ogy to provide health information and health care services to people in rural, remote, or underserved areas. Video conferences or “video clinics” enable health care workers to provide distant consultation to assess and treat ambulatory clients who have a variety of health care needs. These video conferences are similar to any outpatient clinic visit except that the client and health care specialist are miles apart. A related development to telehealth is telenursing, in which nurses provide client teaching and health promotion to distant clients. Tele- monitoring allows transmittal of data from client to health care pro- viders and immediate responses. The literature describes the use of telehealth in a wide variety of clinical conditions. With clients who have chronic conditions such as lung disease or heart failure, a tele- health nurse may be better able to prioritize which clients to see in person and, thus, to manage many times more clients than without the technology (Watson, 2012).

COMMUNITY-BASED NURSING Community-based nursing (CBN) is nursing care directed to- ward specific individuals. However, community-based nursing involves nursing care that is not confined to one practice setting. It extends beyond institutional boundaries and involves a network of nursing services: nursing wellness centers, ambulatory care, acute care, long-term care nursing services, telephone advice, home health, school health, and hospice services. For example, a nurse case manager may be involved in (a) visiting a newly admitted client in the hospital to take a detailed nursing history, confer with the pri- mary nurse, and begin discharge planning; (b) making several home visits to monitor a client recently transferred from a hospital to a long-term care agency to discuss the client’s progress with the nurs- ing staff; or (c) making consultative telephone calls to other health professionals (physicians, social workers, respiratory therapists, and so on) and to clients who are managing self-care independently but who may need support.

CLINICAL ALERT!

Community-based nursing and community health nursing are not the same concept. Community-based nursing focuses on care of indi- viduals in geographically local settings, whereas community health nursing emphasizes the promotion and preservation of the health of groups (populations or aggregates).

Other nurses who work in community-based settings, such as case managers, occupational health nurses, school nurses, and pub- lic health department nurses, need to be prepared to make home visits. Home visits can provide information that is not obtainable in other ways.

Competencies Required for Community-Based Care Nurses practicing in community-based integrated health care sys- tems need to have specialized knowledge and skills. In 1998, the Pew Health Professions Commission (O’Neil & Pew Health Professions Commission) identified 21 competencies that future health profes- sionals would require (Box 7–5). Note that the competencies include the need for knowledge and skills in the areas of primary care, pre- ventive care, population-based care, health care access, community partnerships, interprofessional teams, and public policy—all essential for effective community-based nursing. Although nurses educated at the diploma and associate degree levels are introduced to concepts and experiences of caring for clients in the community, coursework addressing the breadth and depth of knowledge and skills for com- munity health nursing is usually taught in baccalaureate and higher degree programs.

Collaborative Health Care Collaboration among health care professionals becomes increasingly important as more practitioners specialize in progressively more nar- row areas of expertise while others take on the generalist role. Over time, the boundaries and legal scope of practice of each health care profession may change. To deliver optimal health care to the client, nurses must work as a member of the team providing comprehensive health care.

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Executives issued a joint statement of principles for enhancing col- laborative relationships between clinical nurses and nurse managers.

THE NURSE AS A COLLABORATOR Nurses collaborate with nurse colleagues and other health care pro- fessionals. They frequently collaborate about client care but may also be involved, for example, in collaborating on bioethical issues, on legislation, on health-related research, and with professional or- ganizations. Box 7–6 outlines selected aspects of the nurse’s role as a collaborator.

To fulfill a collaborative role, nurses need to assume account- ability and increased authority in practice areas. Education is in- tegral to ensuring that the members of each professional group understand the collaborative nature of their roles, specific contri- butions, and the importance of working together. Each professional needs to understand how an integrated delivery system centers on the client’s health care needs rather than on the particular care given by one group.

COMPETENCIES BASIC TO COLLABORATION Key elements necessary for collaboration include effective commu- nication skills, mutual respect, trust, and a decision-making process.

In 1992, the ANA Congress on Nursing Practice adopted the following operational definition of the concept of collaboration:

Collaboration means a collegial working relationship with another health care provider in the provision of (to supply) patient care. Collaborative practice requires (may include) the discussion of patient diagnosis and cooperation in the man- agement and delivery of care. (ANA, 1992)

A number of different organizations have issued standards and guidelines for collaboration among health care providers. Of the six Quality and Safety Education for Nurses competencies, one is “Teamwork and Collaboration,” defined as the ability to “function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care” (Cronenwett et al., 2007, p. 125). One ANA Standard of Professional Performance (2010) is collaboration. Key words in the competencies for that standard include that the nurse partners, communicates, cooperates, participates, and engages with other members of the team. In 2011, six organizations repre- senting nursing, medicine, pharmacy, dentistry, and public health issued Core Competencies for Interprofessional Collaborative Prac- tice, and in 2012, the ANA and the American Organization of Nurse

BOX 7–5

1. Embrace a personal ethic of social responsibility and service. 2. Exhibit ethical behavior in all professional activities. 3. Provide evidence-based, clinically competent care. 4. Incorporate the multiple determinants of health in clinical care. 5. Apply knowledge of the new sciences. 6. Demonstrate critical thinking, reflection, and problem-solving

skills. 7. Understand the role of primary care. 8. Rigorously practice preventive health care. 9. Integrate population-based care and services into practice.

10. Improve access to health care for those with unmet health needs.

11. Practice relationship-centered care with individuals and families.

12. Provide culturally sensitive care to a diverse society. 13. Partner with communities in health care decisions.

14. Use communication and information technology effectively and appropriately.

15. Work in interdisciplinary teams. 16. Ensure care that balances individual, professional, system,

and societal needs. 17. Practice leadership. 18. Take responsibility for quality of care and health outcomes

at all levels. 19. Contribute to continuous improvement of the health care

system. 20. Advocate for public policy that promotes and protects the

health of the public. 21. Continue to learn and help others learn.

From Recreating Health Professional Practice for a New Century, by E. H. O’Neil and the Pew Health Professions Commission, 1998, San Francisco, CA: Pew Health Professions Commission.

Pew Commission Competencies for Future Practitioners

BOX 7–6

WITH NURSE COLLEAGUES • Shares personal expertise with other nurses and elicits the

expertise of others to ensure quality client care. • Develops a sense of trust and mutual respect with peers that

recognizes their unique contributions.

WITH OTHER HEALTH CARE PROFESSIONALS • Recognizes the contribution that each member of the interpro-

fessional team can make by virtue of his or her expertise and view of the situation.

• Listens to each individual’s views. • Shares health care responsibilities in exploring options, setting

goals, and making decisions with clients and families. • Participates in collaborative interprofessional research to

increase knowledge of a clinical problem or situation.

WITH PROFESSIONAL NURSING ORGANIZATIONS • Seeks opportunities to collaborate with and within professional

organizations. • Serves on committees in state and national nursing

organizations or specialty groups. • Supports professional organizations in political action to create

solutions for professional and health care concerns.

WITH LEGISLATORS • Offers expert opinions on legislative initiatives related to

health care. • Collaborates with other health care providers and consumers

on health care legislation to best serve the needs of the public.

The Nurse as a Collaborator

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client’s health status. In 2012, the ANA issued a position statement on the registered nurse’s role in care coordination. This statement pro- motes the responsibility of the nurse to be prepared to partner with the client to provide quality and access to appropriate health care re- sources across a variety of settings (ANA 2012a).

To provide continuity of care, nurses need to accomplish the following:

• Initiate discharge planning for all clients when they are admitted to any health care setting.

• Involve the client and the client’s family or support persons in the planning process.

• Collaborate with other health care professionals as needed to en- sure that biopsychosocial, cultural, and spiritual needs are met.

Achieving continuity, however, assumes that needed client data are shared with other providers while implementing strategies to pro- tect client privacy. The Health Insurance Portability and Account- ability Act of 1996 (HIPAA) requires that health information about clients be secured in such a way that only those with the right and need to acquire the information are able to do so.

The privacy aspect of HIPAA results in a balance between protecting disclosure of confidential client information and the need for certain data to be released to specific agencies. Ultimately, clients have increased control over their own information, and those who violate the rule face significant penalties. Community nursing practice has altered in the face of the HIPAA regulations. Case managers and public health nurses need to maintain vigi- lance to protect the privacy of client health care information when sending and receiving telephone messages, faxes, and electronic documentation when in field settings as well as within health care facilities.

Care Across the Life Span The majority of children and older adults receive their health care in their communities rather than in hospitals. From home births, to school-based childhood immunization programs, to sex education for teens, to chronic disease management in adults, to hospice care, the nurse works with clients and a wide variety of community health organizations to provide wellness and illness care. A wide variety of initiatives focused on care provided in the community for children is found at the American Academy of Pediatrics website.

COMMUNICATION Collaborating to solve complex problems requires effective communication skills. Effective communication can occur only if the involved parties are committed to understanding each other’s professional roles and appreciating each other as individuals. Additionally, they must be sensitive to differences among communication styles. Instead of focusing on distinctions, a group of professionals needs to center on their common ground: the client’s needs.

MUTUAL RESPECT AND TRUST Mutual respect occurs when two or more people show or feel honor or esteem toward one another. Trust occurs when a person is confident in the actions of another person. Both mutual respect and trust imply a mutual process and outcome. They must be expressed both verbally and nonverbally.

DECISION MAKING The decision-making process at the team level involves shared responsibility for the outcome. To create a solution, the team must follow each step of the decision- making process, beginning with a clear definition of the problem. Team decision making must be directed at the objectives of the specific effort. It requires full consideration and respect for diverse viewpoints. Members must be able to verbalize their perspectives in a nonthreatening environment.

An important aspect of decision making is satisfied when the interprofessional team focuses on the client’s priority needs and organizes interventions accordingly. The discipline best able to address the client’s needs is given priority in planning and is re- sponsible for providing its interventions in a timely manner. For example, a social worker may first direct attention to a client’s social needs when these needs interfere with the client’s ability to respond to therapy. Nurses, by the nature of their holistic practice, are often able to help the team identify priorities and areas requiring further attention.

CONTINUITY OF CARE A major responsibility of the nurse is to ensure continuity of care. Continuity of care is the coordination of health care services by health care providers for clients moving from one health care setting to another and between and among health care professionals. Con- tinuity ensures uninterrupted and consistent services for the client from one level of care to another. When coordinated appropriately, it maintains client-focused individualized care and helps optimize the

The purpose of the study by Krantz, Coronel, Whitley, Dale, Yost, and Estacio (2013) was to determine if a program combining the work of community health nurses and primary care providers could reduce coronary heart disease risk. Building on the effectiveness of a previous program, the authors implemented tailored health educa- tion, assessment of readiness for behavior change, motivational in- terviewing, and longitudinal follow-up for the almost 700 participants in the study. Results showed statistically significant improvement in diet, weight, blood pressure, blood lipids, and cardiovascular risk score among those who received follow-up calls and retesting com- pared to those who did not receive the subsequent care.

IMPLICATIONS This study is an excellent example of extending the work of previ- ous programs and research and integrating the expertise of both community health workers and primary care providers. When work- ing with clients in the community, especially, it is important for each member of the health care team to collaborate with the others in identifying health risks and coordinating interventions. In addition, such studies provide the evidence nurses need to design and imple- ment effective programs.

Evidence-Based Practice Can Community Health Nurses Reduce the Risks of Cardiovascular Disease? EVIDENCE-BASED PRACTICE

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community supports; hazards or barriers that the home environment presents; and need for health care assistance in the home. Box 7–7 outlines details for each of these parameters.

The data are used to establish which nursing activities are re- quired before the client can be discharged. These activities most often include teaching the client to cope with continuing self-care at home and a home care referral.

Medication Reconciliation When a client moves from one location or level of care to another, current information regarding medications must be communicated within the health care team to prevent errors and unintended con- sequences. The Joint Commission (2012) continues to emphasize medication reconciliation as one of the National Patient Safety Goals for hospitals, ambulatory and behavioral health care, and home care settings. Medication reconciliation is the process of comparing all of the medications a client is taking (and should be taking) with newly ordered or changed medications. The comparison addresses duplica- tions, omissions, and interactions. Reconciliation must occur during transitions in care both within and outside of the organization and in- clude client education on safe medication use, and communications with other providers. The organization obtains the client’s medication information at the beginning of an episode of care. The information is updated when the client’s medications change. The responsibility for conducting medication reconciliation often falls to the nurse.

Home Health Care Teaching Clients need help to understand their health condition, to make health care decisions, and to learn new health behaviors. Because of today’s shortened hospital stays, it is often unrealistic to teach clients everything they need to know prior to discharge. Referral to a home health agency for follow-up teaching may be neces- sary. Essential information before discharge includes information about medications, dietary and activity restrictions, signs of com- plications that need to be reported to the primary care provider,

Discharge Planning Discharge planning is the process of preparing a client to leave one level of care for another within or outside the current health care agency. Usually, discharge planning refers to the client leaving the hospital for home. However, discharges occur among many other settings. Within a facility, it can occur from one unit to another. For example, a client with a stroke may move from a medical unit to a rehabilitation unit, or a client with trauma may move from the emer- gency department to an intensive care unit. Clients may move from a hospital to a long-term care agency, from a rehabilitation center to home, or from a home health care setting to a hospital, and so on.

Each agency generally has its own policies and procedures re- lated to discharge. Many agencies have case managers or discharge planners, a health or social services professional who coordinates the transition and acts as a link between the discharging agency and the receiving facility. Often, a nurse assumes this responsibility of provid- ing continuity of care.

Discharge planning needs to begin as soon as a client is admit- ted to the agency, especially in hospitals where stays are relatively short. Effective discharge planning involves ongoing assessment to obtain comprehensive information about the client’s ongoing needs and nursing care plans to ensure that the client’s and receiving agency caregivers’ needs are met. In some situations discharge planning necessitates health team conferences and family conferences. At a health team conference, health care professionals focus on ways to individualize care for the client. At a family conference, both health professionals and the family discuss family issues related to the client. Both types of conferences give the client, family, and health care pro- fessionals the opportunity to mutually plan care and set goals.

Preparing Clients to Go Home Nurses preparing to send clients home from the hospital need to as- sess their clients’ personal and health data; ability to perform activities of daily living; any physical, cognitive, or other functional limitations; caregivers’ responses and abilities; adequacy of financial resources;

BOX 7–7

PERSONAL AND HEALTH DATA Age; sex; height and weight; cultural beliefs and practices; medical history; current health status; prognosis; surgery

ABILITY TO PERFORM ACTIVITIES OF DAILY LIVING Abilities for dressing; eating; toileting; bathing (tub, shower, sponge); ambulating (with or without aids such as a cane, crutches, walker, wheelchair); transferring (from bed to chair, in and out of bath, in and out of car); meal preparation; transportation; shopping

DISABILITIES/LIMITATIONS Sensory losses (auditory, visual); motor losses (paralysis, amputa- tion); communication disorder; mental confusion or depression; incontinence

CAREGIVERS’ RESPONSES/ABILITIES Principal caregiver’s relationship to client; thoughts and feelings about client’s discharge; expectations for recovery; health and cop- ing abilities; comfort with performing needed care

FINANCIAL RESOURCES Financial resources and needs (note equipment, supplies, medica- tions, special foods required)

COMMUNITY SUPPORTS Family members, friends, neighbors, volunteers; resources such as Medicaid; food stamps; nutrition services; health centers; com- munity health nurses; day programs; legal assistance; home care; respite care

HOME HAZARD APPRAISAL Safety precautions (stairs with or without handrails; lighting in rooms, hallways, stairways; night-lights in hallways or bathroom; grab bars near toilet and tub; firmly attached carpets and rugs); self-care barri- ers (lack of running water, lack of wheelchair access to bathroom or home, lack of space for required equipment, lack of elevator) (Note: A detailed home hazard appraisal is provided in Chapter 8 .) NEED FOR HEALTH CARE ASSISTANCE Home-delivered meals; special dietary needs; volunteers for tele- phone reassurance, friendly visiting, transportation, shopping; as- sistance with bathing; assistance with housekeeping; assistance with wound care, ostomies, tubes, intravenous medications

Discharge Planning: Home Assessment Parameters

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follow-up appointments and telephone numbers, and where sup- plies can be obtained. Clients or caregivers also need to demon- strate safe performance of any necessary treatments. Information needs to be provided verbally and in writing. Details about effec- tive teaching strategies are provided in Chapter 27 . Reinforce- ment of acute care discharge information will often fall in the domain of the community-oriented nurse. Client issues related to health literacy, language barriers, and access to resources to carry out the provided health care instruction are major concerns of community nurses.

Referrals The referral process is a systematic problem-solving approach that helps clients to use resources that meet their health care needs. The process involves knowledge of community resources and an ability to solve problems, set priorities, coordinate, and collaborate. Home care referrals are often made before discharge for the following clients:

• Older adults • Children with complex conditions • Frail persons who live alone

LIFESPAN CONSIDERATIONS Health Care Delivery

CHILDREN The Search Institute has identified evidence-based assets charac- teristic of healthy communities and of different age groups of chil- dren. These assets are both external and internal to the individual, and if promoted in communities, will contribute to the healthy de- velopment of children and families and the positive life of the com- munity. The impact of these assets has been studied in children from birth through adolescence, and many communities across the United States are using them to structure programs for children and youth. Among the assets are such things as family support, fam- ily values of equality and social justice, involvement of children and youth with adults and community organizations, constructive use of young people’s time, and engagement in learning. The institute also has five action strategies for transforming communities for the betterment of youth: engaging adults, mobilizing youth, activating organizations, expanding programs, and influencing policy.

OLDER ADULTS Due to the changes caused by aging and the increase of chronic illnesses in older adults, various levels of health care delivery are often required. Clients may go back and forth between these levels as their needs fluctuate. At various times and situations, they might need care from hospitals, home care, extended care facilities, am- bulatory care, and assisted living. Maintaining communications and providing continuity of care during these changes are essential.

Caregivers of older adults are often older themselves and may have health problems of their own. Attention should be given to signs of emotional and physical fatigue and other problems that might arise for them. Community health nurses have the opportunity to do ongoing assessments of this as they see clients and caregiv- ers in their home environment. They can then provide support and resources as needed.

• Those who lack or have a limited support system • Those who have a caregiver whose health is failing • Those whose home presents barriers to their safety (e.g., stairs).

Referrals need to present as much information as possible about the client and the hospitalization to the agency. Most agencies have well-established protocols and detailed referral forms. The assess- ment parameters in Box 7–7 may also be used as a guide. The nurse caring for the hospital client is responsible for confirming and docu- menting that the relevant referrals have been made. To identify and recommend referrals, the nurse must already be familiar with the resources that are available in the community. Using this knowledge, plus information regarding the client’s previous awareness and choice of community resources, hospital nurses play a key role in maintain- ing effective continuity of health care.

To ensure appropriate reimbursement to the home health agency, the primary care provider must provide a written order for a home care referral and subsequent home visits. Clients must meet specific criteria to have Medicare or other third-party payers reim- burse them for home care services. Chapter 8 provides details about home health nursing.

Critical Thinking Checkpoint

Nurses are, and should be, taking an active role in influencing the direction of health care. Recognizing that there are finite limits to the amount of money and health care providers available, desirable out- comes often compete for resources. Consider a clinical situation such as the so-called “drive-through (or 24-hour) mastectomies” in which clients are moved through the acute care (hospital) system extremely quickly compared to previously. The ANA’s Health System Reform Agenda (ANA, 2008) states that (a) health care should be provided in settings that provide treatment and follow-up care that is reason- ably priced with copayments based on the person’s ability to pay; (b) health care should be available during convenient hours, locations, and waiting times to accommodate working families, people with dis- abilities, and people across the life span; and (c) health care services

should be culturally appropriate, respectful of clients and their families, and inclusive of client involvement in treatment decisions. 1. How does the mastectomy clinical example reflect or not reflect

the agenda? 2. Which of the three agenda items listed do you consider the most

important and why? 3. How might different community-based frameworks manage the

clinical example? 4. How would the nurse use collaboration with insurance payers,

women, or surgeons to resolve any concerns with the clinical example?

See Critical Thinking Possibilities on student resource website.

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• Consumers support an increased emphasis on health care mea- sures that promote wellness.

• The ANA’s Health System Reform Agenda (2008) and Healthy People 2020 by the USDHHS (2010) have set forth recommenda- tions for health care reform. These focus on accessibility of health care services, health promotion and disease prevention, and steps to consider how health care costs can be reduced.

• Health care costs, access to health care, and the quality of health care are major areas of concern surrounding the current health care system.

• Community-based health care, akin to primary health care, provides health-related services in places where people spend their time—in homes, in shelters, in long-term care residences, at work, in schools, in senior citizen centers, and so on.

• A community is a collection of people who share some attribute of their lives.

• For community assessment, eight subsystems proposed by Anderson and McFarlane (2011) can be used: physical environment, education, safety and transportation, politics and government, health and social services, communication, economics, and recreation.

• Approaches are emerging to address community-based care. These include an integrated health care system, community ini- tiatives, community coalitions, managed care, case management, and outreach programs using lay health workers.

• Numerous community settings have been established. Ones that are more recent include nurse-managed community nursing cen- ters, parish nursing, corrections nursing, and telehealth projects.

• Community-based nursing directs nursing care toward specific individuals. It is not confined to one practice setting; it extends beyond institutional boundaries involving a network of nursing ser- vices: nursing wellness centers, ambulatory care, long-term care, telephone advice, home health, school health, and hospice care.

• To practice in community health care systems, nurses need knowl- edge and skills in primary care, preventive care, population-based care, health care access, community partnerships, interprofes- sional teams, and public policy.

• Collaboration among health care providers is key to providing comprehensive health care.

• A major responsibility of the nurse is to ensure continuity of care as clients move from one level of care to another.

• Continuity of care involves (a) discharge planning that begins when clients are admitted to an agency, (b) cooperation with the client and support persons, and (c) interprofessional collaboration.

• Nurses need to ensure that clients have essential information and skills to manage self-care before being discharged to their homes. In some situations, referral to a home health agency is necessary.

CHAPTER HIGHLIGHTS

Chapter 7 Review

1. The ANA’s Health System Reform Agenda (2008) included which of the following? 1. Primary health care should be based in acute care hospitals. 2. A minimum standard of health care for all persons should be

paid for completely with public funds. 3. Case management should be focused on clients with

enduring health care needs. 4. Essential services should be initiated simultaneously to avoid

gaps. 2. The Pew Commission competencies for future practitioners included

the need for providers to become skilled in which of the following? 1. Use of technology 2. Emphasizing practice in tertiary settings 3. Traditional clinical approaches 4. Making decisions for incompetent clients

3. Which of the following is characteristic of nursing care provided in community-based health? 1. Clients are primarily those with identified illnesses. 2. Clients are individuals in groups according to their

geographic commonalities. 3. Care is paid for by the community as a whole rather than by

individuals. 4. All clients are case managed.

4. When performing collaborative health care, the nurse must implement which of the following? 1. Assume a leadership role in directing the health care team. 2. Rely on the expertise of other health care team members. 3. Be physically present for the implementation of all aspects of

the care plan. 4. Delegate decision-making authority to each health care provider.

5. The nurse concludes that effective discharge planning (hospital to home) has been conducted when the client states which of the following? 1. “As soon as I get home, the nurse will come out, look at

where I live, and see what kind of care I will need.” 2. “All I need are my medications and a ride home. Then I’m all

ready for discharge.” 3. “When I visit my doctor in 10 days, they will show me how to

change my bandages.” 4. “I have the phone numbers of the home care nurse and the

therapist who will visit me at home tomorrow.” 6. A large disaster in a community resulted in the destruction of

many family homes and many individuals were injured. The as- sistance of community health nurses and home health nurses is needed. The home health nurse is most likely to perform which of the following? 1. Provide for a safe water supply. 2. Monitor for communicable diseases. 3. Establish communication and support systems. 4. Assess and treat individual clients.

See Answers to Test Your Knowledge in Appendix A.

TEST YOUR KNOWLEDGE

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Suggested Reading Nosbusch, J., Weiss, M., & Bobay, K. (2011). An

integrated review of the literature on challenges confronting the acute care staff nurse in discharge planning. Journal of Clinical Nursing, 20, 754–774. doi:10.1111/j.1365-2702.2010.03257.x This article summarizes publications about practices, per- ceptions, and experiences of bedside staff nurses relative to hospital discharge planning. Preparation for hospital discharge should begin at or prior to admission. Forces in the acute care environment, however, often impede com- prehensive discharge planning. Evidence-based redesign of discharge planning processes is a priority for nurses and health care leaders. Seven themes were identified across the studies: intra- and interdisciplinary communication; systems and structures; time; role confusion; care continu- ity; knowledge; and the invisibility of the staff nurse role in discharge planning.

Related Research Falk-Rafael, A., & Betker, C. (2012). The primacy of relation-

ships: A study of public health nursing practice from a criti- cal caring perspective. Advances in Nursing Science, 35, 315–322. doi:10.1097/ANS.0b013e318271d127

Kirkpatrick, P., Wilson, E., & Wimpenny, P. (2012). Research to support evidence-based practice in COPD commu- nity nursing. British Journal of Community Nursing, 17, 486–492.

Phillips, L. R., & Ziminski, C. (2012). The public health nursing role in elder neglect in assisted living facilities. Public Health Nursing, 29, 499–509. doi:10.1111/j.1525-1446.2012.01029.x

References American Nurses Association (ANA). (1991). Nursing’s agenda

for health care reform. Kansas City, MO: Author. American Nurses Association (ANA). (1992). House of

delegates report: 1992 convention, Las Vegas, Nevada (pp. 104–120). Kansas City, MO: Author.

American Nurses Association (ANA). (2007). Corrections nursing: Scope and standards of practice. Silver Spring, MD: Author.

American Nurses Association (ANA). (2008). ANA’s health system reform agenda. Silver Spring, MD: Author. Retrieved from http://www.nursingworld.org/Content/ HealthcareandPolicyIssues/Agenda/ ANAsHealthSystemReformAgenda.pdf

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

American Nurses Association. (2012a). Care coordination and registered nurses’ essential role. Retrieved from http:// nursingworld.org/MainMenuCategories/Policy-Advocacy/ Positions-and-Resolutions/ANAPositionStatements/

Position-Statements-Alphabetically/Care-Coordination- and-Registered-Nurses-Essential-Role.html

American Nurses Association (ANA). (2012b). Faith community nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author.

American Nurses Association (ANA). (2012c). Health care transformation: The Affordable Care Act and more. Retrieved from http://nursingworld.org/ TransformingHealthcareDoc.aspx

American Nurses Association & American Organization of Nurse Executives. (2012). ANA/AONE principles for col- laborative relationships between clinical nurses and nurse managers. Retrieved from http://www.aone.org/resources/ PDFs/ANA_AONE_Principles_of_Collaborative_ Relationships.pdf

Anderson, E. T., & McFarlane, J. (2011). Community as part- ner: Theory and practice in nursing (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Church Health Center. (2013). Job description for the ministry of parish nursing practice. Retrieved from http:// churchhealthcenter.org/samplejobdescription

Church Health Center. (n.d.). History: The beginnings. Retrieved from http://churchhealthcenter.org/fcnhistory

Cronenwett, L., Sherwood, G., Barnsteiner J., Disch, J., Johnson, J., Mitchell, P., . . . Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55, 122–131. doi:10.1016/j.outlook.2007.02.006

Donaldson, M. S., Yordy, K. D., Lohr, K. N., & Vanselow, N. A. (Eds.). (1996). Primary care: America’s health in a new era. Washington, DC: National Academies Press. Retrieved from http://books.nap.edu/catalog.php?record_id=5152

Institute of Medicine. (2012). Primary care and public health: Exploring integration to improve population health. Washington, DC: National Academies Press. Retrieved from http://www.nap.edu/catalog.php?record_id=13381

The Joint Commission. (2012). National patient safety goals. Retrieved from http://www.jointcommission.org/standards_ information/npsgs.aspx

Krantz, M. J., Coronel, S. M., Whitley, E. M., Dale, R., Yost, J., & Estacio, R. O. (2013). Effectiveness of a community health worker cardiovascular risk reduction program in public health and health care settings. American Journal of Public Health, 103(1), e19–27. doi:10.2105/ AJPH.2012.301068

National Center for Health Statistics. (2013). Health: United States, 2013. Hyattsville, MD: Author.

O’Neil, E. H., & Pew Health Professions Commission. (1998). Recreating health professional practice for a new century. San Francisco, CA: Pew Health Professions Commission.

Trossman, S. (2011). Ensuring standards are standard behind bars. The American Nurse, 43(6), 12–13.

U.S. Department of Health and Human Services (USDHHS). (2010). Healthy people 2020. Retrieved from http:// www.healthlypeople.gov/2020/default.aspx

Watson, D. (2012). Case study: The use of telehealth technol- ogy in a community setting. British Journal of Community Nursing, 17, 520–521.

World Health Organization (WHO). (1978). Primary health care: Report of the International Conference on Primary Health Care. Geneva, Switzerland: Author.

Selected Bibliography American Nurses Association. (2007). Public health nursing:

Scope and standards of practice. Washington, DC: American Nurses Publishing.

Harkness, G. A., & DeMarco, R. F. (2012). Community and public health nursing: Evidence for practice. Philadelphia, PA: Lippincott Williams & Wilkins.

Hunt, R. (2012). Introduction to community-based nursing (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Institute of Medicine, Committee on Quality of Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. Retrieved from http://www.nap.edu/ catalog.php?record_id=10027

Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, DC: Interprofessional Education Collaborative. Retrieved from http://www.aacn.nche.edu/education-resources/ ipecreport.pdf

Maitlen, L. A., Bockstahler, A. M., & Belcher, A. E. (2012). Using community-based participatory research in parish nursing: A win–win situation! Journal of Christian Nursing, 29, 222–227. doi:10.1097/CNJ.0b013e318267c862

Maurer, F. A., & Smith, C. M. (2012). Community/public health nursing practice: Health for families and populations (5th ed.). St. Louis, MO: Elsevier.

Miller, L. C., Rosas, S. R., & Hall, K. (2012). Using concept mapping to describe sources of information for public health and school nursing practice. Journal of Research in Nursing, 17, 466–481. doi:10.1177/1744987111403883

Nies, M. A., & McEwen, M. (2011). Community/public health nursing: Promoting the health of populations (5th ed.). St. Louis, MO: Elsevier Saunders.

Pappas-Rogich, M. (2012). Faith community nurses: Protecting our elders through immunizations. Journal of Christian Nursing, 29, 232–237. doi:10.1097/ CNJ.0b013e318266efe5

Stanhope, M., & Lancaster, J. (2010). Foundations of nursing in the community: Community-oriented practice (3rd ed.). St. Louis, MO: Mosby/Elsevier.

Stanhope, M., & Lancaster, J. (2011). Public health nursing: Population-centered health care in the community (8th ed.). St. Louis, MO: Elsevier.

READINGS AND REFERENCES

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INTRODUCTION Historically, home care consisted primarily of nurses providing pri- vate duty care in clients’ homes and care of the ill by their own family members. However, the delivery of professional nursing services in home settings has increased in frequency, scope, and complexity in the past decades. Home care today involves a wide range of health care professionals providing services in the home setting to people recovering from an acute illness or injury or those with a disability or a chronic condition. A number of factors have contributed to this trend, among them rising health care costs, an aging population, and a growing emphasis on managing chronic illness and stress, preventing illness, and enhancing the quality of life. In the not- too-distant past, home health care occurred at the end of the client care continuum—that is, after discharge from an acute care facility. Today the trend is changing to use of home health care services to avoid hospitalization. According to The Joint Commission (2011), approximately 8.6 million individuals currently receive primary care, pre-acute care intervention, postacute services, and hospice/palliative care at home.

Direct nursing care may be provided by nurses from dif- ferent educational backgrounds. Although associate degree and diploma-prepared nurses usually do not work in community health (see Chapter 7 ), they may be employed by home care agencies. Because home health nurses must function indepen- dently in a variety of home settings and situations, some employ- ers prefer that the nurse be prepared at the baccalaureate level or above. The American Nurses Credentialing Center (ANCC) provides certification for home health nursing at both the general- ist and advanced practice levels. Advanced practice certification requires a master’s degree in nursing and recognizes the need for home health clinical specialists who can provide direct care, man- age client care, and engage in consulting, education, administra- tion, and research activities.

HOME HEALTH NURSING The delivery of nursing services in the home has been called a variety of terms, including home health care nursing and visiting nursing. For example, the Visiting Nurse Associations of America’s mission is to assist both visiting nurses’ associations and home health care agen- cies in their work. Home health care nursing or visiting nursing includes the nursing services and products provided to clients in their homes that are needed to maintain, restore, or promote their physical, psychological, and social well-being. The focus of home health care nursing is individuals and their families. This differs somewhat from the focus of community health nursing, which focuses on individu- als, families, and aggregate groups (see Chapter 7 ). Of course, a home may consist of a wide variety of settings from individual dwell- ings to group housing. Even those who are considered homeless may require care from a home health nurse and this could occur in a shel- ter, a mobile care unit, or wherever the person has their belongings.

Hospice nursing, support and care of the dying person and family, is often considered a subspecialty of home health nursing because hospice services are frequently delivered to clients who are terminally ill in their residence. See Chapter 43 for further infor- mation about hospice care.

Home nursing care is one of the growing sectors of the health care system. Expenditures for home health are significantly in- fluenced by increasing or decreasing Medicare payment policies, but they increase approximately 10% each year. The number of Medicare-certified hospice providers increased 56% from 2000 to 2011, and Medicare payments for hospice services increased 517% between 2000 and 2012 (National Center for Health Statistics, 2013). Factors that have contributed to the growth of home health care in- clude (a) the increase in the older population, who are frequent re- cipients of home care; (b) third-party payers who favor home care to control costs; (c) the ability of agencies and institutions to successfully deliver high-technology services in the home; and (d) consumers

caregiver role strain, 123 durable medical equipment (DME)

company, 120

home care, 118 home health care nursing, 118

hospice nursing, 118 registry, 120

visiting nursing, 118

KEY TERMS

After completing this chapter, you will be able to: 1. Define home health care. 2. Compare the characteristics of home health nursing to those

of institutional nursing care. 3. Describe the types of home health agencies, including refer-

ral and reimbursement sources. 4. Describe the roles of the home health nurse.

LEARNING OUTCOMES

8 Home Care

5. Identify the essential aspects of the home visit. 6. Discuss the safety and infection control dimensions appli-

cable to the home care setting. 7. Identify ways the nurse can recognize and minimize caregiver

role strain.

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benefit from the services of an agency with direct connections to a medical equipment company. Payment for home health is accom- plished through private-pay sources, third-party reimbursement, or a combination of sources.

Referral Process Clients may be referred to home health care providers by a phy- sician, nurse, social worker, therapist (e.g., physical therapist), discharge planner, or family member. Families often initiate the process by approaching one of these referral sources or by di- rectly contacting the home health agency to make inquiries. Home care cannot begin, however, without a physician’s order and a physician-approved treatment plan. This is a legal and reimburse- ment requirement.

Hospital nurses may be responsible for assisting with the home health transition by obtaining consent for transfer of confidential records, establishing the initial communication between home care and client, and completing a thorough set of transfer documents. These documents must include a detailed description of the changes in medications from prehospitalization, through hospitalization, and to home orders. This is Goal 3 of the National Patient Safety Goals established by The Joint Commission to help accredited organiza- tions address specific areas of concern in regards to client safety. In addition, client and family teaching, along with a description of their understanding of potential complications and whom and when to contact should those occur, must be included.

After an initial set of physician’s orders is obtained, a nursing evaluation visit is scheduled to enroll the client and identify the cli- ent’s needs. The initial visit, often referred to as “opening the case,” should include the client and the immediate family involved with the client’s care. At this visit, the nurse develops a plan of care, which must be reviewed, approved, authorized, and signed by the attend- ing physician before home health agency providers can continue with services.

SAFETY ALERT!

2014 The Joint Commission National Patient Safety Goals (2013)

GOAL 3: IMPROVE THE SAFETY OF USING MEDICATIONS 1. Obtain and/or update information on the medications the patient

currently takes. 2. Define the types of medication information (for example, name,

dose, route, frequency, purpose) to be collected in different settings and patient circumstances.

3. Compare the medication information the patient is currently taking with the medications ordered for the patient in order to identify and resolve discrepancies.

4. Provide the patient (or family as needed) with written information on the medications the patient should be taking when he or she leaves the organization’s care (for example, name, dose, route, frequency, purpose).

5. Explain the importance of managing medication information to the patient.

Home Health Agencies Home health agencies offer coordinated professional, skilled, and paraprofessional services. Because clients often require the services of several professionals, case coordination (case management) is

who prefer to receive care in the home rather than in an institution. A common misperception by the general public is that home health nursing is only custodial in its scope of practice. However, health promotion is used by home health nurses to promote client self-care. Home care nurses are actively engaged in providing support and edu- cation for family caregivers as well as clients.

Unique Aspects of Home Health Nursing Home care nurses must function independently in a variety of un- familiar home settings and situations. Because the home is the fam- ily’s territory, power and control issues in delivering nursing care differ from those in the hospital. For example, entry into a home is granted, not assumed; the nurse must therefore establish trust and rapport with the client and family. Due to the limited time for visits and the possibly lengthy interval between visits, this process does not always occur as quickly as it might when nursing within a resi- dential care facility.

Health care that is provided in the home is often given with other family members present. Families may feel freer to question ad- vice, to ignore directions, to do things differently, and to set their own priorities and schedules. Home care nurses implement every step of the nursing process, using critical thinking skills in designing, imple- menting, and evaluating the plan of care.

Home health nurses have identified significant advantages in caring for individuals and families in the home. The home setting is intimate; this intimacy fosters familiarity, sharing, connections, and caring among clients, families, and their nurse. Behaviors are more natural, cultural beliefs and practices are more visible, and multigen- erational interactions tend to be displayed. Nurses often get to know the client and family well because they may care for clients over weeks or months.

Home health nurses have also identified issues that negatively affect care in the home. More than any other care providers, these nurses have firsthand knowledge and experience about the burden of caregiving and the role of family dynamics in health care practices. In the interest of cutting health care costs, policy makers, third-party payers, and medical providers are placing increasingly complex re- sponsibilities on clients’ families and significant other(s). Family care- giving demands may go on for months or years, placing the caregivers themselves (many of whom are older adults) at risk for physiological and psychosocial problems. Additionally, nurses enter homes where the living conditions and support systems may be inadequate.

Nurses caring for clients in rural home settings have challenges different from those in urban or suburban environments. These in- clude the need for flexibility (since clients may live far distances from the nurse and require care in the evening or at night), creativity, the ability to practice independently because fewer resources (including other nurses) are available, and the ability to work in an environment over which the nurse has little control. Thus, those nurses who re- quire a high degree of certainty, structure, and consistency are less likely to be successful in rural home health locations.

THE HOME HEALTH CARE SYSTEM The need for home health care may be identified by any person in- volved with the client. Clients are referred to a home health agency or private-duty nursing agency. Individuals with extremely complex needs, beyond those that direct nursing care alone can provide, may

SAFETY

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for home health care. For example, the client must (a) need reason- able and necessary home care including skilled care; (b) be home- bound, that is, confined to the home except for occasional outings for medical treatment, for a trip to the barber, or for a drive; and require the use of supportive devices, special transportation, or the escort of another person; (c) have a plan of care that includes all of Medicare’s criteria; and (d) need nursing care on an intermittent basis (Centers for Medicare and Medicaid Services, 2011). The agency too must meet specific conditions.

Payers other than Medicare or Medicaid, such as Blue Cross, Blue Shield, and HealthNet, typically negotiate reimbursement rates for home health care services. Not-for-profit agencies, like the visiting nurses associations (VNAs), are reimbursed by public and private in- surance plus charitable donations to the agency. Most long-term care insurance plans include coverage for care in the home.

All health care agencies need to adhere to established guide- lines and provide care within the predetermined reimbursement levels. Treatment plans (developed by the home health agency pro- viders and authorized by the physician) are used by the reimburse- ment source. Only interventions identified on the treatment plan are paid for. Periodically the reimbursement source may request the home health provider’s notes to substantiate what is being done in the home. This is a major reason why accurate documentation is critical.

ROLES OF THE HOME HEALTH NURSE Historically, nurses who provided direct services in the home were strong generalists who focused on long-term preventive, educational, and rehabilitative outcomes. Today many home health nurses possess high-technology skills that were formerly used only in acute care set- tings. For example, nurses provide a variety of intravenous therapies in the home setting and monitor clients who are dependent on tech- nologically complex medical equipment, such as ventilators. These nurses collaborate with physicians and other health care profession- als in providing care. They play a key role in facilitating an effective plan of care as clients move among hospitals, home, school, work, and other care settings such as clinics or long-term care.

The major roles of the home health nurse are those of advocate, caregiver (provider of direct care), educator, and case manager or coordinator.

Advocate Advocacy begins on the first visit. The nurse explores and supports the client’s choices in health care; all viable options are considered. Advocacy includes having discussions about the client’s rights, ad- vance medical directives, living wills, and durable power of attorney for health care. It also usually involves providing assistance to access community resources, to make informed decisions, to recognize and cope with necessary changes in lifestyle, to negotiate medical insurance, and to understand ways to effectively use the complex medical system.

Indirect care is provided by the home health nurse to the client each time the nurse consults with other health care providers about ways to improve nursing care for the client. This consultation about client care issues often manifests itself in multidisciplinary care con- ferences where the role of the home health nurse is as client advocate.

essential. This responsibility generally rests with the registered nurse. Depending on the agency, additional providers may include nurse practitioners, practical nurses, nursing assistants, home health care aides, physical therapists, occupational therapists, respiratory thera- pists, speech therapists, social workers, dietitians, and a pastoral care minister or chaplain. In addition, it is not unusual for home health agencies to offer the services of specialized nurses such as wound- ostomy-continence nurses or diabetes educators. The care plan im- plemented by the home health agency may require services once or twice a day, up to 7 days a week. The minimum time of each period of care, or visit, is usually 1 hour.

There are several different types of home health agencies:

• Official or public agencies are operated by state or local govern- ments and financed primarily by tax funds.

• Voluntary or private not-for-profit agencies are supported by do- nations, endowments, charities such as the United Way, and third- party reimbursement.

• Private, proprietary agencies are for-profit organizations and are governed by either individual owners or national corporations. Some of these agencies participate in third-party reimbursement; others rely on “private-pay” sources.

• Institution-based agencies operate under a parent organization, such as a hospital, and are funded by the same sources as the parent.

Regardless of the type of agency, all home health agencies must meet specific standards for licensing, certification, and accreditation.

Private Duty Agencies This type of agency may be referred to as a registry, which contracts with individual practitioners (e.g., nurses, home health aides) to care for the client in the home. The client may require care coverage from the agency for 4 to 24 hours a day. Private duty agencies also supply staff to hospitals, clinics, and other care settings, so they do not af- ford the coordinated focus of a home care agency. Private duty care is expensive. Commercial insurance generally provides limited reim- bursement. Otherwise, the client must pay privately.

Durable Medical Equipment Companies A durable medical equipment (DME) company provides health care equipment for the client at home. The types of equipment can range from hospital beds and bedside commodes to ventilators, oxy- gen units, and apnea monitors. Because of the cost associated with medical equipment, the nurse needs to ensure that clients have a pri- mary care provider’s order and either Medicare/Medicaid or a DME benefit within their commercial insurance, or that they are able to pay privately. Before billing Medicare for any DME, the nurse should consult the list of equipment for which Medicare will reimburse the client. Most DME companies today seek accreditation from The Joint Commission to ensure compliance with quality standards for equip- ment and services.

Reimbursement Health care agencies in the United States receive reimbursement for services they provide from various sources: Medicare and Medicaid, private insurance companies, and private pay. The Medicare and Medicaid programs have strict guidelines governing reimbursement

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Case Manager or Coordinator The home health nurse coordinates the activities of all other home health team members involved in the client’s treatment plan. Coor- dination can occur individually, in person, or by telephone, with a specific team member such as the dietitian or respiratory therapist, or during a team conference where each team member provides infor- mation about the client’s health status. The nurse is the main contact to report any changes in the client’s condition and to bring about a re- vision in the plan of care as needed. Documentation of care coordina- tion is a legal and reimbursement requirement and must be recorded on the client’s medical record.

PERSPECTIVES OF HOME CARE CLIENTS Home care clients include a diverse population that encompasses all ages, a variety of health problems, and families of different structures and cultural backgrounds. Home care clients have a wide range of health problems, including disabilities, perinatal problems, men- tal illnesses, and acute and chronic illnesses. The nurse should not assume that the client understands the various personnel and their roles in providing home health care.

Although the person receiving care is considered the primary client in home care, the client’s family can be considered secondary clients because often they are associated with caregiving and have a major impact on the client’s wellness status. The home health nurse will encounter many different family structures ranging from single families to extended families and dwellings that house multiple fami- lies. In the home setting, family members may include not only per- sons related by birth and marriage, but also friends, other significant individuals, and animals.

Various cultural influences also affect the client’s health care beliefs and practices. The home health nurse needs to be culturally sensitive; that is, to be aware of the client’s culture and form a nursing care plan with the client that incorporates his or her culture. See Chapter 18 for detailed information about making cultural assessments and pro- viding culturally competent and responsive care.

SELECTED DIMENSIONS OF HOME HEALTH NURSING Selected dimensions of home health care include assessing the home for safety features, infection control, and caregiver support.

Client Safety Hazards in the home are major causes of falls, fire, poisoning, and other accidents, such as those caused by improper use of household equipment (e.g., tools and cooking utensils). The appraisal of such hazards and suggestions for remedies is an essential nursing func- tion. See Home Care Considerations for a home hazard appraisal and Chapter 32 for a discussion of potential hazards and preven- tive actions for individuals of all ages.

Obviously home health nurses cannot expect to change a fam- ily’s living space and lifestyle. However, they can express their con- cern and react appropriately when a situation suggests that an injury is imminent. Nurses must document information they provide and the family’s response to instruction, and make ongoing assessments about the family’s use of safety precautions.

Advocacy can be a particular challenge when family members’ or other caregivers’ views differ from those of the client. In the event of conflict, the nurse, being the client’s primary advocate, ensures that the client’s rights and desires are upheld.

Caregiver The home health nurse’s major role as caregiver is to assess and di- agnose the client’s actual and potential health problems, plan care, and evaluate the client’s outcomes. Home health nurses routinely perform physical assessments, change wound dressings, insert and maintain intravenous access for various therapies, establish and monitor indwelling urinary catheters, and monitor exercise or nu- tritional therapies (Figure 8–1 •). Direct personal care activities such as bathing, changing linens, feeding, and light housekeeping activities to maintain a clean and safe home environment are usu- ally provided by a family member or a home health aide arranged by the nurse.

Educator The educator role of the home health nurse focuses on teaching ill- ness care, the prevention of problems, and the promotion of optimal wellness or well-being to the client, the family, caregivers, and other support persons. A common example is that of guiding the health and development of newborns. Some clients of all ages have acute illnesses that will resolve, while others have chronic conditions that will last the lifetime. The nurse’s teaching and learning methods will vary based on the need of these clients. Nurses clarify misconcep- tions about the course of the illness, the treatment plan, and medica- tions and potential interactions with over-the-counter drugs. They also educate the client and family on how to access the health care system appropriately.

The nurse may also be involved in teaching others with whom the client interacts such as the schoolteachers of children with special needs. Education is ongoing and can be considered the crux of home care practice; its goal is to help clients learn to manage as indepen- dently as possible. All home health nurses need to be skilled in teach- ing and learning principles and strategies that facilitate learning. (See Chapter 27 for detailed information.)

Figure 8–1 • Home care nurses perform skilled direct care such as changing dressings. David SucsyGetty Images.

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Other aspects of client safety relate to emergency situations. The home health nurse can assist the client and caregivers as follows:

• Post a list of all emergency telephone numbers (ambulance, fire, police, primary care provider) at each telephone.

• Post a list of all the client’s medications and potential side effects in a central location, such as on the refrigerator.

• Help the client and family apply for a medical alert system such as a bracelet or necklace (Figure 8–2 •). Information on the MedicAlert System can be obtained by contacting MedicAlert Foundation International.

• Enroll the client in a program that places all the client’s vital medi- cal information in one place for emergency personnel to have in the event of a life-threatening situation. The program can be joined through a pharmacy, a primary care provider’s office, a VNA, or other community support groups. The kit contains a plastic vial, a medical information form, a decal, and an instruction sheet. The

Figure 8–2 • MedicAlert emblems. Reproduced with permission: 2014. All rights reserved. MedicAlert® is a federally Registered Trademark and Service Mark.

information form is filled out, rolled, and placed in the vial. The vial is placed in the refrigerator, and emergency personnel are trained to routinely check there. The decal is placed on the refrig- erator as a signal that the vial is inside.

• Recommend the client purchase an emergency response system. These systems provide a small device with a help button that at- taches to a wrist or neck chain. The home base station can require the client to send a signal daily that indicates that he or she is OK. If the signal is not sent or if the portable device is activated, the system automatically calls the client and then dials a previously established list of emergency contacts. This system is particularly useful for clients who are alone because if they should fall, for in- stance, and be unable to reach a telephone, they might be left help- less for extended periods of time.

Nurse Safety Some less desirable living locations can pose personal safety con- cerns for the nurse. Many home health agencies have contracts with security firms to escort nurses needing to see clients in potentially unsafe neighborhoods. The nurse should avoid taking any personal belongings during these visits and have a preestablished mechanism to signal for help. Home health agencies provide training for nurses in ways to decrease personal risk. Little has been published on this important subject.

Home care nurses may also be susceptible to occupational injuries—especially musculoskeletal ones—due to limited resources available in the home. The nurse’s safety is influenced by the function- ality and availability of assistive personnel and devices, number of cli- ents who are obese or dependent, presence of pets, and varying house and yard arrangements. A combination of ergonomics (interactions between the body and the environment that maximize performance) and self-care activities can help keep the nurse safe (Hitt et al., 2012). Both the nurse and the employing agency must assume responsibility for protecting the nurse.

Infection Prevention The goal of infection prevention in the home is to protect clients, care- givers, and the general community from the transmission of disease.

Home Care Assessment Home Hazard Appraisal for Adults

CLIENT AND ENVIRONMENT • Walkways and stairways (inside and outside): Note uneven

sidewalks or paths, broken or loose steps, absence of handrails or placement on only one side of stairways, insecure handrails, congested hallways or other traffic areas, and adequacy of lighting at night.

• Floors: Note uneven and highly polished or slippery floors and any unanchored rugs or mats.

• Furniture: Note hazardous placement of furniture with sharp corners. Note chairs or stools that are too low to get into and out of or that provide inadequate support.

• Bathroom(s): Note presence of grab bars around tubs and toi- lets, nonslip surfaces in tubs and shower stalls, handheld show- erhead, adequacy of night lighting, need for raised toilet seat or bath chair in tub or shower, ease of access to shelves, and water temperature regulated at a maximum of 49°C (120°F).

• Kitchen: Note pilot lights (gas stove) in need of repair, inacces- sible storage areas, and hazardous furniture.

• Bedrooms: Note adequacy of lighting, in particular the avail- ability of night-lights and accessibility of light switches; ease of access to commode, urinal, or bedpan; and need for hospital bed or bed rails.

• Electrical: Note unanchored or frayed electrical cords and out- lets that are overloaded or near water.

• Fire protection: Note presence or absence of smoke detectors, fire extinguisher, and fire escape plan, and improper storage of combustibles (e.g., gasoline) or corrosives (e.g., rust remover).

• Toxic substances: Note improperly labeled cleaning solutions. • Communication devices: Note presence of method to call for

help, such as a telephone or intercom in the bedroom and elsewhere (e.g., kitchen), and access to emergency telephone numbers.

• Medications: Note medications kept beyond date of expiration, adequacy of lighting for medication cabinet or storage, and method of disposal of sharp objects such as needles used for injections.

SAFETY

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laundry; shopping; house repairs; yard work; transportation; doctor’s or hairdresser’s appointments; or respite.

Activities that are commonly done by nurses and aides, such as changing an occupied bed and transferring a client from bed to chair, may be overwhelming to a caregiver who has not performed them before. Demonstrating them in the home and allowing caregivers to perform them with the nurse’s supervision increases their confidence and increases the likelihood of them asking for assistance in other situations.

When activities for which assistance is required are identified, the nurse and caregiver need to identify possible sources of help. Both volunteer and agency sources need to be explored. Volunteer sources of help may include family members (cousins, siblings), neighbors, friends, church associates, or caregiver support groups in the com- munity. Other sources include, for example, a home health aide for light housekeeping and grocery shopping, Meals-on-Wheels, day care, transportation, and counseling and social services. Families with a member who is chronically ill may benefit from a weekend respite—a program some hospitals provide in which the client is admitted to a skilled unit for observation and care, enabling the care- giver to take a break from ongoing health care needs.

Caregivers need to be reminded of the importance of caring for themselves by getting adequate sleep, eating nutritious meals, asking for help, delegating household chores, and making time for leisure activities or simply some time alone. Family members other than the caregiver also may need help to learn ways to support the caregiver. The nurse may discuss the importance to the caregiver of regular phone calls, cards, letters, and visits; offer encourage- ment to take day trips or a vacation; listen without giving advice; acknowledge the burden of caregiving and the need to feel appreci- ated; and so on.

A particular challenge exists when the nurse is in a position to be a caregiver to a family member. Although the nurse’s clinical exper- tise and familiarity with the client and setting can be especially use- ful, negotiating the professional distancing that is sometimes needed when providing care to clients can be difficult with family. The nurse may feel obligated to provide care, even when this is over and above regular employment responsibilities. The nurse must have the oppor- tunity to step back and experience the role and emotions of being a family member—not only those of being a nurse.

THE PRACTICE OF NURSING IN THE HOME The home health nurse assesses the health care demands of the client and family and the home and community environment. This process actually begins when the nurse contacts the client for the initial home visit and reviews documents received from the referral agency. The goal of the initial visit is to obtain a comprehensive clinical picture of the client’s needs.

Most agencies have a packet that includes forms for consent to treatment; physical, psychosocial, and spiritual assessment; medi- cations; pain assessment; family data; financial assessment includ- ing insurance verification; client’s bill of rights; care plan; and daily visit notes. During the initial home visit, the home health nurse obtains a health history from the client (Figure 8–3 •), examines the client, observes the relationship of the client and caregiver, and assesses the home and community environment. Parameters

This is particularly important for clients who are immunocompro- mised, who have infectious or communicable diseases, or who have wounds, drainage tubes, or invasive access devices. The nurse’s major role in infection prevention is health teaching. Clients and caregivers need to learn about effective hand washing, use of gloves, handling of linens, and disposal of wastes and soiled dressings. Infection preven- tion can present a challenge to the home health nurse, especially if the home care facilities are not conducive to basic aseptic requirements such as running water for hand washing.

An important aspect of infection prevention involves handling the home health nurse’s equipment and supplies. Supplies may in- clude materials for hand cleansing; assessment equipment such as a stethoscope, blood pressure cuff and manometer, thermometer, and tape measure; infection control items such as gowns, goggles, masks, gloves, and blood spill kit; and antimicrobial cleaning agents.