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The expanse of nursing theory is wide, covering concepts, models, philosophies, and theories that are considered essential in professional nursing practice. How should theory information be organized in order to provide individual nurses with a foundation for theory-based practice? CC4.0

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Library of Congress Cataloging-in-Publication Data

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

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

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

Practice | Nurse’s Role | Philosophy, Nursing
Classification: LCC RT82 | NLM WY 16.1 | DDC 610.73–dc23
LC record available at https://lccn.loc.gov/2018023086

6048

Printed in the United States of America

22 21 20 19 18 10 9 8 7 6 5 4 3 2 1

Dedication

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

support throughout my career.

1

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CONTENTS

Preface
Contributors

UNIT I: FOUNDATIONS OF PROFESSIONAL NURSING PRACTICE

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

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

2

3

4

5

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

Frameworks for Professional Nursing Practice
Kathleen Masters

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

Philosophy of Nursing
Mary W. Stewart

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

Competencies for Professional Nursing Practice
Jill Rushing and Kathleen Masters

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

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

8

6

7

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

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

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

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

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

UNIT II PROFESSIONAL NURSING PRACTICE AND THE
MANAGEMENT OF PATIENT CARE

Safety and Quality Improvement in Professional Nursing
Practice
Kathleen Masters

10

9

11

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

Evidence-Based Professional Nursing Practice
Kathleen Masters

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

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

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

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

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

13

12

14

15

Conclusion
References

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

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

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

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

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

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

Law and Professional Nursing Practice
Kathleen Driscoll and Kathleen Masters

The Sources of Law

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

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

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PREFACE

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

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

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

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

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

professional nurses. The competency model is explained in detail in
Chapter 4 and is available in its entirety online at
http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

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

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

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

—Kathleen Masters

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

baccalaureate education for professional nursing practice. Retrieved

from http://www.aacnnursing.org/Education-Resources/AACN-
Essentials

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

Massachusetts Department of Higher Education. (2016). Nurse of the
future: Nursing core competencies: Registered nurse. Retrieved from
http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

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

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CONTRIBUTORS

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

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

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

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

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

College of Nursing
Hattiesburg, Mississippi

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

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

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

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

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

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

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

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UNIT I

Foundations of Professional
Nursing Practice

© James Kang/EyeEm/Getty Images

CHAPTER 1

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

Learning Objectives

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

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

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

Key Terms and Concepts

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

© traveler1116/E+/Getty Images

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

During the Crimean War and American Civil War, nurses were

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CRITICAL THINKING QUESTIONS

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

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

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

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

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

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

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

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

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

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

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

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

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

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

BOX 1-1

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

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

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

LILLIAN WALD TAKES A WALK

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

© KidStock/Getty Images

KEY OUTCOME 1-1

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

Essential VIII: Professionalism and Professional Values

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

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

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

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

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

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

improvement, teamwork and collaboration, safety, and informatics.

KEY COMPETENCY 1-1

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Professionalism:

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

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

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

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

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

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

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

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

KEY OUTCOME 1-2

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

Essential V: Healthcare Policy, Finance, and Regulatory Environments

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

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

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

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

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

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

KEY OUTCOME 1-3

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

Essential VII: Clinical Prevention and Population Health

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

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

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

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

KEY COMPETENCY 1-2

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

Leadership:

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

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

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

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

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

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

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

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

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

CRITICAL THINKING QUESTION

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

Classroom Activity 1-1

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

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

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

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

Classroom Activity 1-2

What would Florence Nightingale’s résumé or curriculum vitae look
like? Check out Nightingale’s curriculum vitae at
www.countryjoe.com/nightingale/cv.htm.

References
Abel, E. K. (1997). Take the cure to the poor: Patients’ responses to New
York City’s tuberculosis program, 1894–1918. American Journal of
Public Health, 87, 11.

American Association of Colleges of Nursing. (2008). The essentials of
baccalaureate education for professional nursing practice. Retrieved
from
http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

American Nurses Association. (1965). Educational preparation for nurse
practitioners and assistants to nurses: A position paper. New York, NY:
Author.

American Nurses Association. (1991). Nursing’s agenda for health care
reform: Executive summary. Washington, DC: Author.

American Nurses Association. (2016). ANA’s principles for health system
transformation 2016. Retrieved from
http://www.nursingworld.org/healthcarereform

Andrews, G. (2003). Nightingale’s geography. Nursing Inquiry, 10(4),
270–274.

Attewell, A. (1996). Florence Nightingale’s health-at-home visitors. Health
Visitor, 6.9(10), 406.

Australian Bureau of Statistics. (1985). Year book Australia, 1985.
Retrieved from
http://www.abs.gov.au/ausstats/[email protected]/featurearticlesbytitle/911B5AF72F818795CA2569DE0024ED5A?
OpenDocument

Australian Nursing and Midwifery Accreditation Council. (2016). ANMAC:
About. Retrieved from https://www.anmac.org.au/about-anmac/about

Australian Nursing and Midwifery Federation. (2015). About the ANMF.

Retrieved from http://anmf.org.au/pages/about-the-anmf
Australian Nursing and Midwifery Federation (SA Branch). (2012). Our
history. Retrieved from https://www.anmfsa.org.au/about-us/our-
history/

Australian Nursing Federation. (2004). Nightingale suffered bipolar
disorder. Australian Nursing Journal, 12(2), 33.

Australian War Memorial. (n.d.). Great war nurses. Retrieved from
https://www.awm.gov.au/visit/exhibitions/nurses/ww1

Barker, E. R. (1989). Care givers as casualties. Western Journal of
Nursing Research, 11(5), 628–631.

Biedermann, N., Usher, K., Williams, A., & Hayes, B. (2001). The wartime
experience of Australian Army nurses in Vietnam, 1967–1971. Journal
of Advanced Nursing, 35(4), 543–549.

Boorstin, D. J. (1985). The discoverers: A history of man’s search to
know his world and himself. New York, NY: Vintage.

Brainard, A. M. (1922). The evolution of public health nursing.
Philadelphia, PA: Saunders.

Brockett, L. P., & Vaughan, M. C. (1867). Women’s work in the Civil War:
A record of heroism: Patriotism and patience. Philadelphia, PA: Seigler
McCurdy.

Brooke, E. (1997). Medicine women: A pictorial history of women healers.
Wheaton, IL: Quest Books.

Brown, E. L. (1936). Nursing as a profession. New York, NY: Russell
Sage Foundation.

Brown, E. L. (1948). Nursing for the future. New York, NY: Russell Sage
Foundation.

Brown, P. (1988). Florence Nightingale. Watford, England: Exley.
Brush, B. L., & Lynaugh, J. E. (1999). About this history. In B. L. Brush &
J. E. Lynaugh (Eds.), Nurses of all nations: A history of the
International Council of Nurses, 1899–1999 (pp. xi–xvii). Philadelphia,

PA: Lippincott Williams & Wilkins.
Buhler-Wilkerson, K. (1985). Public health nursing: In sickness or in
health? American Journal of Public Health, 75, 1155–1156.

Bullough, V. L., & Bullough, B. (1978). The care of the sick: The
emergence of modern nursing. New York, NY: Prodist.

Calabria, M. D. (1996). Florence Nightingale in Egypt and Greece: Her
diary and visions. Albany: State University of New York Press.

Canadian Association of Schools of Nursing. (n.d.). CASN/ACESI
mission. Retrieved from http://www.casn.ca/about-casn/casnacesi-
mission/

Canadian Museum of History. (n.d.). Canadian nursing history collection:
A brief history of nursing in Canada from establishment of New France
to present. Retrieved from
http://www.historymuseum.ca/cmc/exhibitions/tresors/nursing/nchis01e.shtml

Canadian Nurses Association. (n.d.). History. Retrieved from
http://www.cna-aiic.ca/en/about-cna/history

Canadian Nurses Foundation. (2014). Our history. Retrieved from
http://cnf-fiic.ca/who-we-are/our-stories/our-history/#.VNwEqiifmmA

Carnegie, M. E. (1991). The path we tread: Blades in nursing 1854–1990
(2nd ed.). New York, NY: National League for Nursing Press.

Cartwright, F. F. (1972). Disease and history. New York, NY: Dorset
Press.

Christman, L. (1971). The nurse specialist as a professional activist.
Nursing Clinics of North America, 6(2), 231–235.

Christy, T. E. (1975). The fateful decade: 1890–1900. American Journal
of Nursing, 75(7), 1163–1165.

Cohen, M. N. (1989). Health and the rise of civilization. New Haven, CT:
Yale University Press.

Cook, E. (1913). The life of Florence Nightingale (Vols. 1–2). London,
England: Macmillan.

D’Antonio, P. (2002). Nurses in war. Lancet, 360(9350), 7–12.
Diamond, J. (1997). Guns, germs, and steel: The fates of human
societies. New York, NY: W. W. Norton.

Dickens, C. (1844). Martin Chuzzlewit. New York, NY: Macmillan.
Dietz, D. D., & Lehozky, A. R. (1963). History and modern nursing.
Philadelphia, PA: F. A. Davis.

Dock, L., & Stewart, I. (1931). A short history of nursing from the earliest
times to the present day (3rd ed.). New York, NY: G. P. Putnam’s Sons.

Donahue, M. P. (1985). Nursing: The finest art. St. Louis, MO: Mosby.
Dossey, B. (2000). Florence Nightingale: Mystic, visionary, healer.
Philadelphia, PA: Lippincott Williams & Wilkins.

Ford, L. C. (1979). A nurse for all seasons: The nurse practitioner.
Nursing Outlook, 27(8), 516–521.

Ford, L. C., & Silver, H. K. (1967). The expanded role of the nurse in child
care. Nursing Outlook, 15(8), 43–45.

Frantz, A. K. (1998). Nursing pride: Clara Barton in the Spanish American
War. American Journal of Nursing, 98(10), 39–41.

Goldmark, J. C. (1923). Nursing and nursing education in the United
States. New York, NY: Macmillan.

Hamilton, D. (1988). Clinical excellence, but too high a cost: The
Metropolitan Life Insurance Company Visiting Nurse Service (1909–
1953). Public Health Nursing, 5, 235–240.

Hanlon, J. J., & Pickett, G. E. (1984). Public health administration and
practice (8th ed.). St. Louis, MO: Mosby.

Heinrich, J. (1983). Historical perspectives on public health nursing.
Nursing Outlook, 32(6), 317–320.

Howell, J. (1996). Technology in the hospital. Baltimore, MD: Johns
Hopkins University Press.

Huch, M. (2001). Advanced practice nursing in the community. In K. S.
Lundy & S. Janes (Eds.), Community health nursing: Caring for the

public’s health (pp. 968–980). Sudbury, MA: Jones and Bartlett.
Institute of Medicine. (1999). To err is human: Building a safer health
system. Washington, DC: National Academy Press.

Institute of Medicine. (2001). Crossing the quality chasm: A new health
system for the 21st century. Washington, DC: National Academy
Press.

Institute of Medicine. (2003). Health professions education: A bridge to
quality. Washington, DC: National Academy Press.

Institute of Medicine. (2011). The future of nursing: Leading change,
advancing health. Washington, DC: National Academy Press.

International Council of Nurses. (n.d.). Who we are. Retrieved from
http://www.icn.ch/who-we-are/who-we-are/

Judd, D. (2014). Nursing in the United States from the 1920s to the early
1940s: Education rather than training for nurses. In D. Judd & K.
Sitzman (Eds.), A history of American nursing: Trends and eras (2nd
ed., pp. 148–180). Burlington, MA: Jones & Bartlett Learning.

Kalisch, P. A., & Kalisch, B. J. (1986). The advance of American nursing
(2nd ed.). Boston, MA: Little, Brown.

Kalisch, P. A., & Kalisch, B. J. (2004). American nursing: A history (4th
ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

LeVasseur, J. (1998). Plato: Nightingale and contemporary nursing.
Image: Journal of Nursing Scholarship, 30(3), 281–285.

Longfellow, H. W. (1857). Santa Filomena. Atlantic Monthly, 1, 22–23.
MacEachern, M. T. (1932). Which shall we choose: Graduate or student
service? Modern Hospital, 38, 97–98, 102–104.

Mansell, D. J. (2004). Forging the future: A history of nursing in Canada.
Ann Arbor, MI: Thomas Press.

Massachusetts Department of Higher Education. (2010). Nurse of the
future: Nursing core competencies. Retrieved from
http://www.mass.edu/currentinit/documents/NursingCoreCompetencies.pdf

Massachusetts Department of Higher Education. (2016). Nurse of the
future: Nursing core competencies: Registered nurse. Retrieved from
http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

McGann, S., Crowther, A., & Dougall, R. (2009). A history of the Royal
College of Nursing 1916–1990: A voice for nurses. New York, NY:
Manchester University Press.

Montag, M. L. (1959). Community college education for nursing: An
experiment in technical education for nursing. New York, NY: McGraw-
Hill.

Monteiro, L. A. (1985). Florence Nightingale on public health nursing.
American Journal of Public Health, 75(2), 181–185.

Mosley, M. O. P. (1996). Satisfied to carry the bag: Three black
community health nurses’ contribution to health care reform, 1900–
1937. Nursing History Review, 4, 65–82.

New South Wales Nurses and Midwives’ Association. (2014). History.
Retrieved from http://www.nswnma.asn.au/about-us/history/

Nightingale, F. (1860). Notes on nursing: What it is and what it is not.
London, England: Harrison.

Nightingale, F. (1893). Sick-nursing and health-nursing. In B. Burdett-
Coutts (Ed.), Women’s mission (pp. 184–205). London, England:
Sampson, Law, Marston.

Nightingale, F. (1979). Cassandra. In M. Stark (Ed.), Florence
Nightingale’s Cassandra. Old Westbury, NY: Feminist Press.

Nursing and Midwifery Board of Australia. (n.d.). State and territory
nursing and midwifery board members. Retrieved from
http://www.nursingmidwiferyboard.gov.au/About/State-and-Territory-
Nursing-and-Midwifery-Board-Members.aspx

Nutting, M. A., & Dock, L. L. (1907). A history of nursing: The evolution of
nursing systems from the earliest times to the foundation of the first
English and American training schools for nurses. New York, NY: G. P.

Putnam’s Sons.
Ontario Nurses’ Association. (n.d.). Our history and milestones. Retrieved
from https://www.ona.org

Palmer, I. S. (1977). Florence Nightingale: Reformer, reactionary,
researcher. Nursing Research, 26(2), 13–18.

Palmer, I. S. (1982). Through a glass darkly: From Nightingale to now.
Washington, DC: American Association of Colleges of Nursing.

Qiu, L. (2017, December 20). Trump falsely claims to have “repealed
Obamacare.” New York Times. Retrieved from
https://www.nytimes.com/2017/12/20/us/politics/factcheck-trump-tax-
repeal-health-care.html

Quality and Safety Education for Nurses. (2018). Quality and safety
competencies. Retrieved from http://qsen.org/competencies/pre-
licensure-ksas/

Rathbone, W. (1890). A history of nursing in the homes of the poor.
Introduction by Florence Nightingale. London, England: Macmillan.

Registered Nurses’ Association of Ontario. (n.d.). About RNAO.
Retrieved from http://rnao.ca/about

Richardson, B. I. W. (1887). The health of nations: A review of the works
of Edwin Chadwick (Vol. 2). London, England: Longmans, Green.

Roberts, M. (1954). American nursing: History and interpretation. New
York, NY: Macmillan.

Robinson, V. (1946). White caps: The story of nursing. Philadelphia, PA:
Lippincott.

Rosen, G. (1958). A history of public health. New York, NY: M. D.
Publications.

Royal Australian Army Nursing Corps. (n.d.). Royal Australian Army
Nursing Corps (RAANC). Retrieved from
http://www.defence.gov.au/health/about/docs/RAANC.pdf

Royal British Nurses’ Association. (n.d.). Registration of nurses.

Retrieved from http://www.rbna.org.uk/registration.asp
Royal College of Nursing. (n.d.). Our history. Retrieved from
https://www.rcn.org.uk/about-us/our-history

Sabin, L. (1998). Struggles and triumphs: The story of Mississippi nurses
1800–1950. Jackson: Mississippi Hospital Association Health,
Research and Educational Foundation.

Sanger, M. (1928). Motherhood in bondage. New York, NY: Brentano’s.
Seymer, L. (1954). Selected writings of Florence Nightingale. New York,
NY: Macmillan.

Shi, L., & Singh, D. A. (2019). Delivering health care in America: A
systems approach (7th ed.). Burlington, MA: Jones & Bartlett Learning.

Shryock, R. H. (1959). The history of nursing: An interpretation of the
social and medical factors involved. Philadelphia, PA: Saunders.

Sitzman, K., & Judd, D. (2014a). Nursing in the American colonies from
the 1600s to the 1700s: The influence of past ideas, traditions, and
trends. In D. Judd & K. Sitzman (Eds.), A history of American nursing:
Trends and eras (2nd ed., pp. 49–62). Burlington, MA: Jones & Bartlett
Learning.

Sitzman, K., & Judd, D. (2014b). Nursing in the United States during the
1800s: Inspiration and insight lead to nursing reforms. In D. Judd & K.
Sitzman (Eds.), A history of American nursing: Trends and eras (2nd
ed., pp. 80–109). Burlington, MA: Jones & Bartlett Learning.

Smith, E. (1934). Mississippi special public health nursing project made
possible by federal funds. Paper presented at the 1934 annual
Mississippi Nurses Association meeting, Jackson, MS.

State board test pool examination. (1952). American Journal of Nursing,
52, 613.

Taylor, H. O. (1922). Greek biology and medicine. Boston, MA: Marshall
Jones.

The 100 people who made the millennium. (1997). Life Magazine,

20(10a).
Tiffany, F. (1890). The life of Dorothea Lynde Dix. Boston, MA: Houghton
Mifflin.

Tooley, S. A. (1910). The life of Florence Nightingale. London, England:
Cassell.

University of Melbourne. (2015). The Australian nursing and midwifery
history project: Military nursing. Retrieved from
http://anmhp.unimelb.edu.au/history/military_nursing

Veterans Affairs Canada. (n.d.). The nursing sisters of Canada. Retrieved
from http://www.veterans.gc.ca/eng/remembrance/those-who-
served/women-and-war/nursing-sisters

Vicinus, M., & Nergaard, B. (1990). Ever yours: Florence Nightingale:
Selected letters. Cambridge, MA: Harvard University Press.

Victorian Order of Nurses. (n.d.). History—more than a century of caring.
Retrieved from http://www.von.ca/en/history

Wald, L. D. (1915). The house on Henry Street. New York, NY: Holt.
Wertz, R. W., & Wertz, D. C. (1977). Lying-in: A history of childbirth in
America. New Haven, CT: Yale University Press.

Williams, C. B. (1961). Stories from Scutari. American Journal of Nursing,
61, 88.

Winslow, C.-E. A. (1946). Florence Nightingale and public health nursing.
Public Health Nursing, 38, 330–332.

Woodham-Smith, C. (1951). Florence Nightingale. New York, NY:
McGraw-Hill.

Woodham-Smith, C. (1983). Florence Nightingale. New York, NY:
Athenaeum.

Young, D. A. (1995). Florence Nightingale’s fever. British Medical Journal,
311, 1697–1700.

Young, J. (2010). “Monthly” nurses, “sick” nurses, and midwives:
Working-class caregivers in Toronto, 1830–91. In M. Rutherdale (Ed.),

Caregiving on the periphery: Historical perspectives on nursing and
midwifery in Canada (pp. 33–60). Montreal, Canada: McGill-Queen’s
University Press.

1Note: This chapter is adapted from Lundy, K. S., & Bender, K. W. (2009). History of community

health and public health nursing. In K. S. Lundy & S. Janes (Eds.), Community health nursing:

Caring for the public’s health (2nd ed., pp. 62–99). Sudbury, MA: Jones and Bartlett.

© James Kang/EyeEm/Getty Images

CHAPTER 2

Frameworks for Professional
Nursing Practice1
Kathleen Masters

Learning Objectives

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

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

competencies.

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

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

Key Terms and Concepts

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

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

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

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

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

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

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

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

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

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

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

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

CRITICAL THINKING QUESTION

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

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

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

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

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

Person Recipient of nursing care.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Nursing

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

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

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

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

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

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

of Caring

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

Healing space
and
environment

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

Health (healing) Harmony, wholeness, and comfort.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Environment
(situation)

A social environment with social definition and
meaningfulness.

Health The human experience of health or
wholeness.

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

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

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

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

of energy fields (Table 2-5).

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Bringing about and maintenance of living conditions that support life

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The propositions of Roy’s theory include the following:

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

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

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

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

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

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

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

Person (client
system)

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

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

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

Nursing Prevention as intervention; concerned with all
potential stressors.

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

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

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

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

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

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

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

Person (human
being)

A personal system that interacts with
interpersonal and social systems.

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

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

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

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

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

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

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

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

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

Person (human
being)

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

Environment Includes internal and external environment.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Environment Coexists in mutual process with the person.

Health Continuously changing process of becoming.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Health A positive high-level state.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

vulnerability related to transitions.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Theory

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

Environment The environment is composed of family, social

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

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

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

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

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

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

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

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

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

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

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

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

Theory

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

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

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

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

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

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

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

are summarized in Table 2-20.

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

Theory

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

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

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

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

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

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

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

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

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

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

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

Care

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

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

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

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

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

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

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

Social Cognitive Theory

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

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

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

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

KEY OUTCOME 2-1

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

Essential I: Liberal Education for Baccalaureate Generalist Nursing
Practice

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

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

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

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

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

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

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

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

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

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

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

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

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

outcome.

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

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

CRITICAL THINKING QUESTION

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

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

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

1.

2.

your professional nursing career.

CASE STUDY 2-1 ▪ MR. M.

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

Case Study Questions

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

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

Classroom Activity 2-1

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

Classroom Activity 2-2

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

Figure 2-1 Student conceptual model.

Used with permission of Heather Grush.

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

References
Ahtisham, Y., & Jacoline, S. (2015). Integrating nursing theory and
process into practice: Virginia Henderson’s need theory. International
Journal of Caring Sciences, 8(2), 443–450.

Alligood, M. R. (2006). Philosophies, models, and theories: Critical
thinking structures. In M. R. Alligood & A. M. Tomey (Eds.), Nursing
theory: Utilization & application (3rd ed., pp. 43–65). St. Louis, MO:
Mosby.

Alligood, M. R., & Tomey, A. M. (2002). Significance of theory for nursing
as a discipline and profession. In A. M. Tomey & M. R. Alligood (Eds.),
Nursing theorists and their work (5th ed., pp. 14–31). St. Louis, MO:
Mosby.

American Association of Colleges of Nursing. (2008). The essentials of
baccalaureate education for professional nursing practice. Retrieved
from
http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

Andrews, H. A., & Roy, C., Sr. (1986). Essentials of the Roy adaptation
model. Norwalk, CT: Appleton-Century-Crofts.

Andrews, H. A., & Roy, C., Sr. (1991). Essentials of the Roy adaptation
model. In C. Roy Sr. & H. A. Andrews (Eds.), The Roy adaptation
model: The definitive statement (pp. 2–25). Norwalk, CT: Appleton &
Lange.

Bailey, D. E., & Stewart, J. L. (2014). Merle H. Mishel: Uncertainty in
illness theory. In M. R. Alligood (Ed.), Nursing theorists and their work
(8th ed., pp. 555–573). Maryland Heights, MO: Mosby.

Bandura, A. (1977). Social learning theory: Toward a unifying theory of
behavior change. Psychological Review, 84, 191–215.

Bandura, A. (1986). Social foundations of thought and action: A social
cognitive theory. Englewood Cliffs, NJ: Prentice Hall.

Bandura, A. (1997). Self-efficacy: The exercise of control. New York, NY:
W. H. Freeman.

Beck, C. (1993). Teetering on the edge: A substantive theory of
postpartum depression. Nursing Research, 42(1), 42–48.

Beck, C. T. (2002). Postpartum depression: A metasynthesis. Qualitative
Health Research, 12(4), 453–472.

Beck, C. T. (2003). Postpartum Depression Predictors Inventory—
Revised. Advances in Neonatal Care, 3(1), 47–48.

Beck, C., & Gable, R. (2000). Postpartum Depression Screening Scale:
Development and psychometric testing. Nursing Research, 49(5), 272–
282.

Benner, P. (2001). From novice to expert: Excellence and power in
clinical nursing practice. Upper Saddle River, NJ: Prentice Hall.
(Original work published 1984)

Benner, P., Hooper-Kyriakidis, P., & Stannard, D. (1999). Clinical wisdom
and interventions in critical care: A thinking-in-action approach.
Philadelphia, PA: Saunders.

Benner, P., & Wrubel, J. (1989). The primacy of caring: Stress and coping
in health and illness. Menlo Park, CA: Addison-Wesley.

Berbiglia, V. A. (2010). Orem’s self-care deficit theory in nursing practice.
In M. R. Alligood (Ed.), Nursing theory: Utilization and application (4th
ed., pp. 261–286). Maryland Heights, MO: Mosby.

Bolton, K. (2006). Nightingale’s philosophy in nursing practice. In M. R.
Alligood & A. M. Tomey (Eds.), Nursing theory: Utilization & application
(3rd ed., pp. 89–102). St. Louis, MO: Mosby.

Boulding, K. E. (1956). General systems theory: The skeleton of science.
Management Science, 2(3), 197–208.

Brykczynski, K. A. (2010). Benner’s philosophy in nursing practice. In M.

R. Alligood (Ed.), Nursing theory: Utilization and application (4th ed.,
pp. 137–159). Maryland Heights, MO: Mosby.

Cody, W. K. (2006). Nursing theory–guided practice: What it is and what
it is not. In W. K. Cody (Ed.), Philosophical and theoretical perspectives
for advanced nursing practice (4th ed., pp. 119–121). Sudbury, MA:
Jones and Bartlett.

Coward, D. D. (2010). Self-transcendence theory: Pamela G. Reed. In M.
R. Alligood & A. M. Tomey (Eds.), Nursing theorists and their work (7th
ed., pp. 618–637). Maryland Heights, MO: Mosby.

Curley, M. A. Q. (1998). Patient–nurse synergy: Optimizing patients’
outcomes. American Journal of Critical Care, 7(1), 64–72.

Curley, M. A. Q. (2007). Synergy: The unique relationship between
nursing and patients. Indianapolis, IN: Sigma Theta Tau International.

Day, L., & Benner, P. (2002). Ethics, ethical comportment, and etiquette.
American Journal of Critical Care, 11(1), 76–79.

Dowd, T. (2010). Katharine Kolcaba: Theory of comfort. In M. R. Alligood
& A. M. Tomey (Eds.), Nursing theorists and their work (7th ed., pp.
706–721). Maryland Heights, MO: Mosby.

Eckberg, D. L., & Hill, L., Jr. (1979). The paradigm concept and
sociology: A critical review. American Sociological Review, 44, 925–
937.

Fawcett, J. (1994). Analysis and evaluation of conceptual models of
nursing. Philadelphia, PA: F. A. Davis.

Fawcett, J. (2005). Contemporary nursing knowledge: Analysis and
evaluation of nursing models and theories (2nd ed., pp. 553–585).
Philadelphia, PA: F. A. Davis.

Flaskerud, J. H., & Holloran, E. J. (1980). Areas of agreement in nursing
theory development. Advances in Nursing Science, 3(1), 1–7.

Furukawa, C. Y., & Howe, J. S. (2002). Definition and components of
nursing: Virginia Henderson. In J. B. George (Ed.), Nursing theories:

The base for professional nursing practice (5th ed., pp. 83–109). Upper
Saddle River, NJ: Prentice Hall.

Geib, K. M. (2006). Neuman’s systems model in nursing practice. In M.
R. Alligood & A. M. Tomey (Eds.), Nursing theory: Utilization &
application (3rd ed., pp. 229–254). St. Louis, MO: Mosby.

Gunther, M. (2006). Rogers’ science of unitary human beings in nursing
practice. In M. R. Alligood & A. M. Tomey (Eds.), Nursing theory:
Utilization & application (3rd ed., pp. 283–306). St. Louis, MO: Mosby.

Gunther, M. (2010). Rogers’ science of unitary human beings in nursing
practice. In M. R. Alligood & A. M. Tomey (Eds.), Nursing theory:
Utilization & application (4th ed., pp. 287–307). St. Louis, MO: Mosby.

Hardin, S. R. (2005). Introduction to the AACN synergy model for patient
care.In S. R. Hardin & R. Kaplow (Eds.), Synergy for clinical
excellence: The AACN synergy model for patient care. (pp. 3–10).
Sudbury, MA: Jones and Bartlett.

Hardin, S. R. (2013). The AACN synergy model. In S. J. Peterson & T. S.
Bredow (Eds.), Middle range theories: Application to nursing research
(3rd ed., pp. 294–305). Philadelphia, PA: Lippincott.

Harmer, B., & Henderson, V. (1955). Textbook of the principles and
practice of nursing. New York, NY: Macmillan.

Henderson, V. (1964). The nature of nursing. American Journal of
Nursing, 64, 62–68.

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

Henderson, V. (1991). The nature of nursing: Reflections after 25 years.
New York, NY: National League for Nursing Press.

Hickman, J. S. (2002). An introduction to nursing theory. In J. B. George
(Ed.), Nursing theories: A base for professional nursing practice (5th
ed., pp. 1–20). Upper Saddle River, NJ: Prentice Hall.

Holaday, B. (2006). Johnson’s behavioral system model in nursing
practice. In M. R. Alligood & A. M. Tomey (Eds.), Nursing theory:
Utilization & application (3rd ed., pp. 157–180). St. Louis, MO: Mosby.

Howk, C. (2002). Hildegard E. Peplau: Psychodynamic nursing. In A. M.
Tomey & M. R. Alligood (Eds.), Nursing theorists and their work (5th
ed., pp. 379–398). St. Louis, MO: Mosby.

Johnson, B. M., & Webber, P. B. (2010). An introduction to theory and
reasoning in nursing (3rd ed.). Philadelphia, PA: Lippincott Williams &
Wilkins.

Johnson, D. (1980). The behavioral systems model for nursing. In J.
Riehl & C. Roy (Eds.), Conceptual models for nursing practice (2nd
ed., pp. 207–216). New York, NY: Appleton-Century-Crofts.

King, I. M. (1981). A theory of nursing: Systems, concepts, process. New
York, NY: Wiley.

King, I. M. (1989). King’s general systems framework and theory. In J. P.
Riehl-Sisca (Ed.), Conceptual models for nursing practice (3rd ed., pp.
149–158). Norwalk, CT: Appleton & Lange.

King, I. M. (1992). King’s theory of goal attainment. Nursing Science
Quarterly, 5(1), 19–26.

Kolcaba, K. (2004). Comfort. In S. J. Peterson & T. S. Bredow (Eds.),
Middle range theories: Application to nursing research (pp. 255–273).
Philadelphia, PA: Lippincott Williams & Wilkins.

Kolcaba, K., Tilton, C., & Drouin, C. (2006). Comfort theory: A unifying
framework to enhance the practice environment. Journal of Nursing
Administration, 36(11), 538–544.

Lawson, T. G. (2014). Betty Neuman: Systems model. In M. R. Alligood
(Ed.), Nursing theorists and their work (8th ed., pp. 281–302).
Maryland Heights, MO: Mosby.

Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New
York, NY: Springer.

Leininger, M. (1991). Culture care diversity and universality: A theory of
nursing. New York, NY: National League for Nursing Press.

Leininger, M. (1995). Transcultural nursing perspectives: Basic concepts,
principles, and culture care incidents. In M. M. Leininger (Ed.),
Transcultural nursing: Concepts, theories, research, and practices (2nd
ed., pp. 57–92). New York, NY: McGraw-Hill.

Leininger, M. (2001). Culture care diversity and universality: A theory of
nursing. Sudbury, MA: Jones and Bartlett.

Leininger, M. M., & McFarland, M. R. (2006). Culture care diversity and
universality: A worldwide theory of nursing (2nd ed.). Sudbury, MA:
Jones and Bartlett.

Lippitt, G. L. (1973). Visualizing change: Model building and the change
process. Fairfax, VA: NTL Learning Resources.

Maeve, M. K. (2014). Cheryl Tatano Beck: Postpartum depression theory.
In M. R. Alligood (Ed.), Nursing theorists and their work (8th ed., pp.
672–687). Maryland Heights, MO: Mosby.

McBride, A. B. (Narrator). (1997). Celebrating Virginia Henderson
(Video). (Available from Center for Nursing Press, 550 West North
Street, Indianapolis, IN 46202).

Meleis, A. I. (2004). Theoretical nursing: Development & progress (3rd
ed.). Philadelphia, PA: Lippincott.

Meleis, A. I. (2007). Theoretical nursing: Development & progress (4th
ed.). Philadelphia, PA: Lippincott.

Meleis, A. I. (2010). Transitions theory: Middle-range and situation-
specific theories in nursing research and practice. New York, NY:
Springer.

Meleis, A. I., Sawyer, L. M., Im, E. O., Hilfinger Messias, D. K., &
Schumacher, K. (2000). Experiencing transitions: An emerging middle
range theory. Advances in Nursing Science, 23(1), 12–28.

Mishel, M. H. (1988). Uncertainty in illness. Image: The Journal of

Nursing Scholarship, 20, 225–231.
Mishel, M. H. (2014). Theories of uncertainty in illness. In M. J. Smith &
P. R. Liehr (Eds.), Middle range theory for nursing (3rd ed., pp. 53–86).
New York, NY: Springer.

Mitchell, G. J. (2006). Rosemarie Rizzo Parse: Human becoming. In A.
M. Tomey & M. R. Alligood (Eds.), Nursing theorists and their work (6th
ed., pp. 522–559). St. Louis, MO: Mosby.

Mitchell, G. J., & Bournes, D. A. (2010). Rosemarie Rizzo Parse:
Humanbecoming. In M. R. Alligood & A. M. Tomey (Eds.), Nursing
theorists and their work (7th ed., pp. 503–535). Maryland Heights, MO:
Mosby.

Neil, R. M., & Tomey, A. M. (2006). Jean Watson: Philosophy and science
of caring. In A. M. Tomey & M. R. Alligood (Eds.), Nursing theorists and
their work (6th ed., pp. 91–115). St. Louis, MO: Mosby.

Neuman, B. (1995). The Neuman systems model (3rd ed.). Norwalk, CT:
Appleton & Lange.

Neuman, B. (2002). The Neuman systems model. In B. Neuman & J.
Fawcett (Eds.), The Neuman systems model (4th ed., pp. 3–34). 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)

Norris, D., & Frey, M. A. (2006). King’s system framework and theory in
nursing practice. In M. R. Alligood & A. M. Tomey (Eds.), Nursing
theory: Utilization & application (3rd ed., pp. 181–205). St. Louis, MO:
Mosby.

Orem, D. (1985). Nursing: Concepts of practice (3rd ed.). New York, NY:
McGraw-Hill.

Orem, D. (1990). A nursing practice theory in three parts, 1956–1989. In
M. E. Parker (Ed.), Nursing theories in practice (pp. 47–60). New York,
NY: National League for Nursing.

Orem, D. (1995). Nursing: Concepts of practice (5th ed.). St. Louis, MO:
Mosby.

Orem, D. (2001). Nursing: Concepts of practice (6th ed.). St. Louis, MO:
Mosby.

Parse, R. R. (1981). Man–living–health: A theory of nursing. New York,
NY: Wiley.

Parse, R. R. (1987). Nursing science: Major paradigms, theories, and
critiques. Philadelphia, PA: Saunders.

Parse, R. R. (1998). The human becoming school of thought: A
perspective for nurses and other health professionals. Thousand Oaks,
CA: Sage.

Pender, N. J. (1996). Health promotion in nursing practice (3rd ed.).
Stamford, CT: Appleton & Lange.

Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2006). Health
promotion in nursing practice (5th ed.). Upper Saddle River, NJ:
Prentice Hall.

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

Pender, N. J., Murdaugh, C. L., & Parsons, M. A. (2015). Health
promotion in nursing practice (7th ed.). Upper Saddle River, NJ:
Prentice Hall.

Peplau, H. (1952). Interpersonal relations in nursing. New York, NY: G. P.
Putnam’s Sons.

Peplau, H. E. (1992). Interpersonal relations: A theoretical framework for
application in nursing practice. Nursing Science Quarterly, 5, 13–18.

Peplau, H. E. (1997). Peplau’s theory of interpersonal relations. Nursing
Science Quarterly, 10(4), 162–167.

Pfettscher, S. A. (2006). Florence Nightingale: Modern nursing. In A. M.
Tomey & M. R. Alligood (Eds.), Nursing theorists and their work (6th

ed., pp. 71–90). St. Louis, MO: Mosby.
Phillips, K. D. (2006). Sister Callista Roy: Adaptation model. In A. M.
Tomey & M. R. Alligood (Eds.), Nursing theorists and their work (6th
ed., pp. 355–385). St. Louis, MO: Mosby.

Phillips, K. D., & Harris, R. (2014). Sister Callista Roy: Adaptation model.
In M. R. Alligood (Ed.), Nursing theorists and their work (8th ed., pp.
303–331). Maryland Heights, MO: Mosby.

Reed, P. G. (2008). Theory of self-transcendence. In M. J. Smith & P. R.
Liehr (Eds.), Middle range theory for nursing (2nd ed., pp. 105–129).
New York, NY: Springer.

Reed, P. G. (2014). Theory of self-transcendence. In M. J. Smith & P. R.
Liehr (Eds.), Middle range theory for nursing (3rd ed., pp. 109–139).
New York, NY: Springer.

Rogers, M. E. (1970). An introduction to the theoretical basis of nursing.
Philadelphia, PA: F. A. Davis.

Rogers, M. E. (1992). Nursing science and the space age. Nursing
Science Quarterly, 5, 27–34.

Rogers, M. E. (1994). The science of unitary human beings: Current
perspectives. Nursing Science Quarterly, 7, 33–35.

Roy, C., Sr. (2009). The Roy adaptation model (3rd ed.). Upper Saddle
River, NJ: Pearson.

Roy, C., Sr., & Andrews, H. A. (1999). The Roy adaptation model (2nd
ed.). Stamford, CT: Appleton & Lange.

Sakraida, T. J. (2010). The health promotion model. In A. M. Tomey & M.
R. Alligood (Eds.), Nursing theorists and their work (7th ed., pp. 434–
453). St. Louis, MO: Mosby.

Sakraida, T. J. (2014). The health promotion model. In A. M. Tomey & M.
R. Alligood (Eds.), Nursing theorists and their work (8th ed., pp. 396–
416). St. Louis, MO: Mosby.

Schumacher, K. L., & Meleis, A. I. (1994). Transitions: A central concept

in nursing. Image: Journal of Nursing Scholarship, 26(2), 119–127.
Selye, H. (1950). Stress and the general adaptation syndrome. British
Medical Journal, 4667, 1383–1392.

Selye, H. (1974). The stress of life. New York, NY: McGraw-Hill.
Sieloff, C. L. (2006). Imogene King: Interacting systems framework and
middle range theory of goal attainment. In A. M. Tomey & M. R.
Alligood (Eds.), Nursing theorists and their work (6th ed., pp. 297–317).
St. Louis, MO: Mosby.

Swanson, K. M. (1991). Empirical development of a middle range theory
of caring. Nursing Research, 40(3), 161–166.

Swanson, K. M. (1993). Nursing as informed caring for the well-being of
others. Image: The Journal of Nursing Scholarship, 25(4), 352–357.

Swanson, K. M. (1999a). The effects of caring, measurement, and time
on miscarriage impact and women’s well-being in the first year
subsequent to loss. Nursing Research, 48(6), 288–298.

Swanson, K. M. (1999b). What’s known about caring in nursing: A literary
meta-analysis. In A. S. Hinshaw, J. Shaver, & S. Freetham (Eds.),
Handbook of clinical nursing research (pp. 31–60). Thousand Oaks,
CA: Sage.

Taylor, S. G. (2006). Self-care deficit theory of nursing. In A. M. Tomey &
M. R. Alligood (Eds.), Nursing theorists and their work (6th ed., pp.
267–296). St. Louis, MO: Mosby.

Tomey, A. M. (2006). Nursing theorists of historical significance. In A. M.
Tomey & M. R. Alligood (Eds.), Nursing theorists and their work (6th
ed., pp. 54–67). St. Louis, MO: Mosby.

Von Bertalanffy, L. (1968). General systems theory: Foundations,
development, applications. New York, NY: George Braziller.

Watson, J. (1979). Nursing: The philosophy and science of caring.
Boston, MA: Little, Brown.

Watson, J. (1985). Nursing: Human science and human care: A theory of

nursing.Sudbury, MA: Jones and Bartlett.
Watson, J. (1989). Watson’s philosophy and theory of human caring in
nursing. In J. P. Riehl-Sisca (Ed.), Conceptual model for nursing
practice (3rd ed., pp. 219–236). Norwalk, CT: Appleton & Lange.

Watson, J. (1996). Watson’s philosophy and theory of human caring in
nursing. In J. P. Riehl-Sisca (Ed.), Conceptual models for nursing
practice (pp. 219–235). Norwalk, CT: Appleton & Lange.

Watson, J. (1997). The theory of human caring: Retrospective and
prospective. Nursing Science Quarterly, 10, 49–52.

Watson, J. (2001). Jean Watson: Theory of human caring. In M. E.
Parker (Ed.), Nursing theories and nursing practice (pp. 343–354).
Philadelphia, PA: F. A. Davis.

Watson, J. (2008). Nursing: The philosophy and science of caring (Rev.
ed.). Boulder: University Press of Colorado.

Wojnar, D. M. (2010). Kristin M. Swanson: Theory of caring. In M. R.
Alligood & A. M. Tomey (Eds.), Nursing theorists and their work (7th
ed., pp. 741–752). Maryland Heights, MO: Mosby.

Young, A., Taylor, S. G., & McLaughlin-Renpenning, K. (2001).
Connections: Nursing research, theory, and practice. St. Louis, MO:
Mosby.

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

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

© James Kang/EyeEm/Getty Images

CHAPTER 3

Philosophy of Nursing
Mary W. Stewart

Learning Objectives

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

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

nursing.

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

Key Terms and Concepts

Paradigm
Realism
Idealism
Values
Values clarification

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

© Georgios Kollidas/Shutterstock, Inc.

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

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

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

and the facts that science discovers.

© Photos.com/Thinkstock.

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

School of Thought Meaning of Truth
(Philosophers)

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

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

Theocratics Truth comes through an
understanding of God.

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

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

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

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

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

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

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

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

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

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

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

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

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

BOX 3-1









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

THE CONTINUUM OF REALISM AND IDEALISM

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

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

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

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

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

KEY OUTCOME 3-1

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

Essential VIII: Professionalism and Professional Values

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

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

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

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

CRITICAL THINKING QUESTION

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

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

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

CRITICAL THINKING QUESTIONS

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

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

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

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

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

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

CRITICAL THINKING QUESTION

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

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

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

CRITICAL THINKING QUESTION

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

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

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

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

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

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

Rokeach (1973) makes the following assertions about values:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

© Iakov Filimonov/Shutterstock.

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

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

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

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

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

CRITICAL THINKING QUESTIONS

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

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

KEY OUTCOME 3-2

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

Essential IX: Baccalaureate Generalist Nursing Practice

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

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

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

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

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

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

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

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

BOX 3-2

1.
a.
b.

2.
a.
b.
c.

3.
a.
b.
c.
d.

4.
a.
b.
c.

5.
a.
b.
c.

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

GUIDE FOR WRITING A PERSONAL PHILOSOPHY OF
NURSING

Introduction
Who are you?
Where do you practice nursing?

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

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

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

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

d. What are your goals for professional development?

KEY COMPETENCY 3-1

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Professionalism:

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

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

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

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

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

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

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

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

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

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

CRITICAL THINKING QUESTIONS

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

CRITICAL THINKING QUESTIONS

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

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

KEY COMPETENCY 3-2

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Professionalism:

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

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

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

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

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

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

Classroom Activity 3-1

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

Classroom Activity 3-2

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

Figure 3-6 Drawing of the concept of person.

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

Publishers.

References
American Association of Colleges of Nursing. (2008). The essentials of
baccalaureate education for professional nursing practice. Retrieved
from
http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Massachusetts Department of Higher Education. (2016). Nurse of the
future: Nursing core competencies: Registered nurse. Retrieved from
http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

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

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

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

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

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

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

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

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

© James Kang/EyeEm/Getty Images

CHAPTER 4

Competencies for Professional
Nursing Practice
Jill Rushing and Kathleen Masters

Learning Objectives

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

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

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

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

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

Key Terms and Concepts

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

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

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

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

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

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

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

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf
The Nurse of the Future: Nursing Core Competencies graphic

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

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

Nursing core competencies: Registered nurse. Retrieved from
http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

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

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

Core Competencies

Human
being/patients

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

KEY OUTCOME 4-1

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

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

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

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

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

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

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

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

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

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

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

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

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

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

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

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

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

© Maridav/Shutterstock

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

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

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

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

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

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

KEY OUTCOME 4-2

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

Essential VII: Clinical Prevention and Population Health

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

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

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

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

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

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

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

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

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

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

CRITICAL THINKING QUESTION

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

Listen to her breath sounds.



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

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

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

Learning to be a nurse requires more than memorizing facts. It
requires that you learn to think like a nurse, to think through and reason
at a greater depth, and to draw a more sophisticated or deeper
understanding of what you are doing in clinical practice so that you
provide safe, good-quality patient care. Nursing is not a careless,
mindless activity. All acts in nursing are deeply significant and require the
nurse’s mind to be fully engaged. The following illustration shows that
nursing involves both thinking and doing: The physician has ordered an
intravenous (IV) line to be placed in a patient. How do you choose
between a butterfly and an IV intracath? First, you have to consider why
the line is being placed. You take into consideration whether it is a short-
term, keep-open IV with limited medications; if so, then the butterfly IV is
more comfortable and presents less of a threat of phlebitis. Doctors vary
in their preferences as well, and this has to be considered. In addition,

the condition of the patient and his or her veins makes a great deal of
difference. For example, special skill is required with older patients. The
veins look as though they are going to be easy to get because they look
large, but they are very fragile. If you do not use a very slight tourniquet,
the vein will pop open (Benner, 1984).

Characteristics of Critical Thinking
How do you know when critical thinking is taking place? Critical thinking
has some of the following characteristics (Wilkinson, 2007):

Critical thinking is rational and reasonable.
Critical thinking involves conceptualization.
Critical thinking requires reflection.
Critical thinking involves cognitive (thinking) skills and attitudes
(feelings).
Critical thinking involves creative thinking.
Critical thinking requires knowledge.

Critical thinking is rational and reasonable. It is based on reasons
rather than on preferences, prejudice, or self-interest. It uses facts and
observations to draw conclusions. For example, suppose that during an
election you decide to vote for the Democratic candidate because your
family has always voted for Democrats. This decision is based on
preference, prejudice, and, possibly, self-interest. By contrast, suppose
you took the time to reflect on what the candidates in the election said
about the issues and based your choice on that. Even though you still
might vote for the Democrat, you would be thinking rationally, using facts
and observations to draw your conclusions (Wilkinson, 2007).

Critical thinking involves conceptualization. Conceptual thinking is the
ability to understand a situation by identifying patterns or connections,

focusing on key underlying issues, and integrating them into a conceptual
framework. It involves using professional training and experience,
creativity, and inductive reasoning that lead to solutions or alternatives
that may not be easily identified. Conceptual thinking involves a
willingness to explore and having an openness to a new way of seeing
things or “looking outside the box.” Consider, for example, a case in
which a patient with heart failure is coughing up yellow sputum. If the
nurse suspects that the patient is short of breath from infection, he or she
will evaluate other indicators of infection. The nurse will check the patient
for an elevated temperature and will assess the last white blood cell
count in the patient’s chart to see if it is elevated. The nurse will also
consider factors that may place the patient at risk for infection, such as
immobility, poor nutrition, or immune suppression (Craven & Hirnle,
2007).

CRITICAL THINKING QUESTION

What do all of the following scenarios have in common?

An elderly male becomes acutely confused and refuses to follow
directions for his safety.
A teen comes into an urgent care setting requesting information
about sexually transmitted infections.
A mother visits a school nurse and requests information about
how the school handles sex education.
A team leader needs to rearrange assignments when one team
member goes home sick.
Nursing staff in an intensive care unit need to develop an
evacuation plan.

Answer: They all require critical thinking skills.

Critical thinking uses reflection. Reflective thinking is deliberate
thinking and careful consideration. It is the process of analyzing, making

judgments, and drawing conclusions. Reflective thinking involves creating
an understanding through one’s experiences and knowledge and
exploring potential alternatives—assessing what you know, what you
need to know, and how to bridge that gap. Processes of reflective
thinking involve the following:

Determine what information is needed (what you need to know) for
understanding the issue.
Examine what you have already experienced about an issue.
Gather the available information.
Synthesize the information and opinions.
Consider the synthesis from different perspectives and frames of
reference.
Create some meaning from the relevant information and opinions.

Reflective thinking is important during complex problem-solving
situations because it provides an opportunity to step back and think about
how to actually solve problems and how problem-solving strategies are
used for achieving set goals. Reflection allows students to observe and
reflect, pulling together what they learn in the clinical and classroom
settings in taking care of patients. Students can build and integrate
knowledge and skills. Reflecting on a nursing experience or situation can
assist nurses in critically reflecting on their practice. Choose a clinical
situation and ask yourself some of the following questions:

CRITICAL THINKING QUESTION

You will be taking care of a patient in a nursing home for the first time.
Your assignment is to care for an older man who has heart disease. In
addition, he has five other medical problems and takes 20
medications. While developing a plan of care for this patient, you can
identify 8 to 10 nursing problems. You have no previous experience
with nursing homes, and most of what you have heard and read about

them is negative. Will you find yourself dreading the clinical day and
expecting a negative experience before you even begin?

What was my role in this situation? Did I feel comfortable or
uncomfortable? Why?
What actions did I take? How did others and I respond? Was it
appropriate?
How could I have improved the situation for myself, the patient, and
others involved? What can I change in the future?
What have I learned through this situation?
Did I expect anything different to happen? What and why?
Has this situation changed my way of thinking in any way?
What knowledge from theory and research can I apply in this
situation?
What broader issues, for example, ethical, social, or political, arise
from this situation?

Through reflection, students manage to be more organized and
effective because they have a better understanding of who the patient is
and what his or her care needs are. Reflection on practice helps the
student develop a self-improving practice (Benner et al., 2010).

Critical thinking involves cognitive (thinking) skills and attitudes
(feelings). Critical thinking involves having thinking skills as well as the
motivation to use them. It involves the willingness to use complex thought
processes compared to easily understood ones. Critical thinkers do not
oversimplify. Critical thinking is about being willing and able to think.

Critical thinking involves creative thinking. Creativity is part of the
thinking process. When you brainstorm potential problem solutions or
possible decisions, you are using creativity. Creative and critical thinkers
combine ideas and information in ways that form new solutions or
innovative ideas. A creative thinker is an open-minded thinker. Nurses

can use creative thinking when encountering a patient situation in which
traditional methods are not effective. For example, a pediatric nurse is
caring for 9-year-old Pauline, who has ineffective respirations following
abdominal surgery. The physician has ordered incentive spirometry
breathing treatments, but Pauline is frightened by the equipment and she
quickly tires during the treatments. The nurse offers Pauline a bottle of
soap bubbles and a blowing wand. The nurse knows that the respiratory
effort in blowing bubbles will promote alveolar expansion and suggests
that Pauline blow bubbles between incentive spirometry treatments
(Wilkinson, 2007).

Critical thinking requires knowledge. In most academic disciplines,
the educational system uses an expert to deliver a body of knowledge to
the unpracticed novice, who will later be expected to go out and apply the
knowledge and rules learned in school to various work situations. In
nursing, a specific educational knowledge base is required before
applying that knowledge in patient care. It is important to know that the
process is being applied correctly. In essence, to become a nurse you
must learn the knowledge to think like a nurse. On the flip side of this, as
the level of experience of the nurse increases, so will the scientific
knowledge base that the nurse applies. For example, you are caring for a
patient with heart failure. After obtaining the vital signs, what heart rate
would prevent you from ambulating this patient? If you did not have
knowledge regarding heart failure or did not know that the normal heart
rate was between 60 and 100 beats per minute, you could not make the
good decision that ambulation should be postponed if the heart rate is
above 100 beats per minute for this patient.

What Are the Characteristics of a Critical
Thinker?

Nurses are required to think critically in all settings. Nurses’ ability to think
critically is one of their most important skills, and a commitment to think
critically increases the nurse’s ability to care for patients most effectively.
A critical thinker has many characteristics, including the following:

KEY COMPETENCY 4-1

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Leadership:

Knowledge (K2) Understands critical thinking and problem-solving
processes

Skills (S2a) Uses systematic approaches in problem solving

Skills (S2b) Demonstrates purposeful, informed outcome-oriented
thinking

Attitudes/Behaviors (A2) Values critical thinking processes in the
management of client care situations

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

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Critical thinkers are flexible—they can tolerate ambiguity and
uncertainty.
Critical thinkers base judgments on facts and reasoning, not personal
feelings. They identify inherent biases and assumptions. Critical
thinkers separate facts from opinions.
Critical thinkers do not oversimplify.
Critical thinkers examine available evidence before drawing
conclusions.

Critical thinkers think for themselves and do not simply go along with
the crowd.
Critical thinkers remain open to the need for adjustment and
adaptation throughout the inquiry stages.
Critical thinkers accept change.
Critical thinkers empathize; they appreciate and try to understand
others’ thoughts, feelings, and behaviors.
Critical thinkers welcome different views and value examining issues
from every angle.
Critical thinkers know that it is important to explore and understand
positions with which they disagree.
Critical thinkers discover and apply meaning to what they see, hear,
and read.

Approaches to Developing Critical Thinking
Skills
As students develop in their nursing role, they learn and build critical
thinking skills and apply them to real healthcare situations. Critical
thinking requires conscious, deliberate effort. Critical thinking does not
just come naturally; people tend to believe what is easy to believe or
what those around them believe (Wilkinson, 2007). With effort and
practice, everyone can achieve some level of critical thinking to become
an effective problem solver and decision maker. As the elements of
critical thought develop into a habit, nurses improve their ability to assess
complex situations and engage in the practice of nursing. The objectives
for critical thinking in nursing include the ability to ask pertinent questions,
analyze multiple forms of evidence, and evaluate options before coming
to a conclusion. Following are examples that can be used as approaches
to developing critical thinking skills.

The Nursing Process
The ANA standards have set forth the framework necessary for critical
thinking in the application of the nursing process. The nursing process
is the tool by which all nurses can become equally proficient at critical
thinking. The nursing process contains the following criteria: (1)
assessment, (2) identifying the problem (nursing diagnosis), (3) planning,
(4) implementation, and (5) evaluation. Through the application of each of
these components, the nurse can become proficient at critical thinking.
Nurses use critical thinking in each stage of the nursing process. This
approach to critical thinking entails purposeful, informed, outcome-
focused thinking, which requires identification of the nursing and
healthcare needs of clients (Knapp, 2007).

KEY COMPETENCY 4-2

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Professionalism:

Knowledge (K1b) Justifies clinical decisions

Skills (S1b) Exercises critical thinking and clinical reasoning within
standards of practice

Attitudes/Behaviors (A1b) Shows commitment to provision of high-
quality, safe, and effective patient care

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

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

The nursing process is a systematic, problem-solving approach to
giving nursing care that allows the nurse to be accountable by using

critical thinking before taking action. Nurses provide effective care based
on sound reasoning, which is the reasonable reflection on nursing
problems before selecting one of a variety of solutions. This is
accomplished by regularly employing the elements of critical thought,
such as defining the problem, identifying the goal, and analyzing the
evidence (Caputi, 2010).

Each of the following thinking skills is commonly used when a nurse
gathers data (Caputi, 2010):

Assessing systematically and comprehensively
Checking accuracy and reliability
Clustering related information
Collaborating with coworkers
Determining the importance of information
Distinguishing relevant from irrelevant information
Gathering complete and accurate data and then acting on those data
Judging how much ambiguity is acceptable
Recognizing inconsistencies
Using diagnostic reasoning

Each of the following thinking skills is commonly used when nurses
provide care to patients (Caputi, 2010):

Applying the nursing process to develop a treatment plan
Communicating effectively
Predicting and managing potential complications
Resolving conflicts
Resolving ethical dilemmas
Setting priorities
Teaching others

Assessment The nursing assessment answers the questions of what

is happening or what could happen (Figure 4-3). It involves
systematically collecting, organizing, and analyzing information about the
client patient. Once data or information have been collected and it is
determined that the data are accurate and complete, the nurse performs
data analysis or data interpretation. What are the client’s patient’s actual
and/or potential problems? A problem list is then developed based on the
data, and the nurse prioritizes the client’s problems. The nurse performs
an ongoing assessment throughout the implementation of the nursing
process.

Figure 4-3 Collecting and analyzing assessment data are critical components of the nursing
process that enable the nurse to prioritize problems and determine appropriate interventions.

© Monkey Business Images/Shutterstock

Diagnosis The nurse analyzes and derives meaning from the
assessment information and selects a diagnosis. Diagnosis is the
identification of a problem. It is a statement that describes a specific
response to an actual or potential health problem. For example, a nursing
diagnosis for a selected patient might be “decreased cardiac output

related to inability of the heart to pump effectively, and occlusion and
constriction of vessels impairing blood flow.”

Planning During planning, the nurse develops a plan to provide
consistent, continuous care that meets the client’s unique needs.
Planning includes developing expected outcomes and working with the
client to identify goals and to determine appropriate nursing actions and
interventions that will reduce the identified problem. The nurse uses
critical thinking to develop goals and nursing interventions for problems
that require an individualized approach. Nurses use judgment to
determine which interventions have a probability of achieving desired
outcomes. To continue with the previous example, expected outcomes
might include the following:

KEY COMPETENCY 4-3

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Patient-Centered Care:

Knowledge (K1) Identifies components of nursing process appropriate
to individual, family, group, community, and population health care
needs across the life span

Skills (S1a) Provides priority-based nursing care to individuals,
families, and groups through independent and collaborative application
of the nursing process

Skills (S1b) Demonstrates cognitive, affective, and psychomotor
nursing skills when delivering patient care

Attitudes/Behaviors (A1a) Values use of scientific inquiry, as
demonstrated in the nursing process, as an essential tool for provision

of nursing care

Attitudes/Behaviors (A1b) Appreciates the difference between data
collection and assessment

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

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Patient will be free of chest pain during my shift.
Patient will maintain O2 saturation of 90% during my shift.
Vital signs will remain stable: T < 99.0°F, HR > 60 < 110 beats/min, R
> 12 < 24 breaths/min, and SBP > 90 mm Hg while under my care.
Patient will have no further weight gain and will have a decrease in
edema during my shift.

Implementation Implementation is carrying out the plan of care and
depends on the first three steps of the nursing process. These steps
provide the basis for nursing actions performed during the
implementation phase of the nursing process (Figure 4-4). The nurse
carries out nursing interventions individualized to the patient, reassesses
the client, and validates that the plan of care is accurate and successful.
In this stage, to each patient care situation the nurse applies knowledge
and principles from nursing and from related courses. The ability to apply,
not just memorize, principles is a component of critical thinking
(Wilkinson, 2007). For the patient with decreased cardiac output, the
nurse could implement some of the following individualized interventions:

Figure 4-4 The nurse carries out nursing interventions individualized for the patient that are
grounded in the nurses clinical judgment and based on the previous steps in the nursing process.

© Monkey Business Images/Shutterstock

Assess level of consciousness—confusion, anxiety.
Provide reassurance to the patient.
Monitor vital signs every 4 hours.
Assess heart rate and rhythm; monitor telemetry or
electrocardiography.
Monitor for jugular vein distension.
Monitor for chest pain.
Monitor peripheral pulses; assess capillary refill.
Auscultate lung sounds; monitor respiratory rate and rhythm; monitor
oxygen saturation; assess for cough and sputum.
Look at skin color and temperature.
Monitor for fatigue and activity tolerance.
Assess intake and output, daily weight, and edema in dependent
areas.
Assess abdomen for distension or bloating, ascites, and bowel
function.
Monitor lab and X-rays: complete blood count, prothrombin
time/partial thromboplastin time, electrolytes, cardiac enzymes,
arterial blood gases, and chest X-ray.
Elevate head of bed to improve gas exchange.
Administer oxygen as ordered to improve gas exchange.

Administer morphine sulfate as prescribed to relieve chest pain,
provide sedation and vasodilation, and monitor for respiratory
depression and hypotension after administration.
Administer diuretics as prescribed to reduce preload, enhance renal
excretion of sodium and water, reduce circulating blood volume, and
reduce pulmonary congestion; closely monitor potassium level, which
might decrease as a result of diuretic therapy.
Provide teaching: Identify precipitating risk factors of heart failure and
prescribed medication regimen; notify physician if unable to take
medications because of illness; avoid large amounts of caffeine;
provide cardiac diet instruction; look for signs of exacerbation;
monitor fluids; balance periods of activity and rest; avoid isometric
activities that increase pressure in the heart.

Evaluation During evaluation, the nurse compares the patient’s
current status to the patient’s goals. Were the goals achieved? The nurse
analyzes outcomes to determine if the interventions worked, and if not,
why? The information provided during evaluation can be used to begin
another plan of care sufficient to meet the patient’s needs. Continuing
with the previous example, the evaluation might include the following:

Patient denies chest pain on my shift. Patient rates pain 0 on pain
scale.
Patient’s O2 saturation dropped to 85% when oxygen at 3 L nasal
cannula was removed. With oxygen on, patient’s O2 saturation
remained at 92%.
Vital signs were: T, 101.0°F; HR, 100–110 beats/min; R, 32
breaths/min and labored; BP, 90/50 mm Hg.
Patient’s weight was 241 pounds with 2+ edema in lower extremities.

Concept Mapping
Concept mapping is a visual representation of the relationships among
concepts and ideas. The concepts are represented by boxes and linked
with lines. In nursing, concept maps are used to organize and link
information about a patient’s health problems. This allows the nurse to
see relationships among the patient’s problems and helps to plan
interventions that can address more than one problem.

To begin a concept map, start in the center of the page with the main
idea or central theme and work outward in all directions, producing a
growing organized structure composed of key words or pictures. Place
words or pictures around the main idea to illustrate how they relate to one
another and to the central theme. Pictures, words, or a combination of
both can be used to create a map.

Concept maps are useful for summarizing information, consolidating
information from different sources, thinking through complex problems,
and presenting information in a format that shows the overall structure of
your subject. Figure 4-5 illustrates a mind mapping technique used by
students with a patient case.

Figure 4-5 Mind mapping techniques.

Journaling
Keeping a journal of clinical experiences that were meaningful or
troubling to you is a recommended way to help enhance and develop
reasoning skills. Think about and record experiences that bother you and
consider what you could and would do differently in the future. This is a
form of reflection and allows you to view your own thinking, reasoning,
and actions. It helps create and clarify meaning and new understandings
of a particular experience. When you encounter a similar situation, you
should be able to recall what you did or would do differently as well as
the reasoning behind your actions (Raingruber & Haffer, 2001).

Some suggestions you should try to address when journaling your

nursing experience include the following:

What happened? What are the facts?
What was my role in the event?
What feelings and senses surrounded the event?
What did I do?
How and what did I feel about what I did? Why?
What was the setting?
What were the important elements of the event?
What preceded the event, and what followed it?
What should I be aware of if the event recurs?

It is important that you write in your journal as soon as possible after
an event to capture the essence of what happened in the clinical
experience. The following is an example of a journal excerpt that
illustrates reflection on events and the feelings elicited by those events
over the course of many patient care encounters during the career of a
nurse:

CRITICAL THINKING QUESTIONS

Think about a clinical experience that was troubling to you. Reflect on
what bothered you about the experience. What could you have done
differently? What were the reasons behind your actions? Try to create
and clarify meaning or a new understanding of the particular situation.

I have learned, not so easily, that my job is not just about saving
a life, trying to keep people well, or helping them get well when
they are ill, but importantly, it also entails providing that same
dedicated care to them as they take their last breaths in life. It is
my job, my duty, and, I have learned, my privilege. As I care for
a dying patient, listening to the rise and fall of methodical

machines imitating life, I hope I never am calloused to the point
that I say, “I do this every day. It is just another patient.” I want to
appreciate that every individual’s life has been remarkable in
some way—which they are remarkable in some way. I want to
make my patient’s journey through this last chapter in their life a
little easier, provide comfort, recognize their fears, hold their
hand, and always realize this is not another patient but a
person.

CRITICAL THINKING QUESTIONS

Beginning nursing students often tend to focus primarily on their
routines, including to get their list of tasks done, including
assessments, ordered treatments, daily care, and charting. What if an
unexpected situation occurred during the day? Do you think you would
be able to reason, plan, and take appropriate action—think critically?

Group Discussions and Reflection
Another way to enhance critical thinking skills is by using group
discussions to explore alternatives and arrive at conclusions (Figure 4-
6). Group discussions among nursing students and teachers can take
place in the classroom or following clinical experiences. During
discussions, students are encouraged to formulate alternatives to clinical
or ethical decisions. Teacher and learner group discussions over clinical
and ethical scenarios should encourage questions, analysis, and
reflection. Group discussions can assist nursing students in connecting
clinical events or decisions with information obtained in the classroom.
This form of cooperative learning occurs when groups work together to
maximize their own and one another’s learning. For example, following a
clinical experience, students and teacher use reflection and discussion
on a certain clinical experience that a student encountered. Together they

discuss different scenarios of “What if?,” “What else?,” and “What then?”
to encourage the formulation of alternatives or clinical decisions. Other
examples of this process include the following:

Figure 4-6 Working through a case study in class is one way to enhance critical thinking skills
through discussion and reflection.

© Jacoblund/iStock/Getty Images Plus

You are going into a patient’s room—what are you going to do?
When you go in there, what are you going to do? Walk yourself
through it step by step.
What are you going to do first? What should be done first? Which
one takes importance and then where do you go from there?
This is the patient, and this happens. What do you do next?
These are your assessment findings. What else do you need to
know?

You are working in an acute care clinical situation. After receiving the
report, you have started your morning routines. Everything is going as
planned, and you are about to start preparing your medications. The wife
of a patient reports that the oxygen is burning his nose and wants you to
get an oxygen humidifier. All of a sudden, the daughter of another patient,
Mr. Peary, rushes toward you and informs you that her father is spitting
up blood. He looked fine when you observed him a few minutes ago. You
walk rapidly toward the patient’s room, thinking, “What am I going to do

when I get there? I have to get the oxygen humidifier for room 202. His
nose was burning, and his wife was waiting for me. What could be
happening with Mr. Peary?”

KEY COMPETENCY 4-4

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Professionalism:

Knowledge (K4c) Understands the importance of reflection to
advancing practice and improving outcomes of care

Skills (S4b) Demonstrates ability for reflection in action, reflection for
action, and reflection on action

Attitudes/Behaviors (A4c) Values and is committed to being a reflective
practitioner

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

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

You enter the room, and the first thing you think is: “He’s lying flat,”
and you think to yourself, “I need to elevate his head. That is what I did
on the respiratory unit where I recently worked.” The daughter tells you
that Mr. Peary coughed up some blood in the emesis basin. There is a
small amount of bright red blood in it. You do not know what to do next.
An RN stops by the room and tells you that the wife of the patient in room
202 is asking about the burning in her husband’s nose again. Your mind
does not seem to be able to think about anything. Do you feel scattered
and things seem out of control at this point? Do you feel a little
overwhelmed and cannot think what to do next? The RN says she will

take over with Mr. Peary while you follow up with the patient in room 202.
Later, you recall the situation and cannot believe you did not think to take
Mr. Peary’s blood pressure, count respirations, ask about pain, or listen
to his lungs or anything else. All you did was just raise his head. You
wonder why you missed so many things.

What do you think was going on in the situation that influenced what
was happening and caused you to lose your ability to think and plan
what to do next?
What would you do differently in this situation after having a chance
to reflect on it? Prioritize the order in which you would have done
things.
If this had happened to you and no one helped you through it, what
would you have done to mobilize yourself to think about what to do?

Conclusion
In nursing, critical thinking is the ability to think in a systematic and logical
manner, solve problems, make decisions, and establish priorities in the
clinical setting. Nurses need to develop critical thinking skills to make
sound clinical judgments and to provide safe, competent patient care.
Nursing requires constant decision making. What should I do first? What
is the most important thing to do at this time? Prioritizing nursing actions
involves recalling important nursing information as well as using complex
problem-solving skills to make decisions in order to provide safe and
effective patient care. Other tips for nurses at the bedside to improve
safety include practicing mindfully, communicating clearly, reporting
unsafe conditions and errors, responding to error justly, and recognizing
personal limitations (Hershey, 2015).

All of us want to believe that we will never be involved in an error that
harms a patient. But as is evident, errors that result in patient harm do
occur. This creates what has become known as the second victim, a term
coined by Wu (2000) to describe the pain and suffering experienced after
making a healthcare error. A nonjudgmental, supportive, and
compassionate environment is recommended with the use of such
responses as “This must be difficult, are you okay?” or “Can we talk
about it?” or “You are a good nurse working in a complex environment”
(Hershey, 2015, p. 149). Creating a defensive environment does not
allow the nurse at the sharp end of care to contribute to the safety
process and therefore does nothing to increase patient safety. Thus,
“responding to second victims with openness and compassion is not only
the right thing to do, it is also the safe thing to do” (Hershey, 2015, p.
149).

1.

2.

3.

4.

1.

2.

3.

4.

CASE STUDY 4-1 ▪ JIM FULLER

Jim Fuller is a 40-year-old male patient. He is currently in the recovery
room following an inguinal hernia repair under general anesthesia. His
vital signs are T, 99.0°F; BP, 120/80 mm Hg; HR, 80 beats/min; R, 18
breaths/min.

Case Study Questions

Are Mr. Fuller’s vital signs within normal limits? List normal adult
ranges.

What factors might affect body temperature?

List sites where a nurse might take a patient’s pulse. What sites are
most commonly used?

What factors might influence respiratory rate?

Two hours postoperative, Mr. Fuller begins to complain of
abdominal pain. Vital signs at this time are T, 99.5°F; BP, 90/60 mm
Hg; HR, 122 beats/min; R, 24 breaths/min.

Case Study Questions

What could Mr. Fuller’s vital signs indicate?

What nursing interventions are indicated? What should the nurse
assess in Mr. Fuller at this time?

What clinical signs associated with an elevated temperature might
the nurse assess?

If Mr. Fuller’s fever persists and increases, what might the nurse
suspect is happening, and what might be done?

Classroom Activity 4-1

Critical thinking gives you the power to make sense of something by
deliberately choosing how to respond to events that you encounter.
You take in information, examine and ask questions about it, look at
new perspectives, and identify a plan. You use problem-solving and
decision-making strategies.

Choose a decision that you need to make soon and write it down.
What goal or desired outcomes do you seek from this decision?
Prioritize goals or desired outcomes and write them down.
Identify who and what will be affected by your decision and indicate
how your decision will affect them.
Identify any available options you might have.
Taking into account and evaluating your information, identify a plan
or decide what you are going to do.
After you have made your decision, evaluate the result.

Classroom Activity 4-2

You are receiving morning reports on the following patients from the
night-shift nurse. After receiving the report, which patient would you
choose to see first? As you make your decision, think about your
thought processes and how you made your decision.

a. A woman who is scheduled to have a biopsy on a breast lump this
morning and who is scared and crying

b. An 85-year-old man who was admitted during the night because of
increased confusion who remains disoriented this morning

c. A woman who had lung surgery the previous day and who has two

chest tubes in place with minimal drainage
d. A man who is scheduled to have a colon resection in 2 hours and is

complaining of chills

Answer: You should have answered the client who is scheduled for
surgery and is exhibiting symptoms of infection. This patient needs to
be assessed immediately for infection and the doctor notified. If an
infection is present, the surgery needs to be postponed. The other
patients are stable, and their needs do not have to be addressed
immediately.

References
Agency for Healthcare Research and Quality. (2008). Patient safety and
quality: An evidence-based handbook for nurses (Vols. 1–3). Rockville,
MD: U.S. Department of Health and Human Services.

Alfaro-Lefevre, R. (2009). Critical thinking and clinical judgment: A
practical approach to outcome-focused thinking (4th ed.). St. Louis,
MO: Saunders Elsevier.

American Association of Colleges of Nursing. (2008). The essentials of
baccalaureate education for professional nursing practice. Retrieved
from
http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

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

Benner, P. (1984). From novice to expert. Menlo Park, CA: Addison-
Wesley.

Benner, P. E., Sutphen, M., Leonard, V., & Day, L. (2010). Educating
nurses: A call for radical transformation. San Francisco, CA: Jossey-
Bass.

Caputi, L. (2010). Developing critical thinking in the nursing student. In L.
Caputi (Ed.), Teaching nursing: The art and science (2nd ed., pp. 381–
390). Glen Ellyn, IL: College of DuPage Press.

Craven, R. F., & Hirnle, C. J. (2007). Fundamentals of nursing: Human
health and function (5th ed.). Philadelphia, PA: Lippincott Williams &
Wilkins.

Fero, L., Witsberger, C., Wesmiller, S., Zullo, T., & Hoffman, L. (2009).
Critical thinking ability of new graduate and experienced nurses.
Journal of Advanced Nursing, 65(1), 139–148.

Hershey, K. (2015). Culture of safety. Nursing Clinics of North America,
50, 139–152.

Institute of Medicine. (2011). The future of nursing: Leading change,
advancing health. Washington, DC: National Academy Press.

Knapp, R. (2007). Nursing education—the importance of critical thinking.
Retrieved from
http://www.articlecity.com/articles/education/article_1327.shtml

Massachusetts Department of Higher Education. (2010). Nurse of the
future: Nursing core competencies. Retrieved from
http://www.mass.edu/currentinit/documents/NursingCoreCompetencies.pdf

Massachusetts Department of Higher Education. (2016). Nurse of the
future: Nursing core competencies: Registered nurse. Retrieved from
http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Quality and Safety Education for Nurses. (2018). Project overview.
Retrieved from http://qsen.org/about-qsen/project-overview/

Raingruber, B., & Haffer, A. (2001). Using your head to land on your feet:
A beginning nurse’s guide to critical thinking. Philadelphia, PA: F. A.
Davis.

Scheffer, B. K., & Rubenfeld, M. G. (2000). A consensus statement on
critical thinking in nursing. Journal of Nursing Education, 39(8), 352–
359.

Scriven, M., & Paul, R. (2017). Defining critical thinking. Retrieved from
http://www.criticalthinking.org/pages/defining-critical-thinking/766

Sitterding, M. C. (2015). An overview of information overload. In M. C.
Sitterding & M. Broome (Eds.), Information overload: Framework, tips,
and tools to manage in complex healthcare environments (pp. 1–9).
Silver Spring, MD: American Nurses Association.

Sitterding, M. C., & Ebright, P. (2015). Information overload: A framework
for explaining the issues and creating solutions. In M. C. Sitterding &
M. Broome (Eds.), Information overload: Framework, tips, and tools to

manage in complex healthcare environments (pp. 11–33). Silver
Spring, MD: American Nurses Association.

Tanner, C. A. (2006). Thinking like a nurse: A research based mode of
clinical judgment in nursing. Journal of Nursing Education, 4(6), 204–
211.

Technology Informatics Guiding Education Reform. (2009). The TIGER
initiative. Collaborating to integrate evidence and informatics into
nursing practice and education: An executive summary. Retrieved from
https://tigercompetencies.pbworks.com/f/TICC_Final.pdf

Wangensteen, S., Johansson, I. S., Bjorkstrom, M. E., & Nordstrom, G.
(2010). Critical thinking dispositions among newly graduated nurses.
Journal of Advanced Nursing, 66(10), 2170–2181.

Weick, K. E., & Sutcliffe, K. M. (2007). Managing the unexpected:
Resilient performance in an age of uncertainty (2nd ed.). San
Francisco, CA: Jossey-Bass.

Wilkinson, J. (2007). Nursing process and critical thinking (4th ed.).
Upper Saddle River, NJ: Pearson.

Wu, A. (2000). Medical error: The second victim: The doctor who makes
the mistake needs help too. British Medical Journal, 320, 726–727.

© James Kang/EyeEm/Getty Images

CHAPTER 5

Education and Socialization to
the Professional Nursing Role
Kathleen Masters and Melanie Gilmore

Learning Objectives

After completing this chapter, the student should be able to:

1. Discuss the essential features of nursing.
2. Describe the stages of educational socialization.
3. Describe the process of socialization or formation in professional

nursing.

4. Identify factors that facilitate professional role development.

Key Terms and Concepts

Socialization
Formation
Professional values
Novice
Advanced beginner
Competent
Ethical comportment
Proficient
Salience
Expert
Role transition

Nursing continues to evolve into a profession with a distinct body of
knowledge, specialized practice, and standards of practice. According to
the American Nurses Association (ANA), “nursing is a learned profession
built on a core body of knowledge that reflects its dual components of
science and art” (2015b, p. 7), and as such it is a scientific discipline as
well as a profession. The science of nursing, based on the nursing
process, is an analytical framework for critical thinking. Nursing practice
also requires knowledge of the principles of biological, physical,
behavioral, and social sciences. The art of nursing is based on respect
for human dignity and caring, although it is important to note that a
compassionate approach to care carries a mandate to provide competent
care. The professional nurse is responsible for practice that incorporates

this specialized body of knowledge and standards of practice with care
that demonstrates respect and caring (ANA, 2015b).

Socialization to professional nursing is the process of acquiring the
knowledge, skills, and sense of identity that are characteristic of the
profession. It is a process by which a student internalizes the attitudes,
beliefs, norms, values, and standards of the profession into his or her
own behavior pattern. Professional socialization has four goals: (1) to
learn the technology of the profession—the facts, skills, and theory; (2) to
learn to internalize the professional culture; (3) to find a personally and
professionally acceptable version of the role; and (4) to integrate this
professional role into all the other life roles (Cohen, 1981). Benner,
Sutphen, Leonard, and Day (2010) make the case for using the term
formation to describe this process that occurs over time because it
better denotes “the development of perceptual abilities, the ability to draw
on knowledge and skilled know-how, and a way of being and acting in
practice and in the world” (p. 166). Whatever terminology is chosen, the
process described in this chapter refers to the transformation of the
layperson into a skilled nurse who is prepared to respond skillfully and
respectfully to persons in need of nursing care, or, as described by
Benner et al. (2010), “the lay student moves from acting like a nurse to
being a nurse” (p. 177). This development of professional identity occurs
initially through the formal educational process and culminates in the
practice setting.

Professional Nursing Roles and
Values
What is it that professional nurses do? The scope of nursing practice
describes the “who,” “what,” where,” “when,” “why,” and “how” of nursing
practice (ANA, 2015b, p. 2). The standards of professional nursing
practice are authoritative statements that describe the duties that all
registered nurses are expected to competently perform. The standards of
professional nursing practice are composed of standards of practice and
standards of professional performance. The standards of practice
describe competent nursing care as demonstrated by use of the nursing
process. The standards of professional performance describe a
competent level of behavior in the professional nursing role (ANA,
2015b).

According to the ANA (2010), there are seven essential features of
nursing. These features include the provision of a caring relationship that
facilitates health and healing, attention to the range of experiences and
responses to health and illness within the physical and social
environments, and integration of assessment data with knowledge gained
from an appreciation of the patient or group. In addition, nursing includes
the application of scientific knowledge to the processes of diagnosis and
treatment through the use of judgment and critical thinking, advancement
of professional nursing knowledge through scholarly inquiry, influence on
social and public policy to promote social justice, and assurance of safe,
high-quality, and evidence-based practice (ANA, 2010).

The American Association of Colleges of Nursing (AACN, 2008) lists
the roles of the professional nurse as provider of care,
designer/manager/coordinator of care, and member of a profession. As a

provider of direct and indirect care, the nurse is a patient advocate and
patient educator. The nurse provides care based on best, current
evidence and from a holistic, patient-centered perspective. Professional
nurses are members of the healthcare team delivering care in an
increasingly complex healthcare environment. Nurses function
autonomously and interdependently within the healthcare team to provide
patient care and are accountable for the care provided and for the tasks
delegated to others. The nurse as a professional implies the formation of
a professional identity and accountability for the professional image
portrayed. Nursing requires a broad knowledge base for practice as well
as strong communication, critical reasoning, clinical judgment, and
assessment skills. In addition, professional nursing requires the
development of an appropriate value set and ethical framework for
practice (AACN, 2008).

KEY OUTCOME 5-1

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential VIII: Professionalism and Professional Values

8.3 Promote the image of nursing by modeling the values and
articulating the knowledge, skills, and attitudes of the nursing
profession (p. 28).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

Professional values are considered a component of excellence, and
the existence of a code is considered a hallmark of professionalism.

Professional values are beliefs or ideals that guide interactions with
patients, colleagues, other professionals, and the public. The
development of professional values begins with professional education in
nursing and continues along a continuum throughout the years of nursing
practice. Professional values associated with nursing are outlined in the
ANA’s Code of Ethics (ANA, 2001, 2015a). The values of (1) commitment
to public service, (2) autonomy, (3) commitment to lifelong learning and
education, and (4) a belief in the dignity and worth of each person
epitomize the caring, professional nurse. Caring is a concept central to
the profession of nursing and inherent in this value is a strong
commitment to public service. Nursing is a helping profession directed
toward service to the public through health promotion and disease
prevention for individuals, families, and communities. The role of the
nurse is focused on assessing and promoting the health and well-being
of all humans. Registered nurses remain in nursing to promote, advocate,
and protect the health and safety of patients, families, and communities
(ANA, 2015b).

KEY COMPETENCY 5-1

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Professionalism:

Knowledge (K4a) Describes factors essential to the promotion of
professional development

Skills (S4a) Participates in lifelong learning

Attitudes/Behaviors (A4a) Committed to lifelong learning

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Autonomy is the right to self-determination as a professional. The role
of the professional nurse is to honor and assist individuals and families to
make informed decisions about health care and to provide information so
that they can make informed choices. The professional nurse respects
patients’ rights to make decisions about their health care.

Commitment to lifelong learning and education is necessary in the
dynamic healthcare arena that surrounds nursing practice in this century.
Nurses need continuous education to maintain a safe level of practice
and to expand their level of competence as professionals. With new
technologies and the rapid growth of medical and nursing knowledge, the
nurse must actively and continuously seek to expand professional
knowledge. Professional nursing involves a commitment to be
resourceful, to respond to the dynamic challenges of delivering health
care, to incorporate technology into their caring, and to remain visionaries
as the future unfolds (ANA, 2010).

Human dignity is respect for the inherent worth and uniqueness of
individuals and communities and is such a deeply held value in the
profession of nursing that it is the topic of Provision 1 in the Code of
Ethics for Nurses (ANA, 2015a). According to the International Council of
Nurses’ Code of Ethics for Nurses (2012), “inherent in nursing is respect
for human rights, including cultural rights, the right to life and choice, to
dignity and to be treated with respect. Nursing care is respectful of and
unrestricted by considerations of age, color, creed, culture, disability or
illness, gender, sexual orientation, nationality, politics, race or social
status” (p. 1).

CRITICAL THINKING QUESTIONS

As a nursing student, do you share the values of commitment to public

service, autonomy, commitment to lifelong learning and education,
and the belief in the dignity and worth of each person? Do nurses with
whom you have interacted demonstrate these values?

KEY OUTCOME 5-2

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential VIII: Professionalism and Professional Values

8.9 Recognize the impact of attitudes, values, and expectations on the
care of the very young, frail older adults, and other vulnerable
populations (p. 28).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

The Socialization (or Formation)
Process
Socialization into a profession is a process of adapting to and becoming
a part of the culture of the profession (Ousey, 2009). This process begins
during the student’s formal educational program and continues after
graduation and licensure in the practice setting.

Socialization Through Education
Students new to the nursing profession begin to learn the role while still
in the educational setting. Cohen (1981) used the theories of cognitive
development to create a model of professional nursing socialization
through education. The model describes four stages students must
experience as they begin to internalize the roles of a profession. In stage
1, Unilateral Dependence, the individual places complete reliance on
external controls and searches for the one right answer (Cohen, 1981). In
essence, the student looks to the instructor for the right answers and is
unlikely to question the authority. As the student gains foundational
knowledge and skill, there begins the process of questioning the
authority.

During stage 2, Negative/Independence, the student begins to pull
away from external controls and is characterized by cognitive rebellion.
The student begins to think critically and begins to question the instructor
and relies more on his or her own judgments.

Stage 3, Dependence/Mutuality, marks the beginning of empathy and
commitment to others (Cohen, 1981). In this stage, the student begins to
apply knowledge to practice and tests information and facts. “Students

have a knowledge base upon which to anchor critical thought and can
relate new material to their previous knowledge base” (Cohen, 1981, p.
18). In this stage, the student is actively engaged in the learning, thinking
through problems. For this stage to emerge, the learning environment
must support and value risk taking. The role of the teacher is that of
coach, mentor, and senior learner. The mentor helps the student link
theory to practice while in the clinical areas, thus helping the student to
learn from experiences and to improve practices to support professional
socialization.

Stage 4, Interdependence, occurs when neither mutuality nor
autonomy is dominant. Learning from others and gaining the ability to
solve problems independently are evident. This is the stage of the
professional lifelong learner who demonstrates reflection in practice and
is responsible for continued learning. Professional socialization toward
the stage of interdependence requires a supportive educational climate
that values autonomy, independent thinking, and authenticity. Students
become professionals.

Professional Formation
Several models in the literature describe professional socialization.
Regardless of the model embraced, socialization into the nursing
profession or formation into a professional nurse must include new
competencies for the 21st century. The Institute of Medicine (IOM, 2011)
reported that nurses need requisite competencies, including leadership,
health policy, system improvement, research and evidence-based
practice, and teamwork and collaboration, to meet the needs of the
current dynamic healthcare environment. Nursing educators must provide
students with opportunities to develop the requisite skills that equip them
for the profession as well as instill in them the desire to become lifelong

learners because nurses currently need continuous education to maintain
a safe level of practice and to expand their level of competence as
professionals.

KEY COMPETENCY 5-2

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Professionalism:

Knowledge (K4c) Understands the importance of reflection to
advancing practice and improving outcomes of care

Skills (S4b) Demonstrates ability for reflection in action, reflection for
action, and reflection on action

Attitudes/Behaviors (A4c) Values and is committed to being a reflective
practitioner

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Benner (1984) describes the development of the professional clinical
practice of nurses. Benner’s model identifies the stages of novice,
advanced beginner, competent, proficient, and expert that are based on
the nurse’s experience in practice. With an understanding of this
progression of knowledge and skills, educational programs have
developed supportive curricula using a continuum of experiences to
enhance skill and knowledge development. Healthcare environments
have also incorporated this model to facilitate the nurse’s professional
practice by assessing the nurse’s stage of development. This model is
not limited to the student experience or to that of the new graduate nurse.

Experienced nurses also benefit from experiences designed to move the
nurse toward the stage of expert.

The first stage, novice, is characterized by a lack of knowledge and
experience. In this stage, the facts, rules, and guidelines for practice are
the focus. Rules for practice are context-free, and the student’s task is to
acquire the knowledge and skills. The stage of novice is not related to the
age of the student but rather to the knowledge and skill in the area of
study. For example, learning how to give injections would be presented
with the procedural guidelines, and the novice would then practice the
skill. At this stage, much of the student’s energy and attention are aimed
at remembering the rules. Because the focus is on remembering rules,
the student’s practice is inflexible, the student is unable to use
discretionary judgment, and the student is dependent on and has
confidence in those with greater expertise rather than having confidence
in his or her own judgment (Benner, 1984; Benner, Tanner, & Chelsea,
2009). This stage can be compared to an experience that most nursing
students can relate to, the experience of learning to drive a car. Initially,
the experience is characterized by halting progress as the student driver
actively tries to gauge the pressure required on the gas pedal and the
brake, remember how many feet before the corner to use the turn signal,
and remember how many feet to keep between cars. This analogy
simplifies the stage of novice related to nurse formation, but most can
remember the excitement and the frustrations of learning to drive a car as
well as the transition when driving began to require less effort.

In the next stage, advanced beginner, the nurse can formulate
principles that dictate action. For example, the advanced beginner grasps
the rationale behind why different medications require different injection
techniques. However, advanced beginners still lack the experience to
know how to prioritize in more complex situations and might feel at a loss
in terms of what they can safely leave out, making the patient care

situation appear as a perplexing set of problems they must figure out how
to solve.

The advanced beginner will still emphasize tasks that need to be
accomplished, as well as rules, but does not have the experience to
adjust or adapt the rules to the situation. In this stage action and
interpretation are the central focus rather than decision making. Both
knowledge and experience are limited in the advanced beginner nurse,
which means that subtle cues about a patient’s condition may be missed
(Sitterding, 2015). The nurse in the stage of advanced beginner still
requires guidance (Figure 5-1). Given the complexity of nursing practice
and the range of clinical experiences, new graduates can be described
as advanced beginners (Benner, 1984; Benner et al., 2009).

Figure 5-1 The nurse at the advanced beginner stage still requires guidance from more
experienced nurses.

© Monkey Business Images/Shutterstock.

Benner’s stage 3, competent, is characterized by the ability to look
at situations in terms of principles, analyze problems, and prioritize, and
thus a nurse in this stage has the ability to plan as well as to alter plans
as necessary. The nurse in this stage has improved time management
and organizational skills as well as technical skills. The nurse in the
competent stage will also demonstrate increased ability in diagnostic
reasoning, which means he or she is able to make a clinical case for
action to other members of the healthcare team. Movement from one

stage to the next does not cross distinct boundaries, but the nurse at this
stage has had experience in a variety of clinical situations and can draw
on prior knowledge and experience; typically, the nurse will have 1 to 2
years of experience in a similar job situation. The competent stage of
learning is important in the formation of the ethical comportment of the
nurse. Ethical comportment refers to good conduct born out of an
individualized relationship with the patient that involves engagement in a
particular situation and entails a sense of membership in the relevant
professional group. It is socially embedded, lived, and embodied in
practices, ways of being, and responses to a clinical situation that
promote the well-being of the patient (Day & Benner, 2002). Continued
active learning and mentoring are important for movement to the
proficient stage. Students who have the opportunity to have extended
internships in a specialty area during their education can graduate
entering this stage (Benner, 1984; Benner et al., 2009).

Stage 4, proficient, refers to the professional nurse who can grasp
the situation contextually as a whole and whose performance is guided
by maxims. This nurse has a solid grasp of the norms as well as solid
experiences that shed light on the variations from the norm. Based on an
intuitive grasp of the situation, the nurse recognizes the most salient
aspects of the situation or the most salient recurring meaningful
components of the situation. Salience is a perceptual stance or
embodied knowledge whereby aspects of a situation stand out as more
or less important (Benner, 1984); therefore, the nurse at this stage knows
what can wait and what cannot. The nurse has moved into a place where
he or she can engage in a clinical situation and connect with the patient
and family in ways that are truly beneficial. Incorporated into practice is
the ability to test knowledge against situations that might not fit and to
solve problems with alternative approaches. In this stage, the
professional tests the rules and theories and looks at cases that can lead

to developing alternative rules and theories. One might say that this is the
stage when the professional begins to “break the rules” because he or
she sees that the rules do not always apply. Achieving this level of
proficiency in nursing typically takes 3 to 5 years of practice with similar
patient populations (Benner, 1984; Benner et al., 2009).

Benner’s final stage, expert, means the nurse has moved beyond a
fixed set of rules (Figure 5-2). The expert has an internalized
understanding grounded in a wealth of experience as well as depth of
knowledge. Benner describes the expert nurse as demonstrating
embodied intelligence. The expert nurse is able to skillfully manage
multiple tasks simultaneously and knows not only what to do and when to
do it but also how to do what is needed. The expert nurse has a grasp of
the whole with an ability to move beyond the immediate clinical situation
but to remain attuned to the clinical situation at a level that allows a
“mindful reading” of the patient responses even without conscious
deliberation. The nurse may have difficulty explaining how he or she
knows something because the recognition and assessment language are
so linked with actions and outcomes that they are obvious to the expert
nurse, although not obvious to others. The expert is always learning and
always questioning using subjective and objective knowing. Benner
(1984, 1999; Benner et al., 2009) proposes that not all nurses can obtain
this stage; when it is obtained, it is only after extensive experience.

Figure 5-2 Critically ill patients require care from nurses with extensive experience.
© NOAH SEELAM/AFP/Getty Images

KEY OUTCOME 5-3

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential VIII: Professionalism and Professional Values

8.13 Articulate the value of pursuing practice excellence, lifelong
learning, and professional engagement to foster professional growth
and discipline (p. 28).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

The typical career in nursing is not a linear process. There is
considerable variation in progression of nurses related to degree

attainment and career growth. In addition, with the focus of increasing the
percentage of nurses with baccalaureate degrees and doctoral degrees
in nursing (IOM, 2011), many nurses are returning to school for additional
academic degrees in order to advance their careers. This often results in
a change in the nurse’s practice role. It can be stressful to transition from
a role where the nurse is an expert to a new role where the nurse will not
function at the same level of expertise. For example, when the expert
pediatric nurse graduates from a pediatric nurse practitioner program,
passes the certification exam, and begins to function in the advanced
practice role, the nurse will not be an expert pediatric nurse practitioner.
With experience in the new, advanced practice role, he or she will again
transition through the stages of professional development. The same
type of role transition occurs when the expert clinician changes practice
roles to become a nurse educator or nurse researcher.

Facilitating the Transition to
Professional Practice
Professional socialization requires that the student learn the technology
of the profession, learn to internalize the professional culture, find a
personally and professionally acceptable version of the role, and
integrate this professional role into all of his or her other life roles (Cohen,
1981).

Students are taught an ideal, theoretical, research-based practice
that shelters them from the realities of the world where nursing practice
consists of not only theory and research but also of human emotion and
response, along with the policies and procedures of the particular
working environment. This concept of idealism is important to the
profession because it contributes to a high standard of professional
practice. The perceived disconnection between education and practice is
known as role discrepancy. Therefore, when students enter the practice
environment, the culture of the classroom and the culture of clinical
practice can seem worlds apart. Reality shock has been the traditional
phrase to describe the transition from nursing student to registered nurse
(Kramer, 1974).

Reality shock occurs when the perceived role (how an individual
believes he or she should perform in a role) comes into conflict with the
performed role (Catalano, 2009). Many new graduates experience this
reality shock of knowing what to do and how to do it but encountering
circumstances that prevent them from performing the role in that way
(Figure 5-3). Role conflict exists when a nurse cannot integrate the ideal,
the perceived, and the actual performed role into one professional role.

Figure 5-3 Role transition shock can result in role conflict and overwhelming stress for the new
graduate nurse.

© GoodMood Photo/Shutterstock, Inc.

Role transition shock is the experience of moving from the known role
of student to the role of practicing professional (Duchscher, 2009). For
many nursing students, role conflict occurs when they transition from the
role of student to that of registered nurse (Pellico, Brewer, & Kovner,
2009). The new graduate moves from a perceived role of what the
professional nurse is and does to the actual performed role where his or
her actions and beliefs might be challenged.

CRITICAL THINKING QUESTIONS

What do you think are the barriers to the process of professional
socialization or formation? Do you think different environments might
foster or hinder the process of professional socialization or formation?
Do you think that the personal characteristics of nurses might
influence the process of professional socialization or formation?

The reality shock or role transition shock that new graduates
experience can be reduced to some extent. Many schools of nursing

have implemented opportunities for externships or prolonged preceptor
clinical experiences with a professional nurse before graduation.
Research (Ruth-Sahd, Beck, & McCall, 2010) shows how participation in
extern programs eases the gap between education and practice. One
goal of this experience is to help the student assimilate the role of the
professional nurse just before graduation. During this time, the student
can experience a more realistic view of clinical practice in the real-world
environment. As one student commented, “All the lectures and
assignments in nursing school cannot compare with the application of
theory that this externship offered” (Ruth-Sahd et al., 2010, p. 83).
Externships and preceptor clinical experiences can help nursing students
begin the role transition from perceived role expectations to actual role
expectations, thus easing the transition from student nurse to practicing
professional.

In addition to internship and externship programs before the
graduation of the nurse, some hospitals are also offering nurse residency
programs to facilitate the socialization into the profession. Nurse
residency programs go beyond the orientation focused on policies and
procedures that occurs to prepare the nurse to function in a particular
setting. A residency program that focuses on transition into practice is
formalized and focused on facilitating the transition of the newly licensed
nurse from education to practice (Spector et al., 2015).

Hospitals offering formalized graduate nurse residency programs
provide graduates with rotations through a number of clinical areas that
include preceptor support. Evidence suggests that a sense of belonging
contributes to professional socialization (Zarshenas et al., 2014). After
the completion of residency programs, new nurses report gaining a sense
of belonging, thus supporting claims that these programs can lead to
enhanced socialization into the clinical workplace (McKenna & Newton,
2009). In addition to formal education, preceptors can assist students to

develop skills of assertion, reflection, and critical thinking that are
required to provide holistic, evidence-based care (Mooney, 2007).

Nurse residency programs focused on transition to practice also
result in decreased stress and increased job satisfaction, with research
demonstrating decreased attrition during the first year of practice for
newly licensed nurses. In addition to promoting retention and assisting
the new nurse to adjust to the practice environment, nurse residency
programs also affect quality and safety. Newly licensed nurses in
hospitals with established transition to practice programs also
demonstrated higher competency levels, fewer patient errors, and fewer
negative safety practices (Spector et al., 2015).

In response to evidence on the effect of nurse residency programs,
the National Council of State Boards of Nursing (NCSBN) has developed
a model for transitioning new nurses into practice. The NCSBN Transition
to Practice (TTP) model comprises five transition models that include
patient-centered care, communication and teamwork, evidence-based
practice, quality improvement, and informatics with a goal of promoting
“public safety by supporting newly licensed nurses during their critical
entry period and progression into practice” (Spector, 2013, p. 55). These
modules are designed as a 6-month program and are available at a cost
per module or cost per program basis. In addition, a preceptor module is
available to nurse preceptors to learn about the roles and responsibilities
of preceptors and effective behaviors and strategies to foster growth in
new graduates (NCSBN, 2018).

Conclusion
The goal in the socialization of nurses today and for the future is to
achieve caring with autonomy. The challenge for the profession is
capitalizing on the strengths of everyone and finding a means of
accommodating all individuals as a way of maintaining the viability of the
profession (Leduc & Kotzer, 2009). Professional socialization of nurses in
a profession that fully embraces caring for self and others reflects the
internalization of what Roach (1991) refers to as “the five C’s:
compassion, competence, confidence, conscience, and commitment” (p.
132), representing a framework for human response from which
professional caring is expressed.

Nursing education should be humanistic and caring, with caring
experts as role models who contribute to the socialization of future
generations of nurses and help them become caring experts in nursing
practice. Through their research, Condon and Sharts-Hopko (2010)
report that reflection can be an effective means of understanding human
emotion and responses. One student stated, “I think the most important
time is after the clinical training when I go home. I think about the
information I get from the patient. What does it mean? What does it mean
for the patient? I should connect to it” (Condon & Sharts-Hopko, 2010, p.
169). Regarding role development and socialization, it is important to
remember that we learn what we live (Becker-Hentz, 2004).

Classroom Activity 5-1

Incorporate actual quotes from the nurses who were interviewed in
Benner’s book From Novice to Expert (1984) in class discussions to

illustrate the differences among each of the stages: novice, advanced
beginner, competent, proficient, and expert. This activity is simple but
enlightening to students.

Classroom Activity 5-2

Read excerpts from the 2006 article “What Do Nurses Really Do?” by
Suzanne Gordon (available at
www.medscape.com/viewarticle/520714) in class to stimulate
discussion, and ask the following questions:

What do you think nurses actually do?
What do you think about the current image of nurses?
What do you think about the effect of the focus on caring over the
knowledge of nurses?

References
American Association of Colleges of Nursing. (2008). The essentials of
baccalaureate education for professional nursing practice. Washington,
DC: Author.

American Nurses Association. (2001). Code of ethics for nurses with
interpretive statements. Washington, DC: Author.

American Nurses Association. (2010). Nursing’s social policy statement:
The essence of the profession. Silver Spring, MD: Author.

American Nurses Association. (2015a). Code of ethics for nurses with
interpretive statements. Silver Spring, MD: Author.

American Nurses Association. (2015b). Nursing: Scope and standards of
practice (3rd ed.). Silver Spring, MD: Author.

Becker-Hentz, P. (2004). Understanding relationships: Learning what we
live. Unpublished manuscript.

Benner, P. (1984). From novice to expert. Menlo-Park, CA: Addison-
Wesley.

Benner, P. (1999). From novice to expert: Excellence and power in
clinical nursing practice. Menlo Park, CA: Addison-Wesley.

Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses:
A call for radical transformation. San Francisco, CA: Jossey-Bass.

Benner, P. E., Tanner, C. A., & Chelsea, C. A. (2009). Expertise in
nursing practice: Caring, clinical judgment, and ethics (2nd ed.). New
York, NY: Springer.

Catalano, J. (2009). Nursing now! (5th ed.). Philadelphia, PA: F. A. Davis.
Cohen, H. A. (1981). The nurse’s quest for a professional identity. Menlo-
Park, CA: Addison-Wesley.

Condon, E., & Sharts-Hopko, N. (2010). Socialization of Japanese

nursing students. Nursing Education Perspectives, 31(3), 167–169.
Day, L., & Benner, P. (2002). Ethics, ethical comportment, and etiquette.
American Journal of Critical Care, 11(1), 76–79.

Duchscher, J. E. B. (2009). Transition shock: The initial stage of role
adaptation for newly graduated registered nurses. Journal of Advanced
Nursing, 65(5), 1103–1113. doi:10.1111/j.1365-2648.2008.04898.x

Gordon, S. (2006). What do nurses really do? Topics in Advanced
Practice Nursing eJournal, 6(1). Retrieved from
http://www.medscape.com/viewarticle/520714

Institute of Medicine. (2011). The future of nursing: Leading change,
advancing health. Washington. DC: National Academy Press.

International Council of Nurses. (2012). The ICN code of ethics for
nurses. Geneva, Switzerland: Author. Retrieved from
http://www.icn.ch/images/stories/documents/about/icncode_english.pdf

Kramer, M. (1974). Reality shock, why nurses leave nursing. St. Louis,
MO: Mosby.

Leduc, K., & Kotzer, M. (2009). Bridging the gap: A comparison of the
professional nursing values of students, new graduates and seasoned
professionals. Nursing Education Perspectives, 30(5), 279–284.

Massachusetts Department of Higher Education. (2016). Nurse of the
future: Nursing core competencies: Registered nurse. Retrieved from
http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

McKenna, L., & Newton, J. M. (2009). After the graduate year: A
phenomenological exploration of how new nurses develop their
knowledge and skill over the first 18 months following graduation.
Contemporary Nurse: A Journal for the Australian Nursing Profession,
31(2), 153–162.

Mooney, M. (2007). Professional socialization: The key to survival as a
newly qualified nurse. International Journal of Nursing Practice, 30,
75–80.

National Council of State Boards of Nursing. (2018). NCSBN learning
extension: Transition to practice. Retrieved from
https://learningext.com/new-nurses/

Ousey, K. (2009). Socialization of student nurses—the role of the mentor.
Learning in Health and Social Care, 8(3), 175–184.

Pellico, L. H., Brewer, C. S., & Kovner, C. T. (2009). What newly licensed
registered nurses have to say about their first experiences. Nursing
Outlook, 57, 194–203.

Roach, M. S. (1991). Creating communities of caring. In National League
for Nursing (Ed.), Curriculum revolution: Community building and
activism (pp. 123–138). New York, NY: National League for Nursing
Press.

Ruth-Sahd, L. A., Beck, J., & McCall, C. (2010). Transformative learning
during a nursing externship program: The reflections of senior nursing
students. Nursing Education Perspectives, 31(2), 78–83.

Sitterding, M. C. (2015). An overview of information overload. In M. C.
Sitterding & M. E. Broome (Eds.), Information overload: Framework,
tips, and tools to manage in complex healthcare environments (pp. 1–
9). Silver Spring, MD: American Nurses Association.

Spector, N. (2013). Transition to practice: An essential element of quality
and safety. In K. S. Amer (Ed.), Quality and safety for transformational
nursing: Core competencies. Boston, MA: Pearson, 2013: 48–60.

Spector, N., Blegen, M. A., Silvestre, J., Barnsteiner, J., Lynn, M. R.,
Ulrich, B., . . . Alexander, M. (2015). Transition to practice in hospital
settings. Journal of Nursing Regulation, 6(1), 4–13.

Zarshenas, L., Farhondeh, S., Molazem, Z., Khayyer, M., Zare, N., &
Ebadi, A. (2014). Professional socialization in nursing: A content
analysis. Iranian Journal of Nursing and Midwifery Research, 14(4),
432–438.

© James Kang/EyeEm/Getty Images

CHAPTER 6

Advancing and Managing Your
Professional Nursing Career
Mary Louise Coyne and Cynthia Chatham

Learning Objectives

After completing this chapter, the student should be able to:

1. Discuss the difference between a job and a career.
2. Articulate the importance of proactively managing his or her

nursing career.
3. Discuss the benefits of a mentoring relationship.

4. Explore the effect of work-related stress.

Key Terms and Concepts

Career management
Professional portfolio
Mentoring
Burnout
Compassion fatigue

Successful management of your professional nursing career does not
occur by accident or default. Rather, it is a deliberate, purposeful,
informed process requiring self-appraisal of your need for further
professional growth and development, attentiveness to projected trends
in healthcare delivery, dialogue with nurse colleagues who have
demonstrated success in advancing their careers, exploration of nursing
education programs that will support your career advancement,
consideration of how to balance work and study demands and remain
healthy, and investment of self to pursue these professional nursing
career options. Be reflective and proactive in seizing opportunities to
shape and refine your professional nursing career.

Nursing: A Job or a Career?
Your initial motivators for choosing to become a professional registered
nurse (RN) may be far different from the reasons why you stay in
professional nursing practice. Over time, nurses begin to appreciate that
the practice of professional nursing as a career is a serious, sustained,
and rewarding undertaking, dedicated to “the protection, promotion, and
optimization of health and abilities, prevention of illness and injury,
facilitation of healing, alleviation of suffering through the diagnosis and
treatment of human response, and advocacy in the care of individuals,
families, groups, communities, and populations” (American Nurses
Association [ANA], 2015b, p. 1). Further, many seasoned nurses come to
realize that a career in professional nursing requires academic
preparation at the bachelor of science in nursing (BSN) degree level or
higher, engagement in lifelong learning to expand knowledge and clinical
and management competencies, willingness to translate research
evidence into practice on a continuous basis, and commitment to
advance the health of patients and the profession of nursing.

Professional nursing is a career to be managed and not just a job
where you “punch in and punch out.” Table 6-1 compares two views of
nursing as a job and as a career. In advocating for career management
in nursing, Daggett (2014) notes,

TABLE 6-1 Do You View Nursing as a Job or as a Professional Career?

Factor View Nursing as a
Job

View Nursing as a
Career

Academic
preparation

Obtains the least
amount needed for
nursing licensure

Obtains a BSN and
often pursues an
advanced nursing

degree: master of
science in nursing
(MSN), doctor of
nursing practice
(DNP), and/or
doctor of philosophy
(PhD)

Continuing
education

Obtains the
minimum
continuing
education (CE)
units required for
licensure and/or
the job

Engages in formal
and informal lifelong
learning
experiences across
the nurse’s
professional career
in order to:
Deepen and
broaden knowledge
and skill
competencies
Improve the
delivery of safe,
cost-effective,
quality-based
patient care
Improve patient
outcomes

Level of
commitment

Continues with the
job as long as it
meets his or her
personal needs;
expects
reasonable work
for reasonable pay;
responsibility ends
with shift

Actively and joyfully
engages in
practicing the art
and science of
professional nursing
as a member and,
possibly, leader in
professional nursing
initiatives within the
nurse’s healthcare
agency and in

professional nursing
organizations (local,
regional, state,
national, and/or
international levels)

A degree and a nursing license might be the ticket that gets you
started on the journey, but without a destination, an itinerary,
and a map, you will not travel very far. Like any important
journey, a career requires research and planning; otherwise, you
risk missing opportunities and critical milestones along the way.
One should always assess the current location before planning
future directions. Just as you track progress with a map while on
a road trip, you should have a plan for managing your career,
lest you find yourself wandering in the wilderness without
making any true progress toward your career goals. (p. 168)

CRITICAL THINKING QUESTIONS

Do you view nursing as a career or as a job? What are your
professional goals related to nursing?

Purposefully manage your career—no one else can do this for you!
Do not rely on healthcare employers to manage your career. Your best
interests are yours and yours alone. Your career management and your
short- and long-term goals are yours. For the career-oriented nurse,
goals usually include (1) pursuit of an academic program to obtain a BSN
degree or graduate-level nursing education for advanced practice,
administration, teaching, or research within a specified time frame, and/or
(2) assuming a new position within a healthcare organization that has
more responsibility and accountability in order to advance his or her
nursing career.

Direction is needed to accomplish these goals. Without such a career
map, nurses may wander aimlessly. Where am I going? How am I going?
Part of career management is having the map to accomplish goals.
Career mapping provides nurses with a clear direction, including short-
term stops to accomplish goals and a realistic time of arrival at the
ultimate career destination. This may include position changes within an
agency or a change in agencies. The map includes the skills obtained,
the skills needed, and the resources needed to obtain skills (Hein, 2012).
The pathway usually includes yearly goals as well as long-term goals.
Without goals, nurses may leave the profession or risk beginning to view
nursing as only a job that pays the bills.

Trends That Affect Nursing Career
Decisions
Healthcare agencies are constantly changing, with the goal of providing
care to the community while containing costs. Although there is sufficient
evidence demonstrating a professional nursing shortage in many areas
across the United States, healthcare agencies are confronted with
escalating costs, stringent cost containment initiatives, streamlined
reimbursement systems, and a plethora of state and federal regulations
that often constrain how well or poorly these agencies are able to deliver
health care. In response to these budgetary constraints, many hospitals
have responded by moving traditional inpatient care to outpatient
settings, hiring fewer professional nurses, training more unlicensed
assistive nursing personnel, cutting nursing salaries, hiring more RNs to
part-time positions to avoid providing health and retirement benefits, and
relying on fewer RNs to cover unfilled positions.

As you consider how to advance your nursing career, it is critical to
examine projected trends in health care, particularly as they apply to (1)
where health care is delivered, (2) the type of practitioners needed, and
(3) the nursing educational preparation required to provide this care. The
U.S. Department of Labor, Bureau of Labor Statistics (2016) reported that
94% of RNs worked in the following areas:

61% hospitals; state, local, and private
18% ambulatory healthcare services
7% nursing and residential care facilities
5% government
3% educational services; state, local, and private

In forecasting the future needs of the U.S. healthcare delivery
system, the Institute of Medicine (IOM, 2010) projects that by 2020, the
profession of nursing will need to double the number of nurses with a
doctorate and increase the number of nurse practitioners in hospitals,
home health, hospice, and nursing homes. In addition, the American
Association of Colleges of Nursing (AACN, 2015b) reports that the
nursing shortage may be easing in some parts of the country, but the
demand for RNs prepared with baccalaureate, master’s, and doctoral
degrees continues to increase.

Investigate where the shortages are in the location where you will be
practicing, what types of practitioners are needed to meet these needs,
and what type of advanced nursing education is required for these
positions. Remember, you are in charge of making choices that best fit
your short- and long-term career goals. You are your own best advocate
in planning your nursing career!

Crafting the direction of your professional nursing career and
executing the plan is transformational. The IOM (2011) report, The Future
of Nursing: Leading Change, Advancing Health, provides a blueprint for
how the entire profession must be transformed in order to advance the
health of patients and simultaneously direct needed changes in the
healthcare delivery system. In setting the agenda for nursing’s future, the
IOM Committee on Nursing identified four key messages and eight
related recommendations that have potential for the greatest effect and
for accomplishment within the next decade. The four key messages are:

Nurses should practice to the full extent of their education and
training.
Nurses should achieve higher levels of education and training
through an improved education system that promotes seamless
academic progression.

BOX 6-1


Nurses should be full partners, with physicians and other healthcare
professionals, in redesigning health care in the United States.
Effective workforce planning and policy making require better data
collection and an improved information infrastructure (IOM, 2011, p.
4).

The eight specific recommendations include:

Remove scope of practice barriers
Expand opportunities for nurses to lead and diffuse collaborative
improvement efforts
Implement nurse residency programs
Increase the proportion of nurses with a baccalaureate degree to
80% by 2020
Double the number of nurses with a doctorate by 2020
Ensure that nurses engage in lifelong learning
Prepare and enable nurses to lead change to advance health
Build an infrastructure for the collection and analysis of
interprofessional healthcare workforce data (IOM, 2011, pp. 9–14)

The IOM report on the future of nursing is a great starting point for
setting your professional nursing career goals and planning your career
trajectory. Careful deliberation on these initiatives and recommendations
provides insight into the questions that you might ask in setting your own
professional nursing career goals. See Box 6-1 for a list of questions to
ask yourself as you plan your career goals.

QUESTIONS TO ASK AS YOU PLAN YOUR CAREER
GOALS

What is the future of nursing for me?
Am I currently practicing to the fullest extent of my nursing education

and training? (IOM, 2011, Initiative 1)
What changes need to occur in my current practice in order to
actualize this personal vision of my career?
What are the projected employment trends and opportunities for
nursing in my area?
Have I achieved the highest level of education and training (IOM,
2011, Initiative 2) to support my desired career goals?
What career path am I best equipped for and motivated to pursue to
lead change and advance health? Should I pursue a BSN, MSN,
DNP, or PhD, and if so, what specialization should I consider: a
nurse practitioner, a nurse educator, a nurse anesthetist, a nurse–
midwife, a nurse researcher, and/or a nurse executive?
Have I sought out and had a dialogue with seasoned colleagues
who have demonstrated success in advancing their nursing careers
and elicited their input on trends in nursing practice and nursing
education options?
Have I explored nursing education program options at accredited
academic institutions that will support my career advancement
interests?
Have I pursued ways to pay for advancing my nursing education
through reimbursement at work, state and federal scholarships and
traineeships, and/or public and private foundations?
How will I balance work/family/study demands and remain
physically, psychologically, and financially healthy?
Last and perhaps most important, am I ready to take action in
advancing my professional nursing career?

Showcasing Your Professional Self
Showcasing your nursing story is an important aspect of career
management and includes how you present yourself in your
professional portfolio and in the interview process. A résumé and cover
letter will assist in getting an interview, but a complete professional
portfolio may be what secures you the new position. A portfolio provides
several advantages, including self-enlightenment, career enhancement, a
record of growth and development, a record of performance over time,
and a tool for planning, and it can act as a resource for others looking to
create one (Masor, 2013).

A professional portfolio, whether a print or electronic version, contains
a cover letter; a résumé; examples of accomplishments cited but not
elaborated upon in your résumé; selections of high-quality projects,
papers, presentations, teaching tools/programs, patient or nursing care
forms, policies, or procedures that you may have developed or
codeveloped across your career; and copies of licensure, certifications,
awards, and professional organizational membership cards. In today’s
culture, being bilingual can be a definite advantage. Each language and
dialect, if appropriate, should be included in your portfolio, including
competencies in reading, understanding, speaking, and writing. Awards
received can be a testament to your diligence in a position and
willingness to go beyond the job requirements. Being an officer in an
organization shows leadership abilities (Schmidt, n.d.).

The portfolio will look different depending on the position you are
seeking and the competencies you wish to showcase. Examples of some
differences in the portfolio based on experience and desired position are
as follows:

If you are applying for a first-time position as a new RN, the portfolio
can be used to showcase your competencies, intellectual skills, and
teamwork while a student. New graduates, in particular, have to
showcase themselves to stand apart from other applicants (Health
eCareers Network, 2012).
If you are applying for an advanced practice position, the IOM (2011)
recommends that the portfolio be used as a means to document
competencies and experience with patient populations.
If you are applying for a staff position, you may consider providing a
short case study describing the types of patients you have cared for
and the specific skills and competencies you demonstrated in caring
for this patient population.
If you are applying for a management position, you may consider
providing examples of leadership/management situations you have
been engaged in, such as decision-making situations, schedules
completed, and quality improvement initiatives.

Your cover letter should be directed to the human resources director,
one page in length, word-processed, and printed on white stock paper
with black ink, and should clearly identify the correct title of the position
you are seeking, the length of time you have been an RN, a request for
an interview, and your contact information.

Your résumé provides a brief overview of your professional career.
Most résumés contain the following sections: identification, education,
licensure and certifications, professional nursing employment history,
professional committee engagement, and professional nursing
organizations. Most résumés are one page in length and order entries
from most recent to distant. See Figure 6-1 for an example résumé.

Figure 6-1 Example résumé.

First impressions made during the interview are also important.
Arriving early and dressing professionally are a good beginning. Being
prepared with answers for potential questions will only enhance the
impression you make. Information concerning the job requirements,
including duties, patient census and type, salary, and benefits, should be

provided by the interviewer. Your follow-up questions assist you in
understanding the expectations of the position. In “What Every Nursing
Student Should Know When Seeking Employment: An Interview Tip
Sheet for Baccalaureate and Higher Degree Prepared Nurses,” the
AACN (n.d.-c) discusses characteristics of the organization that the
applicant should assess. These eight hallmarks or characteristics are in
the following list. Prior to your interview, refer to the brochure, which is
available on the AACN website, for specific questions under each of the
categories. The brochure is available at
http://www.aacnnursing.org/Students/Career-Resources.

Manifest a philosophy of clinical care emphasizing quality, safety,
interdisciplinary collaboration, continuity of care, and professional
accountability.
Recognize the value of nurses’ expertise on clinical care quality and
patient outcomes.
Promote executive-level nursing leadership.
Empower nurses’ participation in clinical decision making and
organization of clinical care systems.
Demonstrate professional development support for nurses.
Maintain clinical advancement programs based on education,
certification, and advanced preparation.
Create collaborative relationships among members of the healthcare
team.
Use technological advances in clinical care and information systems.

It is illegal for employers to ask certain questions. Knowing those
questions and, more important, knowing the questions that are allowed
are key in preparation for the interview (Compare Business Products,
2013). Many interviewers use silence as a tool to evaluate the candidate.
Use the silence to gather your thoughts and let the interviewer break the

silence. At the conclusion of the interview, thank the interviewer for his or
her time and ask about the timeline for filling the position. Send a follow-
up note thanking the person for the interview and state that you are
looking forward to a response.

CRITICAL THINKING QUESTION

What kind of first impression do you make when searching for a new
position?

Mentoring
The IOM report on The Future of Nursing (2011) recommends mentoring
to assist in increasing the readiness and retention of nurses to improve
patient outcomes (Figure 6-2). Mentoring is a relationship between two
nurses in which the more experienced nurse provides leadership and
guidance to the nurse with less experience, often referred to as the
“mentee” (Minority Nurse, 2013). Preceptors and mentors play different
roles. A mentor provides counsel regarding career management, and the
mentoring relationship may take place in the beginning of a nursing
career, when changing positions, or when a nurse is furthering his or her
education. The mentor–mentee relationship may be a long-term
relationship. In contrast, a preceptor provides direct short-term coaching
to a new graduate nurse, a newly hired nurse, or a nurse who transfers to
another unit and orients the nurse to roles and responsibilities on the unit
and within the organization. A mentor may also serve as a preceptor;
however, a preceptor is not a mentor. It is not uncommon for mentees to
become mentors, guiding others in their pursuit of professional growth
and development.

Figure 6-2 Mentoring is a formalized relationship with a more experienced nurse providing
guidance to a nurse with less experience.

© Monkey Business Images/Shutterstock

Being a mentor takes time and requires patience. The mentor must
be reasonable, competent, committed to assisting the mentee in being
successful in his or her career, adept at providing feedback, and open to
sharing knowledge. Professional growth should be the outcome for both
mentor and mentee. It is the responsibility of the person seeking career
mentorship to find a mentor. The mentor may be a nursing faculty
member, an experienced nurse within a healthcare organization or
nursing school, or a nurse from a professional nursing organization. This
relationship has benefits for both. The mentor receives confirmation from
witnessing the career development and advancement of the mentee in
professional nursing. The benefits of being mentored are many and
include:

KEY COMPETENCY 6-1

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Professionalism:

Knowledge (K4b) Describes factors essential to the promotion of
professional development

Skills (S3b) Provides and receives constructive feedback to/from peers

Attitudes/Behaviors (A3b) Values collegiality, openness to critique, and
peer review

Attitudes/Behaviors (A4b) Values the mentoring relationship for
professional development

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Increased self-confidence
Enhanced leadership skills
Accelerated acclimation to the culture of the unit/facility
Advancement opportunities
Enhanced communication skills
Reduced stress
Improved networking ability
Political savvy
Legal and ethical insight

Problems with mentoring may occur with either person (Minority
Nurse, 2015). The mentee may outgrow the mentor in knowledge and in
the profession. The commitment in time and energy of the mentor may
become overwhelming. The relationship may even become toxic if the
mentor becomes inaccessible or harmful to the mentee and may even
block the learning and progression of the mentee. If any of these become
evident in the relationship, both must communicate and discuss the
situation. They may agree to a separation or to repairing the relationship.

Education and Lifelong Learning
The profession of nursing needs a more educated workforce for the sake
of increasing healthcare quality and patient safety. The ANA standards of
professional nursing practice, Standard 12, indicate that it is the
responsibility of every nurse to seek “knowledge and competence that
reflects current nursing practice and promotes futuristic thinking” (2015b,
p. 76). The competencies associated with this standard reflect
commitment to lifelong learning, the maintenance of a professional
portfolio, and a commitment to mentoring. Every state board of nursing
should require mandatory continuing education for all practicing RNs, but
not all do. The call for a more educated professional nursing workforce to
lead change and advance health has been mandated in the initiatives of
the IOM (2011):

“Increase the proportion of nurses with a baccalaureate degree to 80
percent by 2020.” (Initiative 4)
“Double the number of nurses with a doctorate by 2020.” (Initiative 5)
“Ensure that [all] nurses engage in lifelong learning.” (Initiative 6)

In 2010, the U.S. Department of Health and Human Services, Health
Resources and Services Administration reported that the distribution of
RNs by highest nursing or nursing-related educational preparation was
as follows:

13.9% were diploma-prepared RNs.
36.1% of RNs had an associate degree in nursing (ADN).
36.8% had a BSN.
3.2% had a master’s or doctoral degree.

According to Nurse.com, as of 2018, in the United States of 50 states,

the District of Columbia, and 2 territories:

34% (18) had no mandatory continuing education (CE) requirement
for RN licensure.
66% (35) had a mandatory CE requirement ranging from 14 to 30
CEs every 2 years or, in some cases, only if the RN was not engaged
in practice during the previous renewal time.

The profession of nursing expects that nurses will practice the
science of nursing with care. At the core of ADN and BSN academic
programs are foundational science courses in biology, anatomy,
physiology, microbiology, chemistry, pathophysiology, pharmacology, and
statistics (Figure 6-3). These courses serve as the basis for translating
research evidence into the science of nursing practice in such courses as
adult health, pediatrics, obstetrics, psychiatric-mental health, and
community health nursing. Although we readily acknowledge the essence
of nursing as “caring for patients,” we often do not embrace that nurses
are also scientists committed to practicing the science of nursing with
care and compassion toward patients. Caring is not enough. Science is
not enough. Nursing is both an art and a science that is continuously
evolving based on research findings, resulting in a deepening and
broadening of the knowledge base fundamental to professional nursing
practice. As nurses, we must be committed to and actively engaged in
lifelong professional learning across our careers. Ongoing nursing
education through CE programs, certification programs, and/or formal
academic programs to pursue a BSN, an MSN, a DNP, and/or a PhD
must be an expectation of professional nurses if we are to keep pace with
the science of nursing, have credibility as a profession, and maintain our
commitment to patients. It is only in this way that the profession of
nursing will actualize the IOM mandates for leading change and
advancing health.

Figure 6-3 Formal academic education is required to become eligible for both nursing licensure
and advanced practice certification.

© alejandrophotography/E+/Getty Images

Advancing your nursing career often means returning to school. In an
unprecedented move advocating support for academic progression in
nursing, the American Association of Community Colleges, the
Association of Community College Trustees, the AACN, the National
League for Nursing, and the National Organization for Associate Degree
Nursing issued a powerful joint statement calling for nursing to

work together in order to facilitate unity of nursing education
programs and advance opportunities for academic progression,
which may include seamless transition into associate,
baccalaureate, master’s, and doctoral programs. Collectively,
we agree that every nursing student and nurse should have
access to additional nursing education, and we stand ready to
work together to ensure that nurses have the support needed to
take the next step in their education. (AACN, 2015a, para. 3)

At the core of a seamless academic progression in nursing is respect
for the academic integrity of educational programs provided by
community colleges, colleges, and universities and efforts made to
enable nursing students and nurses to readily progress from ADN to RN-
BSN or RN-MSN to DNP or PhD programs. The AACN (n.d.-a) website
provides a user-friendly search engine called Nursing Program Search

for academic programs in nursing at every level, such as RN-BSN, RN-
MSN, LPN to BSN, entry-level BSN, accelerated BSN, BSN to DNP, BSN
to PhD, entry-level MSN, MSN, CNL, MSN to DNP, DNP, and PhD
programs.

If you are contemplating or have decided to return to school to pursue
a BSN or an advanced graduate degree in nursing, be sure that you
consider and investigate the following:

Possess certainty about the specific courses that will successfully
transfer and knowledge of the specific courses and their associated
credit hours that need to be taken prior to admission.
Prepare for and take any preliminary test required, such as the
Graduate Record Examination, and know the expected scores for
admission.
Adhere to the application process, including admission dates.
Be knowledgeable of the cost of the program in its entirety: tuition,
books, and fees, such as online fees, clinical fees by course, and
fees for validation credits of previously earned coursework that has
been successfully completed. Some programs advertise that they
give “life experience” credits. Be sure you receive in writing what
these experiences are, whether you meet the criteria or if additional
courses need to be taken or papers written describing these
experiences, how many credit hours are awarded, and what the fees
are for transferring these credits into your program of study.
Be aware of tuition reimbursement options through work and the
expected time commitment in return for tuition assistance.
Be cognizant of and investigate opportunities and requirements for
scholarships, loans, and/or traineeship programs awarded by the
state government, the federal government, private foundations,
and/or professional nursing organizations.

KEY COMPETENCY 6-2

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Professionalism:

Skills (S4a) Participates in lifelong learning
Skills (S8g) Develops goals for health, self-renewal, and
professional development
Attitudes/Behaviors (A4a) Committed to lifelong learning

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Information is power! In appraising your nursing career options, be
informed about specialty areas available and of interest to you. The BSN
degree is the sole academic portal of entry for graduate studies in
nursing (MSN, DNP, and PhD) for such roles as nurse practitioner, nurse
anesthetist, clinical nurse leader, nurse executive, nurse educator, and
nurse researcher. There are several nursing career paths supported by
graduate-level academic programs for you to consider:

An expert clinician is an advanced practice registered nurse prepared
at the graduate level, such as an adult, family, geriatric, or
psychiatric-mental health nurse practitioner, nurse anesthetist, or
nurse–midwife, who provides safe, evidence-based, and cost-
effective care to a specific patient population (academic level: MSN,
DNP).
A clinical nurse leader (CNL) guides nurse colleagues and
interdisciplinary teams in direct patient care situations to implement

clinical practice guidelines and to enable these patient populations to
achieve positive outcomes (academic level: MSN, DNP).
A nurse executive directs the infrastructure of the practice of nursing
within an organization on clinical and fiscal levels and represents and
advocates for nursing within the context of the business of health
care (academic level: MSN, DNP, PhD).
A nurse educator works in academic settings, guiding students to
deepen and broaden their knowledge and practice of safe, quality-
based professional nursing practice (academic level: MSN, DNP,
PhD).
A nurse researcher is dedicated to executing and translating
evidence-based research into practice and expanding the body of
knowledge fundamental to the art and science of nursing (academic
level: MSN, DNP, PhD).

The Graduate Nursing Student Academy, established by the AACN (n.d.-
b), has established a series of webinars to inform you of areas of
specialization and graduate degrees that may be of interest to you as you
plan your career.

Professional Engagement
Professional engagement is a characteristic that discriminates between a
person employed in a job and one pursuing a career. A professional
nurse who is managing and advancing his or her career will actively
engage in professional nursing initiatives within the nurse’s healthcare
agency and in professional nursing organizations.

KEY OUTCOME 6-1

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential I: Liberal Education for Baccalaureate Generalist Nursing
Practice

1.9 Value the ideal of lifelong learning to support excellence in nursing
practice (p. 12).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

Engagement in Your Healthcare Organization
As you are planning your nursing career path, seize opportunities now to
actively engage in quality improvement activities that are currently under
way within your healthcare organization. Examples of quality initiatives
include, but are not limited to, committees within your agency that
address nursing policy and procedures, quality improvement, core
measures, clinical practice guidelines, safety, the Hospital Consumer

Assessment of Healthcare Providers and Systems Hospital Survey of
Customer Satisfaction, and the Medicare and Medicaid Survey Process
for Nursing Homes or Home Health Agencies.

Engagement in programs to improve quality for patients, staff, and
your organization will help you gain experience in clinical problem
resolution, aid you in translating clinical practice guidelines and research
evidence into practice, assist you with co-contributing to the creation of a
milieu of safety and quality, and connect you in a collegial manner with
the quality champions in your organization. If you are not sure how to get
connected with these committees, start by meeting with your nurse
manager and/or chief nursing officer and express your interest in serving
on one or more of these committees. You will learn from your
participation on these committees and you will maximize your visibility as
an engaged, motivated employee.

Engagement in Professional Nursing
Organizations
Engaging in professional nursing organizations connects students and
RNs with membership and leadership opportunities. Some of the benefits
of participating in these organizations include ongoing growth and
development pertinent for your career and areas of specialization,
receiving mentorship and guidance from seasoned members, obtaining
reduced membership rates for students, and accessing scholarship and
grant opportunities for members to supplement tuition in academic
programs.

You may join many professional nursing organizations as a student or
as an RN. These organizations include, but are not limited to, the ANA
and its affiliate state nurses associations; Sigma Theta Tau International
Honor Society of Nursing; American Organization of Nurse Executives;

American Association of Nurse Practitioners; American Association of
Nurse Anesthetists; American Association of Critical-Care Nurses;
Association of Women’s Health, Obstetric and Neonatal Nurses; and
American College of Nurse-Midwives. A more thorough list of
professional nursing organizations at national, state, and international
levels is provided by the ANA (n.d.).

KEY OUTCOME 6-2

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential VIII: Professionalism and Professional Values

8.13 Articulate the value of pursuing practice excellence, lifelong
learning, and professional engagement to foster professional growth
and development (p. 28).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

Expectations for Your Performance
Assessment of your performance as an RN is conducted on several
levels, such as self-appraisal, work performance evaluations conducted
by nurse managers on behalf of healthcare organizations, and collegial
evaluations. Many performance appraisals for nurses and nursing
students have their roots in professional documents, such as Nursing:
Scope and Standards of Practice (ANA, 2015b), Nurse of the Future:
Nursing Core Competencies (Massachusetts Department of Higher
Education, 2016), The Essentials of Baccalaureate Education for
Professional Nursing Practice (AACN, 2008), and The Essentials of
Master’s Education in Nursing (AACN, 2011) as well as criteria
established by specialty-based professional nursing organizations.

KEY COMPETENCY 6-3

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Professionalism:

Knowledge (K4b) Describes the role of a professional organization in
shaping the culturally congruent practice of nursing

Skills (S8c) Advocates for professional standards of practice using
organizational and political processes

Skills (S8i) Assumes professional responsibility through participation in
professional nursing organizations

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

The core questions in most of these assessments are: “Am I currently
practicing competently?” and “Am I currently practicing to the fullest
extent of my nursing education and training in my current position?”
(IOM, 2011, Initiative 1). It is important to know proactively the
expectations of professional nurse competency in your specific setting so
that you can meet and exceed them and continuously use them as
indicators for identifying your strengths and areas that need further
professional growth and development. Assessment of your performance
as an RN is your own personal quality improvement program and is
essential for professional growth and development. This should not be
just an annual event but an ongoing process of improving one’s practice.
Here are some suggestions for the evaluation of your performance as an
RN:

Conduct your own self-appraisal first in order to have a more
informed dialogue with your nurse manager.
Identify your areas of strength and areas in need of growth.
Pursue continuing education to both enhance your strengths and
narrow your limitations.
Accept constructive feedback with respect, gratitude, and civility.
If feedback does not make sense to you, ask the person to clarify
what he or she said.
Develop an ongoing plan of quality improvement for yourself.

Taking Care of Self
A nurse is a person who is present at birth, at death, and during the entire
life span. A nurse makes life and death decisions. A nurse interacts with
everyone in the healthcare community. A nurse interacts with people from
every walk of life. A nurse must multitask during every shift. A nurse
works every shift, weekends, and holidays. A nurse experiences stress
unknown to most other professions. To prevent overwhelming stress, a
nurse must take care of him- or herself by:

CRITICAL THINKING QUESTIONS

Do you plan to be a part of a professional organization after
graduation? Why or why not? What do you anticipate will be your level
of involvement?

Eating a balanced diet
Getting enough sleep
Avoiding addictive substances
Exercising on a regular basis
Paying attention to mental and spiritual health
Being vigilant in coping with stress triggers at work and at home

Seig (2015) notes that “more than 40 percent of hospital nurses today
suffer from the physical, emotional, or mental exhaustion characteristic of
burnout. The result of unmanaged stress, burnout accounts for what is
often a negative perception among nurses of their work and workplaces”
(para. 1). Managing time is essential to preventing burnout and
compassion fatigue. Francisco and Abarra (n.d.) present the following
12 tips for time management. Nurses can use these tips at work and

during off time.

CRITICAL THINKING QUESTIONS

KEY COMPETENCY 6-4

Example of applicable Nurse of the Future: Nursing Core
Competencies

Professionalism:

Knowledge (K8b) Recognizes the relationship between personal
health, self-renewal, and the ability to deliver sustained quality care

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Do you have the courage to ask for honest feedback? Do you have
the courage to give honest feedback to a friend or colleague? How do
you respond to negative feedback?

Be organized.
Make a list of the tasks you will need to do and post it in a place that
you can easily see.
Before making your rounds, make a checklist of the things you need
to do for each patient.
When doing rounds, always see your most critical patient first.
Don’t do other tasks when giving medications.
Pay attention to time.
Learn how to write quickly.
Always bring easy-to-eat snacks.
Be keen on details.

Learn how to communicate.
Learn to multitask.
Be realistic.

Burnout and compassion fatigue may be the end result of stress not
being managed. Burnout is progressive and involves disengagement and
withdrawal. Compassion fatigue is acute and may present itself as
overinvolvement in patient care (Lombardo & Eyre, 2011). The two
concepts may occur simultaneously. In caring for patients, the nurse may
be depleted physically, emotionally, and spiritually. These indicators
involve compassion fatigue. Burnout causes physical symptoms that lead
to feelings of being constantly tired. Some observed signs are avoiding
certain patients; not feeling compassion for your patients and their
families; experiencing headaches, digestive problems, fatigue, mood
swings, anxiety, and/or poor concentration; and/or feeling
underappreciated and overworked. In response, nurses may not want to
go to work and/or just go through the motions when at work.

KEY OUTCOME 6-3

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential VIII: Professionalism and Professional Values

8.14 Recognize the relationship between personal health, self-renewal,
and the ability to deliver sustained quality care (p. 28).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

The healthcare workplace is demanding, requiring many caregiving

responsibilities from various members of the interdisciplinary team that
must be accomplished and communicated within an abbreviated time.
Sustained workplace stress can dramatically influence how we interact
with colleagues, how professionally satisfied we are with current career
choices, and employee retention rates.

Stress at work can be managed in a civil environment. Civility builds
community and allows for efficient functioning units. Civility is defined as
respect for others (Clark, 2010). A code of conduct establishes ways of
behaving for interacting with people. The ANA (2015a) developed a Code
of Ethics for Nurses with Interpretive Statements that requires nurses to
communicate with respect when interacting with colleagues, patients, and
students. Civil behavior is not always easy to accomplish; it requires
courage and genuine concern for others. We have the choice to be
colleagues who habitually respect and assist one another and who are
instrumental in creating a milieu of civility and safety or to be colleagues
who are engaged either overtly or subtly in lateral and vertical workplace
violence exhibited by bullying, harassing, speaking ill of one another,
demeaning one another, and excluding colleagues.

KEY OUTCOME 6-4

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential IX: Baccalaureate Generalist Nursing Practice

9.12 Create a safe care environment that results in high quality patient
outcomes. (p. 31).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

The first step toward managing stress and creating a civil milieu is to
assess your work environment. Some of the characteristics of healthy
collegial relationships include being a reliable and respectful colleague
who works his or her scheduled days, arrives on time, shares equally in
patient care and management responsibilities, provides care in a timely
manner, and actively volunteers to help a colleague who needs
assistance.

Self-care strategies that promote resilient nurses may include:

Saying no to additional shifts and reducing overtime in order to
conserve energy
Taking a day off in order to renew energy
Changing shift or unit in order to gain a new outlook on being a nurse

Consulting a social worker, a chaplain, your preceptor, and/or your
mentor can provide you with resources for caring for self, managing
burnout and compassion fatigue, and sustaining a resilient self.

Conclusion
You are responsible for actively managing and advancing your nursing
career across your entire life span as a professional nurse. This means
that you will need to make purposeful and strategic choices about your
professional practice, academic preparation, and continuing education.
Mentors, preceptors, and engagement in your healthcare organization
and professional nursing organization serve as guides for advancing your
professional path. Creating a healthy lifestyle and reducing the risk of
burnout and compassion fatigue are essential for sustaining your
personal and professional life.

KEY COMPETENCY 6-5

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Professionalism:

Knowledge (K8d) Contributes to building and fostering a nurturing and
healthy work environment, promoting health safety in the workplace

Attitudes/Behaviors (A8b) Values and upholds altruistic and humanistic
principles

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Classroom Activity 6-1

Have students begin creating a career map that includes short-term
and long-term goals and strategies to achieve those goals. The
Nursing License Map (available at http://nursinglicensemap.com) may
be useful in this activity if students want to compare educational
requirements and salaries as they consider career goals.

Classroom Activity 6-2

Have students begin working on a professional portfolio that contains a
cover letter and résumé, along with examples of accomplishments and
selections of high-quality projects, papers, and presentations.

References
American Association of Colleges of Nursing. (2008). The essentials of
baccalaureate education for professional nursing practice. Retrieved
from
http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

American Association of Colleges of Nursing. (2011, March 21). The
essentials of master’s education in nursing. Retrieved from
http://www.aacnnursing.org/Portals/42/Publications/MastersEssentials11.pdf

American Association of Colleges of Nursing. (2015a). Joint statement on
academic progression for nursing students and graduates. Retrieved
from http://www.aacnnursing.org/News-Information/Position-
Statements-White-Papers/Academic-Progression

American Association of Colleges of Nursing. (2015b). Talking points:
HRSA report on nursing workforce projections through 2025. Retrieved
from www.aacnnursing.org/Portals/42/News/Nursing-Shortage/HRSA-
Nursing-Workforce-Projections.pdf

American Association of Colleges of Nursing. (n.d.-a). Students: Member
program directory. Retrieved from
http://www.aacnnursing.org/Students/Find-a-Nursing-Program

American Association of Colleges of Nursing. (n.d.-b). GNSA webinars.
Retrieved from http://www.aacnnursing.org/GNSA/Webinars

American Association of Colleges of Nursing. (n.d.-c). What every
nursing student should know when seeking employment: An interview
tip sheet for baccalaureate and higher degree prepared nurses.
Retrieved from www.aacnnursing.org/Portals/42/Student/what-every-
nursing-student-should-know-when-seeking-employment.pdf

American Nurses Association. (2015a). Code of ethics for nurses with

interpretive statements. Retrieved from
https://www.nursingworld.org/practice-policy/nursing-
excellence/ethics/code-of-ethics-for-nurses/

American Nurses Association. (2015b). Nursing: Scope and standards of
practice (3rd ed.). Silver Spring, MD: Author.

American Nurses Association. (n.d.). Nursing organizations. Retrieved
from http://www.nurse.org/orgs.shtml

Clark, C. (2010). Why civility matters. Retrieved from
https://www.reflectionsonnursingleadership.org/features/more-
features/Vol36_1_why-civility-matters

Compare Business Products. (2013). 30 interview questions you can’t
ask and 30 legal alternatives. Retrieved from
https://www.comparebusinessproducts.com/fyi/30-interview-questions-
you-cant-ask-and-30-sneaky-legal-get

Daggett, L. M. (2014). Career management and care of the professional
self. In K. Masters (Ed.), Role development in professional nursing
practice (3rd ed., pp. 167–193). Burlington, MA: Jones & Bartlett
Learning.

Francisco, M. E. V., & Abarra, J. (n.d.). 12 time management tips every
nurse should know. Retrieved from
http://www.nursebuff.com/2014/05/time-management-tips-for-nurses/

Health eCareers Network. (2012, December 11). 5 common career myths
for nurses. Retrieved from
https://www.healthecareers.com/article/career/5-common-career-
myths-for-nurses

Hein, R. (2012, December 5). Career mapping offers a clear path for both
employees and employers. Retrieved from
http://www.cio.com/article/2448964/careers-staffing/career-mapping-
offers-a-clear-path-for-both-employees-and-employers.html

Institute of Medicine. (2010). Report brief: The future of nursing: Focus

on education. Retrieved from
http://nationalacademies.org/hmd/~/media/Files/Report%20Files/2010/The-
Future-of-
Nursing/Future%20of%20Nursing%202010%20Report%20Brief.pdf

Institute of Medicine. (2011). The future of nursing: Leading change,
advancing health. Washington, DC: National Academy Press.
Retrieved from http://www.nap.edu/read/12956/chapter/1

Lombardo, B., & Eyre, C. (2011). Compassion fatigue: A nurse’s primer.
Online Journal of Issues in Nursing, 16. Retrieved from
http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-
16-2011/No1-Jan-2011/Compassion-Fatigue-A-Nurses-Primer.html

Masor, M. B. (2013). Let your light shine: Portfolio principles. In J. Phillips
& J. M. Brown (Eds.), Accelerate your career in nursing: A guide to
professional advancement and recognition (pp. 29–44). Indianapolis,
IN: Sigma Theta Tau International Honor Society of Nursing.

Massachusetts Department of Higher Education. (2016). Nurse of the
future: Nursing core competencies: Registered nurse. Retrieved from
http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Minority Nurse. (2013). Mentoring nurses toward success. Retrieved from

Nurse.com (2018). Nursing CE requirements by state. Retrieved from
https://www.nurse.com/state-nurse-ce-requirements

Schmidt, K. (n.d.). Top 10 details to include on a nursing resume [Web
log]. Retrieved from http://blog.bluepipes.com/top-10-details-to-include-
on-a-nurse-resume/

Seig, D. (2015). 7 habits of highly resilient nurses. Retrieved from
http://www.reflectionsonnursingleadership.org/Pages/Vol41_1_Sieg_7%20Habits.aspx

U.S. Department of Health and Human Services, Health Resources and
Services Administration. (2010, March). The registered nurse
population: Findings from the 2008 national sample survey of

registered nurses. Retrieved from
https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/rnsurveyfinal.pdf

U.S. Department of Labor, Bureau of Labor Statistics. (2016).
Occupational outlook handbook. Retrieved from
https://www.bls.gov/ooh/healthcare/registered-nurses.htm#tab-3

© James Kang/EyeEm/Getty Images

CHAPTER 7

Social Context and the Future
of Professional Nursing
Mary W. Stewart, Katherine E. Nugent, and Kathleen
Masters

Learning Objectives

After completing this chapter, the student should be able to:

1. Describe the social context of professional nursing.
2. Identify factors that influence the public’s image of professional

nursing.

3. Identify ways that nurses can promote an accurate image of
professional nursing.

4. Discuss the gender gap in nursing.
5. Recognize connections between changing demographics and

cultural competence.
6. Evaluate current barriers to health care in our society.
7. Discuss present trends in society that influence professional

nursing.
8. Identify present trends associated with the profession of nursing.

Key Terms and Concepts

Stereotypes
Cultural competence
Access to care
Incivility
Violence
Global aging
Consumerism
Complementary and alternative medicine
Disaster preparedness
Nursing shortage
Nursing faculty shortage

When you hear the word nurse, what images, thoughts, perceptions, and
assumptions come to mind? Ask yourself, “Why did I have those
perceptions and assumptions about nurses?” The answer to your
question reveals much about the social context of nursing or how society

views nurses and the nursing profession. For many, the image that first
comes into view is one of a white female who is dressed in a meticulously
ironed white uniform with white hose and white shoes and wearing a stiff
white cap. For those of us in nursing, we recognize that this traditional
American view of nursing is rarely seen in the real world of professional
nursing. How do we communicate the true image of nursing in the 21st
century?

In this chapter, we explore the social context of professional nursing
and identify major influences that affect nursing in today’s society. This
quest for a deeper understanding of nursing challenges us to identify our
individual responsibilities in educating our patients and the public about
professional nursing as well as meeting our professional obligations to
the public. The result is not necessarily an immediate change in the
picture that comes to mind when one says “nursing”; however, we might
begin to see nursing and those of us committed to nursing in new, more
accurate ways.

Nursing’s Social Contract with
Society
A mutually beneficial relationship exists between nursing and society. The
profession of nursing grew out of a need within society and continues to
evolve based on the needs of society. Because nursing has a
responsibility to society, the interests of the profession must be perceived
as serving the interests of society. Society provides the nursing
profession with the authority to practice, grants the profession authority
over functions, and grants autonomy over professional affairs. The
profession is expected to regulate itself and to act responsibly. This
relationship is the essence of nursing’s social contract with society
(American Nurses Association [ANA], 2010).

Foundational to nursing’s social contract with society are some basic
values. In brief, these values include that humans manifest an essential
unity of mind, body, and spirit; human experience is contextually and
culturally defined; health and illness are human experiences; and the
relationship between the nurse and the patient occurs within the context
of the values and beliefs of the patient and the nurse. In addition, public
policy and the healthcare delivery system influence the health and well-
being of society and professional nursing, and individual responsibility
and interprofessional involvement are essential (ANA, 2010).

According to Nursing’s Social Policy Statement (ANA, 2010), nursing
is particularly active in relation to six key areas of health care that include
the organization, delivery, and financing of high-quality health care;
provision for the public’s health through health promotion, disease
prevention, and environmental measures; and expansion of nursing and
healthcare knowledge (through research and evidence in practice) and

application of technology. Also included are expansion of healthcare
resources and health policy to enhance the capacity for self-care;
definitive planning for health policy and regulation; and duties under
extreme conditions, which means that nurses weigh their duty to provide
care with obligations to their own health during extreme emergencies.

Public Image of Nursing
The public values nursing. According to a Gallup poll in 2017, nurses
received the top ranking for honesty and ethical standards (Brenan,
2017). The honor of being the most trusted profession has been
bestowed on the profession of nursing every year but one since 1999,
when nursing was first added to the Gallup poll. The only year when
nurses did not rank number one was in 2001 when firefighters took the
top spot after the September 11 terrorist attacks. When asked to defend
this nationwide trust of nurses, people often respond with anecdotal
stories of personal experiences with nurses. Popular stories include
those of relatives or friends who are nurses and positive experiences with
nurses in a clinical setting. The fact that nurses serve society seems to
have an automatically positive effect on society’s value of nursing.

Although the trust is evident, there remains a gap between the
public’s perception of the nursing profession and the reality of nursing.
For example, the general public might think that it requires only 2 years to
become a registered nurse (RN), with the “training” consisting primarily of
learning to administer medications, providing personal care, and sitting at
the bedside. However, reality provides a stark revelation that nurses are
educated at the baccalaureate, master’s degree, and doctoral levels and
work in areas of education, research, and independent clinical practice.

Nurses are aware of the gaps in society’s knowledge of nursing.
Hence, nurses should take the lead in ensuring that the public has an
accurate picture of the vast knowledge and expertise that are present in
the 3 million RNs in the United States (U.S. Department of Health and
Human Services [USDHHS], 2010b). Where do we start? We must first
begin with the realization that not all nurses are the same. As previously

stated, many well-educated persons do not understand the various
educational programs available to become an RN. Likewise, knowledge
about the differences in preparation and responsibility of licensed
practical nurses, RNs, and advanced practice nurses is lacking.

As you are preparing to be a professional nurse, ask yourself, “How
do I clarify and communicate the significance of professional nursing?”
First, become familiar with the scope of practice of professional nurses
and understand the multifaceted roles for which you are being educated.
Second, be able to identify the unique place that professional nurses
have in the healthcare system. This comes by acquiring knowledge of the
nursing profession and by being aware of the roles, responsibilities, and
contributions of other healthcare professionals. Most important, it is
imperative that you share your story of nursing. Although the public holds
nurses in high regard, they know very little about what nurses actually do
(Buresh & Gordon, 2000, 2006, 2013). Without articulating more clearly
and loudly on our profession’s behalf, we might be at a loss when trying
to defend our place in the current healthcare system.

Suzanne Gordon, an award-winning journalist, has dedicated much
of her career to telling the stories of nursing. Not a nurse herself, Gordon
writes to empower nurses to find their voices and to be heard. Gordon is
committed to obtaining a firsthand account from nurses as they face the
real challenges of being a nurse that include (1) inconvenient problems of
improving patient safety (Gordon, Buchanan, & Bretherton, 2008); (2) the
challenges of standing up for themselves, their patients, and the nursing
profession (Gordon, 2010); and (3) the effect of cutting healthcare costs
on patient care (Gordon, 2005), to name a few. If a journalist can commit
to sharing “our” stories, that should provide a spark of motivation in us to
share our experiences, triumphs, and defeats.

KEY OUTCOME 7-1

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential VIII: Professionalism and Professional Values

8.3 Promote the image of nursing by modeling the values and
articulating the knowledge, skills, and attitudes of the profession (p.
28).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

When nurses are asked about the nurse’s reluctance to promote
nursing effectively, the responses are riddled with excuses, such as a
lack of time, resources, and support from colleagues. Professional nurses
work in very demanding, stressful, and taxing jobs. Frequently, we are so
consumed with the responsibilities of our work that we fail to notice what
we are actually accomplishing. In addition, we rarely take the time to
become fully aware of and to celebrate what our nursing colleagues are
doing within the profession. Professional nursing organizations exist to
communicate and support these achievements. However, only a small
percentage of RNs are actually members of their professional nursing
associations.

Better insight into professional nursing must start with nurses at all
levels of practice and education. Once we have obtained the necessary
insight, we can provide a clear picture of the nursing profession to
society. When these two actions are taken, the public image of nursing
will be directly reflective of the reality of nursing. We want to maintain the
positive impression the public now holds of nursing and to sustain the
earned trust, but nursing and the public deserve a great deal more than

that. All of us should be convinced of the expertise that professional
nursing offers: mastery of complicated technological skills; appreciation
for the whole person; commitment to public health for all people; a keen
knowledge of anatomy, physiology, pathophysiology, biochemistry,
pharmacology, and other disciplines; the ability to think critically and to
connect the dots in today’s ever-changing healthcare system; and
proficiency in communication. The list continues.

KEY COMPETENCY 7-1

Examples of applicable Nurse of the Future: Nursing Core
Competencies
Professionalism:

Knowledge (K5b) Understands the culture of nursing, cultural
congruence and the healthcare system

Skills (S5b) Promotes and maintains a positive image of nursing

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Media’s Influence
It is obvious that the media (television, radio, Internet) play a major role in
how society views professional nursing. Historically, the nurse has been
portrayed in the media in a variety of ways. First, the nurse appears as a
young, seductive female whose principal qualification is the length of her
slender legs and the amount of cleavage showing through her uniform.
Needless to say, this nurse is usually depicted as one who is not
educated and who lacks common sense and intelligence. Another

popular view of the nurse as portrayed by the media is an unattractive,
overweight, and mean female. Her intelligence is not questioned, but her
compassion for others is highly debatable. This nurse is shown as
threatening and uncaring. Neither of these views is accurate, and
probably no one would argue with this. At the same time, we continue to
be perplexed when asked to define or describe the professional nurse.

In their book From Silence to Voice: What Nurses Know and Must
Communicate to the Public, Buresh and Gordon (2006) state that “a
profession’s public status and credibility are enhanced by having its
expertise acknowledged in the journalistic media” (p. 1). Buresh and
Gordon also cite the study “Who Counts in News Coverage of Health
Care,” where the data show that many professional groups had a greater
voice on health issues compared to nurses. Physicians were quoted the
most in media, followed by government, business, education, public
relations, and so forth. This is significant and shocking because nurses
are the largest group of healthcare professionals, yet we are the most
silent group. As nurses, we have been complacent about refuting the
negative stereotypes portrayed in the media. Furthermore, we have been
lax in articulating our expertise to the media.

Buresh and Gordon (2006, p. 4) describe three communication
challenges faced by the nursing profession that need to be addressed:

1. Not enough nurses are willing to talk about their work.
2. When nurses and nursing organizations do talk about their work, too

often they intentionally project an inaccurate picture of nursing by
using a “virtue” instead of a “knowledge” script.

3. When nursing groups give voice to nursing, they sometimes bypass,
downplay, or even devalue the basic nursing work that occurs in
direct care of the sick while elevating an image of “elite” nurses in
advanced practice, administration, and academia.

Nurses should face the stereotypes present in our society and erase
the lines that define us. To do this, we must first recognize our value to
society and ourselves. When introducing ourselves in the professional
role, we should do so with confidence and clarity. For example, we can
say, “Good morning, Mr. Smith. I’m Susan Jones, your registered nurse.”
Such day-to-day engagement is important. We must tell the world what
we do.

In From Silence to Voice, the authors identify the following actions to
promote the real image of nursing:

Educate the public in daily life.
Describe the nurse’s work.
Make known the agency—independent thinker—of the RN.
Deal with the fear of angering the physician.
Accept thanks from others.
Be ready to take advantage of openings to promote nursing.
Respond to queries with real-life stories from nursing.
Tell the details.
Avoid using nursing jargon.
Be prepared ahead of time to tell your story.
Do not suppress your enthusiasm.
Reflect the nurse’s clinical judgment and competency.
Connect your work to pressing contemporary issues.
Respect patient confidentiality.
Deal with and confront the fear of failure.

CRITICAL THINKING QUESTION

How can you, as a student nurse, tell members of society what
professional nurses do?

In an effort to address the challenges faced by nursing, Buresh and
Gordon (2000, 2006, 2013) present a history and understanding of
modern media and provide examples of how to interconnect with them.
Knowing how news media work, how to write a letter to the editor, how to
present oneself on television or radio, and how to converse with
community groups are among the guidelines provided. Being proactive is
essential, especially at a time when healthcare costs and cuts demand
that only the fundamental players are left standing. Society needs to
know that nurses are fundamental players.

Sigma Theta Tau International commissioned the 1997 Woodhull
Study on Nursing and the Media, which reported the lack of
representation that nurses have in the media (Sigma Theta Tau
International, 1998). In approximately 20,000 articles from 16 major news
publications, nurses were cited fewer than 4% of the time. Although
nurses are highly relevant participants in patients’ stories, they were
neglected in almost every case. Key recommendations from the
Woodhull Study include the following:

Nurses and media should be proactive in establishing ongoing
dialogue.
If the aim is to provide comprehensive coverage of health care, the
media should include information by and about nurses.
Training should be provided to nurses on how to speak about
business, management, and policy issues.
Health care needs to be clearly identified as the umbrella term for
specific disciplines, such as medicine and nursing.
Nurses with doctoral degrees should be identified correctly as
doctors, and those with medical doctorate (MD) degrees should be
identified as physicians.
Language needs to reflect the diverse options for health care by

avoiding such phrases as “Consult your doctor.” Rather, media need
to state, “Consult your primary healthcare provider.”

In recent years, we have seen more accurate portrayals of nurses
supported in the media. Instead of portraying sexual prowess or
disrespect and anger, nurses have been presented as intelligent,
competent, and essential to patient care. Johnson & Johnson continues
the Campaign for Nursing’s Future to raise public awareness of
professional nursing. This positive promotion has supported student and
faculty recruitment into the profession. Johnson & Johnson has taken
additional steps to recognize the courageous efforts of many nurses,
including those who were intensely engaged in responding during
national crises, such as Hurricane Katrina. Nurses must continually
evaluate the portrayal of nurses in the media. After all, if the image is
inaccurate, we have a responsibility to correct it.

The Gender Gap

Women in Nursing
In Western culture, women have traditionally been socialized as the more
passive of the genders—to avoid conflict and to yield to authority. The
implications of this conventional thought are still evident in nursing
practice today. Many nurses lack confidence in dealing with conflict and
in communicating with those in authority. For some, it is a matter of a
short supply of energy and too many other commitments. Others
perceive assertiveness as clashing with people’s expectations. We
should ask ourselves, “Isn’t the reward of knowing we do a good job
enough?” For female nurses who assume multiple personal and
professional roles, career is often not at the top of our priorities. This can
be attributed to the fact that the role of women in past society was
primarily geared toward family responsibility, not career. Many women
who chose nursing did so without the expectation of a long-term
commitment to the profession. Rather, nursing was a “good job” when
and if a woman needed to work. This centeredness on service continues
in nursing today, albeit with less intensity than in the past.

The women’s movement in the 1960s empowered intelligent career-
seeking women to enter professions other than the traditional ones of
teaching and nursing. After some years of competing for students,
nursing saw a return of interest in the 1980s and 1990s. At this point,
more women chose nursing as a career because nursing provided a
natural complement to their gifts, not because it was one of only a few
options available to them. As the message of varied opportunities for
women and men in nursing is shared, the social status of all nurses is

elevated.

Men in Nursing
At the start of the new millennium, men represented approximately 5.4%
of the RN population in the United States (Trossman, 2003). By 2004,
men comprised 5.8% of the RN population and then 6.6% in 2008
(USDHHS, 2010b). In 2011, 9% of all nurses were men, with male
representation greatest at 41% among nurse anesthetists (U.S. Census
Bureau, 2013).

This steady increase can be attributed to recruitment campaigns
focused on attracting men into nursing. For example, the Oregon Center
for Nursing (2002) created a poster of men in nursing with the slogan
“Are you man enough to be a nurse?” The Mississippi Hospital
Association published an all-male calendar with monthly features of men
in nursing, ranging from men who were nursing students to practicing
professionals in a variety of roles. The calendar was used as a recruiting
tool to help encourage men, young and old, to consider career
opportunities in nursing (Health Careers Center, 2012). These strategies
help diminish the stigma associated with men in nursing.

The ANA inducted the first man into its Hall of Fame in 2004 (ANA,
2007). Dr. Luther Christman was recognized for his 65-year career and
contributions to the profession, including the founding of the American
Assembly for Men in Nursing. In 2007, the ANA established the Luther
Christman Award to recognize the contributions of men in nursing.
Current literature also helps to keep the discussion of men in nursing at
the forefront. In 2006, the Men in Nursing journal was launched as the
first professional journal dedicated to addressing the issues and topics
facing the growing number of men who work in the nursing field.

Although a seemingly recent topic, men have served in nursing roles

throughout history. In the 13th century, men played a vital role in
providing nursing care to vulnerable individuals. John Ciudad (1495–
1550) opened a hospital in Grenada, Spain, so that he (along with
friends) could provide care to the mentally ill, the homeless, and
abandoned children (Blais, Hayes, Kozier, & Erb, 2001). Saint Camillus
de Lellis (1550–1614) was the founder of the Nursing Order of Ministers
of the sick. Men in this order were charged with providing care to
alcoholics and to those affected by the plague (Blais et al., 2001). In the
United States, in the 1700s James Derham was an African American
man who worked as a nurse in New Orleans and was subsequently able
to buy his freedom and become the first African American physician in
the United States.

Despite her many contributions to the nursing profession, Florence
Nightingale did not encourage the participation of men in nursing. She
believed that such traits as nurturance, gentleness, empathy, and
compassion were needed to provide care and that these traits existed
primarily in women. Nightingale opposed men being nurses and stated
that their “hard and horny” hands were not fit to “touch, bathe, and dress
wounded limbs, however gentle their hearts may be” (Chung, 2000, p.
38). Thus, nursing became a predominantly female discipline in the late
1800s.

Even with negative societal perceptions and stereotypes, men are
now more open to pursuing nursing as a career choice (Figure 7-1). In
the fall of 2003, the percentage of men enrolled in undergraduate schools
of nursing was 8.4%. In 2014, the percentage of male students enrolled
in baccalaureate nursing programs increased to 11.7%. Male students
enrolled in master’s degree nursing programs represented 10.8% of that
group of students. Male students represented 9.6% of the students
enrolled in research-focused doctoral programs and 11.7% of students
enrolled in practice-focused doctoral programs (American Association of

Colleges of Nursing [AACN], 2015). In 2016, males comprised 12% of
students enrolled in baccalaureate and graduate nursing programs
(AACN, 2017a). These increases are largely the result of diminishing
misconceptions and increased recruiting efforts. Men tend to prefer
distinct practice areas, including high-technology, fast-paced, and intense
environments. Emergency departments, intensive care units, operating
rooms, and nurse anesthesiology are examples of areas to which men
are often attracted. Some speculate that men make these choices to
avoid potential role strain if they were to choose other areas, such as
obstetrics and pediatrics, and because they prefer areas that require
more technical expertise (American Society of Registered Nurses, 2008).

Figure 7-1 More males are choosing a career in nursing, although they do tend to prefer specific
practice areas.

© Monkey Business Images/iStock/Getty Images

There is some debate that men in nursing have an advantage over
their female peers. It is not unusual for patients to assume that a male
nurse is a physician or a medical student. On the other hand, men in
nursing have been mistaken for orderlies. However, the percentage of

men in leadership roles in nursing is much higher than the percentage of
men in nursing overall. This is partly because male nurses are more
oriented and motivated to upgrade their professional status (American
Society of Registered Nurses, 2008). As a result, women in nursing are
challenged to learn how to promote themselves within the profession.

What issues and challenges do men face in nursing? According to
research conducted by Armstrong (2002) and Keogh and O’Lynn (2007),
male nurses may be unfairly stereotyped in the profession as
homosexuals, low achievers, and feminine. These false assumptions and
perceptions deter other men from entering the profession, create gender-
based barriers in nursing schools, and decrease retention rates of male
nurses once they are licensed. Also, because most nursing faculty are
female, most nursing textbooks are written by females, and most leaders
in nursing are female, men might have to learn new ways of thinking and
understanding to find a comfortable place of belonging in the nursing
profession. For example, it is reported that a male nursing student was
having difficulty answering questions on a nursing examination. When the
student shared a sample question with his wife (who was not a nurse),
she answered the question correctly (Brady & Sherrod, 2003).

CRITICAL THINKING QUESTIONS

What advantages do women have in nursing? What advantages do
men have in the profession? What are the risks of being gender
exclusive?

As a consequence of gender bias, some patients might refuse or feel
reluctant to allow men in the nursing role to care for them (American
Society of Registered Nurses, 2008; Cardillo, 2001). During labor and
delivery, patients and their partners might request a female nurse to be at
the bedside. Overall, the presence of a male nurse alone in the room with

a patient is out of the ordinary. On the other hand, male nurses are
assumed to be physically stronger and willing to do the heavier tasks of
nursing care, such as lifting and moving patients (Cardillo, 2001). Still,
many men and women are learning to appreciate and enjoy the emerging
culture in the profession (Meyers, 2003). The old biases continue to
disappear as patients and providers become more educated about the
need for gender diversity in nursing.

Changing Demographics and
Cultural Competence
Despite national trends of increasing diversity, with ethnic and racial
minorities reaching almost one-third of the U.S. population, minorities
overall are underrepresented in the healthcare professions. The 2010
U.S. Census reports that 63.7% of the population is white and non-
Hispanic. In contrast, the RN population remains predominantly female
(91%) and 83.2% white, non-Hispanic (U. S. Census Bureau, 2013).
Although currently most RNs are white women, more minority students
are enrolling in nursing programs now than in past decades. In 2014,
30.1% of students enrolled in baccalaureate programs were minorities,
as were 31.9% of nurses enrolled in master’s programs, 28.7% of nurses
enrolled in practice-focused doctoral programs, and 29.7% of nurses
enrolled in research-focused doctoral programs. In 2016, 32.3% of
students enrolled in baccalaureate programs were minorities, as were
33.6% of nurses enrolled in master’s programs and 32.8% of nurses
enrolled in research-focused doctoral programs. These numbers have
increased since 2014 and have increased substantially since 2005, when
only 24.1% of students enrolled in baccalaureate programs, 22% of
nurses enrolled in master’s programs, and 18.4% of nurses enrolled in
research-focused doctoral programs were minorities (AACN, 2015,
2017d).

In 2003, the Institute of Medicine (IOM) warned of the “unequal
treatment” minorities sometimes face when encountering the healthcare
system. Cultural differences, a lack of access to health care, high rates of
poverty, and unemployment contribute to the substantial ethnic and racial
disparities in health status and health outcomes (IOM, 2003b). Health

services research shows that minority health professionals are more
likely to serve minority and medically underserved populations.
Increasing the number of underrepresented minorities in the health
professions as well as improving the cultural competency of providers are
key strategies for reducing health disparities (Betancourt, Green, Carrillo,
& Ananeh-Firempong, 2003; IOM, 2003b).

Cultural competence in multicultural societies continues as a major
initiative for health care and specifically for nursing. The mass media,
healthcare policymakers, the Office of Minority Health and other
governmental organizations, professional organizations, the workplace,
and health insurance payers are addressing the need for individuals to
understand and become culturally competent as one strategy to improve
quality and eliminate racial, ethnic, and gender disparities in health care
(Purnell & Paulanka, 2008).

KEY COMPETENCY 7-2

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Communication (Collegial Communication & Conflict Resolution):

Knowledge (K6) Identifies cultural variations in approaches to
interactions with others

Skills (S6) Applies self-reflection to better understand one’s own
manner of communicating with others

Attitudes/Behaviors (A6) Identifies how one’s own personality,
preferences, and patterns of behavior impact communication with
others

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Culturally competent healthcare providers increase access to and
satisfaction with health care. The beginning of cultural competence is
self-awareness. Culture has a powerful unconscious effect on health
professionals and the care they provide. Purnell and Paulanka (2008)
indicate that self-knowledge and understanding promote strong
professional perceptions that free healthcare providers from prejudice
and facilitate culturally competent care.

Nursing has a long history of incorporating culture into nursing
practice (DeSantis & Lipson, 2007). In 2008, the AACN released a
publication identifying cultural competency in baccalaureate nursing
education (AACN, 2008a). Yet some maintain that no matter how
culturally competent the nurse might be, the patient’s experience remains
structured in the nurse’s culture (Dean, 2005). Despite nurses’ best
efforts to understand the culture of the patient, nurses often fail to
understand that the patient might be experiencing health care for the first
time not in his or her own culture but in the nurse’s culture of healthcare
delivery. The understanding of this concept associated with cultural
competence increases the reality of the urgency of increasing the
diversity in the nursing workforce.

The Joint Commission and the National Committee for Quality
Assurance also identified the need for healthcare professionals to
recognize and respect cultural differences, including dialects, regional
differences, and slang (Levine, 2012). In an effort to respond to this
national message, many hospitals and healthcare agencies have initiated
the use of interactive patient-engagement technology as part of their
education programs. These services are provided in several languages,
including Russian, Spanish, and Mandarin. Nurses know that illness and
associated stress, pain, and fear can hinder patients’ comprehension

when learning about their condition and treatment plan. Language
barriers compound the problem, resulting in major obstacles to learning
and subsequent issues with adhering to the treatment plan. As nursing
focuses more on cultural behaviors, norms, and practices, healthcare
outcomes can move in a positive direction (Levine, 2012).

KEY OUTCOME 7-2

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential I: Liberal Education for Baccalaureate Generalist Nursing
Practice

1.5 Apply knowledge of social and cultural factors to the care of diverse
populations (p. 12)

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

As the general population of healthcare consumers becomes
increasingly diverse, there is a greater need for culturally competent care
(Jacob & Carnegie, 2002). To provide such nursing care, we must strive
for a nursing population that more accurately represents the communities
we serve. As the population continues to become more diverse, culturally
competent care will be the basis for high-quality care, access to care, and
alleviation of health disparities, thus promoting healthier population
outcomes. Being culturally competent—that is, having the ability to
interact appropriately with others through cultural understanding—is an
expectation for people entering the nursing profession (Grant & Letzring,
2003), keeping in mind that there is a difference between learning of

another culture and learning from another culture.

Access to Health Care
Many Americans have health insurance coverage and access to some of
the best healthcare professionals in the nation. However, a large number
of individuals experience disparities in our healthcare system. These
disparities, or unfair differences in access, can result in poor quality and
quantity of health care. According to the Agency for Healthcare Research
and Quality (AHRQ, 2010), individuals who are at greatest risk for
experiencing healthcare disparities are racial and ethnic minorities and
those with a low socioeconomic status. Lack of health insurance is the
most significant contributing factor to a decrease in disease prevention
and thus is one of the foci of the Patient Protection and Affordable Care
Act. Although lack of health insurance has a major effect on access to
health care, other factors, such as continuity of care, economic barriers,
geographic barriers, and sociocultural barriers, have a detrimental effect
on the health and quality of life of individuals and are discussed in the
following subsections.

Continuity of Care
Individuals who have a provider or facility where they receive routine care
are more likely to receive preventive health care (AHRQ, 2010). These
individuals usually have better health outcomes and experience reduced
disparities. In 2008, the percentage of people with a specific source of
ongoing care was significantly lower for poor people than for high-income
people (77.5% compared with 92.1%). The AHRQ also notes that having
a routine provider of care correlates with a greater trust in the provider
and an increased likelihood that the person coordinates care with the
provider. In this regard, one role and responsibility of the nurse is to

educate the community and patients on the importance of continuity of
care with a routine healthcare provider and/or facility.

KEY COMPETENCY 7-3

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Patient-Centered Care:

Knowledge (K4c) Understands how human behavior is affected by
socioeconomics, culture, race, spiritual beliefs, gender identity, sexual
orientation, lifestyle, and age

Knowledge (K4d) Understands the effects of health and social policies
on persons from diverse backgrounds and cultures

Skills (S4b) Implements nursing care to meet holistic needs of patient
on socioeconomic, cultural, ethnic, and spiritual values and beliefs
influencing health care and nursing practice

Attitudes/Behaviors (A4a) Values opportunities to learn about all
aspects of human diversity and the inherent worth and uniqueness of
individuals and populations

Attitudes/Behaviors (A4b) Recognizes impact of personal attitudes,
values, and beliefs regarding delivery of care to diverse clients

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Economic Barriers
Undoubtedly, poverty poses the greatest risk to health status (Kavanagh,
2001). The United States has a long-standing reputation for providing the

highest quality health care to persons in the highest socioeconomic
strata. Likewise, the lowest quality health care is provided to those at the
other end of the socioeconomic continuum (Jacob & Carnegie, 2002). As
the largest segment of the healthcare industry, RNs can have a positive
effect on the change required in this established system. Recognizing the
stronghold that poverty currently has on the health care of citizens is a
beginning to the much-needed work in the fight for equality.

Although stereotypes communicate to us that poverty is limited to
certain groups, we understand that poverty affects people of all cultures
and ethnicities. We must recognize the effect that poverty has on
healthcare practices. If poverty were eradicated, there would be no
homelessness, none who are uninsured, and no more choices between
food and medicine. Until that time, nursing continues to face the
challenge of meeting the needs of all people.

Geographic Barriers
Those living in rural areas have unique concerns regarding access to
care. As many rural hospitals close because of a lack of financing, more
communities find themselves struggling to find primary care providers
who will work in those areas. State and national efforts attempt to provide
more service to these areas, but the demand outweighs the supply.

Urban dwellers are not immune to geographic barriers. Large cities
have economically depressed sections with fewer healthcare providers
than the more affluent areas. Dependency on public transportation is
another factor to be managed. Finally, most rural and many urban
communities do not support a full range of healthcare services in one
location. These variables affect patients’ access to care and their
continuation in prescribed treatment plans. It is imperative for the nurse
to collaborate with other members of the healthcare team to become

aware of various services available to enhance the health and quality of
life of patients.

Sociocultural Barriers
The need for cultural and ethnic diversity in the nursing workforce has
been discussed. Moreover, healthcare settings are challenged to provide
an environment where people of various sociocultural backgrounds are
respected. For example, having translators on site or within easy contact
is critical for ensuring safe care to non-English-speaking clients. Written
materials should also be provided in appropriate languages and at an
appropriate reading level. It is not feasible or cost effective to provide
educational materials and products to patients who will not use them
because they are in a foreign language or too advanced. Specifically,
consent forms for surgery and other procedures must be available in the
client’s language. To ignore the need for language-appropriate literature
leads to patient harm as well as disrespect for the uniqueness of others.

Societal Trends
At any time in history, societal trends affect the nursing profession. Major
current movements include incivility, violence in the workplace, global
aging, consumerism, complementary and alternative care, and disaster
preparedness. Discussion of these issues allows us to see more clearly
the social landscape and some of the challenges we face as a
profession.

Incivility
Incivility, or bullying, has been exposed in the media to a great extent in
the past few years. This heightened attention is partly the result of media
coverage of suicide attempts and homicides that were instigated by
harassment at the physical, verbal, and electronic levels. Incivility is seen
in every area of society, including high school, college, and even on the
job. Nursing is not immune to this behavior. Greater light has been shed
on the incidence and prevalence of bullying in nurse-to-nurse, faculty-to-
student, and even student-to-faculty interactions. Rocker (2008) reports
that some of the behaviors include criticism, humiliation in front of others,
undervaluing of effort, and teasing. It is also reported that bullying
contributes to burnout, school dropout, isolation, and even attempted
suicides. Bullying is costly to organizations because it contributes to
increased leave, nurse attrition, and decreased nurse productivity,
satisfaction, and morale.

In light of this, it is vital that the nursing profession take an active step
in preventing incivility not only in our communities but also in nursing
programs and places of employment. The ANA (2012) has taken such
action by developing a booklet, Bullying in the Workplace: Reversing a

Culture, to help nurses recognize, understand, and deal with bullying in
the work environment. The ANA supports zero-tolerance policies related
to workplace bullying.

CRITICAL THINKING QUESTIONS

What barriers to health care do you see in your community? How are
the underprivileged served in our current healthcare system?

In addition, in its professional performance standards, the ANA
(2015) indicates that nurses are required to take a leadership role in the
practice setting and within the profession. Two of the competencies listed
that demonstrate the expected performance related to this standard
include communicating in a way that manages conflict and contributing to
environments that support and maintain respect, trust, and dignity.

Violence in the Workplace
The violence in our society is evident and appears to be increasing in
frequency and severity. What is more alarming is our desensitization to
the constant exposure by Internet, radio, and television. As nurses, we
can easily put a face on violence. We see the man in the emergency
department with a gunshot wound to the chest. Only 30 minutes before,
he was leaving work for a weekend with family when someone decided
that they needed his car more than this man needed his life. We see
violence at the women’s shelter when we rotate through that clinical site
in community health nursing. We also see troubled individuals who take
out their frustration on children, colleagues, and supervisors by going on
a shooting rampage, leaving a path of death and destruction. All these
examples affect nurses because we are caring for the ones who are
injured and sometimes also providing care to the injurer. Nurses are

required to know how to act and to provide competent care when violent
incidents occur.

Nurses must become socially aware and politically involved in
preventing violence. We have to support legislation that proactively
addresses violence and lobby for funding that provides nursing research
into violence prevention and treatment. In every potential case, nurses
must use keen assessment skills to identify people at risk and to promote
reporting, treatment, and rehabilitation.

Global Aging
In 2010, adults 62 years of age or older comprised 16.2% of the U.S.
population (49.9 million) compared to 14.7% (41.2 million) in the year
2000. By 2030, it is estimated that the population of older adults will rise
to 71 million (Howden & Meyer, 2011). By 2050, it is estimated that one in
five Americans will be 65 years or older, with the greatest increases being
in the group over 85 years (USDHHS, 2014).

However, this is not a trend unique to the United States. The Year of
the Older Person—this is what the United Nations called the year 1999 to
recognize and reaffirm global aging and the fact that our global
population is aging at an unprecedented rate (Figure 7-2) (Kinsella &
Velkoff, 2001). After World War II, fertility increased and death rates of all
ages decreased. Not only are people in developed countries living longer
and healthier but also so are those in the developing world. In the 1990s,
developed countries had equal numbers of young (people 15 years or
younger) and old (people 55 years or older), with approximately 22% of
the population in each category. On the other hand, 35% of the people in
developing countries were children compared with 10% who were older.
Still, absolute numbers of older persons are large and growing. In the
year 2000, more than half of the world’s older people (59%, or 249 million

people) lived in developing nations.

Figure 7-2 Nurses will care for an increasing number of older persons as this population
continues to grow.

© Monkey Business Images/iStock/Getty Images

In the United States, a decrease in fertility, an increase in
urbanization, better education, and improved health care all contribute to
this social phenomenon. In addition, the older baby boomers who have
turned 65 years of age have started to affect health care significantly with
increasing numbers receiving Medicare benefits. The effect this will have
on our healthcare system is daunting. According to the USDHHS (2014),
more than 60% of older adults manage more than one chronic medical
condition, such as diabetes, arthritis, heart failure, and dementia.
Currently 46% of critical care patients and 60% of medical-surgical
patients in U.S. hospitals are older adults. These acute care patients are
challenging for nurses and resource intensive to the healthcare system
because these vulnerable patients generally have multiple chronic
conditions to treat simultaneously (Ellison & Farrar, 2015).

There is a need for clear health policy at a national level if we are to
be prepared to care for the increasing number of aging citizens.

Preventive health services for older adults are delineated as provisions
made in the Affordable Care Act of 2010. Healthy People 2020 included
objectives specifically for older adults that should be used by healthcare
professionals, including nurses, to promote healthy outcomes, including
improved health, function, and quality of life for this population. Issues
that emerge as nurses promote these outcomes may include
coordination of care and helping older adults manage their own care
(USDHHS, 2014).

KEY OUTCOME 7-3

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential V: Healthcare Policy, Finance, and Regulatory Environments

5.6 Explore the impact of sociocultural, economic, legal, and political
factors influencing healthcare delivery and practice (p. 21).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

In response to the global aging phenomenon and the specialized set
of skills required to care for older adults, most schools of nursing have
either incorporated gerontology courses or increased the geriatric content
throughout the curriculum. Geriatric nurse practitioner programs have
grown in number, and some schools offer dual-track adult/geriatric nurse
practitioner and geriatric psychiatric mental health nurse practitioner
programs in graduate programs. Clinical experiences in nursing
programs include many experiences with older persons. Still, as a nation,
we lack an organized plan to make certain that healthcare needs will be

BOX 7-1

1.
2.
3.

a.

b.

met—not only for the aging but also for those who come after them.

Consumerism
Since the American Hospital Association’s development of A Patient’s Bill
of Rights in 1973, consumers have assumed more control of their
healthcare experiences; this shift is called consumerism. The 1992
version of the document was replaced by the brochure The Patient Care
Partnership: Understanding Expectations, Rights, and Responsibilities
(American Hospital Association, 2003). This brochure is available in
several languages and can be accessed in its entirety via the American
Hospital Association website at https://www.aha.org/system/files/2018-
01/aha-patient-care-partnership.pdf. A summary of the original document
is presented in Box 7-1. Gone are the days when patients blindly
followed the instructions of their physicians. This is cause for celebration
in the nursing arena because nursing has long sought to empower
patients to take responsibility for their own health. Although pockets of
medical paternalism may continue to exist, a shift has occurred, and
consumers of health care now hold healthcare providers to a higher
standard than ever before.

THE PATIENT CARE PARTNERSHIP

What to expect during your hospital stay:

High-quality patient care
A clean and safe environment
Involvement in your care

Discussing your medical condition and information about
medically appropriate treatment choices
Discussing your treatment plan

c.
d.
e.

4.
5.
6.

Getting information from you
Understanding your healthcare goals and values
Understanding who should make decisions when you cannot

Protection of your privacy
Preparing you and your family for when you leave the hospital
Help with your bill and filing insurance claims

The Picker Institute (2012) is another organization that has provided
a road map to assist healthcare organizations in making rapid, dramatic
advances in patient-centered care using what they call Always Events.
Always Events refer to aspects of the patient or consumer experience
that are so important to patients and families that healthcare providers
should always get them right and include improving communication,
providing consistent transitions, partnering effectively with patients and
families, and improving patient safety.

Information technology has given patients an enormous resource for
gaining knowledge about diseases, medications, and treatment options
as well as support groups and other self-help resources. In today’s
environment, healthcare consumers search for answers to their
healthcare questions and compare provider and healthcare system
outcomes online. Based on the information available, they are able to
make informed choices related to health care.

Complementary and Alternative Approaches
As the consumer’s perspective grows in influence, and individuals take
on greater responsibility in their healthcare decisions, they explore
approaches to health care that can actually contrast with Western
traditions. Different terminology has been used synonymously to define
this growing field, such as complementary care practices and alternative

medicine. According to the National Center for Complementary and
Alternative Medicine (2012), “Complementary and alternative medicine is
a group of diverse medical and healthcare systems, practices, and
products that are not presently considered to be part of conventional
medicine.” Complementary medicine refers to an approach that combines
conventional medicine with less conventional options, whereas
alternative medicine is an approach used instead of conventional
medicine. Major types of complementary and alternative medicine
include the following:

Alternative medical systems (built on complete systems of practice,
such as homeopathic medicine or naturopathic medicine)
Mind–body interventions (techniques designed to enhance the mind’s
capacity to affect bodily function, such as meditation, prayer, music,
and support groups)
Biologically based therapies (use of substances found in nature, such
as herbs, foods, and vitamins)
Manipulative and body-based methods (based on manipulation or
movement of one or more parts of the body, such as chiropractic
manipulation or massage)
Energy therapies (involves the use of energy fields through either
biofield therapies, such as therapeutic touch, qi gong, or Reiki, or
bioelectromagnetic-based therapies, such as magnetic therapy)

KEY OUTCOME 7-4

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential IX: Baccalaureate Generalist Nursing Practice

9.17 Develop a beginning understanding of complementary and

alternative modalities and their role in health care (p. 32).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

Alternative and complementary therapies affect the selection of
traditional choices for treatment and ignoring their existence is not an
option. People persist in the use of alternative and complementary
therapies for obvious reasons: (1) the therapies have been found
valuable, and (2) Western medicine has limited options. Many people are
inclined not to divulge information about complementary therapy to their
healthcare provider; however, some alternative therapies may interact
with medications and may be contraindicated in certain circumstances,
so it is imperative that healthcare providers seek out this information.
Nurses should provide a safe, trusting atmosphere where patients feel
free to discuss their healthcare routines and preferences.

Disaster Preparedness
Prior to the turn of this century, disaster preparedness was not a major
topic of discussion in programs of nursing. The key roles that
professional nurses now play in preparing and responding to disasters
have been explored only in recent history. The World Trade Center attack
in 2001 and the shock of Hurricane Katrina in 2005 opened the nation’s
eyes to our vulnerabilities and our strengths. As a result, disaster
management has become common language in our schools, agencies,
and communities.

Disaster management, plans designating responses during an
emergency, are coordinated by local, state, and federal groups.
Firefighters, police officers, and healthcare professionals are part of

response teams. Disaster training is also available to other volunteers.
We have learned that caring for large groups affected by disaster
requires an organized, thoughtful, unbiased approach. Professional
nurses carry the burden of being knowledgeable about potential
disasters, educating the public about the risks, and responding when
persons are affected.

Disaster resources are available from many organizations. The
American Red Cross and the ANA make available policies, resources,
and educational opportunities on disaster preparedness for nurses. In
addition, the IOM (2009) provides guidance for entities establishing
standards of care for disaster preparedness. The Centers for Disease
Control and Prevention (CDC) Clinician Outreach and Communication
Activity program formed in 2011 in response to the anthrax attacks in the
United States. The mission of the outreach program is to help healthcare
professionals provide optimal care by facilitating communication between
clinicians and the CDC about emerging health threats, identifying clinical
issues during emergencies to help inform outreach strategies, and
disseminating evidence-based health information and public health
emergency messages (CDC, 2012).

KEY OUTCOME 7-5

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential IX: Baccalaureate Generalist Nursing Practice

9.20 Understand one’s role and participation in emergency
preparedness and disaster response with an awareness of
environmental factors and the risks they pose to self and patients (p.
32).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

Trends in Nursing
The profession of nursing is currently facing some daunting challenges
that include a projected nursing shortage, workplace issues, the
education–practice gap, unclear practice roles, and changes in
population demographics. Although it is true that each of these issues is
not a new challenge to nursing practice, it is critical to now acknowledge
the collective influence of all these together in the contemplation of future
directions in professional nursing practice.

Nursing is rich in history, resilient in its journey to develop as a
profession and discipline and adaptive in its practice to meet the
healthcare needs of the patient. Throughout the history of nursing, there
are identifiable periods of time in which the practice and education of
nurses responded to the evolving changes in health care and society.
Today nursing is again at the crossroads of a major transition in its
education and practice. An awareness of the merging of these issues
creates urgency when contemplating the role, practice, and education of
nurses.

Nurse Shortage
The shortage of nurses is not a new issue; the predicted nursing
shortage has been prominent in the media for most of nursing’s history.
Projections for the shortage are based on trends that include an increase
in population, a larger proportion of elderly persons, and advances in
technology and medical science. Other issues affecting the projected
supply of nurses include declines in the number of nursing school
graduates, aging of the RN workforce, declines in relative earning, and
emergence of alternative job opportunities, especially for women, who

are still the prominent gender in nursing. History documents a cyclic
pattern of nursing shortages, making it difficult to comprehend the
seriousness of this shortage, especially viewed through the lens of
history. The economic slowdown beginning in 2008 that resulted in
decreased vacancies in healthcare agencies and the uncertainty of the
consequences of healthcare reform given the Affordable Care Act
(USDHHS, 2010a) further complicated predictions related to future
nursing workforce needs.

Beginning in 2008, employers in various parts of the United States
began to report a decrease in the demand for RNs, and nursing students
report that it is more challenging after graduation to find employment.
These findings have led many people to question whether the nursing
shortage still existed. Experts claimed that the recession might have
given some hospitals a temporary reprieve from chronic shortages, but it
is not curing the longer term problem and might be making it worse (OR
Manager, 2009). The Tri-Council for Nursing (2010) released a joint
statement cautioning stakeholders about declaring an end to the nursing
shortage. The statement says, “The downturn in the economy has led to
an easing of the shortage in many parts of the country, a recent
development most analysts believe to be temporary” (p. 1). The council
raised serious concerns about slowing the production of RNs given the
projected demand for nursing services, particularly in light of healthcare
reform. It further states that diminishing the pipeline of future nurses
could put the health of many Americans at risk, particularly those from
rural and underserved communities, and leave our healthcare delivery
system unprepared to meet the demand for essential nursing services.

Where do we stand today? A report from the Bureau of Labor
Statistics (2017) on employment projections identifies the registered
nursing workforce as one of the top occupations in terms of job growth
through 2024, with predictions that include expected growth in the

registered nurse workforce from 2.7 million in 2014 to 3.2 million in 2024,
an increase of 16%. Projections also include growth in nursing positions
as well as the need for 649,100 replacement nurses, bringing the total
number of job openings for nurses because of growth and replacements
to 1.09 million by 2024. The AACN (2017b) reported a 3.6% enrollment
increase in entry-level baccalaureate programs of nursing in 2016, but
this increase will be not sufficient to meet the projected demand for
nursing services. Although nursing school enrollments and graduations
are increasing, “many more baccalaureate prepared nurses will be
needed to meet the health care needs of the population” (AACN, 2012, p.
3).

Nurse Faculty Shortage
In previous cycles of nursing shortages, the primary solution was to
increase the enrollment in nursing programs. However, ample evidence
supports the conclusion that a national nursing faculty shortage also
exists, limiting the ability to increase student enrollment. Based on data
from the 2015–2016 AACN survey, we know that the professoriate
continues to age, and an exodus from the ranks of faculty looms due to
retirement (Figure 7-3). The mean age of doctoral faculty holding the
rank of professor is 62.2 years, for faculty holding the rank of associate
professor it is 57.6 years, and for assistant professors it is 51.1 years.
The national faculty vacancy rate is 7.9%. This shortage is limiting
student capacity in nursing programs across the nation (AACN, 2017c).

Figure 7-3 The aging population also includes nurses and nursing faculty making solutions to the
looming shortage of nurses more complicated than simply increasing enrollment in nursing

programs.

© Monkey Business Images/Shutterstock

CRITICAL THINKING QUESTIONS

As people age and experience health problems, their needs are often
more complex and acute, thereby demanding an even more highly
skilled nursing workforce. Considering the projections related to the
nursing shortage, who will provide these healthcare services? Who
will care for the old?

The number of nurses employed in nursing education has changed
little since 1980, with 31,065 nurses working as faculty. When the number
of nurse educators is compared to the increase in the number of RNs, the
result is actually a decline (2.4%) in the percentage of nurses working in
education (Health Resources and Services Administration [HRSA],
2010). The statistics associated with nursing faculty are concerning,
especially in consideration of the nursing shortage and healthcare
projections of nurse demand in the future.

Nursing Practice and Workplace Environment

Given the anticipated nursing shortage and the increased demand for
nurses, it is important to address the issues associated with the practice
of nursing and the environment where nurses work. It is understandable
how the shortage of nurses affects the practicing nurse, especially in staff
and patient ratios and workload and the resulting influences on nurse
turnover rate. However, other issues associated with the nurse practice
setting result in problematic quality outcomes, such as nurse job
dissatisfaction, unsafe patient care, unhealthy workplace environment,
and unclear role expectations.

It is evident that health care and healthcare delivery have changed
significantly in the past 2 decades. Most of these changes have been
associated with response to the increasing cost of care, the decreasing
reimbursement to healthcare providers, increased use of technology in
practice, and the knowledge explosion concerning disease management.
A full discussion of each of these issues is beyond the scope of this
chapter; however, it is important to note that most of the changes result
from a focus on reducing the cost of health care. Cost containment
strategies aim to determine the setting of the delivery of care, the length
of stay in the hospital, the cost reimbursed to providers of care, and the
designation of the appropriate provider of care.

Hospitals remain the most common employment setting for RNs in
the United States, with 62.2% of employed RNs reporting hospitals as
their primary place of employment (HRSA, 2010). Contrary to earlier
predictions, the percentage of nurses working in hospitals increased from
2004 to 2008 (HRSA, 2010); however, note that the percentage of nurses
working in home health services has also increased. Data from the
national survey of RNs reflect that the percentage of nurses working in
hospitals decreases with the increasing age of nurses, with only 50% of
RNs age 55 years or older working in hospital settings.

Nurses in hospitals provide care for patients who are sicker, older,

and have more complex physical, psychosocial, and economic needs
(Brown, 2004; Clark, 2004). The combination of older patients with higher
acuity, sophisticated technology, and shorter hospital stays creates a
chaotic environment and demands that nurses assume greater
responsibility (Cram, 2011). This chaos increases not only the risk of
errors in patient care but also the risk of health concerns for the nurse,
such as the threat of infection, needle sticks, ever-increasing sensitivity to
latex, back injuries, and stress-related health problems. In addition to
these health risks, nurses are susceptible to workplace violence (e.g.,
physical violence, horizontal violence) and sexual harassment (Longo &
Sherman, 2006; Ray & Ream, 2007; Smith-Pittman & McKoy, 1999;
Valente & Bullough, 2004).

The issues associated with the hospital work environment have been
shown to dominate problems and outcomes associated with nursing
practice. Because of this environment, the profession of nursing has
been challenged to evaluate its practice and outcomes. In fact, a majority
of nurses completing surveys stated they perceived that the unsafe
working environment interfered with their ability to provide quality patient
care (ANA, 2011; Pellico, Djukic, Kovner, & Brewer, 2009). Staff nurses
strongly desire a practice setting in which they feel that they have the
ability to provide high-quality patient care (Schmalenberg & Kramer,
2008) and a work environment that facilitates clinical decision making.

Confounding the issues of the workplace environment are the
shortage of qualified nonnurse healthcare workers, the supervision of
unlicensed personnel, the appropriate delegation of care, mandatory
overtime, and staffing ratios. The debate over the use of unlicensed
personnel and the use of other licensed personnel in providing patient
care is well documented in the literature (ANA, 1992, 1997, 1999;
Zimmerman, 2006) despite the evidence from research studies that
indicate that a decrease in RN staff increases patient care errors,

infection rates, readmission, and morbidity (Aiken, Clarke, Sloane,
Sochalski, & Silber, 2002; Needleman, Buerhaus, Mattke, Stewart, &
Zelevinsky, 2002; Sofer, 2005; Stanton & Rutherford, 2004).

Given that research indicates that a decrease in RN staff or the use
of unlicensed personnel and other licensed personnel influences patient
quality outcomes, what is a rationale for this practice? One answer that is
quickly provided is the increased costs of a higher RN–patient ratio.
Nurses represent about 23% or more of the hospital workforce. The
salary of a licensed RN is higher compared to other nonphysician
healthcare providers. Thus, the basic assumption is that to employ more
unlicensed personnel or other licensed personnel reduces the cost of
care. This assumption is not necessarily true when costs other than
salary, such as costs of hiring, benefits, training, staff turnover, and
responsibilities that must be assumed by a licensed care provider, are
considered. Aiken et al. (2002) found that nurses in hospitals with low
nurse–patient ratios are more than twice as likely to experience job-
related burnout and dissatisfaction with their jobs when compared to
nurses in hospitals with the highest nurse–patient ratios. Cooper (2004)
and Kalisch and Kyung (2011) note that lower nursing staff ratios also
indicate higher costs in a plethora of areas that reflect the actual reality of
nursing practice. McCue, Mark, and Harless (2003) found that a 1%
increase in nonnurse personnel increased operating costs by 0.18% and
diminished profits by 0.021%. These data are significant in the overall
budget considering the rising costs of health care and the current
emphasis on the association of quality and safety indicators with
reimbursement.

Nurse Retention
There is a connection among nurse satisfaction, work environment, and
nurse retention. The strongest predictor of nurse job dissatisfaction and

intent to leave a job is personal stress related to the practice
environment. The various causes of job stress include patient acuity,
work schedules, poor physician–nurse interactions, new technology, staff
shortages, unpredictable workflow or workload, and the perception that
the care provided is unsafe (Groff-Paris & Terhaar, 2010). Surveys of
practicing nurses document that job dissatisfaction, patient safety
concerns, decreases in the quality of care, inadequate staffing, patient
care delays, and mandated overtime are issues that negatively affect
nursing practice (Aiken et al., 2002; Cooper, 2004; Pellico et al., 2009).
Nurses have also reported their concern about their own health and
safety issues, with job stress the most frequent health problem reported.

Despite the effort to address the issues of the chaotic and potentially
harmful work environment, strategies to address these issues have fallen
short of the target, and the dissatisfaction of hospital nurses persists. In
national studies, 41% of nurses currently working report being
dissatisfied with their jobs, 43% score high in a range of burnout
measures, and 22% are planning to leave their jobs in the next year. Of
the latter group, 33% are younger than age 30 years (Beecroft, Dorey, &
Wentin, 2008; Laschinger, Finegan, & Welk, 2009). These factors help to
fuel the shortage of nurses.

In 2008, 29.3% of RNs reported that they were extremely satisfied
with their principal nursing positions, 50.5% were moderately satisfied,
and 11.1% were dissatisfied (HRSA, 2010). Nurses working in academic
education, ambulatory care, and home health settings reported the
highest rate of job satisfaction (86.6%, 85.5%, and 82.8%, respectively).
Almost 12% of RNs employed in hospitals reported moderate or extreme
dissatisfaction (HRSA, 2010).

The retention of competent professional nurses in jobs is a major
problem of the U.S. healthcare industry, particularly in hospitals and long-
term care facilities. An average yearly nurse turnover rate is reported as

between 5% and 21% (PricewaterhouseCooper’s Health Research
Institute, 2007). Other research has found that during the first year of
professional practice, new RNs experience turnover rates around 35% to
61% (Almada, Carafoli, Flattery, French, & McNamara, 2004). Kovner
and colleagues (2007) found that 13% of newly licensed RNs had
changed principal jobs after 1 year, and 37% reported that they felt ready
to change jobs (Huntington et al., 2012; Pellico et al., 2009). In a
comprehensive report initiated by the AHRQ, the authors found that the
shortage of RNs, in combination with an increased workload, poses a
potential threat to the quality of care. In addition, every 1% increase in
nurse turnover costs a hospital about $300,000 a year.

Complexity of Nursing Work
The healthcare workplace has changed over the past 20 years in
response to economic and service pressures. However, some of these
reforms have had undesirable consequences for nurses’ work in
hospitals and the use of their time and skills. As the pace and complexity
of hospital care increase, nursing work is expanding at both ends of the
complexity continuum. Nurses often undertake tasks that less qualified
staff could do, whereas at the other end of the spectrum they are unable
to use their high-level skills and expertise. This inefficiency in the use of
nursing time can also negatively affect patient outcomes. Nurses’ work
that does not directly contribute to patient care, engage higher order
cognitive skills, or provide opportunity for role expansion can decrease
retention of well-qualified and highly skilled nurses in the health
workforce (Duffield, Gardner, & Catling-Paull, 2008).

The major barrier to making progress in patient safety and quality is
the failure to appreciate the complexity of the work in health care today.
Current research focusing on work complexity and related issues enables
an increased understanding of RN decision making, known as the

invisible, cognitive work of nursing, in actual care situations and
demonstrates how both the knowledge and the competencies of RNs, as
well as the complex environments in which RNs provide care, contribute
to patient safety, quality of care, and healthy work environments or lack
thereof (Ebright, 2010, Sitterding & Ebright, 2015).

KEY OUTCOME 7-6

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential IX: Baccalaureate Generalist Nursing Practice

9.22 Demonstrate tolerance for the ambiguity and unpredictability of
the world and its effect on the healthcare system as related to nursing
practice (p. 32).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

Krichbaum et al. (2007) identify a nurse care-delivery experience they
term “complexity compression” and note that this experience occurs
when nurses are expected to assume, in a condensed time frame,
additional, unplanned responsibilities while simultaneously conducting
their other multiple responsibilities. Nurses report that personal,
environmental, practice, administrative, system, and technology factors,
as well as autonomy and control factors, all contribute to this experience.
Associated with complexity compression is the phenomenon of stacking.
Stacking is the invisible, decision-making work of RNs about the what,
how, and when of delivering nursing care to an assigned group of
patients (Ebright, Patterson, Chalko, & Render, 2003). This process

results in decisions about what care is needed, what care is possible, and
when and how to deliver this care (Figure 7-4).

Figure 7-4 Advances in health care technology over the past several decades have created
complex care environments; simultaneously, nursing work has become increasingly complex.

© ERproductions Ltd/Blend Images/Getty Images

A commitment to understanding and appreciating the complexity
involved in RN work is needed to guide the more substantive and
sustained improvements required to achieve safety and quality. Attention
to and action based on an understanding of the complexity of RN work
and the value of safe, high-quality care; desired patient outcomes; and
nurse recruitment and retention have the potential to achieve the goals of
healthy work environments. Using complexity science to understand the
work of nursing is becoming increasingly accepted as a very fitting
approach to explaining healthcare organizational dynamics and the work
of nursing (Lindberg & Lindberg, 2008).

KEY COMPETENCY 7-4

Examples of applicable Nurse of the Future: Nursing Core
Competencies
Systems-Based Practice:

Knowledge (K2a) Understands the impact of healthcare system
changes on planning, organizing, and delivering patient care at the
work unit level

Attitudes/Behaviors (A2a) Appreciates the complexity of the work unit
environment

Attitudes/Behaviors (A2b) Recognizes the complexity of individual and
group practice on a work unit

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Nursing Education
The healthcare system of the 21st century is complex, technologically
rich, ethically challenging, and ever changing. The roles of all healthcare
providers evolve continually, and boundaries of practice shift regularly.
Knowledge explodes at unprecedented rates, and although the evidence
base for practice grows stronger every day, healthcare providers must
repeatedly make decisions and take action in situations that are
characterized by ambiguity and uncertainty (Cowan & Moorhead, 2011).

Faculty in nursing have made efforts to transition curriculum and
programs to accommodate the knowledge explosion and the advanced
technology associated with health care. However, the transition within the
programs of nursing has assumed a patchwork approach instead of
significant reform. This is in part the result of the tradition associated with
the history of nursing education, the inability to resolve the differences in
prelicensure programs, and the faculty propensity to be reluctant to leave
behind what is no longer successful in a changing practice arena. In
addition, nurse educators are caught in the “perfect storm” composed of

a changing healthcare delivery system, changing practice models,
nursing shortage, faculty shortage, changes in external standards of care
and educational accreditation, university budget cuts, and changes in
external funding that support new nursing programs.

In 2003, the IOM issued a report titled Health Professions Education:
A Bridge to Quality (IOM, 2003a). This report, which focuses on
knowledge that healthcare professionals need to provide high-quality
care, states that students in the health professions are not prepared to
address the shifts in the country’s demographics nor are they educated to
work in interdisciplinary teams. It further states that students were not
able to access evidence for use in practice, determine the reasons for or
prevent patient care errors, or access technology to acquire the latest
information. Specifically, the report expresses concern with the adequacy
of nursing education at all levels, yet it focuses intensely on education at
the prelicensure level. The report identifies five core competencies that
all clinicians should possess: (1) provide patient-centered care, (2) work
in interdisciplinary teams, (3) use evidence-based practice, (4) apply
quality improvement and identify errors and hazards in care, and (5)
utilize informatics (IOM, 2003a).

Despite these recommendations, new standards of instruction, and
new competencies for postgraduates, the educational preparation of
nurses has remained virtually unchanged for more than 50 years.
Nursing education remains content focused and teacher centered (Valiga
& Champagne, 2011). Recently the results of two national studies
reinforced the belief that nursing education must be reformed. The two
reports, Educating Nurses: A Call for Radical Transformation (Benner,
Sutphen, Leonard, & Day, 2010) and The Future of Nursing: Leading
Change, Advancing Health (IOM, 2011), explore the issue of whether
nurses are entering practice equipped with the knowledge and skills
needed for today’s practice and prepared to continue clinical learning for

tomorrow’s nursing, given the enormous changes in and complexity of
current nursing practice and practice settings. In both reports the
response is that nurses are not prepared for future healthcare change.
Both reports challenge nursing education to make reforms in preparation
of new graduates in terms of establishing new competencies and
outcomes for graduates, new curriculum designs, new pedagogy, better
evaluation models, and new models for clinical education, such as
residency programs.

KEY COMPETENCY 7-5

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Leadership:

Knowledge (K1) Identifies leadership skills essential to the practice of
nursing

Skills (S1) Integrates leadership skills of systems thinking,
communication, and facilitating change in meeting patient care needs

Attitudes/Behaviors (A1) Recognizes the role of the nurse as leader

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

In response to the changes in healthcare delivery and the call for new
roles in nursing, two new degrees have been introduced by the AACN
since the turn of the century: the doctor of nursing practice and the
clinical nurse leader (AACN, 2007). The clinical nurse leader (CNL) is
an advanced generalist role prepared at the master’s level of education.
The CNL oversees the coordination of care for a group of patients,

assesses cohort risk, provides direct patient care in complex situations,
and functions as part of an interdisciplinary team (AACN, 2007). The
lateral integration of care has been what is missing in the delivery of care
to patients with complex needs. No single person oversees patient care
laterally and over time and is able to intervene, facilitate, or coordinate
care for the entire patient experience. The CNL will be instrumental in
helping all disciplines see the interdependencies that exist between and
among them (Begun, Hamilton, Tornabeni, & White, 2006).

The other new program within nursing is the doctor of nursing
practice (DNP). The need for this terminal practice degree is based on
the series of reports from the IOM that address quality of health care,
patient safety, and educational reform as well as following the movement
of other healthcare professions to the practice doctorate. After much
national debate, it was determined that a practice doctorate was needed
that encompasses advanced nursing roles to influence healthcare
outcomes for individual patients, management of care for individuals and
populations, administration of nursing and health organization, and the
development and implementation of health policy (AACN, 2004). It is
clearly stated that this practice degree is not the same as the research
doctoral degree and that graduates would be prepared to blend clinical,
economic, organizational, and leadership skills and to use science in
improving the direct care of patients, care of patient populations, and
practice that supports patient care (Champagne, 2006).

CRITICAL THINKING QUESTION

How do changes in nursing education reflect nursing’s responsibility in
the context of the social contract discussed earlier in this chapter?

The development of the DNP and CNL programs of study represents
a bold effort by the profession of nursing to address new roles of nursing

and educational reform needed to prepare graduates to meet the
healthcare needs of the future. Although questions and concerns related
to the implementation of these new programs still exist, the evaluation of
the implementation of these programs is mostly positive. One must
applaud the spirit of evidence-based educational innovation.

KEY COMPETENCY 7-6

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Leadership:

Knowledge (K5) Explains the importance, necessity, and process of
change

Skills (S5a) Implements change to improve patient care

Attitudes/Behaviors (A5b) Values new ideas and interventions to
improve patient care

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Closing the Education and Practice Gap
The gap between education and practice looms larger as the healthcare
setting continuously changes. In general, curricula in nursing programs
have not evolved to keep pace with changes in the practice setting;
however, the current emphasis on integrating clinical simulation, the
dedicated education unit, and nurse residency programs are steps in the
right direction.

Evidence supports that a better-educated nurse is needed in practice.

The initial educational preparation for the largest proportion of RNs is the
associate degree. During the last national nurse survey in 2008, the initial
educational level of RNs indicated that 20.4% were diploma, 45.4% were
associate degree, and 34.2% were baccalaureate (HRSA, 2010).
Leaders in nursing education must identify ways to move registered
nurses to the desired graduate level of education more expediently.

Where do we go from here? The IOM (2011) report The Future of
Nursing: Leading Change, Advancing Health provides us with a blueprint.
The IOM and Robert Wood Johnson Foundation partnered to assess and
respond to the need to transform nursing to ensure that the nursing
workforce has the capacity, in terms of numbers, skills, and competence,
to meet the present and future healthcare needs of the public. This
transformation would enable nurses to be partners and leaders in
advancing health for the future. The key messages of the study include
the following: (1) nurses should practice to the full extent of their
education and training; (2) nurses should achieve higher levels of
education and training through an improved education system that
promotes seamless academic progression; (3) nurses should be full
partners, with physicians and other health professionals, in redesigning
health care in the United States; and (4) effective workforce planning and
policy making require better data collection and an improved information
infrastructure (IOM, 2011, p. 4). Recommendations include to (1) remove
scope-of-practice barriers, (2) expand opportunities for nurses to lead
and diffuse collaborative improvement efforts, (3) implement nurse
residency programs, (4) increase the proportion of nurses with a
baccalaureate degree to 80% by 2020, (5) double the number of nurses
with a doctorate by 2020, (6) ensure that nurses engage in lifelong
learning, (7) prepare and enable nurses to lead change to advance
health, and (8) build an infrastructure for the collection and analysis of
interprofessional healthcare workforce data. It is imperative that

professional nurses control their future and redefine their roles in
practice; the recommendations and the strategies identified in this report
provide the way.

CRITICAL THINKING QUESTIONS

Based on the trends and recommendations presented in this chapter,
what do you think nursing education will look like in 2025? What do
you think the profession of nursing will look like in the year 2025?

Conclusion
Now, when you hear the word nursing, what image comes to mind? If the
picture is blurry or confused by the expanding social context presented in
this chapter—good! The cloudiness indicates that the tradition continues
to be questioned. We have looked at some of the social phenomena and
trends within the profession that help define nursing practice. Because
those experiences change constantly, what we envision now will also be
transformed. Are you ready to be a part of transforming professional
nursing practice toward a future that continues to meet the needs of
society?

Classroom Activity 7-1

Discuss what it means to be a professional nurse considering societal
trends and the current trends in the healthcare environment and
whether the identified trends pose barriers or opportunities for
professional nursing practice. This could be a class discussion, online
discussion, or prompt for an essay.

References
Agency for Healthcare Research and Quality. (2010). 2010 national
healthcare quality and disparities reports. Retrieved from
https://www.ahrq.gov/research/findings/nhqrdr/index.html

Aiken, L., Clarke, S., Sloane, D., Sochalski, J., & Silber, J. (2002).
Hospital nurse staffing and patient mortality, nurse burnout, and job
dissatisfaction. Journal of the American Medical Association, 288(16),
1987–1993.

Almada, P., Carafoli, K., Flattery, J., French, D., & McNamara, M. (2004).
Improving the retention rate of newly graduated nurses. Journal for
Nurses in Staff Development, 20(6), 268–273.

American Association of Colleges of Nursing. (2004). AACN position
statement on the practice doctorate in nursing. Retrieved from
http://www.aacnnursing.org/Portals/42/News/Position-
Statements/DNP.pdf

American Association of Colleges of Nursing. (2007). White paper on the
education and role of the clinical nurse leader. Washington, DC:
Author.

American Association of Colleges of Nursing. (2008a). Cultural
competency in baccalaureate nursing education. Retrieved from
http://www.aacnnursing.org/Portals/42/AcademicNursing/CurriculumGuidelines/Cultural-
Competency-Bacc-Edu.pdf?ver=2017-05-18-143551-883

American Association of Colleges of Nursing. (2008b). The essentials of
baccalaureate education for professional nursing practice. Washington,
DC: Author.

American Association of Colleges of Nursing. (2012). Enrollment and
graduations in baccalaureate and graduate programs in nursing.

Washington, DC: Author.
American Association of Colleges of Nursing. (2015). New AACN data
confirm enrollment surge in schools of nursing. Syllabus, 41(2), 1.
Retrieved from
http://www.aacnnursing.org/Portals/42/Publications/Syllabus/March-
April-2015.pdf

American Association of Colleges of Nursing. (2017a). 2016–2017
enrollment and graduations in baccalaureate and graduate programs in
nursing. Washington, DC: Author.

American Association of Colleges of Nursing. (2017b). Fact sheet:
Nursing shortage. Retrieved from
http://www.aacnnursing.org/Portals/42/News/Factsheets/Nursing-
Shortage-Factsheet-2017.pdf?ver=2017-10-18-144118-163

American Association of Colleges of Nursing. (2017c). Nursing faculty
shortage fact sheet. Retrieved from
http://www.aacnnursing.org/Portals/42/News/Factsheets/Faculty-
Shortage-Factsheet-2017.pdf?ver=2017-07-11-103742-167

American Association of Colleges of Nursing. (2017d). Race/ethnicity of
students enrolled in generic (entry-level) baccalaureate, master’s, and
doctoral (research-focused) programs in nursing, 2007–2016.
Retrieved from http://www.aacnnursing.org/Portals/42/News/Surveys-
Data/EthnicityTbl.pdf

American Hospital Association. (2003). The patient care partnership:
Understanding expectations, rights, and responsibilities. Retrieved
from https://www.aha.org/system/files/2018-01/aha-patient-care-
partnership.pdf

American Nurses Association. (1992). Position statement on registered
nurse utilization of unlicensed assistive personnel. Washington, DC:
Author.

American Nurses Association. (1997). Implementing nursing’s report

card: Study of RN staffing, length of stay, and patient outcomes.
Washington, DC: Author.

American Nurses Association. (1999). Principles for nurse staffing.
Washington, DC: Author.

American Nurses Association. (2007). American Nurses Association
recognizes the contributions of men in nursing with the (ANA) Luther
Christman Award. Wyoming Nurse, 20(2), 13.

American Nurses Association. (2010). Nursing’s social policy statement:
The essence of the profession. Silver Spring, MD: Author.

American Nurses Association. (2011). 2011 ANA health and safety
survey. Retrieved from
http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-
Work-Environment/Work-Environment/2011-HealthSafetySurvey.html

American Nurses Association. (2012). Bullying in the workplace:
Reversing a culture. Silver Spring, MD: Author.

American Nurses Association. (2015). Nursing: Scope and standards of
practice (3rd ed.). Silver Spring, MD: Author.

American Society of Registered Nurses. (2008). Men in nursing.
Retrieved from http://www.asrn.org/journal-nursing/374-men-in-
nursing.html

Armstrong, F. (2002). Not just women’s business: Men in nursing.
Australian Nursing Journal, 9(11), 24–26.

Beecroft, P., Dorey, F., & Wentin, M. (2008). Turnover intention in new
graduate nurses: A multivariate analysis. Journal of Advanced Nursing,
62(11), 41–52.

Begun, J., Hamilton, J., Tornabeni, J., & White, K. (2006). Opportunities
for improving patient care through lateral integration: The clinical nurse
leader. Journal of Healthcare Management, 51(1), 19–25.

Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses:
A call for radical transformation. San Francisco, CA: Jossey-Bass.

Betancourt, J. R., Green, A. R., Carrillo, J. E., & Ananeh-Firempong, O.
(2003). Defining cultural competence: A practical framework for
addressing racial/ethnic disparities in health and health care. Public
Health Report, 118(4), 293–302.

Blais, K., Hayes, J. S., Kozier, B., & Erb, G. (2001). Professional nursing
practice: Concepts and perspectives (4th ed.). Upper Saddle River, NJ:
Pearson.

Brady, M. S., & Sherrod, D. R. (2003). Retaining men in nursing
programs designed for women [Electronic version]. Journal of Nursing
Education, 42, 159–163.

Brenan, M. (2017). Nurses keep healthy lead as most honest, ethical
profession. Retrieved from http://news.gallup.com/poll/224639/nurses-
keep-healthy-lead-honest-ethical-profession.aspx

Brown, B. (2004). From the editor: Restoring caring back into nursing.
Nursing Administration Quarterly, 28, 237–238.

Bureau of Labor Statistics. (2017, October). Employment projections:
2016–26. Retrieved from
https://www.bls.gov/news.release/pdf/ecopro.pdf

Buresh, B., & Gordon, S. (2000). From silence to voice: What nurses
know and must communicate to the public. New York, NY: Cornell
University Press.

Buresh, B., & Gordon, S. (2006). From silence to voice: What nurses
know and must communicate to the public (2nd ed.). Ithaca, NY:
Cornell University Press.

Buresh, B., & Gordon, S. (2013). From silence to voice: What nurses
know and must communicate to the public (3rd ed.). Ithaca, NY:
Cornell University Press.

Cardillo, D. W. (2001). Your first year as a nurse: Making the transition
from total novice to successful professional. Roseville, CA: Prima.

Centers for Disease Control and Prevention. (2012). Clinical outreach

and communication activity (COCA). Retrieved from
https://emergency.cdc.gov/coca/index.asp

Champagne, M. (2006). The future of nursing education: Educational
models for future care. In P. Cowen & S. Moorhead (Eds.), Current
issues in nursing (7th ed., pp. 57–67). St. Louis, MO: Mosby Elsevier.

Chung, V. (2000, Summer). Men in nursing: Representing less than 1%
of all working R.N.s, minority men are shattering stereotypes and
making their mark on the nursing profession. Minority Nurse, 38–42.

Clark, J. (2004). An aging population with chronic disease compels new
delivery systems focused on new structures and practice. Nursing
Administration Quarterly, 28, 105–115.

Cooper, P. (2004). Nurse–patient ratios revisited [Editorial]. Nursing
Forum, 39(2), 3–4.

Cowan, P., & Moorhead, S. (2011). Nursing education in transition. In P.
S. Cowen & S. Moorhead (Eds.), Current issues in nursing (8th ed., pp.
72–74). St. Louis, MO: Mosby Elsevier.

Cram, E. (2011). Staff nurses working in hospitals: Who they are, what
they do, and what are their challenges? In P. Cowen & S. Moorhead
(Eds.), Current issues in nursing (8th ed., pp. 13–22). St. Louis, MO:
Mosby Elsevier.

Dean, P. (2005). Transforming ethnocentricity in nursing: A culturally
relevant experience of reciprocal visits between Malta and the
Midwest. Journal of Continuing Education in Nursing, 36(4), 163, 167.

DeSantis, L., & Lipson, J. (2007). Brief history of inclusion of content on
culture in nursing education. Journal of Transcultural Nursing, 18(7),
7s–9s.

Duffield, C., Gardner, G., & Catling-Paull, C. (2008). Nursing work and
the use of time. Journal of Clinical Nursing, 17, 3269–3274.

Ebright, P. (2010). The complex work of RNs: Implications for healthy
work environments. Online Journal of Issues in Nursing, 15(1).

doi:10.3912/OJIN.Vol15No01Man04
Ebright, P., Patterson, E., Chalko, B., & Render, M. (2003).
Understanding the complexity of registered nurse work in acute care
settings. Journal of Nursing Administration, 33(12), 630–638.

Ellison, D, & Farrar, F. C. (2015). Aging population. Nursing Clinics of
North America, 50(1), 185–213.

Gordon, S. (2005). Nursing against the odds: How health care cost
cutting, media stereotypes, and medical hubris undermine nurses and
patient care. Ithaca, NY: Cornell University Press.

Gordon, S. (2010). When chicken soup isn’t enough: Stories of nurses
standing up for themselves, their patients, and their profession. Ithaca,
NY: Cornell University Press.

Gordon, S., Buchanan, J., & Bretherton, T. (2008). Safety in numbers:
Nurse-to-patient ratios and the future of health care. Ithaca, NY:
Cornell University Press.

Grant, L. F., & Letzring, T. D. (2003). Status of cultural competence in
nursing education: A literature review [Electronic version]. Journal of
Multicultural Nursing and Health, 9(2), 6–13.

Groff-Paris, L., & Terhaar, M. (2010). Using Maslow’s pyramid and the
National Database of Nursing Quality Indicators to attain a healthier
work environment. Online Journal of Issues in Nursing, 16(1), 1–8.

Health Careers Center. (2012). Mississippi men in nursing calendar 2005.
Retrieved from http://www.mshealthcareers.com/calendar/

Health Resources and Services Administration. (2010). The registered
nurse population: Findings from the 2008 National Sample Survey of
Registered Nurses. Washington, DC: Health Resources and Services
Administration, Bureau of Health Professions.

Howden, L. M., & Meyer, J. A. (2011). Age and sex composition: 2010.
Washington, DC: U.S. Census Bureau. Retrieved from
http://www.census.gov/prod/cen2010/briefs/c2010br-03.pdf

Huntington, A., Gilmour, J., Tuckett, A., Neville, S., Wilson, D., & Turner,
D. (2012). Is anybody listening? A qualitative study of nurses’
reflections on practice. Journal of Clinical Nursing, 20, 1413–1422.

Institute of Medicine. (2003a). Health professions education: A bridge to
quality. Washington, DC: National Academies Press.

Institute of Medicine. (2003b). Unequal treatment: Confronting racial and
ethnic disparities in health care. Washington, DC: National Academies
Press.

Institute of Medicine. (2009). Guidance for establishing standards of care
for use in disaster situations. Retrieved from
http://iom.nationalacademies.org/Reports/2009/DisasterCareStandards.aspx

Institute of Medicine. (2011). The future of nursing: Leading change,
advancing health. Washington, DC: National Academies Press.

Jacob, S. R., & Carnegie, M. E. (2002). Cultural competency and social
issues in nursing and health care. In B. Cherry (Ed.), Contemporary
nursing: Issues, trends, and management (pp. 239–262). St. Louis,
MO: Mosby.

Kalisch, B., & Kyung, H. (2011). Nurse staffing levels and teamwork: A
cross-sectional study of patient care units in acute care hospitals.
Journal of Nursing Scholarship, 43(1), 82–88.

Kavanagh, K. H. (2001). Social and cultural dimensions of health and
health care. In J. L. Creasia & B. Parker (Eds.), Conceptual
foundations: The bridge to professional nursing practice (pp. 294–314).
St. Louis, MO: Mosby.

Keogh, B., & O’Lynn, C. (2007). Male nurses’ experiences of gender
barriers: Irish and American perspectives. Nurse Educator, 32(6), 256–
259.

Kinsella, K., & Velkoff, V. A. (2001). An aging world: 2001. Washington,
DC: U.S. Census Bureau. Retrieved from
http://www.census.gov/prod/2001pubs/p95-01-1.pdf

Kovner, C., Brewer, C., Fairchild, S., Poornima, S., Hongsoo, K., &
Djukic, M. (2007). Newly licensed RNs’ characteristics, work attitudes,
and intentions to work. American Journal of Nursing, 107(9), 58–70.

Krichbaum, K., Diemart, C., Jacox, L., Jones, A., Koenig, P., Mueller, C.,
& Disch, J. (2007). Complexity compression: Nurses under fire.
Nursing Forum, 42(2), 86–95.

Laschinger, H., Finegan, J., & Welk, P. (2009). New graduate burnout:
The impact of professional practice environment, workplace civility, and
empowerment. Nursing Economic$, 27(6), 377–383.

Levine, K. (2012). When speaking the same language means speaking
different languages. Retrieved from http://minoritynurse.com/when-
speaking-the-same-language-means-speaking-different-languages/

Lindberg, C., & Lindberg, C. (2008). Nurses take note: A primer on
complexity science. In C. Lindberg, S. Nash, & C. Lindberg (Eds.), On
the edge: Nursing in the age of complexity (pp. 23–47). Bordentown,
NJ: Plexus.

Longo, J., & Sherman, R. (2006). Leveling horizontal violence. Nursing
Management, 38(3), 34–37, 50–51.

Massachusetts Department of Higher Education. (2016). Nurse of the
future: Nursing core competencies: Registered nurse. Retrieved from
http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

McCue, M., Mark, B., & Harless, D. (2003). Nurse staffing, quality, and
financial performance. Journal of Healthcare Finance, 29(4), 54–76.

Meyers, S. (2003). Real men choose nursing [Electronic version].
Hospitals and Health Networks, 77(6), 72–74.

National Center for Complementary and Alternative Medicine. (2012).
Complementary, alternative, or integrative health: What’s in a name?
Retrieved from https://nccih.nih.gov/health/integrative-health

Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K.
(2002). Nurse staffing levels and the quality of care in hospitals. New

England Journal of Medicine, 346, 1715–1722.
Oregon Center for Nursing. (2002). Nursing posters. Retrieved from
http://oregoncenterfornursing.org/resources/nursing-posters/

OR Manager. (2009). The recession and the nursing shortage. OR
Manager, 25(5). Retrieved from https://www.ormanager.com/wp-
content/uploads/pdfx/ORMVol25No5RecessionAndNursingShortage.pdf

Pellico, L., Djukic, M., Kovner, C., & Brewer, C. (2009). Moving on, up, or
out: Changing work needs of new RNs at different stages of their
beginning nursing practice. Online Journal of Issues in Nursing, 15(1).
doi:10.3912/OJIN.Vol15No01PPT02

Picker Institute. (2012). Always Events® blueprint for action: Improve the
patient experience, engage staff, transform healthcare. Retrieved from
http://alwaysevents.pickerinstitute.org/wp-
content/uploads/2013/01/Always-Events-Blueprint-for-Action-11-
2012.pdf

PricewaterhouseCooper’s Health Research Institute. (2007, July). What
works: Healing the healthcare staffing shortage. Retrieved from
https://council.brandeis.edu/pdfs/2007/PwC%20Shortage%20Report.pdf

Purnell, L., & Paulanka, B. (2008). Transcultural health care: A culturally
competent approach (3rd ed.). Philadelphia, PA: F. A. Davis.

Ray, M., & Ream, K. (2007). The dark side of the job: Violence in the
emergency department. Journal of Emergency Nursing, 33(3), 257–
261.

Rocker, C. F. (2008). Addressing nurse-to-nurse bullying to promote
nurse retention. Online Journal of Issues in Nursing, 13(3).
doi:10.3912/OJIN.Vol13No03PPT05

Schmalenberg, C., & Kramer, M. (2008). Essentials of a productive nurse
work environment. Nursing Research, 57(1), 2–13.

Sigma Theta Tau International. (1998). The Woodhull study on nursing
and the media: Health care’s invisible partner. Indianapolis, IN: STTI

Center Nursing Press.
Sitterding, M. C., & Ebright, P. (2015). Information overload: A framework
for explaining the issues and creating solutions. In M. C. Sitterding &
M. E. Broome (Eds.), Information overload: Framework, tips, and tools
to manage in complex healthcare environments (pp. 11–33). Silver
Spring, MD: American Nurses Association.

Smith-Pittman, M., & McKoy, Y. (1999). Workplace violence in healthcare
environments. Nursing Forum, 34(3), 5–13.

Sofer, D. (2005). You get what you pay for: News flash: Higher nurse–
patient ratios still save lives. American Journal of Nursing, 105(11), 20.

Stanton, M., & Rutherford, M. (2004). How many nurses are enough?
Hospital staff nursing and quality care research. Accidents and
Emergency Nursing, 15(1), 1–2.

Tri-Council for Nursing. (2010). Joint statement from the Tri-Council for
Nursing on recent registered nurse supply and demand projections.
Retrieved from
http://tricouncilfornursing.org/documents/JointStatementRecentRNSupplyDemandProjections.pdf

Trossman, S. (2003). Caring knows no gender: Break the stereotype and
boost the number of men in nursing. American Journal of Nursing, 103,
65–68.

U.S. Census Bureau. (2013). Male nurses becoming more commonplace,
Census Bureau reports. Retrieved from
https://www.census.gov/newsroom/press-releases/2013/cb13-32.html

U.S. Department of Health and Human Services. (2010a). About the
Affordable Care Act. Retrieved from
https://www.hhs.gov/healthcare/about-the-aca/index.html

U.S. Department of Health and Human Services. (2010b). The registered
nurse population: Findings from the 2008 National Sample Survey of
Registered Nurses. Retrieved from
https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/rnsurveyfinal.pdf

U.S. Department of Health and Human Services. (2014). Healthy people
2020: Older adults. Retrieved from
https://www.healthypeople.gov/2020/topics-objectives/topic/older-
adults

Valente, S., & Bullough, V. (2004). Sexual harassment of nurses in the
workplace. Journal of Nursing Care Quality, 19(3), 234–241.

Valiga, T., & Champagne, M. (2011). Creating the future of nursing
education: Challenges and opportunities. In P. Cowen & S. Moorhead
(Eds.), Current issues in nursing (pp. 75–83). St. Louis, MO: Mosby
Elsevier.

Zimmerman, P. (2006). Who should provide nursing care? In P. Cowen &
S. Moorhead (Eds.), Current issues in nursing (7th ed., pp. 324–331).
St. Louis, MO: Mosby Elsevier.

© James Kang/EyeEm/Getty Images

UNIT II

Professional Nursing Practice
and the Management of Patient

Care

© James Kang/EyeEm/Getty Images

CHAPTER 8

Safety and Quality
Improvement in Professional
Nursing Practice
Kathleen Masters

Learning Objectives

After completing this chapter, the student should be able to:

1. Explore various definitions of safety.
2. Describe the system approach to patient care safety.
3. Describe organizational culture in relationship to patient safety.

4. Describe the role of nurses in delivering safe health care.
5. Explore the link between quality and safety.
6. Discuss the relationship of transparency and reporting to

healthcare quality.
7. Describe nursing-sensitive measures.
8. Discuss the need for continuous quality improvement (CQI) in

the provision of patient care.
9. Discuss the role of the nurse in quality improvement.

Key Terms and Concepts

Safety
Error
Culture of safety
Just culture
Patient handoff
Never events
Sentinel events
Quality
Quality improvement
Care bundle
Benchmarking
Healthcare transparency
Core measures
Accountability measures
Composite measures
Nursing-sensitive measures
Continuous quality improvement (CQI)

Patient Safety
The definition of safety provided by the Quality and Safety Education for
Nurses (QSEN) (Cronenwett et al., 2007; QSEN, 2007) project refers to
the minimization of risk of harm to patients and providers through both
system effectiveness and individual performance. The Massachusetts
Department of Higher Education (2010) uses the QSEN definition in the
development of its safety competencies for the “nurse of the future.”

In its landmark report To Err Is Human: Building a Safer Health
System, the Institute of Medicine (IOM, 2000) defined patient safety as
freedom from accidental injury. In the same report, it estimated that at
least 44,000 and possibly up to 98,000 people died each year as the
result of preventable harm while receiving health care that was supposed
to help them. Subsequent to this report, the IOM produced nine more
reports regarding patient quality and safety. Why? Because the original
report brought attention to the problems related to patient safety that
permeate the healthcare system.

Culture of Safety
The IOM report (2000), although identifying alarming problems related to
safety, was clear that the cause of the errors was defective system
processes that either led people to make mistakes or failed to stop them
from making a mistake, not the recklessness of individual providers. The
report included such recommendations as the development of safer
systems that would make it more difficult for humans to make mistakes.

KEY OUTCOME 8-1

Example of applicable outcomes expected of the graduate from a

baccalaureate program

Essential II: Basic Organizational and Systems Leadership for Quality
Care and Patient Safety

2.7 Promote factors that create a culture of safety and caring (p. 14).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

The IOM report (2000) defined error as the failure of a planned
action to be completed as intended or the use of a wrong plan to achieve
an aim with the goal of preventing, recognizing, and mitigating harm.
Adverse drug events and improper transfusions, surgical injuries and
wrong site surgeries, suicides, restraint-related injuries or death, falls,
burns, pressure ulcers, and mistaken patient identities were among the
commonly occurring errors. Any aspect of required nursing care that is
not provided or missed nursing care is classified as an error of omission
(Kalisch, 2015) and by description is included in the IOM definition of an
error.

When errors occur, it is possible to analyze the event in two ways, a
person approach or a system approach. Historically, in healthcare
organizations errors were viewed from the person approach to safety or
finding out who is at fault. This approach results in making the person
who committed the error the target of blame and creates an environment
where providers fear admitting to mistakes and thus hide mistakes. This
approach is counter to creating a culture of safety and transparency
because it frequently results in disciplinary action. A safety culture, or
culture of safety, is one that promotes trust and empowers staff to report
risks, near misses, and errors (Hershey, 2015). Three key attributes in a
culture of safety are trust of peers and management, reporting unsafe

conditions, and improvement. Trust and reporting are increased when
staff can observe improvements being made to correct unsafe conditions
(Chassin & Loeb, 2013). Trust is lacking in many healthcare
organizations, with many staff believing that error reporting will be held
against them (Agency for Healthcare Research and Quality [AHRQ],
2014). This lack of trust leads to underreporting of errors and to the
potential for more errors (Hershey, 2015). In a culture of safety, the focus
is on what went wrong rather than on who made the error. Patient safety
initiatives can succeed when embedded in an organizational culture of
safety (Rovinski-Wagner & Mills, 2014).

A system approach to safety includes viewing the error in the context
of prevention of future errors by looking at all the factors related to the
incident. Nurses working in an organization with a system approach to
safety are more likely to admit to errors or near misses because the
identification of system issues will lead to patient safety. The system
approach does not negate the accountability of the nurse for his or her
actions but allows for analysis of the error in a way that explores system
problems to prevent future errors (Figure 8-1). This balance between not
blaming individuals for errors and not tolerating careless or egregious
behaviors is known as a just culture (Mitchell, 2008).

Figure 8-1 A person centered or blaming approach to error will not solve system issues and may
lead to employees hiding errors due to fear of reprimand.

© Blaj Gabriel/Shutterstock, Inc.

KEY COMPETENCY 8-1

Examples of applicable Nurse of the Future: Nursing Core
Competencies
Safety:

Knowledge (K4b) Describes factors that create a culture of safety

Skills (S4a) Participates in collecting and aggregating safety data

Skills (S4b) Uses organizational error reporting system for “near miss”
and error reporting

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Measures of safety culture indicate that three areas of health care are
in greatest need of improvement: a nonpunitive response to error,
handoffs and transitions, and safe staffing (Hershey, 2015). If the

healthcare system does include disciplinary action for error, then the
basis of the punishment should be the type of behavior rather than the
outcome of the error. The types of behavior that may result in error are
human behavior, negligence, intentional rule violations, and reckless
conduct. Human error does not change because of disciplinary action.
There are arguments for and against punishment for negligence. Much
can be learned to create safer systems to prevent future errors that result
from human error and negligence. In the case of intentional rule
violations, it is important to look at the latent issues creating a situation in
which staff are violating rules intended to promote patient safety rather
than revert to discipline. However, in the case of reckless behavior,
punishment is warranted (Marx, 2001).

A root cause analysis is one method to review error that has already
occurred, and along with actions to eliminate risks, it is required by the
Joint Commission for all sentinel events. A common approach to root
cause analysis is a cause-and-effect diagram or fishbone diagram.
During this process, the problem is clarified by completing an event flow
diagram. The problem statement is the “head of the fish,” and the related
processes or categories that are potential causes of the problem are
clarified by completing an event flow diagram that consists of the main
bones of the fish. Next, subcategories of causation or contributing factors
are developed that create each of the smaller bones or branches of the
diagram. The diagram is completed as relationships among causal
chains are identified and causal statements are developed.

This process requires asking why the event happened in order to
identify the underlying source of the error (Barnsteiner, 2012). This
method considers elements of the total system rather than just the
behavior of an individual involved in an error and can be used to review
data over time to identify the system variables that contributed to errors
during the identified period (Rovinski-Wagner & Mills, 2014). See Figure

8-2 for a typical fishbone diagram.

Figure 8-2 Typical fishbone diagram.

An example of the use of an ongoing root cause analysis to increase
patient safety is the Taxonomy of Error, Root Cause Analysis, and
Practice-Responsibility (TERCAP) initiative by the National Council of
State Boards of Nursing (2013). The goal of the TERCAP initiative is to
develop a data set to distinguish human and system errors from
negligence or misconduct while identifying the areas of nursing practice
breakdown in relation to standards of nursing practice (Malloch, Benner,
Sheets, Kenward, & Farrell, 2010). Practice breakdown categories
include safe medication administration, documentation,
attentiveness/surveillance, clinical reasoning, prevention, intervention,
interpretation of authorized providers’ orders, and professional
responsibility/patient advocacy. System factors include communication,
leadership/management, backup and support, environment, other health
team members, staffing issues, and the healthcare team. Twenty-six
state boards of nursing participate in TERCAP.

KEY COMPETENCY 8-2

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Safety:

Knowledge (K5) Describes how patients, families, individual clinicians,
healthcare teams, and systems can contribute to promoting safety and
reducing errors

Skills (S4f) Participates in safety surveys

Skills (S5) Participates in analyzing errors and designing systems
improvements

Attitudes/Behaviors (A5) Recognizes the value of analyzing systems
and individual accountability when errors or near misses occur

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

KEY COMPETENCY 8-3

Examples of applicable Nurse of the Future: Nursing Core
Competencies
Safety:

Knowledge (K6a) Describes processes used in understanding causes
of error and in allocation of responsibility and accountability

Skills (S6b) Participates within methods for evaluating and improving
the overall reliability of a complex system

Attitudes/Behaviors (A6b) Values the importance for using a model for
applying the principles of reliability to healthcare systems: prevent
failure, identify and mitigate failure and redesign processes on
identified failure

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Another framework that is used to identify events or characteristics of
a system that may allow potential errors is known as Reason’s Adverse
Event Trajectory or the Swiss Cheese Model (Reason, 2000). This model
explains how faults in different layers of the system can lead to error
through triggers that can set up a sequence of events. Multiple defenses
that have been set in place to prevent errors may at times line up,
allowing multiple triggers to align and thus allow an error to occur. The
lining up of triggers has been illustrated as an arrow and the lining up of
defenses the alignment of holes in Swiss cheese (thus the name Swiss
Cheese Model). When the defenses line up, the arrow or trigger goes
through the defenses (holes) and an error may occur. When the defenses
do not line up, then the trigger (arrow) is blocked and the error is averted.

Classification of Error
Errors may be classified by type. Types of errors include communication,
patient management, and clinical performance before, during, or after
interventions. Improper delegation is an example of a patient
management error. The potential for communication error occurs during
transitions in care and handoffs. Standardization in handoff processes
with face-to-face communication is key to patient safety. Standardized
change of shift checklists and SBAR (situation, background, assessment,
recommendation) are two frequently used approaches to effective
communication (Barnsteiner, 2012). A patient handoff is the transfer of
responsibility for a patient from one clinician to another (Rovinski-Wagner
& Mills, 2014) and provides a frequent opportunity for error. Because of
the vulnerability inherent in the patient handoff process, the Joint

Commission has published expectations for handoffs in the National
Patient Safety Goals. These expectations include an opportunity for
questioning between the giver and receiver; provision of current
information regarding patient care, treatment, services, conditions, and
any changes; verification of information in the form of repeat-back or
read-back; the recipient of information having the opportunity to review
patient data; and limits on interruptions during handoffs to minimize
opportunities for information transfer failures (Barnsteiner, 2012).

Errors may also be classified according to where the error occurs in
the healthcare system. These errors include latent failure, arising from
decisions affecting such things as organizational policies or allocation of
resources, and active failure, referring to errors or harm at the “sharp”
end or in direct contact with the patient. Organizational system failures
are those errors related to management, organizational culture, and
system process; technical failure refers to indirect failure of facilities or
external resources. These terms also help identify the root cause of harm
or error (Mitchell, 2008). An example of a potential error that results from
management decisions is related to staffing levels on patient care units.
There is a clear and documented relationship among insufficient staffing,
excessive workloads, staff fatigue, and adverse events in health care,
with nurses working shifts longer than 12.5 hours being three times more
likely to make a patient care error (Joint Commission, 2011).

KEY COMPETENCY 8-4

Examples of applicable Nurse of the Future: Nursing Core
Competencies
Safety:

Knowledge (K3) Discusses effective strategies to enhance memory
and recall and minimize interruptions

Skills (S3) Uses appropriate strategies to reduce reliance on memory
and interruptions

Attitudes/Behaviors (A3) Recognizes that both individuals and systems
are accountable for a safe culture

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Errors that result from human factors can be classified as skill-based,
rule-based, or knowledge-based error (Henriksen, Dayton, Keyes,
Carayon, & Hughes, 2008). Skill-based errors occur when there is a
deviation in the pattern of a routine activity; for example, a skill-based
error could result if a nurse is interrupted during medication
administration. Workarounds and shortcuts by the nurse are examples of
rule-based and knowledge-based errors that occur because of mistakes
in conscious thought. Workarounds occur when nurses create a quick
way to solve a problem caused by some obstruction to providing care.
Workarounds generally occur because nurses are busy or the process is
time consuming or complicated. Workarounds may result in harm to
patients when system defense mechanisms are bypassed. Strategies to
eliminate workarounds include the addition of nurses in workflow
planning as well as mechanisms within organizations for reporting and
solving workflow issues in a timely manner (Barnsteiner, 2012).

KEY COMPETENCY 8-5

Examples of applicable Nurse of the Future: Nursing Core
Competencies
Safety:

Knowledge (K4a) Delineates general categories of errors and hazards
in care

Skills (S4d) Utilizes timely data collection to facilitate effective transfer
of patient care responsibilities to another professional during transitions
in care (“handoffs”)

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Improving Patient Safety
Reports prepared by the IOM propelled the quality and safety movement
in the healthcare system during the first decade of the 21st century. The
American Nurses Association (ANA) has contributed to patient safety
through the development and dissemination of practice documents, such
as Nursing’s Social Policy Statement (2010), Nursing: Scope and
Standards of Practice (2015b), and Code of Ethics with Interpretive
Statements (2015a), as well as through credentialing and legislative
efforts (Rowell, 2003). Other organizations, such as the Joint
Commission and the National Quality Forum (NQF), have also
contributed to the effort to improve patient safety through the
dissemination and development of standards and patient safety
resources. In addition, the Centers for Medicare and Medicaid Services
have linked quality indicators that relate to patient safety, such as
pressure ulcer prevalence and hospital-acquired infections, with hospital
payment, and some states have passed error-reporting laws. All these
efforts have begun to affect patient safety.

To Err Is Human: Building a Safer Health System

In addition to drawing attention to the problem of error in the healthcare
system, To Err Is Human: Building a Safer Health System (IOM, 2000)
also identified system approaches to the implementation of change in the
recommendation section of the report. The nine recommendations were
the development of user-centered designs, avoidance of reliance on
memory, attending to work safety, avoidance of reliance on vigilance,
training concepts for teams, involving patients in their care, anticipating
the unexpected, designing for recovery, and improving access to
accurate, timely information.

KEY COMPETENCY 8-6

Examples of applicable Nurse of the Future: Nursing Core
Competencies
Safety:

Knowledge (K1) Identifies human factors and basic safety design
principles that affect safety

Knowledge (K2) Describes the benefits and limitations of commonly
used safety technology

Skills (S1) Demonstrates effective use of technology and standardized
practices that support safe practice

Skills (S2) Demonstrates effective use of strategies at the individual
and systems levels to reduce risk of harm to self and others

Attitudes/Behaviors (A1) Recognizes the cognitive and physical
limitations of human performance

Attitudes/Behaviors (A2) Recognizes the tension between professional
autonomy and standardization

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

The development of user-centered designs builds on human
strengths and avoids human weaknesses. The first step is to make
things visible to users so that users can determine what actions are
possible during processes. A second step is to include affordances
and natural mappings in relation to equipment and workspace, which
includes clear communication of how the equipment is to be used,
whether by design or through symbols indicating operations. Finally,
user-centered design also includes what are known as constraints or
forcing functions. Constraints make it hard to do the wrong thing. A
forcing function makes it impossible to do the wrong thing; for
example, using different tubing connections for intravenous lines and
enteral lines makes it impossible to inadvertently switch the
connections.
Standardization reduces reliance on memory and allows even those
unfamiliar with a device to use it safely. When devices or medications
cannot be standardized, they should be clearly distinguishable. In
addition, simplifying procedures minimizes the chance of error
because less problem solving and fewer steps are required.
Work conditions, such as work hours, workloads, staffing ratios, and
shift changes, that affect the circadian rhythm of the nurse affect both
patient safety and worker safety.
People cannot remain vigilant for long periods, so the use of
checklists and auditory and visual alarms can increase patient safety
by avoiding reliance on vigilance. Avoiding long work shifts also helps
decrease errors related to the limitations in vigilance of humans.
Because healthcare professionals work in teams, the establishment
of training programs for interprofessional teams is recommended. As

team members, professionals must trust the judgment and expertise
of colleagues.
Patients and family members should be invited to be active partners
in the care process. The healthcare team is able to provide better
care when they are able to obtain accurate information from patients,
and safety improves when patients and their caregivers know about
their care.
Whenever there are changes in an organization or technologies,
healthcare professionals should anticipate the unexpected, which
includes the possibility of an increase in error. Most organizations
pilot new technologies prior to organization-wide implementation in
order to test and modify as necessary to decrease the potential of
unintended harm.
Another recommendation includes the assumption that errors will
occur and to design and plan for recovery from errors. An example of
a strategy used to anticipate and plan for recovery from error is using
simulation training to rehearse procedures for responding to adverse
events.
Finally, improving access to accurate, timely information, such as the
use of decision-making tools at the point of care, will increase patient
safety. Information coordinated across settings will also improve
patient safety (Donaldson, 2008).

Crossing the Quality Chasm: A New Health
System for the 21st Century
Building on the previous IOM report (2000), Crossing the Quality Chasm:
A New Health System for the 21st Century (IOM, 2001) introduced
performance expectations to create a system in which patients are
assured care that is safe, timely, effective, efficient, equitable, and patient

centered. These expectations are known as the six aims for improving
healthcare quality and are sometimes referred to in the literature as
STEEEP.

In addition, the report outlined 10 rules for redesign to move the
healthcare system toward the identified performance expectations. Most
of the rules relate primarily to quality, but one of the rules is specific to
safety. Rule number six states that safety is a system property. This
means that patients should be safe from harm caused by the healthcare
system and that reducing risk and ensuring safety require attention to
system processes.

Keeping Patients Safe: Transforming the Work
Environment of Nurses
Nurses are the healthcare professionals who spend the most time with
patients and who provide the majority of direct care to patients. The IOM
(2004) report Keeping Patients Safe: Transforming the Work Environment
of Nurses specifically addressed the link between the work environment
of nurses and patient quality and safety. The report identified six major
concerns related to direct care in nursing: monitoring patient status and
surveillance, physiologic therapy, helping patients compensate for loss of
function, emotional support, education for patients and families, and
integration and coordination of care. Some of the key safety
recommendations of this report included that the chief nursing executive
should have a leadership role in the organization, the creation of
satisfying work environments for nurses, evidence-based nurse staffing
and scheduling to control fatigue, giving nurses a voice in patient care
delivery, and designing work environments and cultures that promote
patient safety.

Medication error is an area that affects nurses and is directly affected

by nurses because nurses are primarily responsible for medication
administration in acute care settings. Medication errors make up the
largest category of errors, with 3% to 4% of patients experiencing a
serious error during hospitalization (IOM, 2006). Medication error
accounts for over 7,000 deaths per year; on average, a patient in an
inpatient setting will experience at least one medication error per day
(Aspen, Walcott, Bootman, & Cronenwett, 2007). In response to these
errors, the IOM (2006) made several recommendations to decrease
medication error and to increase patient safety. These recommendations
included a paradigm shift in the patient–provider relationship in which the
patient takes an active role in the healthcare process and the provider
does a better job of educating the patient about medications (Figure 8-3).
Additional recommendations included using information technology to
reduce medication errors, improving medication labeling and packaging,
and policy changes to encourage the adoption of practices that will
reduce medication errors.

Figure 8-3 The nurse has a responsibility to educate the patient about medications.
© phakimata

Other Safety Initiatives

The goal of the NQF (2010) is to improve the quality of health care by
setting national goals for performance improvement, endorsing national
consensus standards for measuring and public reporting on performance,
and promoting the attainment of national goals. The original set of the
NQF–endorsed safe practices was released in 2003, and it was updated
in 2006, 2009, and again in 2010 with the most current evidence. The
endorsed safe practices “were defined to be universally applied in all
clinical settings in order to reduce the risk of error and harm for patients”
(NQF, 2010, p. i). The NQF presents 34 practices that have been shown
to decrease the occurrence of adverse health events. The practices are
organized into seven categories for improving patient safety: creating and
sustaining a culture of safety; informed consent, life-sustaining treatment,
disclosure, and care of the caregiver; matching healthcare needs with
service delivery capability; facilitating information transfer and clear
communication; medication management; prevention of healthcare-
associated infections; and condition and site-specific practices that
include such topics as fall prevention, pressure ulcer prevention, and
wrong site surgery (NQF, 2010).

KEY OUTCOME 8-2

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential III: Scholarship for Evidence-Based Practice

3.8 Acquire an understanding of the process for how nursing and
related healthcare quality and safety measures are developed,
validated, and endorsed (p. 16).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

The NQF (2010) also endorses a list of 29 preventable, measurable,
serious adverse events for public reporting. These events are known as
never events. Never events are not expected, and Medicare has
eliminated reimbursement for certain never events. Example never
events include patient suicide, sexual assault on a patient, abduction of a
patient, patient death associated with a fall, infant discharged to the
wrong person, surgery performed on the wrong body part, and patient
death or disability associated with the use of restraints or bedrails
(Haviley, Anderson, & Currier, 2014). These never events are organized
into seven categories—six relating to provision of care (surgical or
invasive procedure events, product or device events, patient protection
events, care management events, environmental events, and radiologic
events) and one category relating to four potential criminal events. The
NQF acknowledges that a healthcare organization cannot eliminate all
risk of adverse events; however, it can take measures to reduce risk.

In 2002, the Joint Commission introduced the National Patient Safety
Goals in order to promote improvements in patient safety. These goals
are reviewed and updated annually and focus on systemwide solutions to
problems identified in healthcare organizations (Barnsteiner, 2012).
National Patient Safety Goals are organized by setting but are very
similar across settings. The Hospital National Patient Safety Goals for
2018 include identifying patients correctly, using medications safely,
improving staff communication, using alarms safely, preventing infection,
identifying patient safety risks (suicide risk), and preventing mistakes in
surgery (Joint Commission, 2018a).

Never events are also sentinel events. A sentinel event is an
unexpected occurrence involving death or serious physical or
psychological injury or the risk thereof and is termed sentinel because the

event signals the need for immediate investigation and response.
Organizations are not required to report sentinel events to the Joint
Commission, but those accredited by the Joint Commission are
encouraged to do so. Examples of sentinel events include wrong patient,
wrong site, wrong procedure, delay in treatment, operative or
postoperative complication, retention of foreign body, suicide, medication
error, perinatal death or injury, and criminal events. Between 1995 and
2017, 13,688 sentinel events were reviewed by the Joint Commission,
most of which were self-reported occurrences in hospital settings (Joint
Commission, 2018d). State laws generally require the reporting of
sentinel events.

KEY COMPETENCY 8-7

Examples of applicable Nurse of the Future: Nursing Core
Competencies
Safety:

Knowledge (K6b) Discusses potential and actual impact of established
patient safety resources, initiatives and regulations

Skills (S6a) Uses established safety resources for professional
development and to focus attention on assuring safe practices

Attitudes/Behaviors (A6a) Values the systems’ benchmarks that arise
from established safety initiatives

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

With all these reports and initiatives related to patient safety, have we
made progress over the past decade? Progress toward IOM goals has

been slow, but studies show that there has been some measurable
progress in relation to patient safety. Healthcare organizations have
responded to incentive programs, accreditation standards, and public
opinion. Professional organizations have responded with revisions to
professional standards that place more emphasis on healthcare quality
and patient safety. Educators have responded by revising curricula to
infuse quality and safety concepts into student didactic and clinical
experiences guided by such projects as the QSEN initiative (QSEN,
2007) and Nurse of the Future (Massachusetts Department of Higher
Education, 2010, 2016).

When we talk about the reports and the data, we see the scope of the
problem; however, when we see and hear patient stories, we understand
the effect of healthcare error on patient lives. Numerous videos are
available that relay the stories of patients who became victims of faulty
systems and errors during their care. Some of the families of patient
victims have used their devastating experience to try to improve the
healthcare system and prevent other to patients and families from
suffering.

Quality Improvement in Health Care
The overall quality of health care and patient safety is improving,
particularly for hospital care and for measures that are being publicly
reported by the Centers for Medicare and Medicaid Services (CMS).
According to the Agency for Healthcare Research and Quality, hospital
care was safer in 2013 than it was in 2010, with 17% less harm to
patients and an estimated 1.3 million fewer hospital-acquired conditions
and 50,000 fewer deaths. We have come a long way; however, quality is
still far from optimal, with millions of patients harmed by the care they
receive and with only 70% of recommended care being delivered across
a broad array of quality measures (AHRQ, 2015).

Many reports, such as the one just cited, refer to quality and safety
together. But what do we mean in health care when we speak about
quality? According to the IOM (2001), quality is the degree to which
health services for individuals and populations increase the likelihood of
desired health outcomes and are consistent with current professional
knowledge. Because professional knowledge is continually increasing,
quality is a moving target; because quality is a moving target, there will
always be room for quality improvement.

KEY COMPETENCY 8-8

Examples of applicable Nurse of the Future: Nursing Core
Competencies
Safety:

Skills (S4c) Communicates observations or concerns related to
hazards and errors involving patients, families, and/or healthcare team

Skills (S4e) Discusses clinical scenarios in which sensitive and skillful

management of corrective actions to reduce emotional trauma to
patients/families is employed

Attitudes/Behaviors (A4a) Recognizes the importance of transparency
in communication with the patient, family, and health care team around
safety and adverse events

(A4b) Recognizes the complexity and sensitivity of the clinical
management of medical errors and adverse events

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

What is quality improvement? Quality improvement refers to the
use of data to monitor the outcomes of care processes and uses
improvement methods to design and test changes to continuously
improve the quality and safety of healthcare systems (Cronenwett et al.,
2007; Massachusetts Department of Higher Education, 2010; QSEN,
2007). Quality improvement focuses on systems, processes, satisfaction,
and cost outcomes, usually within a specific organization. Quality
improvement models assume that the process is continuous and that
quality can always be improved, whereas quality assurance models seek
to ensure that current quality exists (Owens & Koch, 2015).

As mentioned previously, Crossing the Quality Chasm: A New Health
System for the 21st Century (IOM, 2001) introduced performance
expectations to create a system where patients are assured care that is
safe, timely, effective, efficient, equitable, and patient centered
(STEEEP). Safe care refers to avoiding harm to patients from care that is
supposed to help them. Timely care includes reducing delays for those
who receive care and for those who provide care. Effective care refers to
the provision of services based on evidence to all who could benefit and

refraining from providing services to those not likely to benefit. Efficient
care refers to avoiding waste. Equitable refers to providing care that does
not vary in quality based on such characteristics as ethnicity, gender,
socioeconomic status, or geographic location. Patient-centered care
refers to providing care that is responsive to patient preferences, needs,
and values and ensuring that patient values guide clinical decisions.

In addition, the report outlined principles or rules for redesign to move
the healthcare system toward the identified performance expectations.
The 10 rules for redesign follow:

Care is based on continuous healing relationships with patients
receiving care whenever and wherever it is needed.
Care can be customized according to the patient’s needs and
preferences, even though the system is designed to meet the most
common types of needs.
The patient is the source of control and as such should be given
enough information and opportunity to exercise the degree of control
the patient chooses regarding decisions that affect him or her.
Knowledge is shared and information flows freely so that patients
have access to their own medical information.

CRITICAL THINKING QUESTION

How do best practices contribute to quality and safety?

Decision making is evidence based; that is, it is based on the best
available scientific knowledge and should not vary illogically between
clinicians or locations.
Safety is a system property, and patients should be safe from harm
caused by the healthcare system.
Transparency is necessary where systems make information

available to patients and families that enable them to make informed
decisions when selecting a health plan, hospital, or clinic or when
choosing alternative treatments.
Patient needs are anticipated rather than the system merely reacting
to events.
Waste of resources and patient time is continuously decreased.
Cooperation among clinicians is a priority to ensure appropriate
exchange of information and coordination of care (IOM, 2001).

KEY OUTCOME 8-3

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential II: Basic Organizational and Systems Leadership for Quality
Care and Patient Safety

2.8 Promote achievement of safe and quality outcomes of care for
diverse populations (p. 14).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

This IOM report and the quality reports that followed set the quality
standard for the healthcare system. Because patient safety and the
quality of health care cannot be separated, the report addressed both.
Recommendations in this report have affected healthcare professional
education, innovation in the realm of information technology for use in
health care, accreditation, and regulation as well as policies to align
payment for healthcare services with outcomes and purchasing of health
care with outcomes.

Another organization that has contributed to the quality movement is
the Institute for Healthcare Improvement (IHI). In 2001, the IHI and the
Voluntary Hospital Association collaborated to determine specifically how
to achieve good outcomes with high levels of reliability in critical care
units. The result of this collaborative initiative was the development of the
concept of care bundles. A care bundle is defined by IHI as a small set
of evidence-based interventions for a defined population of patients and
care settings. Several bundles have been developed, but the original two
bundles developed from the initiative were the IHI ventilator bundle and
the IHI central line bundle. The use of bundles has significantly increased
quality of care and improved patient outcomes (Owens & Koch, 2015).

One of the best-known initiatives of the IHI was the 100,000 lives
campaign when hospitals were challenged to extend or save 100,000
lives from January 2005 to June 2006 by deploying rapid response
teams; delivering reliable, evidence-based care for acute myocardial
infarction; preventing adverse drug events; preventing central line
infections; preventing surgical site infections; and preventing ventilator-
associated pneumonia. The goal of the next campaign was to prevent
harm to 5 million lives from 2006 to 2008 by preventing pressure ulcers;
reducing methicillin-resistant Staphylococcus aureus; preventing harm
from high-alert medications; reducing surgical complications; delivering
reliable, evidence-based care for congestive heart failure to reduce
readmission; and getting boards of directors involved by defining and
spreading new and leveraged processes for hospitals’ boards of directors
so that they could become far more effective in accelerating the
improvement of care (Berwick, 2014).

One of the most significant drivers of the quality movement in the
healthcare system in the United States has been the implementation of
pay for performance and more recently value-based purchasing. In a
pay-for-performance approach, there is financial benefit for healthcare

providers to report measures and to give high-quality care. Value-based
purchasing combines quality and payment but also includes strategies to
direct purchasers to high-performing institutions and health plans.
Examples of these approaches include hospitals not being paid for
secondary diagnoses related to preventable adverse events, such as
harm from fall, hospital-acquired infection, or wrong site surgery, and the
systems that make these types of data available to consumers (Johnson,
2012).

Quality Improvement Measurement
and Process
Quality improvement is data driven. One must have data to measure the
effectiveness of care or the outcomes of care in order to know how good
the care was that was provided to the patient. Another requirement for
data to be useful is that language is consistent across institutions. For
example, if one institution reports a fall only if the patient lands on the
floor and another institution reports a fall based on the patient falling,
even though she is caught before landing on the floor, fall data will be
measuring different phenomena in the two institutions (Johnson, 2012).
For data to be meaningful, the measures must be valid. For data to be
comparable across multiple institutions, the data must reflect measures
of the same phenomena. Data collected can then provide information
related to how much care varies among nurses, units, and organizations
as well as from the standard that is based on current professional
knowledge.

KEY OUTCOME 8-4

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential II: Basic Organizational and Systems Leadership for Quality
Care and Patient Safety

2.6 Apply concepts of quality and safety using structure, process, and
outcome measures to identify clinical questions and describe the
process of changing current practice (p. 14).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

In addition, measures of quality may vary based on various
perspectives. For example, hospital administrators may define quality in
terms of patient satisfaction, physicians may define quality in terms of
treatment of disease, and nurses may define quality in terms of meeting
all goals made with patients (Amer, 2013). Regardless of the quality
indicators chosen, measures are the most useful when they can be
compared with measures that are considered the standard or best
practice measures, thus allowing institutions to compare outcomes.
Commonly, benchmarks are national or state averages and may include
highest and lowest score by category (Johnson, 2012). Benchmarking
may be defined as seeking out and implementing best practices or
seeking to attain an attribute or achievement that serves as a standard
for other institutions to emulate. Benchmarking may be either internal or
external. Internal benchmarking may have the limitation of small numbers
of units for comparison, whereas external benchmarking allows
comparison with large numbers and top performers. Using
benchmarking, data are compared to determine level of performance and
use a systematic method to identify a problem, select best practices,
determine how best practices fit the unit or organization, initiate a change
process, and evaluate outcomes (Vottero, Block, & Bonaventura, 2012).

KEY COMPETENCY 8-9

Examples of applicable Nurse of the Future: Nursing Core
Competencies
Quality Improvement:

Knowledge (K1) Describes the nursing context for improving care

Skills (S1a) Actively seeks information about quality initiatives in their
own care settings and organization

(S1b) Actively seeks information about quality improvement in the care
setting from relevant institutional, regulatory and local/national sources

Attitudes/Behaviors (A1) Recognizes that quality improvement is an
essential part of nursing

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Benchmarking begins with identification of the quality indicator that
will be measured. Quality indicators are classified as structure, process,
or outcome indicators. Structure indicators reflect attributes of the care
environment and may include elements like staffing or availability of
technology. Process indicators include the evidence-based interventions
or actions that help achieve outcomes. Outcome indicators include the
end results of care delivery, such as hospital-acquired infection or
pressure ulcer (Vottero et al., 2012).

Healthcare Quality Reporting
Healthcare transparency tends to improve care because the public
availability of data allows patients to make informed choices about where
they want to receive healthcare services. Healthcare transparency, as
defined by the IOM (2001), is making information on the healthcare
system’s quality, efficiency, and consumer satisfaction with care, which
includes safety data, available to the public so that patients and families
can make informed decisions when choosing care and to influence the
behavior of providers, payers, and others to achieve better outcomes.

Numerous websites are available that allow consumers to access
information related to provider and healthcare system safety and quality.
Some of the best-known sites include:

CMS: www.medicare.gov/hospitalcompare/search.html?
CMS Home Health Compare:
www.medicare.gov/homehealthcompare/
The Joint Commission Quality Check:
www.qualitycheck.org/consumer/searchQCR.aspx
The Leapfrog Group Hospital Safety: www.hospitalsafetyscore.org
United Health Foundation: www.americashealthrankings.org
IPRO: www.ipro.org/for-consumers
IPRO: Why Not the Best? www.whynotthebest.org
The Commonwealth Fund: www.commonwealthfund.org

In 1998, the Joint Commission launched the first national program for
the measurement of hospital quality, initially requiring only the reporting
of nonstandardized data on performance measures. In 2002, accredited
hospitals were required to collect and report data for at least two of four
core measure sets; these data were made publicly available by the Joint
Commission in 2004 (Chassin, Loeb, Schmaltz, & Wachter, 2010).

From this beginning, we now have a healthcare quality landscape in
which the National Quality Forum has endorsed more than 600 quality
measures, and the CMS has begun to financially penalize hospitals
based on performance (Chassin et al., 2010). The Joint Commission has
collaborated with the CMS to align common measures to provide
hospitals with some relief related to numerous data collection
requirements. The system in place allows the same data sets to be used
to satisfy multiple data requirements. For example, the Joint Commission
and the CMS common measures, as well as Joint Commission–only
measures, are used in the CMS Quality Reporting Programs, and the

CMS Hospital Compare website reflects measures that the CMS and the
Joint Commission have in common (Joint Commission, 2018b).

In 2002, the Joint Commission introduced the core measures
program. Core measures are standardized performance indicators.
Because the indicators are standardized, they allow for comparison of the
measures across healthcare organizations and over time (Haviley et al.,
2014).

Measurement of performance indicator data reporting has been
integrated into the accreditation process by the Joint Commission
through what is known as the ORYX initiative. The initiative was one of
the Joint Commission’s first steps to focus the accreditation process on
an ongoing picture of performance to facilitate focus on continuous
quality improvement related to patient care, treatment, and service issues
versus looking at data only once every 3 years during the accreditation
visit (Joint Commission, 2017b).

For several years hospitals were required to report on four mandatory
measure sets: acute myocardial infarction, heart failure, pneumonia, and
surgical care improvement. In 2012, the Joint Commission also
reclassified process performance measures into accountability and
nonaccountability measures. Accountability measures are evidence-
based care processes closely linked to positive patient outcomes (Joint
Commission, 2017a). Accountability measures are quality indicators that
must meet four criteria and that are designed to identify measures that
produce the greatest positive effect on patient outcomes when hospitals
demonstrate improvement. The four criteria used to determine if an
indicator is an accountability measure are as follows:

1. Research: Strong scientific evidence demonstrates that performing
the evidence-based care process improves health outcomes.

2. Proximity: Performing the care process is closely connected to the

patient outcome.
3. Accuracy: The measure accurately assesses whether the care

process has actually been provided.
4. Adverse effects: Implementing the measure has little or no chance of

inducing unintended adverse consequences (Joint Commission,
2017a).

Measures that meet all four criteria can be used by organizations for
purposes of accountability, such as public reporting and accreditation.
Those measures that are not designated as reportable accountability
measures are still useful for quality improvement within individual
healthcare organizations (Joint Commission, 2018b).

Composite measures combine the results of related measures into
a single percentage rating calculated by adding up the number of times
recommended evidence-based care was provided to patients and
dividing this sum by the total number of opportunities to provide this care.
Composite accountability measures are derived from 44 accountability
measures within the 10 sets of measures. The current 10 sets of
measures are heart attack care, heart failure care, pneumonia care,
surgical care, children’s asthma care, inpatient psychiatric services,
venous thromboembolism care, stroke care, immunization, and perinatal
care.

Hospitals now have greater flexibility in meeting the performance
measure requirements. Data reporting requirements are intended to
support healthcare organizations in their quality improvement efforts and
are available to the public on the Joint Commission website at
www.qualitycheck.org. The public availability of performance measure
data permits comparisons of hospital performance at the state and
national levels by consumers (Joint Commission, 2017b, 2018c).

Measures of Nursing Care
Quality measurement can be viewed in terms of structure, process, and
outcome. Structure refers to the context of healthcare delivery and
includes such things as buildings, staffing, and equipment. Process refers
to the delivery of care, which includes the interactions between providers
and patients. Finally, outcomes refer to the effect of health care on the
health status of patients and populations. Using this framework,
appropriate structure is required to support processes that will lead to
desired outcomes (Donabedian, 1966). It stands to reason, then, that if
the outcome measured has not achieved the desired standard, some
attention should be given to the structures and processes in place that
affect the outcome in order to achieve the desired standard. This
framework is proving successful for increasing the quality of care
provided to patients. It is important to note, however, that although
tremendous strides have been made, most of the measures captured in
the standardized data sets described previously relate to outcomes of
medical care processes rather than reflect the effect of nursing care. The
following sections describe some ongoing efforts to capture data that
reflect the contribution of nursing to patient outcomes.

CAHPS Hospital Survey
The Hospital Consumer Assessment of Healthcare Providers and
Systems (HCAHPS, pronounced “H-CAPS”) survey, also known as the
CAHPS Hospital Survey, is the only national survey that includes a
measure of nursing quality. The survey asks a core set of questions, with
four of the questions relating specifically to nursing. The standardized
questions allow for comparisons of patient care experiences. For
example, one question asks the patient about how often they got help as
soon as they wanted after pushing the call button. The following

questions also are included in the category, How often did nurses
communicate well with patients?

KEY OUTCOME 8-5

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential II: Basic Organizational and Systems Leadership for Quality
Care and Patient Safety

2.9 Apply quality improvement processes to effectively implement
patient safety initiatives and monitor performance measures, including
nurse-sensitive indicators in the microsystem of care (p. 14).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

How often did nurses treat you with courtesy and respect?
How often did nurses listen carefully to you?
How often did nurses explain things in a way you could understand?
(U.S. Department of Health and Human Services, 2011).

These are simple questions, yet one can see that they relate to
quality in terms of the timeliness of care and the provision of patient-
centered care. Standardized questions allow for comparisons of patient
care experiences across settings.

National Voluntary Consensus Standards for Nursing-
Sensitive Care
Another effort to identify nursing-sensitive indicators to measure quality
was born in 2003 when the Robert Wood Johnson Foundation (RWJF)

funded eight research projects to examine and evaluate existing
indicators of nursing performance. The projects found that data typically
did not include the specific variables that quantify aspects of nurses’
activities or contributions to quality of care. The studies also highlighted
the need for “nursing-sensitive” measures. Nursing-sensitive measures
were identified as patient-related processes or outcomes—or structural
variables that serve as proxies to these processes and outcomes—that
reflect the nurse-quality relationship (RWJF, 2011).

The RWJF turned to the NQF to endorse the compilation of nursing-
sensitive measures through a consensus development process. In 2004,
the NQF endorsed 15 voluntary consensus standards for nursing-
sensitive care that could be used for performance measurement. These
initial nursing-sensitive measures were referred to as the NQF-15 and
included measures in three domains: patient-centered measures,
nursing-centered measures, and system-centered measures (NQF,
2004). The original list of measures included three measures related to
smoking cessation that have since been retired from the list. The current
list includes 12 endorsed measures:

Death among surgical inpatients with treatable serious complications
(“failure to rescue”): The percentage of major surgical inpatients who
experience hospital-acquired complications and die
Pressure ulcer prevalence: The percentage of inpatients who have a
hospital-acquired pressure ulcer
Falls prevalence: The number of inpatient falls per inpatient day
Falls with injury: The number of inpatient falls with injury per inpatient
day
Restraint prevalence: The percentage of inpatients who have a vest
or limb restraint
Urinary catheter–associated urinary tract infection for intensive care

unit (ICU) patients: The rate of urinary tract infections associated with
use of urinary catheters for ICU patients
Central line catheter–associated bloodstream infection rate for ICU
and high-risk nursery patients: The rate of bloodstream infections
associated with the use of central line catheters for ICU and high-risk
nursery patients
Ventilator-associated pneumonia for ICU and high-risk nursery
patients: The rate of pneumonia associated with the use of
ventilators for ICU and high-risk nursery patients
Skill mix: The percentage of registered nurse, licensed
vocational/practical nurse, unlicensed assistive personnel, and
contracted nurse care hours to total nursing care hours
Nursing care hours per patient day: The number of registered nurses
per patient day and the number of nursing staff hours (registered
nurse, licensed vocational/practical nurse, unlicensed assistive
personnel) per patient day
Practice Environment Scale of the Nursing Work Index (composite
plus five subscales):

Nurse participation in hospital affairs
Nursing foundations for quality care
Nurse manager ability, leadership, and support of nurses
Staffing and resource adequacy
Collegiality of nurse–physician relations

Voluntary turnover of nursing staff: The number of nurses who leave
their jobs of their own volition during the month, by category (NQF,
2004, p. 14; RWJF, 2011, pp. 15–16)

The NQF report also identified a number of areas in which adequate
measurements simply did not exist and called for further research about
such topics as the relationship between nursing variables, including

staffing (turnover, experience, etc.) and patient outcomes, the
contribution of nurses to pain management, and the relationship between
patient outcomes and process measures for nursing-centered
interventions, including measures that describe the distinctive
contributions of nurses, such as assessment, problem identification,
prevention, and patient education. The original work was intended to be a
starting point rather than an ending point in identification of nursing-
sensitive measures. The 2009 Implementation Guide for the National
Quality Forum (NQF) Endorsed Nursing-Sensitive Care Performance
Measures provided detailed specifications for the 12 national voluntary
consensus standards for nursing-sensitive care endorsed by the NQF
(Joint Commission, 2009); however, the work to identify a comprehensive
set of nursing-sensitive measures is far from complete. Once rigorous
studies that demonstrate reliability and validity related to a nursing-
sensitive measure have been completed, they can be submitted to the
NQF for possible endorsement.

National Database of Nursing Quality Indicators (NDNQI)
In 1997, the American Nurses Association also began identifying nursing-
sensitive measures. These data are now part of a repository known as
the National Database of Nursing Quality Indicators (NDNQI). Some of
the measures included in the NDNQI are also NQF-approved measures,
but other measures are not included in the NQF approved measures list.
The NDNQI provides reporting on structure, process, and outcome on 19
nursing-sensitive indicators at the unit level. Because the data from the
NDNQI are unit-level data, they can be compared to other units in the
organization or to similar units in other geographic locations. Because the
data are unit based, the data have been used to demonstrate linkages
between unit staffing levels and patient outcomes to demonstrate the
contributions of nursing to quality patient care. Measures include patient

falls, nursing hours per patient day, staff mix, restraints, hospital-acquired
pressure ulcers, nurse satisfaction, nurse education and certification, and
pediatric pain assessment, among others (Montalvo, 2007). The NDNQI
is currently owned and operated by Press Ganey, a healthcare
improvement organization.

Quality Improvement Process and Tools
Continuous quality improvement (CQI) is defined as a structured
organizational process that involves personnel in planning and
implementing the continuous flow of improvements in the provision of
high-quality health care that meets or exceeds expectations. There are
two typical pathways in the quality improvement process. The first
process occurs as data that are regularly collected are monitored. If the
data indicate that a problem exists, then an analysis is done to identify
possible causes and a process is initiated to pilot a change. The second
pathway involves the identification of a problem outside of the routine
data monitoring system (Johnson, 2012).

In addition to data, CQI generally has a common set of
characteristics that include a link to key elements of the organization’s
strategic plan, a quality council composed of the organization’s
leadership, training programs for personnel, mechanisms for the
selection of improvement opportunities, the formation of process
improvement teams, staff support for process analysis and redesign,
policies that motivate and support staff participation in process
improvement, and the application of current and rigorous techniques of
scientific method and statistical process control (Sollecito & Johnson,
2013). Collaboration and evidence-based practice are also key elements
of successful quality improvement programs (Caramanica, Cousino, &
Petersen, 2003).

There are several quality improvement tools that can assist in
monitoring measures. Common tools include histograms, control charts,
run charts, and scattergrams (Figure 8-4). These tools can assist in the
identification of problems by visually showing the frequency of events and
events outside of set parameters (Johnson, 2012). Once problems are
identified, the root cause analysis technique can be used to
systematically identify the reason for the problem. A common approach to
root cause analysis is to use a cause-and-effect diagram known as the
Ishikawa or fishbone diagram, described previously in this chapter, which
assists in identifying such problems as system issues with multiple
dimensions. After all possible causes are identified, the team chooses the
top two possible causes and then initiates a change process using one of
several selected quality improvement methodologies.

Figure 8-4 Many types of tools are available to assist providers in monitoring quality.
© Mc Satori/Shutterstock.

KEY COMPETENCY 8-10

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Quality Improvement:

Knowledge (K4) Describes approaches for improving processes and
outcomes of care

Skills (S4a) Participates in the use of quality improvement practices
and implements changes in the delivery of care with consideration for
population-based health care

Skills (S4b) Implements best practices for preventing harm

Attitudes/Behaviors (A4) Recognizes the value of what individuals and
teams can do to improve care processes and outcomes of care

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Popularized by William Edwards Deming, the Deming cycle of Plan,
Do, Check, Act or, as he later modified it, the Plan, Do, Study, Act
(PDSA) process is the most commonly used quality improvement
methodology in health care (Figure 8-5). The basic premise of the PDSA
is to encourage innovation by experimenting with a change, studying the
results, and making refinements as necessary to achieve sustained
desired outcomes (Strome, 2013). The process includes questions and
activities that guide each phase. Examples include:

Figure 8-5 Plan, Do, Study, Act (PDSA) cycle.

Plan: Begin with planning the changes to a process that are to be

implemented and tested.
What is the objective?
What is the test of change?

Do: Carry out the plan and make the desired changes to the process.
Conduct the test.
Document unexpected observations and problems.

Study: Review the effect and outcomes of the implemented changes.
Analyze the data.
Were the outcomes as expected?
What was learned from the test?

Act: Determine if the changes can be implemented as is or if further
cycles are necessary for refinement.

What modifications should be made?
What is the next test? (Johnson, 2012, p. 126; Strome, 2013, p.
64)

KEY OUTCOME 8-6

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential II: Basic Organizational and Systems Leadership for Quality
Care and Patient Safety

2.5 Participate in quality and patient safety initiatives, recognizing that
these are complex system issues, which involve individuals, families,
groups, communities, populations, and other members of the
healthcare team (p. 14).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

Six Sigma is another quality improvement methodology frequently
used in health care. The goal of Six Sigma is to decrease the defects or
errors from the current level within an organization. Six Sigma uses an
approach that “emphasizes the use of information and statistical analysis
to rigorously and routinely measure and improve an organization’s
performance, practices, and systems” (Strome, 2013, p. 71). Approaches
to Six Sigma vary by organization, but initiatives generally have five
elements in common. The common elements include intent, strategy,
methodology, tools, and measurements. Six Sigma initiatives are
undertaken with the intent of achieving significant improvement in a short
time and can be applied at a corporate level or aimed strategically at an
individual project. Several Six Sigma methodologies exist, but the most
common one used in health care is what is known as DMAIC (Define,
Measure, Analyze, Improve, Control). Tools involved in Six Sigma are
numerous but fall into three categories: requirements gathering, statistical
analysis, and experimentation. Finally, the most common measurements
used in Six Sigma include defects/errors per unit, defects per million
opportunities, and Sigma level (Strome, 2013).

The five phases of the Six Sigma methodology using the DMAIC,
discussed in the following list, must always be followed in precisely the
same order, but they provide a rigorous approach that is effective in
identifying opportunities for improvement (Figure 8-6).

Figure 8-6 Five phases of the Six Sigma cycle.
© iStockphoto.com/sorendls.

Define: Clearly identify and state the problem that is the focus of the
quality improvement initiative and outline the scope of the project.
Determine the critical requirements and key benefits. Agree on the
process to be improved and the plan to achieve the improvements.
Measure: Review all available data, measure the extent of the quality
problem, and obtain baseline performance information.
Analyze: Use tools (such as a fishbone diagram) to study the root
cause of the problem and to develop potential solution alternatives.
Improve: Develop alternative processes to help achieve the desired
outcomes. Evaluate the alternatives based on each one’s potential
effect on the outcome, using statistical analysis to determine the
highest likelihood of achieving the desired performance.
Control: Sustain improvements through ongoing measurement and
by conducting ongoing communication, reviews, and training
(Strome, 2013, p. 72).

Another framework that is used to improve quality by identifying
events or characteristics of a system that may allow potential errors to be

averted is the Reason’s Adverse Event Trajectory or the Swiss Cheese
Model, discussed previously (Reason, 2000).

Regardless of the methodology chosen for a quality improvement
initiative, there are some general commonalities among processes. In all
successful quality improvement initiatives, the problem must be defined,
opportunities for improvement must be identified, and improvement
activities executed. Outcomes must be evaluated, and finally, change
must be sustained (Strome, 2013).

The Role of the Nurse in Quality
Improvement
As early as the 1860s, Florence Nightingale measured patient outcomes
in relation to environmental conditions and proposed standardization in
the presentation of hospital statistics (Kovner, Brewer, Yingrengreung, &
Fairchild, 2010; Owens & Koch, 2015). Today nurses continue to have a
role in quality improvement.

KEY COMPETENCY 8-11

Examples of applicable Nurse of the Future: Nursing Core
Competencies
Quality Improvement:

Knowledge (K3) Explains the importance of variation and
measurement in providing high-quality nursing care with awareness of
diverse populations and/or issues

Skills (S3) Participates in the use of quality improvement tools to
assess performance and identify gaps between local and best
practices

Attitudes/Behaviors (A3a) Appreciates how standardization supports
high-quality patient care

(A3b) Recognizes how unwanted variation compromises care

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

The ANA standard of professional performance number 14 states that
the registered nurse contributes to high-quality nursing practice with
competencies that include the nurse’s role in various quality improvement
activities, such as collecting data to monitor quality and collaboration with
the interprofessional team to implement quality improvement plans and
interventions (ANA, 2015b). Knowing that the registered nurse
participates in quality improvement activities, the American Association of
Colleges of Nursing (AACN, 2008) includes statements in The Essentials
of Baccalaureate Education for Professional Nursing Practice related to
the expectations of nurses graduating from programs of nursing in the
realm of quality improvement. According to the AACN (2008), a graduate
of a baccalaureate nursing program will “understand and use concepts,
processes, and outcome measures . . . be able to assist or initiate basic
quality and safety investigations; be able to assist in the development of
quality improvement action plans; and assist in monitoring the results of
these action plans” (p. 13).

The role of the nurse in quality improvement builds on the ability of
the nurse to collect and analyze patient data, something all nursing
students learn early in their programs of study. The novice nurse and the
expert nurse alike participate in quality improvement initiatives. The
novice nurse will be involved in data collection and will assist with
improvement interventions, whereas the expert nurse may be leading the
quality improvement initiative, but all nurses should be prepared for this
nursing role (Figure 8-7).

Figure 8-7 The professional nurse is responsible for the use of quality improvement tools to
assess performance and identify gaps between local and best practices.

© Blend Images – Jose Luis Pelaez Inc/Brand X Pictures/Getty.

The nurse’s role in quality improvement is especially important in
hospitals that promote a culture of patient safety. Registered nurses at
the bedside use quality improvement techniques that were once
employed only by quality assurance personnel. Nurses actively monitor
outcomes of patient care processes using spreadsheets, flow diagrams,
computer programs, and control charts to record and monitor data when
analyzing a clinical problem or situation. Trended data collected by
nurses are provided by the risk management department or performance
improvement council and disseminated to the units.

CRITICAL THINKING QUESTION

How can the commitment to quality improvement be integrated
throughout all roles and at all levels of professional nursing practice?

In addition to the processes of data monitoring, analysis, and change
that occur as a part of the routine quality improvement cycle, nurses are
frequently involved in the identification of a problem outside of the routine

data monitoring system. Nurses may initiate the process of quality
improvement based on observations of clinical issues in daily practice.
These observations may lead to the conduct of health record audits to
compare care provided to standards or evidence-based clinical practice
guidelines. The results of such a health record audit lead to the
development of a quality improvement plan to align practice with current
best practices. The recommendations may be based on a variety of
guidelines depending on the setting and patient population. Examples of
possible guidelines for use in the audit include IHI care bundles or best
practice guidelines from the Registered Nurses’ Association of Ontario.
Based on the results of the health record audit, the nurse will present the
data visually (as a control chart or histogram, for example) and
collaborate with appropriate stakeholders to develop the quality
improvement plan. The resulting quality improvement implementation
plan will need to include a specific plan for sustainability and evaluation
to be successful. An example template for a health record audit matrix
based on guideline recommendations is provided in Table 8-1. In the
example template, an x indicates that the guideline recommendation was
documented in the health record. A blank indicates that there was no
documentation of the recommended activity. The matrix may alternatively
be marked with Y and N for yes and no because just as with a cause-
and-effect diagram, there is no one correct way to create this document.
The quality improvement tools should be developed in the format that
best fosters data collection, analysis, and planning, evaluating, and
sustaining quality outcomes.

TABLE 8-1 Example of a Simple Audit Matrix Template

KEY OUTCOME 8-7

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential II: Basic Organizational and Systems Leadership for Quality
Care and Patient Safety

2.10 Use improvement methods, based on data from the outcomes of
care processes, to design and test changes to continuously improve
the quality and safety of health care (p. 14).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

KEY COMPETENCY 8-12

Examples of applicable Nurse of the Future: Nursing Core
Competencies
Quality Improvement:

Knowledge (K2) Comprehends that nursing contributes to systems of
care and processes that affect outcomes

Skills (S2) Participates in the use of quality improvement models and
tools to make processes of care interdependent and explicit

Attitudes/Behaviors (A2) Recognizes how team collaboration is

important to quality improvement and values the input from the
interprofessional team

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Quality improvement is also tied into a nurse’s performance
evaluation. Individual nurse and team goals for quality and safety are
important components of each staff member’s annual review. As nursing
leadership and staff foster a culture of safety and quality, they emphasize
reporting near misses and unintended outcomes as a means to identify
and fix weak links in processes of care (Caramanica et al., 2003). But
nurses have identified challenges to their role in quality improvement
processes, including adequacy of resources, engaging nurses from
management to the bedside in the process, the increasing number of
quality improvement activities, the administrative burden of quality
improvement initiatives, and the lack of preparation of nurses in
traditional nursing education programs for their role in quality
improvement (Draper, Felland, Liebhaber, & Melichar, 2008). Thirty-nine
percent of new graduates report that they are not prepared to adequately
implement quality improvement initiatives or to use quality improvement
techniques, despite having the content in their prelicensure programs
(Kovner et al., 2010).

Conclusion
Why is it important for nurses to be involved in quality improvement
efforts? Nurses are at what is known as the sharp end of health care,
meaning that nurses have significant, direct contact with patients at the
bedside. Because of this closeness to clinical activity, nurses recognize
the need for change, see the effects when the best care is not provided,
and see the effect of changes. Thus, nurses are able to bring both clinical
expertise and firsthand experience to discussions about quality
improvement efforts within their organizations (Haviley et al., 2014). More
than ever before, quality improvement is considered a core responsibility
of the professional nurse.

Classroom Activity 8-1

Provide students with a list of measures and have students search
some of the websites listed under the Healthcare Transparency
heading to find safety and quality information about your local
hospitals. Discuss the results in the context of quality outcomes and
consumer choice.

Classroom Activity 8-2

Provide students with case studies that describe nursing errors, such
as the historical case studies in Emrich (2010). Have students work in
groups to either identify the root cause of the error using a fishbone
diagram and then engage in a PDSA process to plan a small-scale
quality improvement initiative or identify how to prevent errors such as

these using the Swiss cheese framework.

Classroom Activity 8-3

Provide small groups of students with chart audit results and
appropriate clinical guidelines. The students should work together as a
team to develop a quality improvement plan.

Classroom Activity 8-4

The IHI is a quality improvement organization dedicated to sharing
information to improve healthcare safety. IHI Open School has free
online courses and experiential learning opportunities available at
www.ihi.org/education/ihiopenschool/Pages/default.aspx. Choose
activities from the website for students to complete that meet specific
course objectives.

Classroom Activity 8-5

Numerous classroom and clinical activities related to safety and quality
improvement are available on the QSEN website at
www.qsen.org/teaching-strategies/strategy-search/. Choose activities
from the website for students to complete that meet specific course
objectives.

References
Agency for Healthcare Research and Quality. (2014). 2013 national
healthcare quality report. Rockville, MD: U.S. Department of Health
and Human Services. Retrieved from
http://www.ahrq.gov/research/findings/nhqrdr/

Agency for Healthcare Research and Quality. (2015). 2014 national
healthcare quality and disparities report (AHRQ Publication No. 15-
0007). Rockville, MD: Author.

American Association of Colleges of Nursing. (2008). The essentials of
baccalaureate education for professional nursing practice. Washington,
DC: Author.

American Nurses Association. (2010). Nursing’s social policy statement:
The essence of the profession. Silver Spring, MD: Author.

American Nurses Association. (2015a). Code of ethics with interpretive
statements. Silver Spring, MD: Author.

American Nurses Association. (2015b). Nursing: Scope and standards of
practice (3rd ed.). Silver Spring, MD: Author.

Amer, K. S. (2013). Quality and safety models. In K. S. Amer (Ed.),
Quality and safety for transformational nursing: Core competencies
(pp. 16–40). Boston, MA: Pearson.

Aspen, P., Walcott, J., Bootman, L., & Cronenwett, L. (2007). Identifying
and preventing medication errors. Washington, DC: National
Academies Press.

Barnsteiner, J. (2012). Safety. In G. Sherwood & J. Barnsteiner (Eds.),
Quality and safety in nursing: A competency approach to improving
outcomes (pp. 149–169). West Sussex, England: Wiley.

Berwick, D. M. (2014). Promising care: How we can rescue health care

by improving it. San Francisco, CA: Jossey-Bass.
Caramanica, L., Cousino, J. A., & Petersen, S. (2003). Four elements of
a successful quality program: Alignment collaboration, evidence-based
practice, and excellence. Nursing Administration Quarterly, 27(4), 336–
343.

Chassin, M. R., & Loeb, J. M. (2013). High-reliability healthcare: Getting
there from here. Milbank Quarterly, 91, 459–490.

Chassin, M. R., Loeb, J. M., Schmaltz, S. P., & Wachter, R. M. (2010).
Accountability measures—Using measurement to promote quality
improvement. New England Journal of Medicine, 363, 683–688.
doi:10.1056/NEJMsb1002320

Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J.,
Mitchell, P., . . . Warren, J. (2007). Quality and safety education for
nurses. Nursing Outlook, 55(3), 122–131.

Donabedian, A. (1966). Evaluating the quality of medical care. Milbank
Memorial Fund Quarterly, 44(3 Suppl.), 166–206.

Donaldson, M. S. (2008). An overview of To Err Is Human: Re-
emphasizing the message of patient safety. In R. G. Hughes (Ed.),
Patient safety and quality: An evidence-based handbook for nurses
(Vol. 1, pp. 37–45; Publication No. 08-0043). Rockville, MD: Agency for
Healthcare Research and Quality.

Draper, D. A., Felland, L. E., Liebhaber, A., & Melichar, L. (2008). The
role of nurses in hospital quality improvement (Vol. 3). Washington,
DC: Center for Studying Healthcare System Change.

Emrich, L. (2010). Practice breakdown: Medication administration. In P.
E. Benner, K. Malloch, & V. Sheets (Eds.), Nursing pathways for
patient safety (pp. 30–46). St. Louis, MO: Mosby.

Haviley, C., Anderson, A. K., & Currier, A. (2014). Overview of patient
safety and quality of care. In P. Kelly, B. A. Vottero, & C. A. Christie-
McAuliffe (Eds.), Introduction to quality and safety education for nurses

(pp. 1–37). New York, NY: Springer.
Henriksen, K., Dayton, E., Keyes, M. A., Carayon, P., & Hughes, R.
(2008). Understanding adverse events: A human factors framework. In
R. G. Hughes (Ed.), Patient safety and quality: An evidence-based
handbook for nurses (Vol. 1, pp. 67–85; Publication No. 08-0043).
Rockville, MD: Agency for Healthcare Research and Quality.

Hershey, K. (2015). Culture of safety. Nursing Clinics of North America,
50, 139–152.

Institute of Medicine. (2000). To err is human: Building a safer health
system. Washington, DC: National Academies Press.

Institute of Medicine. (2001). Crossing the quality chasm: A new health
system for the 21st century. Washington, DC: National Academies
Press.

Institute of Medicine. (2004). Keeping patients safe: Transforming the
work environment of nurses. Washington, DC: National Academies
Press.

Institute of Medicine. (2006). Preventing medication errors: Quality
chasm series. Washington, DC: National Academies Press.

Johnson, J. (2012). Quality improvement. In G. Sherwood & J.
Barnsteiner (Eds.), Quality and safety in nursing: A competency
approach to improving outcomes (pp. 113–132). West Sussex,
England: Wiley.

Joint Commission. (2009). Implementation guide for the NQF endorsed
nursing-sensitive care measure set, 2009. Retrieved from
https://www.jointcommission.org/assets/1/6/NSC%20Manual.pdf

Joint Commission. (2011). Sentinel event alert issue 48: Health care
worker fatigue and patient safety. Retrieved from
http://www.jointcommission.org/sea_issue_48/

Joint Commission. (2017a). Facts about accountability measures.
Retrieved from

https://www.jointcommission.org/facts_about_accountability_measures
Joint Commission. (2017b). Facts about ORYX® for hospitals (national
hospital quality measures). Retrieved from
https://www.jointcommission.org/facts_about_oryx_for_hospitals/

Joint Commission. (2018a). 2018 hospital national patient safety goals.
Retrieved from
https://www.jointcommission.org/assets/1/6/2018_HAP_NPSG_goals_final.pdf

Joint Commission. (2018b). America’s hospitals: Improving quality and
safety: Annual report 2017. Retrieved from http://jointcommission.new-
media-release.com/2017_annual_report/

Joint Commission. (2018c). Quality check. Retrieved from
https://www.qualitycheck.org

Joint Commission. (2018d). Summary data of sentinel events reviewed
by the Joint Commission. Retrieved from
https://www.jointcommission.org/assets/1/18/Summary_4Q_2017.pdf

Kalisch, B. (2015). Errors of omission: How missed nursing care imperils
patients. Silver Spring, MD: American Nurses Association.

Kovner, C. T., Brewer, C. S., Yingrengreung, S., & Fairchild, S. (2010).
New nurses’ views of quality improvement education. Joint
Commission Journal of Quality and Patient Safety, 36(1), 29–35.

Malloch, K., Benner, P., Sheets, V., Kenward, K., & Farrell, M. (2010).
Overview: NCSBN practice breakdown initiative. In P. E. Benner, K.
Malloch, & V. Sheets (Eds.), Nursing pathways for patient safety (pp.
1–29). St. Louis, MO: Mosby.

Marx, D. (2001). Patient safety and the “just culture”: A primer for health
care executives. Medical event reporting system-transfusion medicine.
New York, NY: Columbia University.

Massachusetts Department of Higher Education. (2010). Nurse of the
future: Nursing core competencies. Retrieved from
http://www.mass.edu/currentinit/documents/NursingCoreCompetencies.pdf

Massachusetts Department of Higher Education. (2016). Nurse of the
future: Nursing core competencies: Registered nurse. Retrieved from
http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Mitchell, P. (2008). Defining patient safety and quality care. In R. G.
Hughes (Ed.), Patient safety and quality: An evidence-based handbook
for nurses (Vol. 1, pp. 1–6; Publication No. 08-0043). Rockville, MD:
Agency for Healthcare Research and Quality.

Montalvo, I. (2007). The national database of nursing quality indicators
(NDNQI). Online Journal of Issues in Nursing, 12(3).
doi:10.3912/OJIN.Vol12No03Man02

National Council of State Boards of Nursing. (2013). Practice errors and
risk factors (TERCAP). Retrieved from https://www.ncsbn.org/113.htm

National Quality Forum. (2004). National voluntary consensus standards
for nursing-sensitive care: An initial performance measure set.
Washington, DC: Author.

National Quality Forum. (2010). Safe practices for better healthcare
2010: A consensus report. Washington, DC: Author.

Owens, L. D., & Koch, R. W. (2015). Understanding quality patient care
and the role of the practicing nurse. Nursing Clinics of North America,
50, 33–43.

Quality and Safety Education for Nurses. (2007). QSEN competencies.
Retrieved from http://qsen.org/competencies/pre-licensure-ksas/

Reason, J. (2000). Human error: Models and management. British
Medical Journal, 320, 768–770.

Robert Wood Johnson Foundation. (2011). Measuring the contributions
of nurses to high-value health care: Special report. Retrieved from
http://www.rwjf.org/content/dam/farm/reports/program_results_reports/2011/rwjf70343

Rovinski-Wagner, C., & Mills, P. D. (2014). Patient safety. In P. Kelly, B. A.
Vottero, & C. A. Christie-McAuliffe (Eds.), Introduction to quality and
safety education for nurses (pp. 95–130). New York, NY: Springer.

Rowell, P. (2003). The professional nursing association’s role in patient
safety. Online Journal of Issues in Nursing, 8(3). Retrieved from
http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume82003/No3Sept2003/AssociationsRole.aspx

Sollecito, W. A., & Johnson, J. K. (2013). McLaughlin and Kaluzny’s
continuous quality improvement in health care (4th ed.). Burlington,
MA: Jones & Bartlett Learning.

Strome, T. L. (2013). Healthcare analytics for quality and performance
improvement. Hoboken, NJ: Wiley.

U.S. Department of Health and Human Services. (2011). National
strategy for quality improvement in health care. Washington, DC:
Author.

Vottero, B. A., Block, M. E., & Bonaventura, L. (2012). Benchmarking
quality performance. In P. Kelly, B. A. Vottero, & C. A. Christie-
McAuliffe (Eds.), Introduction to quality and safety education for nurses
(pp. 221–247). New York, NY: Springer.

© James Kang/EyeEm/Getty Images

CHAPTER 9

Evidence-Based Professional
Nursing Practice
Kathleen Masters

Learning Objectives

After completing this chapter, the student should be able to:

1. Describe the importance of evidence-based nursing care.
2. Identify barriers to the implementation of evidence-based nursing

practice.
3. Identify strategies for the implementation of evidence-based

nursing practice.
4. Describe how and where to search for evidence.
5. Identify methods to evaluate the evidence.
6. Discuss approaches to integrating evidence into practice.
7. Identify models of evidence-based nursing practice.

Key Terms and Concepts

Evidence-based practice
PICO(T)
Clinical practice guidelines

Evidence-Based Practice: What Is It?
Evidence-based practice—it is more than a recent buzzword in nursing.
Evidence-based practice is a mechanism that allows nurses to provide
safe, high-quality patient care based on evidence grounded in research
and professional expertise rather than on tradition, myths, hunches,
advice from peers, outdated textbooks, or even what the nurse learned in
school 5, 10, or 15 years ago. Advances in information technology have
facilitated the dissemination of research and other types of evidence,
making them widely available. Only 3 decades ago nurses had to hand
search indexes and hard-copy journals to access research results, but
nurses now have quick access to the most current evidence from
professional journals and best practice guidelines available via the
Internet.

Evidence-based practice provides a strategy to ensure that nursing
care reflects the most up-to-date knowledge available so that what we do
in practice matches what we know. Nursing practice that is based on
evidence is now the accepted standard for practice as well as one of the
six core competencies for all registered nurses identified in the Quality
and Safety Education for Nurses (QSEN) project (Cronenwett et al.,
2007). Nurses are accountable for the interventions they provide to
patients. Evidence-based practice provides a systematic approach for
decision making and offers a framework for the nurse to use to
incorporate best nursing practices into the clinical care of patients (Pugh,
2012).

KEY OUTCOME 9-1

Example of applicable outcomes expected of the graduate from a

baccalaureate program

Essential III: Scholarship for Evidence-Based Practice

3.6 Integrate evidence, clinical judgment, interprofessional
perspectives, and patient preferences in planning, implementing, and
evaluating outcomes of care (p. 16).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

According to the American Association of Colleges of Nursing
(AACN, 2008), professional nursing practice is grounded in the
translation of current evidence into practice. One of the skills expected of
prelicensure graduates of nursing programs is the ability to base an
individualized care plan on patient values, clinical expertise, and
evidence (QSEN, 2015). In addition, Standard 13 of the standards of
professional nursing practice indicates that the nurse will integrate
evidence and research findings into practice (American Nurses
Association [ANA], 2015).

Most nurses want to provide care for their patients based on the most
current evidence, but for many nurses, trying to integrate evidence-based
practice into patient care in the clinical environment raises questions. The
goal of this chapter is to answer those questions. To begin with, what
exactly is evidence-based practice?

Evidence-based practice is a framework used by nurses and other
healthcare professionals to deliver optimal health care through the
integration of best current evidence, clinical expertise, and patient/family
values (QSEN, 2015). Houser (2008) describes this triad of evidence-
based practice using the illustration of a three-legged stool. Just as each
leg of the stool is necessary for the function of the stool, each of the three

components—best current evidence, clinical expertise, and incorporation
of patient/family values—are all necessary for the effective use of
evidence-based practice.

KEY OUTCOME 9-2

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential IX: Baccalaureate Generalist Practice

9.8 Implement evidence-based nursing interventions as appropriate for
managing the acute and chronic care of patients and promoting health
across the lifespan (p. 31).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

Another question one might ask is, How is evidence-based practice
relevant and applicable to nursing practice? Evidence-based practice is
relevant to nursing practice because it does the following:

Helps resolve problems in the clinical setting
Results in effective patient care with better patient outcomes
Contributes to the science of nursing through the introduction of
innovation to practice
Keeps practice current and relevant by helping nurses deliver care
based on current best research
Decreases variations in nursing care and increases confidence in
decision making
Supports Joint Commission readiness because policies and
procedures are current and include the latest research

Supports high-quality patient care and achievement of magnet status
(Beyea & Slattery, 2006; Spector, 2007)

It takes approximately 17 years for clinical research to be integrated
into patient care practices. Nurses and other healthcare providers can
minimize the time from discovery to implementation through the process
inherent in evidence-based practice that in turn will lead to improved
patient outcomes. Because of the link between evidence-based practice
and improved patient outcomes, the Institute of Medicine (IOM, 2008)
has promoted the goal that by the year 2020, 90% of all health decisions
will be based on evidence.

KEY OUTCOME 9-3

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential VII: Clinical Prevention and Population Health

7.5 Use evidence-based practices to guide health teaching, health
counseling, screening, outreach, disease and outbreak investigation,
referral, and follow-up throughout the lifespan (p. 24).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

The evidence-based practice process enhances practice by
encouraging reflection about what we know; it is applicable to virtually
every area of nursing practice, including patient assessment, diagnosis of
patient problems, planning, patient care interventions, and evaluation of
patient responses. In addition, evidence can be used as the foundation
for policies and procedures and as the basis for patient care

management tools, such as care maps, pathways, and protocols
(Houser, 2011).

The seven steps involved in the evidence-based practice process
address the question of how to begin.

1. Cultivate a spirit of inquiry and culture of evidence-based practice
among nurses and within the organization.

2. Identify an issue and ask the question.
3. Search for and collect the most relevant and best evidence to answer

the clinical question.
4. Critically appraise and synthesize the evidence.
5. Integrate evidence with clinical expertise and patient preferences to

make the best clinical decision.
6. Evaluate the outcome of any evidence-based practice change.
7. Disseminate the outcomes of the change (Melnyk & Fineout-

Overholt, 2014).

Barriers to Evidence-Based Practice
Because evidence-based practice is now the standard for professional
nursing practice, one would think that practice based on evidence is
commonplace; however, this is not the case. Practicing nurses cite many
barriers to evidence-based practice. Common barriers to implementing
evidence-based practice include the following:

Lack of value for research in practice
Difficulty in changing practice
Lack of administrative support
Lack of knowledgeable mentors
Insufficient time
Lack of education about the research process
Lack of awareness about research or evidence-based practice
Research reports and articles not readily available
Difficulty accessing research reports and articles
No time on the job to read research
Complexity of research report
Lack of knowledge about evidence-based practice
Lack of knowledge about the critique of articles
Feeling overwhelmed by the process
Lack of sense of control over practice
Lack of confidence to implement change
Lack of leadership, motivation, vision, strategy, or direction among
managers (Beyea & Slattery, 2006; Revell, 2015; Spector, 2007)

KEY COMPETENCY 9-1

Examples of applicable Nurse of the Future: Nursing Core

Competencies

Evidence-Based Practice:

Knowledge (K2) Describes the concept of evidence-based practice
(EBP), including the components of research evidence, clinical
expertise, and patient/family values

Skills (S2) Bases individualized care on best current evidence, patient
values, and clinical expertise

Attitudes/Behaviors (A2) Values the concept of EBP as integral to
determining best clinical practice

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Additional barriers to using evidence-based practice include the
overwhelming information available in the research literature that is
sometimes contradictory as well as the perception that evidence-based
practice is equivalent to “cookbook medicine.” In addition, there may be a
perceived lack of authority for clinicians to make changes in practice or
peer pressure to maintain the status quo (Houser, 2011).

Promoting Evidence-Based Practice
Despite barriers, nurses are making a difference in patient outcomes
through the use of evidence-based practice. Strategies that can be useful
in the promotion of evidence in practice generally fall into two categories:
strategies for individual nurses and organizational strategies.

Strategies for individual nurses include the following:

Educate yourself about evidence-based practice through such
avenues as websites original research articles, evidence reports,
conferences, and participation in professional organizations that
provide resources related to evidence-based practice (Revell, 2015).
Conduct face-to-face or online journal clubs that can be used to
educate yourself about the appraisal of evidence, share new
research reports and guidelines with peers, and provide support to
other nurses.
Share your results through posters, newsletters, unit meetings, or a
published article to support a culture of evidence-based nursing
practice within the organization and the profession.
Adopt a reflective and inquiring approach to practice by questioning
the rationale for approaches to care that do not result in desired
patient outcomes and by continuously asking yourself and others
within your organization such quesitons as “What is the evidence for
this intervention?” or “How do my patients respond to this
intervention?” (Beyea & Slattery, 2006; QSEN, 2015).

CRITICAL THINKING QUESTIONS

How do I know what I know about nursing practice? Are my nursing
decisions based on myths, traditions, experience, authority, trial and

error, ritual, or scientific knowledge?

KEY OUTCOME 9-4

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential IX: Baccalaureate Generalist Nursing Practice

9.11 Provide nursing care based on evidence that contributes to safe
and high-quality patient outcomes within healthcare microsystems (p.
31).

Reproduced from American Association of Colleges of Nursing. (2008b). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

Strategies for overcoming barriers and increasing adoption of
evidence-based practice within an organization include:

Specific identification of the facilitators and barriers to evidence-
based practice. This will require administrative support by providing
the time and the funds for necessary resources as well as
enhancement of job descriptions to include criteria related to
evidence-based practice.
Education and training to improve knowledge and strengthen beliefs
related to the benefits of evidence-based practice. This may require
offering incentives, such as a paid registration to a conference for the
best clinical question in a unitwide contest.
Creation of an environment that encourages an inquisitive approach
to patient care. Achievement of this environment may require the
development of a center of evidence-based practice, access to
electronic resources in the workplace, providing opportunities for

nurses to collaborate with nurse researchers or faculty with nursing
research expertise, and providing opportunities to disseminate the
results of evidence-based practice projects (Houser, 2011, p. 12).

Whichever strategies are incorporated, it is important to note that
multifaceted interventions are much more likely to be effective in
facilitating evidence-based practice within an organization. It is also
important to note that once evidence-based practice projects are
complete, passive dissemination of results within an organization is
ineffective in changing practice.

Searching for Evidence
Competencies expected of the nurse include reading original research
and evidence reports related to the practice area and the ability to locate
relevant evidence reports and guidelines (QSEN, 2015). In order to find
the evidence, the nurse must learn to ask clinical questions and to search
electronic indexes and other resources (Figure 9-1).

Figure 9-1 The nurse must know both how to ask the question and how to search electronic
resources for evidence.

© wavebreakmedia/Shutterstock, Inc.

CRITICAL THINKING QUESTIONS

How is new evidence disseminated to the bedside nurse in the
organization in which you practice as a nursing student? How does
the organization promote evidence-based practice? Do the nurses in
the organization use current evidence in practice?

Asking the Question
Nurses must learn to ask questions in a format that facilitates searching

for evidence. Developing a question that accurately reflects the practice
to be evaluated, in a format that focuses the search for evidence, is a
good place to begin (Tracy & Barnsteiner, 2014). It has been suggested
that all nurses should learn how to use the PICO(T) format to ask clinical
questions. PICO(T) is an acronym that assists in the formatting of clinical
questions. Using this format helps the nurse to ask pertinent clinical
questions, focus on asking the right questions, and choose relevant
guidelines.

P = Patient, Population, or Problem
How would I describe a group of patients similar to mine?
What group do I want information on?

I = Intervention or Exposure or Topic of Interest
Which main intervention am I considering?
What event do I want to study the effect of?

C = Comparison or Alternate Intervention (if appropriate)
What is the main alternative to compare with the intervention?
Compared to what? Better or worse than no intervention at all or
than another intervention?

O = Outcome
What can I hope to accomplish, measure, improve, or affect?

What is the effect of the intervention? (Levin, 2006a)
Some researchers also add the element of time or time frame to the

PICO question format and refer to the format as PICOT, although the
time frame might not be applicable to all questions.

T = Time or Time Frame
How much time is required to demonstrate an outcome?
How long are participants observed?

KEY COMPETENCY 9-2

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Evidence-Based Practice:

Knowledge (K1) Demonstrates knowledge of basic scientific methods
and processes

Skills (S1a) Participates in the development of clinical questions for
potential research (S1b) Critiques/appraises research for application to
practice (S1c) Participates in data collection and other research
activities (S1d) Follows the guidelines and requirements pertaining to
Human Subject Protection for conducting research

Attitudes/Behaviors (A1a) Appreciates strengths and weaknesses of
scientific bases for practice (A1b) Values the need for ethical conduct
of practice and research

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

After determining the patient, intervention, comparison, and outcome
of interest, the nurse then combines these four elements into a single
question in combinations, such as the following examples:

In (patient or population), what is the effect of (intervention or
exposure) on (outcome) compared with (comparison)? (Levin,
2006b)
For (patient or population), does the introduction of (intervention or
exposure) reduce the risk of (outcome) compared with (comparison
intervention)? (Levin, 2006b)

Electronic Resources
Because the PICO(T) question may have already been asked and
answered by other nurses, beginning the search with sites that provide
systematic reviews or guidelines is helpful (Tracy & Barnsteiner, 2014).
Electronic resources are available that can assist the nurse in uncovering
the most current evidence for practice in the form of systematic reviews
and guidelines. Some of the most commonly used include these:

National Library of Medicine: www.nlm.nih.gov
Cochrane Library: www.cochrane.org
National Guideline Clearinghouse: www.guideline.gov
Joanna Briggs Institute: www.joannabriggs.org
Agency for Healthcare Research and Quality (AHRQ):
www.effectivehealthcare.ahrq.gov
Centre for Health Evidence: www.cche.net
Registered Nurses’ Association of Ontario:
http://rnao.ca/bpg/guidelines
McGill University’s Ingram School of Nursing’s Clinical and Research
Resources: www.mcgill.ca/nursing/outreach/today/links/clinical

The Cochrane Library is a collection of databases that contain high-
quality, independent evidence to inform healthcare decision making.
Cochrane reviews represent the highest level of evidence on which to
base clinical treatment decisions. In addition to the Cochrane systematic
reviews, the Cochrane Library also offers other sources of information,
including the Database of Abstracts of Reviews of Effects, Cochrane
Controlled Trials Register, Cochrane Methodology Register, NHS
Economic Evaluation Database, Health Technology Assessment
Database, and Cochrane Database of Methodology Reviews.

Another site with high-quality evidence is the National Guideline
Clearinghouse. As a part of the AHRQ, the National Guideline

Clearinghouse includes structured summaries containing information
about each guideline, including comparisons of guidelines covering
similar topics that show areas of similarity and differences; full text or
links to full text; ordering details for full guidelines; annotated
bibliographies on guideline development, evaluation, implementation, and
structure; weekly email updates; and guideline archives. Guidelines may
be searched by topic or by organization.

The Registered Nurses’ Association of Ontario provides high-quality
best practice guidelines specifically focused on nursing care. Many of
these guidelines are also available via the National Guideline
Clearinghouse site. The guidelines are available online in full text and
free of charge.

Electronic Indexes
Reviews may also be indexed, but if no reviews or guidelines are found
relevant to your PICO(T) question, then individual articles must be
searched (Tracy & Barnsteiner, 2014). Electronic indexes provide options
for narrowing or broadening a topic to identify relevant literature. Most
electronic indexes provide citation information and will indicate if the
selected articles are available locally in print form or if the items are
available in an electronic format. Three of the most common electronic
indexes used in health care are the Cumulative Index to Nursing and
Allied Health Literature (CINAHL), available at www.cinahl.com;
MEDLINE, available at www.nlm.nih.gov; and PubMed, a web-based
format of MEDLINE available at www.pubmed.gov.

Evaluating the Evidence
Regardless of the source, the nurse needs to evaluate the quality of the
evidence. By evaluating the rigor of the evidence, we can have
confidence that the evidence is accurate. This is important because it
could contribute to a decline rather than to an improvement in patient
outcomes if we base changes to care on inaccurate research evidence
(Sellers & McCrea, 2014). Begin by asking such questions as the
following:

What is the source of the information?
When was it developed?
How was it developed?
Does it fit the current clinical environment?
Does it fit the current situation?

Levels of Evidence
Best evidence for practice includes empirical evidence from randomized
controlled trials, evidence from descriptive and qualitative research, and
information from case reports, scientific principles, and expert opinion.
When insufficient research is available, healthcare decision making is
derived principally from nonresearch evidence sources, such as expert
opinion and scientific principles (Titler, 2008).

KEY COMPETENCY 9-3

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Evidence-Based Practice:

Knowledge (K3) Describes reliable sources for locating evidence
reports and clinical practice guidelines

Skills (S3) Locates evidence reports related to clinical practice topics
and guidelines within appropriate databases

Attitudes/Behaviors (A3) Appreciates the importance of accessing
relevant clinical evidence

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Several classification systems exist to evaluate the level or strength
of the evidence. The AHRQ serves as the recognized authority regarding
the assessment of clinical research in the United States. Standard levels
of evidence include the classifications listed here (Melnyk & Fineout-
Overholt, 2014):

1. Meta-analysis or systematic reviews of multiple well-designed
controlled studies

2. Well-designed randomized controlled trials
3. Well-designed nonrandomized controlled trials (quasiexperimental)
4. Observational studies with controls (retrospective, interrupted time,

case-control, cohort studies with controls)
5. Systematic review of descriptive and qualitative studies
6. Single descriptive or qualitative study
7. Opinions of authorities and/or reports of expert committees

Using this classification system, the strongest evidence comes from
the first level, representing systematic reviews that integrate findings from
multiple well-designed controlled studies. The weakest evidence is
represented by the seventh level and is based on expert opinion (Polit &

Beck, 2017).
In addition, grading the strength of a body of evidence should

incorporate three domains: quality, quantity, and consistency. Quality has
to do with the extent to which a study minimizes bias in the design,
implementation, and analysis. Quantity refers to the number of studies
that have evaluated the research question as well as the sample size
across the studies and the strength of the findings. The category of
consistency refers to both the similarities and the differences of study
designs that investigate the same research question and report similar
findings (AHRQ, 2002; LoBiondo-Wood & Haber, 2014).

Appraisal of Research
Prior to applying evidence in clinical practice, there must be an appraisal
process (Figure 9-2). Key issues to address in an appraisal include the
credibility of the study, including the researcher’s credentials and
experience; any evidence of bias due to a conflict of interest of the
researcher or the journal; the statement of a blind peer review; and dates
included in the journal to indicate the timeliness of publication. In
addition, appraisals should include questions about the design of the
study, sample size, sampling procedures, reliability and validity of
instrumentation, and appropriate statistical analysis (DelMonte & Oman,
2011).

Figure 9-2 The nurse is responsible for appraising the strength and relevance of evidence when
choosing practice interventions.

© goodluz/Shutterstock.

The Critical Appraisal Skills Programme (CASP, 2010) is a resource
that provides checklists that help the user to interpret research evidence.
The checklists are specific to various types of research, including
randomized controlled trials, systematic reviews, cohort studies, case-
control studies, and qualitative studies. The checklists provide
frameworks to determine the strength and reliability of research reports.
CASP tools are available free of charge at www.casp-uk.net (Sellers &
McCrea, 2014).

KEY OUTCOME 9-5

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential III: Scholarship for Evidence-Based Practice

3.5 Participate in the process of retrieval, appraisal, and synthesis of
evidence in collaboration with other members of the healthcare team to
improve patient outcomes (p. 16).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

Appraisal of Clinical Practice Guidelines
In addition to the appraisal of research, the nurse will need skill in the
appraisal of guidelines to practice based on evidence. Clinical practice
guidelines are developed to guide clinical practice and to represent an
effort to put a large body of evidence into a manageable form. Clinical
practice guidelines are usually based on systematic reviews and give
specific recommendations for clinicians. Guidelines usually attempt to
address all the issues relevant to a clinical decision, including risks and
benefits.

The IOM (2011), at the request of the U.S. Congress, developed a set
of eight standards for the development of rigorous and trustworthy clinical
practice guidelines. To evaluate the effects of the standards on clinical
practice guideline development and healthcare quality and outcomes, the
IOM has encouraged the AHRQ to pilot test the standards and to assess
their reliability and validity. The standards are:

Standard 1: Establishing transparency related to funding and
development processes.
Standard 2: Management of conflict of interest.
Standard 3: Guideline development group composition should be
multidisciplinary and balanced, including a variety of experts and
patient populations.
Standard 4: Use of systematic reviews that meet standards.
Standard 5: Establishing evidence foundations for and rating strength
of recommendations.

Standard 6: Articulation of recommendations maintains a
standardized form.
Standard 7: External review by stakeholders.
Standard 8: Updating should occur when new evidence suggests the
need for modification of clinically important recommendations.

KEY COMPETENCY 9-4

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Evidence-Based Practice:

Knowledge (K4) Differentiates clinical opinion from research and
evidence summaries

Skills (S4a) Applies research and evidence reports related to area of
practice

(S4b) Understands the use of best practice and evidence at the patient
level, clinical level, population level, and across the system

Attitudes/Behaviors (A4) Appreciates that the strength and relevance of
evidence should be determinants when choosing clinical interventions

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

In addition to the relatively new IOM standards, there is an ongoing
collaboration that has focused on improving the quality and effectiveness
of clinical practice guidelines for over a decade. The group has
established a framework for determining the quality of guidelines for
diagnoses, health promotion, treatments, or clinical interventions. The
instrument, known as the Appraisal of Guidelines for Research and

Evaluation (AGREE), can be used with new, existing, or updated
guidelines. First published in 2003 by the AGREE Collaboration, the
instrument has been revised and is now known as AGREE II (AGREE
Next Steps Consortium, 2009). The AGREE II replaces the original
instrument and is the preferred tool. The full version of the AGREE II
instrument and training materials are available online at no cost at
www.agreetrust.org. The AGREE instrument is composed of six
categories containing the 23 items listed here as well as 2 final items that
require an overall judgment about the practice guideline:

Scope and purpose
Overall objectives of the guideline are specifically described.
The health questions covered by the guideline are specifically
described.
The population (patients, public, etc.) to whom the guideline is
meant to apply is specifically described.

Stakeholder involvement
The guideline development group includes individuals from all
relevant professions.
The views and preferences of the target population (patients,
public, etc.) have been sought.
Target users of the guideline are clearly defined.

Rigor of development
Systematic methods were used to search for evidence.
The criteria for selecting the evidence are clearly described.
The strengths and limitations of the body of evidence are clearly
described.
The methods used for formulating the recommendations are
clearly described.
The health benefits, side effects, and risks have been considered

in formulating recommendations.
There is an explicit link between the recommendations and the
supporting evidence.
The guideline has been externally reviewed by experts prior to
publication.
A procedure for updating the guideline is provided.

Clarity and presentation
Recommendations are specific and unambiguous.
Different options for management of the condition or health issue
are clearly presented.
Key recommendations are easily identifiable.

Application
The guideline describes facilitators and barriers to its application.
The guideline provides advice and/or tools on how the
recommendations can be put into practice.
The potential resource implications of applying the
recommendations have been considered.
The guideline presents monitoring and/or auditing criteria.

Editorial independence
The views of the funding body have not influenced the content of
the guideline.
Competing interests of guideline development group members
have been recorded and addressed (AGREE Next Steps
Consortium, 2009, pp. 2–3).

The usefulness of a guideline depends on whether the actual
recommendations in the guideline are meaningful and practical.
Recommendations should be practical in relation to implementation, be
as unambiguous as possible, address the frequency of screening and
follow-up, and address clinically relevant actions. Other questions that

the clinician must address in relation to guidelines include such factors as
the setting of care, the patient population, and the strength of the
recommendations (Beyea & Slattery, 2006).

Implementation Models for
Evidence-Based Practice
A number of models have been developed to guide the design and
implementation and to strengthen evidence-based decision making.
Forty-seven prominent evidence-based practice models can be identified
in the literature (Stevens, 2013).

Differences exist among evidence-based practice models, but most
models do have common elements that include selection of a practice
topic, critique and synthesis of evidence, implementation, evaluation of
the effect on patient care and provider performance, and consideration of
the context in which the practice is implemented (Titler, 2008). No one
model of evidence-based practice is a perfect fit for every organization.
Some models focus on the perspective of the individual clinician, or the
researcher, whereas others focus on institutional efforts. Therefore,
before embarking on this journey, the nurse or organization should
consider several models and select or adapt one that fits the needs of the
nurse or organization.

KEY OUTCOME 9-6

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential III: Scholarship for Evidence-Based Practice

3.2 Demonstrate an understanding of the basic elements of the
research process and model for applying evidence to clinical practice
(p. 16).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

ACE Star Model of Knowledge Transformation
The Center for Advancing Clinical Evidence (ACE) Star Model of
Knowledge Transformation, developed by Dr. Kathleen Stevens, is
available at http://nursing.uthscsa.edu/onrs/starmodel/star-model.asp.
The model involves five steps: knowledge discovery, evidence summary,
translation into practice recommendations, integration into practice, and
evaluation. Discovery refers to the original research. During the second
step, the task is to synthesize all the related research into a meaningful
whole. It is during this step that information is reduced to a manageable
form. During the step of translation, the scientific evidence is considered
in the context of clinical expertise and values. This results in clinical
practice guidelines, best practices, protocols, standards, or clinical
pathways. During the stage of implementation, changes take place in
practice. During evaluation, the effect of the change is measured. Such
variables as specific health outcomes, length of stay, or patient
satisfaction are examples of possible outcomes that might be examined.

The Iowa Model of Evidence-Based Practice
The Iowa Model of Evidence-Based Practice resembles a decision-
making tree that identifies either problem-focused or knowledge-focused
triggers that initiate the process in the organization. Problem-focused
triggers within an organization can include risk management data,
process improvement data, benchmarking data, financial data, or the
identification of clinical problems. Knowledge-focused triggers within an
organization can include the publication of new research or literature, a

change in organizational standards and guidelines, changes in
philosophies of care within the profession or organization, or questions
from an institutional standards committee. Once there is either a
problem-focused or a knowledge-focused trigger within the organization,
a team must identify whether the topic is a priority for the organization. If
the topic is indeed a priority, evidence is examined, and the change in
practice can be piloted. This process is followed by monitoring and
analysis of both the process and the outcome data and finally by
dissemination of the results.

Agency for Healthcare Research and Quality
Model
A model for maximizing and accelerating the transfer of research results
from the AHRQ patient safety research portfolio to healthcare delivery
includes three major stages of knowledge transfer: (1) knowledge
creation and distillation, (2) diffusion and dissemination, and (3)
organizational adoption and implementation. More specifically,
knowledge creation and distillation refer to conducting research and then
packaging relevant research findings into usable form, such as practice
recommendations. The diffusion and dissemination stage involves
partnering with professional leaders, professional organizations, and
healthcare organizations to disseminate knowledge to potential users,
such as nurses, physical therapists, or physicians. During the final stage
of the process, the focus is on organizational adoption and
implementation of evidence-based research findings and innovations in
practice. In this model, the stages of knowledge transfer are viewed from
the perspective of the researcher or the creator of new knowledge and
begin with decisions about which research findings ought to be
disseminated (Titler, 2008).

KEY OUTCOME 9-7

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential III: Scholarship for Evidence-Based Practice

3.7 Collaborate in the collection, documentation, and dissemination of
evidence (p. 16).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

KEY COMPETENCY 9-5

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Evidence-Based Practice:

Knowledge (K5) Explains the role of evidence in determining best
clinical practice

Skills (S5) Facilitates integration of new evidence into standards of
practice, policies, and nursing practice guidelines

Attitudes/Behaviors (A5a) Questions the rationale of supporting routine
approaches to care processes and decisions

(A5b) Values the need for continuous improvement in clinical practice
based on new knowledge

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Johns Hopkins Nursing Evidence-Based
Practice Model
The process used in the Johns Hopkins Nursing Evidence-Based
Practice Model is known as PET, which refers to asking a practice
question, finding the evidence, and translating the evidence to practice
(Newhouse, Dearholt, Poe, Pugh, & White, 2007). In the model,
questions are stated in the PICO format. Next, the research and
nonresearch evidence undergoes appraisal. Nonresearch evidence
includes not only expert opinion, patient experience data, and guidelines
but also evidence gathered from organizational experience, such as
quality improvement reports, program evaluations, and financial data
analysis. The final step of the PET process is translation, assessing the
evidence-based recommendations for transferability to the practice
setting. During this process, practices are implemented, evaluated, and
communicated, leading to a change in nursing processes and outcomes.

Diffusion of Innovation Framework
Rogers’s Diffusion of Innovation Framework (2003) posits that if a third of
any group adopts a practice change based on new evidence, then the
rest of the group will follow, considering the change in practice to be the
norm. The key to using this framework to guide implementation is to work
with people within the organization who are known to be innovators and
early adopters of change. There are five steps included in the framework:
knowledge, persuasion, decision, implementation/trial, and confirmation.
During the knowledge step, the innovation is described so that the
decision-making unit develops an understanding of the suggested
change. Next, the change agent works to develop favorable attitudes
toward the innovation and subsequently a decision is made to adopt or
reject the innovation. During the implementation or trial step, the

innovation is in place and adjustments may occur. Finally, during the step
of confirmation, the decision-making unit seeks reinforcement that the
decision was correct, or they may choose to reverse the decision (Sellers
& McCrea, 2014).

Conclusion
Numerous models are available in the literature to guide nurses in the
use of evidence-based practice. The models share similarities and
differences but do have a common foundation because all use a planned
action approach to moving knowledge to practice. The steps taken
together provide a process for locating and synthesizing knowledge and
for systematically using the change process for integrating and sustaining
evidence-based changes in practice (Tracy & Barnsteiner, 2014).

Currently, the greatest challenge we face in fully implementing
evidence-based practice in nursing as a profession is how to get the
evidence to the practicing nurse. Nurses are very busy taking care of
patients. From the perspective of the individual, it can indeed be
daunting, especially when many practicing nurses are not knowledgeable
about evidence-based nursing practice. Nevertheless, daunting or not,
the impetus for evidence-based practice will continue to grow. As
healthcare costs continue to climb, consistent, data-based answers to
patient care problems are an expectation.

CASE STUDY 9-1 ▪ MR. P.

Mr. P. is a 52-year-old, married, Hispanic male who is approximately
100 pounds overweight. Mr. P. has developed hypertension and adult-
onset diabetes. He is currently being followed in a clinic setting. As a
nurse working in the clinic setting, you have noticed that many of the
patients you see in the clinic who are demographically similar to Mr. P.
experience poorer health outcomes as compared with your patients
who are members of different patient populations.

1.

2.

Case Study Questions

What PICO(T) questions can you ask to generate evidence for the
patient population and patient problem(s) represented in the case
study?

Based on a search of the literature, your expertise, and what you
know about the preferences of this patient population, what are
some evidence-based nursing interventions that you might want to
translate into clinical practice in this clinic setting?

Classroom Activity 9-1

Have students create clinical questions in the PICO(T) format for a
patient in a case study provided by the instructor or for patient recently
cared for in the clinical setting.

Classroom Activity 9-2

Have students bring laptops to class or go to the computer lab as a
class and access evidence from such resources as CINAHL, the
National Guideline Clearinghouse, or the Cochrane Library to plan
evidence-based care based on the questions created in Classroom
Activity 9-1. If laptops or a computer lab is not available, then adapt
this activity by having either students or faculty access the sites via a
computer projection system in the classroom and plan care as a group
based on the search results. As an alternative, the students can do this
activity outside of class and share their results during the following
class.

Classroom Activity 9-3

Provide students with a clinical guideline (choose one that has
recommendations students can audit for using the patient records
provided), a clinical audit tool, and several example patient records.
Have students perform an evidence-based clinical review (or audit)
using the records provided to them. Have students summarize their
findings for each recommendation and then suggest quality
improvement actions to correct the identified problems.

Classroom Activity 9-4

Have students partner individually or as a group with a local clinical
facility to work jointly on a project. Collaborate to identify PICO(T)
questions, find evidence, and plan the process of translation of
evidence into practice within the facility or on a nursing unit within the
facility.

Classroom Activity 9-5

Numerous classroom and clinical activities related to evidence-based
practice are available on the QSEN website at www.qsen.org/teaching-
strategies/strategy-search/. Choose activities from the website for
students to complete that meet specific course objectives.

References
Agency for Healthcare Research and Quality. (2002). Systems to rate the
strength of scientific evidence (Evidence Report/Technology
Assessment No. 47, AHRQ Publication No. 02-E016). Rockville, MD:
Author.

AGREE Collaboration. (2003). Development and validation of an
international appraisal instrument for assessing the quality of clinical
practice guidelines: The AGREE project. Quality and Safety in Health
Care, 12, 18–23.

AGREE Next Steps Consortium. (2009). Appraisal of guidelines for
research and evaluation. Ontario, Canada: AGREE Research Trust.

American Association of Colleges of Nursing. (2008). The essentials of
baccalaureate nursing education for professional nursing practice.
Washington, DC: Author.

American Nurses Association. (2015). Nursing: Scope and standards of
practice (3rd ed.). Silver Spring, MD: Author.

Beyea, S. C., & Slattery, M. J. (2006). Evidence-based practice in
nursing: A guide to successful implementation. Marblehead, MA:
Healthcare Compliance.

Critical Appraisal Skills Programme. (2010). CASP checklists. Retrieved
from https://casp-uk.net/casp-tools-checklists/

Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J.,
Mitchell, P., . . . Warren, J. (2007). Quality and safety education for
nurses. Nursing Outlook, 55(3), 122–131.

DelMonte, J., & Oman, K. S. (2011). Preparing and sustaining staff
knowledge about EBP. In J. Houser & K. S. Oman (Eds.), Evidence-
based practice: An implementation guide for healthcare organizations

(pp. 55–71). Sudbury, MA: Jones & Bartlett Learning.
Houser, J. (2008). Nursing research: Reading, using, and creating
evidence. Sudbury, MA: Jones and Bartlett.

Houser, J. (2011). Evidence-based practice in health care. In J. Houser &
K. S. Oman (Eds.), Evidence-based practice: An implementation guide
for healthcare organizations (pp. 1–19). Sudbury, MA: Jones & Bartlett
Learning.

Institute of Medicine. (2008). Evidence-based medicine and the changing
nature of healthcare: 2007 IOM annual meeting summary. Washington,
DC: National Academies Press.

Institute of Medicine. (2011). Clinical practice guidelines we can trust.
Washington, DC: National Academies Press. Retrieved from
http://www.nationalacademies.org/hmd/Reports/2011/Clinical-Practice-
Guidelines-We-Can-Trust.aspx

Levin, R. F. (2006a). Evidence-based practice in nursing: What is it? In R.
F. Levin & H. R. Feldman (Eds.), Teaching evidence-based practice in
nursing: A guide for academic and clinical settings (pp. 5–14). New
York, NY: Springer.

Levin, R. F. (2006b). Teaching students to formulate clinical questions:
Tell me your problems and then read my lips. In R. F. Levin & H. R.
Feldman (Eds.), Teaching evidence-based practice in nursing: A guide
for academic and clinical settings (pp. 27–36). New York, NY: Springer.

LoBiondo-Wood, G., & Haber, J. (2014). Integrating research, evidence-
based practice, and quality improvement processes. In G. LoBiondo-
Wood & B. Haber (Eds.), Nursing research: Methods and critical
appraisal for evidence-based practice (8th ed., pp. 5–24). St. Louis,
MO: Mosby.

Massachusetts Department of Higher Education. (2016). Nurse of the
future: Nursing core competencies: Registered nurse. Retrieved from
http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Melnyk, B. M., & Fineout-Overholt, E. (2014). Evidence-based practice in
nursing and healthcare: A guide to best practice (3rd ed.). Philadelphia,
PA: Lippincott Williams & Wilkins.

Newhouse, R. P., Dearholt, S. L., Poe, S. S., Pugh, L. C., & White, K. M.
(2007). Johns Hopkins nursing evidence-based practice: Model and
guidelines. Indianapolis, IN: Sigma Theta Tau International.

Polit, D. F., & Beck, C. T. (2017). Nursing research: Generating and
assessing evidence for nursing practice (10th ed.). Philadelphia, PA:
Lippincott Williams & Wilkins.

Pugh, L. C. (2012). Evidence-based practice: Context, concerns, and
challenges. In S. L. Dearholt & D. Dang (Eds.), Johns Hopkins nursing
evidence-based practice: Model and guidelines (2nd ed., pp. 5–23).
Indianapolis, IN: Sigma Theta Tau International.

Quality and Safety Education for Nurses. (2015). Evidence-based
practice. Retrieved from http://qsen.org/competencies/pre-licensure-
ksas/#evidence-based_practice

Revell, M. A. (2015). Role of research in best practices. Nursing Clinics
of North America, 50, 19–32.

Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York, NY:
Free Press.

Sellers, K. F., & McCrea, K. L. (2014). Evidence-based practice. In P.
Kelly, B. A. Vottero, & C. A. Christie-McAuliffe (Eds.), Introduction to
quality and safety education for nurses (pp. 339–370). New York, NY:
Springer.

Spector, N. (2007). Evidence-based health care in nursing regulation.
Chicago, IL: National Council of State Boards of Nursing.

Stevens, K. (2013). The impact of evidence-based practice in nursing
and the next big ideas. Online Journal of Issues in Nursing, 18(2).
Retrieved from
http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-

18-2013/No2-May-2013/Impact-of-Evidence-Based-Practice.html
Titler, M. G. (2008). The evidence for evidence-based practice
implementation. In R. G. Hughes (Ed.), Patient safety and quality: An
evidence-based handbook for nurses (pp. 1–49). Rockville, MD:
Agency for Healthcare Research and Quality.

Tracy, M. F., & Barnsteiner, J. (2014). Evidence-based practice. In G.
Sherwood & J. Barnsteiner (Eds.), Quality and safety in nursing: A
competency approach to improving outcomes (pp. 133–148). West
Sussex, England: Wiley.

© James Kang/EyeEm/Getty Images

CHAPTER 10

Patient Education and Patient-
Centered Care in Professional
Nursing Practice
Kathleen Masters

Learning Objectives

After completing this chapter, the student should be able to:

1. Describe the characteristics of patient-centered care (PCC) and
family-centered care (FCC).

2. Discuss the dimensions of PCC.

3. Discuss communication in the context of PCC and FCC.
4. Describe patient education in the context of PCC.
5. Describe the evaluation of PCC.

Key Terms and Concepts

Patient-centered care (PCC)
Family-centered care (FCC)
Patient education
Patient teaching
Learning domains
Andragogy
Health Belief Model (HBM)
Social Learning Theory
Self-efficacy
Readiness to learn
Health literacy
Age-related changes

What exactly is patient-centered care (PCC)? As one of the six
dimensions of quality identified by the Institute of Medicine (IOM), PCC is
defined as “providing care that is respectful of and responsive to
individual patient preferences, needs, and values and ensuring that
patient values guide all clinical decisions” (2001, p. 40). The Quality and
Safety Education for Nurses (QSEN) initiative refined this definition in the
formation of the PCC competency. PCC is defined by QSEN in terms of
the nurse recognizing “the patient or designee as the source of control
and full partner in providing compassionate and coordinated care based

on respect for the patient’s preferences, values, and needs” (Cronenwett
et al., 2007, p.123). Another competency-based definition for PCC is that
the nurse “will provide holistic care that recognizes an individual’s
preferences, values, and needs and respects the patient or designee as
a full partner in providing compassionate, coordinated, age and culturally
appropriate, safe and effective care” (Massachusetts Department of
Higher Education, 2016, p. 10).

All three definitions share a common focus. The provision of care that
is appropriate for each patient is based on the patient’s preferences with
the patient as a partner on the healthcare team. It is important to note
that PCC is not the same as patient-focused care. In the patient-focused
care scheme, the healthcare provider, rather than the patient, retains
decision-making control (Walton & Barnsteiner, 2012). The remainder of
this chapter focuses on the components of PCC and the nurse’s role in
the maintenance of a patient-centered environment.

KEY COMPETENCY 10-1

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Patient-Centered Care:

Knowledge (K2) Understands that care and services are delivered in a
variety of settings along a continuum of care that can be accessed at
any point

Skills (S2) Assesses patient values, preferences, decisional capacity,
and expressed needs as part of ongoing assessment, clinical interview,
implementation of care plan, and evaluation of care

Attitudes/Behaviors (A2a) Values and respects assessing the
healthcare situation from the patient’s perspective and belief systems

Attitudes/Behaviors (A2b) Respects and encourages the patient’s
participation in decisions about health care and services

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Dimensions of Patient-Centered
Care
Dimensions of PCC that are characteristic of a patient-centered
environment include respect for patients’ values, preferences, and
expressed needs; coordination and integration of care; information,
communication, and education; physical comfort; emotional support;
involvement of family and friends; and transition and continuity (Gerteis,
Edgman-Levitan, Daley, & Delbanco, 1993).

Nurses show respect for patients as individuals by sharing
information with them and by actively partnering to determine care
priorities and the plan of care (Figure 10-1). In addition, tailoring the
patient’s level of involvement based on his or her preferences rather than
on the nurse’s preferences and revising the plan as the situation changes
also demonstrate respect for patients (Gerteis et al., 1993). For PCC to
be a reality, clinicians must relinquish the role of expert, realizing that
although they are technical experts, the patient and family are the experts
regarding their own life experiences.

Figure 10-1 It is the responsibility of the nurse to create a patient-centered care environment.
© monkeybusinessimages/iStock/Getty Images.

The concept of compliance must be replaced by one of engagement
and partnership, and clinicians must believe that the best decisions
emerge through input from all who have knowledge relevant to a
particular patient situation (Disch, 2012).

Coordination and integration of care are evident as members of the
healthcare team communicate effectively with one another and in turn
deliver consistent messages to the patient and as nurses create smooth
transitions across episodes of care. The role of nursing in the
coordination and integration of care is increasingly important as care
becomes more complex because of the simultaneous existence of
multiple chronic conditions, increasing numbers of care providers
involved in the episodes of care, numerous settings for care, and shorter
episodes of care (Gerteis et al., 1993).

Adapting education and communication based on the patient’s
preference is a foundation of PCC. Information on clinical status,
progress, and prognosis communicated to patients needs to make sense
to patients and families and be at a level that they can understand.

Education provided to patients to facilitate self-care and health promotion
must also be at a level that the patient can understand (Gerteis et al.,
1993).

Physical comfort should form the basis for the individualized plan of
patient care. Ensuring that the patient will be free of pain is an
expectation of PCC, as are assistance with activities of daily living and a
clean and private environment (Gerteis et al., 1993). Periodic
assessments of patient comfort are essential, as are the timely
administration of medications and the monitoring of the effects of
medications and treatments (Walton & Barnsteiner, 2012). In addition to
physical discomfort, patients may experience anxiety and distress during
their experience of care. Patients frequently experience anxiety over their
clinical status, treatments, and prognosis as well as the effect of the
illness on themselves, their families, and their finances. The nurse is in a
position that allows for spiritual and emotional support of the patient and
family during the care experience (Gerteis et al., 1993).

KEY COMPETENCY 10-2

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Patient-Centered Care:

Knowledge (K3) Understands multiple dimensions of patient-centered
care including (a) Patient/family/community preferences, values (b)
Coordination and integration of care (c) Information, communication
and education (d) Physical comfort and emotional support (e)
Involvement of family and significant other (f) Care transition and
continuity

Skills (S3a) Communicates patient values, preferences, and expressed
needs to other members of the health care team

Skills (S3b) Seeks information from appropriate sources on behalf of
the patient

Attitudes/Behaviors (A3a) Respects the patient’s perspective regarding
own health and concerns

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Patient/family-centered care or family-centered care (FCC) is an
extension of PCC that “widens the circle of concern to include those
persons who are important to the patient’s life” (Henneman & Cardin,
2002, p. 13), although it is important to note that FCC does not negate
the patient’s right to privacy and control (Figure 10-2). FCC requires the
structuring of all aspects of the process of engaging the patient’s family
and friends around meeting the patient’s needs rather than around the
convenience of the organization. This includes accommodating family
and friends, including family in decision making (based on patient
preference), recognizing the needs of the family, and providing support
for the family in their caregiving role (Gerteis et al., 1993). It is important
to view this aspect of PCC within the total context of the patient’s care
rather than based on a few policies because FCC is a philosophy that
considers the patient in the context of his or her family (Walton &
Barnsteiner, 2012); however, policies that promote the inclusion of the
family may reflect the family-centered care philosophy of an organization.
It is also important to note that in the context of PCC, family refers to
those persons whom the patient decides to call family rather than those
defined by the provider (Walton & Barnsteiner, 2012).

Figure 10-2 The nurse, viewing the patient in the context of family, will encourage a family-
centered care environment.

© Creatas Images/Creatas/Thinkstock.

Lastly, patients express anxiety about their ability to care for
themselves once discharged from the healthcare setting. PCC includes
support for patients as they transition to home, including information
related to medications, diet, and symptoms to report, provided in a
manner that patients understand. PCC also provides for continuity of care
and assures that patients understand the plan, how to obtain support
services, and whom to call for help once they are discharged from the
acute care facility (Gerteis et al., 1993).

An eighth dimension, access to care, was added when these
principles became known as the Picker Principles of Patient-Centered
Care (Picker Institute, n.d.). This principle simply states that patients
need to know that they can access care when it is needed and also deals
with waits for admission and allocation of hospital beds.

CRITICAL THINKING QUESTION

One recent change on some nursing units has been the establishment

of walking rounds to patient rooms during change of shift report. Using
this model, the nurses, patient, and family members (if the patient
wishes) are all involved in the exchange of information during the
transition of care to the nurse coming on shift. Can you think of any
other changes that you have observed in the healthcare setting that
help to facilitate a PCC environment?

In January 2010, the Joint Commission released a set of standards
for patient-centered communication to advance effective communication,
cultural competence, and PCC. One of the new requirements specifically
states that a family member, friend, or other individual will be allowed to
be present with the patient to provide emotional support and comfort and
to alleviate fear during the course of the hospital stay (2010). This
requirement is not meant to mandate visiting hours or other hospital
policies; it is, however, intended to encourage patient-centered and FCC
environments where policies allow for inclusion of those persons
important to the patient.

KEY COMPETENCY 10-3

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Patient-Centered Care:

Knowledge (K4b) Describes how cultural diversity, ethnic, spiritual and
socioeconomic backgrounds function as sources of patient, family, and
community values

Skills (S4a) Provides patient-centered care with sensitivity and respect
for the diversity of human experience

Attitudes/Behaviors (A4b) Implements nursing care to meet the holistic
needs of patient on socioeconomic, cultural, ethnic, and spiritual values
and beliefs influencing health care and nursing practice

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Commonly cited components of PCC and FCC delivery models
include many of the same types of strategies. Some of these components
are:

Coordination of care conference that includes the patient and/or
family, along with the interdisciplinary team, to discuss goals of
treatment and to initiate discharge planning
Hourly rounding by the nurse to complete treatments that also
includes assessment of pain, elimination, and positioning as well as
other concerns of the patient and/or family members
Bedside report with the patient at the center of the discussion, with
family and friends present at the discretion of the patient or patient
advocate
Use of a patient care partner (may be a family member, friend, or
volunteer) selected by the patient to participate at various times in
educational, psychological, physical, and spiritual support
Individualized care that is established on admission to include the
patient’s preferred name, the patient’s priorities for care, the patient’s
learning style preference, and the patient’s care partner selection
Open medical record policy that allows patients to view their medical
record and document their perspective if they choose
Eliminating visiting restrictions in relation to family members
because, in the context of FCC, family members are members of the
healthcare team rather than visitors
Allowing family presence with a chaperone during resuscitation and
other invasive procedures, thus never separating them from the

patient unless the patient requests it
Silence and a healing environment where the patient is invited to
report any discomfort with the noise level in their environment to the
nurse, who will then intervene to decrease the noise level as much
as is possible (Flagg, 2015; Hunter & Carlson, 2014).

Communication as a Strategy to
Support Patient-Centered Care
Effective communication between healthcare providers and the patient is
an essential component of PCC (IOM, 2001). Communicating effectively
in all areas of practice and with all members of the healthcare team,
including the patient and the patient’s support network, is an expectation
of all registered nurses (American Nurses Association [ANA], 2015),
including entry-level nurses (American Association of Colleges of Nursing
[AACN], 2008; QSEN, 2012). The nurse is responsible for assessment of
his or her own communication skills, continuous improvement of
communication skills, assessment of communication ability and
preferences of patients, and communication of accurate information in a
manner that demonstrates respect (ANA, 2015).

KEY COMPETENCY 10-4

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Communication (Therapeutic Communication):

Knowledge (K1a) Understands the principles of effective
communication through various means

Skills (S1a) Uses clear, concise, and effective written, electronic, and
verbal communications

Attitudes/Behaviors (A1a) Accepts responsibility for communicating
effectively

Attitudes/Behaviors (A1b) Recognizes one’s individual responsibility to

communicate effectively utilizing a collegial tone and voice

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

In terms of a competency, communication is defined as the nurse
interacting “effectively with patients, families, and colleagues, fostering
mutual respect and shared decision making, to enhance patient
satisfaction and health outcomes” (Massachusetts Department of Higher
Education, 2016, p. 32). This definition includes not only the standards
for communication and PCC but also the desired outcomes of PCC.

The new standards published by the Joint Commission (2010) related
to patient-centered communication were designed to improve the safety
and quality of care for all patients and to promote better communication
and patient engagement. The standards include requirements that the
hospital identifies the patient’s oral and written communication needs,
including the patient’s preferred language, and that the hospital
communicates in a manner that meets the patient’s needs.

Communication may be viewed from different vantage points and
may be manifested in a variety of formats and styles. For example,
communication may be oral or written, empathetic or nonempathetic, and
verbal or nonverbal (Bankert, Lazarek-LaQuay, & Joseph, 2014).

Empathetic communication refers to communication with someone
from the vantage point of the other person’s feelings, values, and
perspective (Figure 10-3). The nurse–patient relationship based on
empathetic communication is characterized by a genuine respect for the
patient’s opinions and decisions. Empathetic communication is the
foundation for establishing relationships that are consistent with PCC
(Bankert et al., 2014). Behaviors that facilitate empathetic communication

include:

Figure 10-3 Engaging in empathetic communication is essential in creating a patient-centered
care environment.

© Monkey Business Images/Shutterstock.

Listens carefully and reflects back a summary of the patient’s
concerns
Uses terms and vocabulary appropriate for the patient
Calls the patient by his or her preferred name
Uses respectful and professional language
Asks the patient what he or she needs and responds promptly to
those needs
Provides helpful information
Solicits feedback from the patient
Uses self-disclosure appropriately
Employs humor as appropriate
Provides words of comfort when appropriate (Bankert et al., 2014, p.
165)

KEY COMPETENCY 10-5

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Communication (Therapeutic Communication):

Knowledge (K2c) Describes the impact of one’s own communication
style on others

Skills (S2e) Assesses barriers to effective communication

Skills (S2g) Assesses the impact of use of self in effective
communication

Attitudes/Behaviors (A2b) Values mutually respectful communication

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Behaviors can also hinder empathetic communication. Some of these
behaviors may include:

Interrupts the patient with irrelevant information
Uses vocabulary that is either beneath the level of the patient or not
understandable to the patient
Uses language that may be perceived as patronizing or demeaning
Uses nonprofessional language
Reprimands or scolds the patient
Preaches to the patient
Provides the patient with inappropriate information
Asks questions at inappropriate times or gives the patient advice
inappropriately
Self-discloses inappropriately (Bankert et al., 2014, p. 165)

Other elements to consider are verbal communication and nonverbal

behaviors that, although discussed separately, take place simultaneously.
The empathetic communicator will be attentive to conflicting messages
related to verbal and nonverbal communication, paying particular
attention to nonverbal messages because these provide the nurse with
insight into the patient’s inner feelings. Nonverbal behaviors that the
nurse will want to observe include eye movement, body position and
movement, facial expression, and tone of voice. To communicate
effectively, the nurse must learn to attend to all these elements of the
communication process (Bankert et al., 2014).

KEY COMPETENCY 10-6

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Communication (Therapeutic Communication):

Knowledge (K3a) Understands the nurses’ role and responsibility in
applying the principles of verbal and nonverbal communication

Knowledge (K3b) Understands the nurse’s role and responsibility in
applying principles of active listening

Skills (S3b) Actively listens to comments, concerns, and questions

Skills (S3c) Demonstrates effective interviewing techniques

Skills (S3d) Provides opportunity to ask and respond to questions

Skills (S3e) Assesses verbal and non-verbal responses

Attitudes/Behaviors (A3a) Values the therapeutic use of self in patient
care

Attitudes/Behaviors (A3b) Appreciates the dynamics of physical and
emotional presence on communication

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Examples of specific questions, known as Kleinman’s questions, that
can help clinicians relate to a patient on his or her level to provide PCC
are included here. The questions are designed to elicit the patient’s
perception of his or her illness. The wording of the questions can be
revised based on the setting, illness, and characteristics of the patient.

What do you think has caused your problem?
Why do you think it started when it did?
What do you think your problem does inside your body?
How severe is your problem? Will it have a short or long course?
What kind of treatment do you think you should receive?
What are the most important results you hope to receive from this
treatment?
What are the chief problems your illness has caused you?
What do you fear most about your illness/treatment? (Kleinman,
1980)

Patient Education as a Strategy to
Support Patient-Centered Care
Patient education has formally been a part of nursing care since the
time of Florence Nightingale (1860/1969). During the 1900s, patient
education increasingly became identified as a role of the professional
nurse; however, it was not until 1973 that the ANA defined patient
education as a component of the practice of the registered nurse.
Beginning in 1976, the Joint Commission on Accreditation of Healthcare
Organizations (Joint Commission, 1995) included patient and family
education as a function critical to patient care. The AACN (1998, 2008)
also recognized that the implementation of the professional nursing role
requires that nurses are prepared to teach patients effectively. Standard
5 of the standards of professional nursing practice states that the nurse is
responsible for implementation of an identified plan (ANA, 2015). A
subcategory of this standard titled Health Teaching and Health Promotion
indicates that the nurse employs strategies to promote health and a safe
environment. Competencies under this standard include those related to
the nurse providing health promotion education and health teaching
(ANA, 2015). Thus, in contemporary nursing practice, patient education is
both a professional expectation and a legal obligation of the nurse
(Figure 10-4).

Figure 10-4 The nurse must possess the skills to effectively communicate with patients.
© asiseeit/E+/Getty Images.

“Patient education is any set of planned, educational activities
designed to improve patients’ health behaviors, health status, or both”
(Lorig, 2001, p. xiii). There is nothing in this definition about improving
knowledge, although a change in knowledge might be necessary to reach
the goal of changing health status or health behaviors. In contrast,
activities aimed at improving knowledge are known as patient teaching
(Lorig, 2001). The point is that the purposes of patient education are
more than a change in knowledge. The purposes of patient education are
to maintain health, to improve health, or to slow deterioration of health.
These purposes are met through changes in health-related behaviors
and attitudes (Lorig, 2001), and these changes are not easily achieved.
Effective patient education requires the nurse to have the ability to
communicate effectively with patients to assess the individual needs,
attitudes, and preferences of the patient that can affect health behaviors
before any changes can be expected (Falvo, 2004, 2011).

Principles and Theories Related to Patient
Education
In addition to communication and assessment skills, if the nurse is to be
effective as a patient educator, then he or she must also have sufficient
knowledge of the information that needs to be taught. If the knowledge
base of the nurse is insufficient, the nurse risks providing inadequate or
inaccurate information to the patient (Falvo, 2004, 2011). Finally, to be an
effective patient educator, it is important that the nurse have an
understanding of how to conduct patient education. Many educational
theories and principles can be used to guide the patient education
process. Some that are most commonly used in the healthcare setting
are presented here.

Domains of Learning
First, we should examine the nature of learning in relationship to learning
domains. Identification of the learning domain reflects the type of
learning desired as a result of the patient education process. Learning
occurs in three domains: the cognitive, the psychomotor, and the
affective (Bloom, 1956). The framework includes categories or levels of
learning that comprise knowledge, comprehension, application, analysis,
synthesis, and evaluation. Each level builds on the previous one in a
hierarchical fashion. In the cognitive and psychomotor domains, levels
are arranged in order of increasing complexity. In the affective domain,
levels are organized according to the degree of internalization of a value
or attitude.

KEY COMPETENCY 10-7

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Communication (Teaching/Learning):

Knowledge (K8d) Is aware of the three domains of learning: cognitive,
affective, and psychomotor

Attitudes/Behaviors (A8d) Values the need for teaching in all three
domains of learning

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

In the revised taxonomy (Anderson & Krathwohl, 2001), cognitive
learning encompasses the intellectual skills of remembering,
understanding, applying, analyzing, evaluating, and creating. The use of
verbs rather than nouns to name the categories in the revised taxonomy
underscores the dynamic nature of learning. Psychomotor learning refers
to learning of motor skills and performance of behaviors or skills that
require coordination. Affective learning requires a change in feelings,
attitudes, or beliefs.

Understanding which domain is the target of learning helps guide the
planning, implementation, and evaluation of learning. For example, if
based on assessment you know that a patient is knowledgeable about
insulin administration and is committed to administering the injection but
has not yet been able to manipulate the syringe correctly to administer
the injection, you know that your target domain for learning is the
psychomotor domain. Thus, the focus of your objectives, planning,
learning activities, and evaluation will be on the performance of the
identified behaviors.

Andragogy
Andragogy, initially defined as “the art and science of helping adults

learn” (Knowles, 1970), has taken on a broader meaning over the past 40
years and is currently used to refer to learner-focused education for
people of all ages (Conner, 2004). The andragogic model asserts that the
following four issues be considered and addressed in learning (Knowles,
Swanson, & Holton, 1998, 2011):

Letting learners know why something is important to learn
Showing learners how to direct themselves through information
Relating the topic to the learners’ experiences
Realizing that people will not learn until they are ready and motivated

Adults learn best when there is immediate opportunity for application.
Adults in particular are motivated to learn when they recognize a gap
between what they know and what they want to know or what they need
to know (Knowles, 1970). Therefore, adult learners are rarely interested
in learning detailed anatomy and physiology related to their chronic
disease, but they are motivated to learn how to care for themselves after
discharge from the hospital. Effective patient education will be based on
principles that capitalize on these characteristics of the adult learner.

Health Belief Model
The Health Belief Model (HBM) is one of the most widely used
frameworks in research and programs related to health promotion and
patient education. This model was originally developed to predict the
likelihood of a person following a recommended action and to understand
the person’s motivation and decision making regarding seeking health
services (Hochbaum, 1958).

According to the HBM, the likelihood of a person acting in response
to a health threat depends on six factors:

The person’s perception of the severity of the illness
The person’s perception of susceptibility to illness and its

consequences
The value of the treatment benefits (i.e., do the cost and side effects
of treatment outweigh the consequences of the disease?)
Barriers to treatment (i.e., expense, complexity of treatment)
Costs of treatment in physical and emotional terms
Cues that stimulate taking action toward treatment of illness (i.e.,
mass media campaigns, pamphlets, advice from family or friends,
and postcard reminders from healthcare providers)

The HBM can provide a framework for assessing areas where
patients have gaps in knowledge, such as severity of illness or
susceptibility to illness, and then addressing those areas to increase the
potential for compliance with the treatment regimen. Through use of the
HBM, you can easily categorize and cover the essential components of
your educational message, thus providing the patient with a basic
understanding of the severity of the illness, the risk and consequences of
the illness, the value of treatment, the barriers to treatment, and the costs
of treatment.

Social Learning Theory
According to Bandura’s Social Learning Theory, if a person believes
that he or she is capable of performing a behavior (self-efficacy) and
also believes that the behavior will lead to a desirable outcome, the
person will be more likely to perform the behavior (Bandura, 1997). In
contrast, if a person does not believe that he or she is capable of
performing a behavior, he or she will have no incentive to do so, even if
the person is actually capable. Perceptions of self-efficacy are particularly
important in relation to a patient’s learning complex activities or long-term
changes in behavior (Prohaska & Lorig, 2001).

There are four methods for developing or enhancing efficacy

expectations if assessment reveals a need for such enhancement:

Performance accomplishments
Vicarious experience or modeling
Verbal persuasion
Interpretation of physiologic state

Performance accomplishment is the most direct and influential way to
enhance self-efficacy. In this method, the patient first performs tasks that
he or she can easily handle. By succeeding with these first tasks, the
patient develops a sense of competence and enhancement of self-
efficacy before proceeding to more difficult tasks. Along these same
lines, it is also important to set short-term goals that are measurable so
that patients can see their success and the effect of the change in their
behavior. A patient who can see the benefits of a behavior change within
a reasonable time is more likely to continue practicing the behavior.

KEY OUTCOME 10-1

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential VII: Clinical Prevention and Population Health

7.4 Use behavioral change techniques to promote health and manage
illness (p. 24).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

The second method for enhancing self-efficacy is through modeling,
where the patient observes others who appear to be similar and who are
successfully performing behaviors. Modeling can also be achieved

through the use of illustrations in pamphlets or in programming materials
by using illustrations and models that are of various cultures, body
shapes, and ages (Prohaska & Lorig, 2001).

Verbal persuasion can also be an effective method of enhancing self-
efficacy expectations. The content of the message needs to include basic
factual information that emphasizes the importance of performing the
behavior. It is usually better to ask for incremental changes or to ask the
patient to do just slightly more than he or she is currently doing
(Prohaska & Lorig, 2001). Encouragement and support not only from the
nurse but also from family and friends help the patient to be successful.

Most illnesses present with symptoms, and most new behaviors
cause some physiologic changes. Addressing the meaning of symptoms
and physiologic states can influence self-efficacy. For example, a patient
who is trying to quit smoking can expect withdrawal symptoms. If the
patient understands the reasons for the symptoms and the limitation in
the duration of the symptoms, the patient might decide that he or she has
the ability to make the change. Without that knowledge, the patient might
give up because he or she experiences physiologic changes that are not
understood.

CRITICAL THINKING QUESTION

Think about your own life. Do you act to prevent a disease or accident
when you perceive that you are not susceptible to the disease or at
risk for the accident?

The Patient Education Process: Assessment
According to Redman (2001, 2006), the process of patient education can
be viewed as parallel to the nursing process. Each of these processes
begins with assessment, negotiation of goals and objectives, planning,

intervention, and finally evaluation (Rankin, 2005; Rankin & Stallings,
2001; Rankin, Stallings, & London, 2005).

The goal of the nurse in the process of patient education is to assist
the patient in obtaining the knowledge, skills, or attitude that will help the
patient develop behaviors to meet needs and to maximize the potential
for positive health outcomes (Falvo, 2004, 2011). Because no patient or
situation is exactly the same, an assessment is required.

KEY COMPETENCY 10-8

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Communication (Teaching/Learning):

Knowledge (K8c) Understands the principles of teaching and learning

Skills (S8c) Assists patients and families in accessing and interpreting
health information and identifying healthy lifestyle behaviors

Attitudes/Behaviors (A8g) Accepts the role and responsibility for
providing health education to patients and families

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Many available guides are helpful in assessing the learning needs of
patients (Redman, 2003). Some nurses construct their own assessment
tools to meet specific needs. Observation, interviews, open-ended
questions, focus groups, and the patient’s medical record are additional
ways to gather information for the assessment of learning needs. Rankin
and Stallings (2001, p. 200) suggest some specific questions that must
be addressed in the assessment of learning needs:

What information does the patient need?
What attitudes should be explored?
What skill does the patient need to be able to perform healthcare
behaviors?
What factors in the patient’s environment may be barriers to the
performance of desired behaviors?
Is the patient likely to return home?
Can the family or caregiver handle the care that will be required?
Is the home situation adequate or appropriate for the type of care
required?
What kinds of assistance will be required?

Learning Styles
To provide the most effective patient teaching, the nurse must also
assess patient learning style. Although most people learn best when
multiple techniques are used in patient teaching, assessment of the
patient’s learning style is a fundamental step before beginning any
learning activity. Learning styles are methods of interacting with, taking
in, and processing information that allow individuals to learn. Learning
styles are generally categorized as visual, auditory, or tactile/kinesthetic.

The patient who is a visual learner prefers written instructions rather
than oral instructions but prefers photographs and illustrations to written
instructions. The nurse teaching the patient who is a visual learner should
use a variety of interesting visual learning materials, including organized
visual presentations, photographs, or computerized materials (Russell,
2006).

KEY COMPETENCY 10-9

Examples of applicable Nurse of the Future: Nursing Core

Competencies

Communication (Teaching/Learning):

Knowledge (K8a) Understands the influences of different learning
styles on the education of patients and families

Knowledge (K8b) Identifies differences in auditory, visual, and tactile
learning styles

Skills (A8b) Recognizes learning styles vary by individual

Attitudes/Behaviors (S8a) Assesses factors that influence the patient’s
and family’s ability to learn, including readiness to learn, preferences
for learning style, and levels of health literacy

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

The patient who is an auditory learner remembers oral instructions
well and learns through discussion. The nurse teaching a patient who is
an auditory learner will want to be sure that the patient is positioned to be
able to hear and will want to rephrase what is said several different ways
to be sure the intended message is communicated. The nurse might also
want to use multimedia that incorporates sound in patient teaching
(Russell, 2006).

The patient who learns best through getting physically involved is the
tactile or kinesthetic learner. The kinesthetic learner learns through doing
or experiencing physically. The kinesthetic learner has difficulty staying in
one place for very long and enjoys hands-on activities. The nurse
teaching the kinesthetic learner should provide activities during the
session and should provide samples or supplies for practicing or
demonstrating skills (Russell, 2006).

Readiness to Learn
An important variable in the patient education process is readiness to
learn. After a need to learn has been identified, a patient’s readiness or
evidence of motivation to receive information at that particular time must
also be assessed (Falvo, 2004, 2011; Joint Commission, 2003; Redman,
2001). A variety of factors, such as pain, anxiety, and emotional
reactions, can affect a patient’s readiness to learn. Moderate to severe
anxiety has been shown to interfere with a patient’s ability to concentrate
and understand new information (Stephenson, 2007). If a patient is
distracted by physical or emotional pain, attempts at patient teaching will
not be successful. The better choice is to wait until the pain has subsided
or to address the anxiety that the patient is experiencing, and then when
the patient is ready, proceed with patient education activities (Redman,
2001, 2006; Stephenson, 2007).

Health Literacy
Considering a patient’s health literacy is an important component in
PCC. Health literacy is generally defined as the ability to read,
understand, and act on health information. The IOM (2004) consensus
report on health literacy defined the concept as “the degree to which
individuals have the capacity to obtain, process, and understand basic
health information and services they need to make appropriate health
decisions” (p. 31).

Today there is more access to healthcare information than at any
time in history. The low health literacy problem for most is not an issue of
access to information but rather is a crisis of not understanding medical
information (Doak & Doak, 2002). Research studies have demonstrated
that patients with low health literacy skills make more errors with their
medications and treatments (Baker et al., 1996; Williams, Baker, Honig,
Lee, & Nowlan, 1998) and are also at risk for experiencing preventable

adverse events (Bartlett, Blais, Tamblyn, Clermont, & MacGibbon, 2008).
They often fail to seek preventive care and are also at higher risk for
hospitalization, which results in higher annual healthcare costs (Agency
for Healthcare Research and Quality [AHRQ], 2011; Baker, Parker,
Williams, & Clark, 1998; U.S. Department of Health and Human Services
[USDHHS], 2012; Weiss, 1999).

In the United States, one in five adults and nearly two in five older
adults and minorities read at the fifth-grade level or below. Only 12% of
U.S. adults are considered to have proficient health literacy. The number
of adults with only basic health literacy skills or below basic-level health
literacy skills has reached 77 million. One-third of the U.S. adult
population has difficulty with common health tasks, such as following
instructions on a medication label (USDHHS, 2012). This is significant
because persons with only basic health literacy skills or below basic-level
health literacy skills have difficulty processing and understanding
information and services and thus have difficulty making healthcare-
related decisions (Miller & Stoeckel, 2011). Although health literacy is
partially dependent on the patient’s skill set, it is also dependent on the
complexity of the information as well as how information is communicated
(USDHHS, 2012).

The National Patient Safety Foundation (2015) has developed a
program called Ask Me 3. According to the foundation, this program
promotes improved health outcomes by encouraging patients to become
active members of their healthcare team through improved
communication between patients and their healthcare providers. The
following are the three questions the program encourages patients to ask
their healthcare provider:

What is my main problem?
What do I need to do?

Why is it important for me to do this?

Another program that is used by nurses to become more effective
patient educators is ACTS, an acronym for assess; compare; teach three,
teach back; and survey. The best education strategies begin by asking
the patient to identify his or her main concern. This simple question will
shift the focus of the interaction from the nurse to a patient-centered
encounter. Next, the nurse must discover the needs and preferences of
the patient as well as how the patient prefers to learn in order to
individualize the teaching plan. Asking the patient or caregiver what they
already know acknowledges his or her current level of expertise and
supports the concepts of patient control and shared decision making.
Finally, the nurse assesses patient core values and cultural, social,
language, and physical influences. During the compare phase, the nurse
compares the available resources to the needs and preferences of the
patient to match relevant content to identified knowledge gaps. Teach
three, teach back refers to the process in which patients are taught three
or fewer key concepts or care skills in short segments and then the
patient restates the concept in his or her own words or demonstrates the
skill. If the patient has difficulty with restating or with skill demonstration,
teaching should be repeated. Nurses should then close the loop by
asking in an open-ended manner if there are additional questions or
learning needs (French, 2015).

When information is complex or time is limited, nurses frequently
provide printed materials for patients to read or review at home. These
materials are helpful when they provide patients who have adequate
reading skills with a resource to remind them of the instructions given by
the nurse, but for those patients with low health literacy skills, the printed
materials might be of no use. The average American reads at the eighth-
to ninth-grade level. Most materials used for patient education are written

above the 10th-grade reading level (Doak & Doak, 2002; Doak, Doak, &
Root, 1996). We know that when the reading level of printed materials is
beyond the skill of the learner, comprehension is decreased, recall is
sketchy and inaccurate, and motivation to learn is decreased (Redman,
2001, 2006).

Patients with low health literacy skills are generally too embarrassed
to reveal to the nurse that they cannot read or cannot read well enough to
understand the written instructions. It is therefore important that the nurse
take the initiative in assessing the literacy skills of patients before using
written materials in the patient education process and to provide
educational materials in various formats when possible.

Direct questioning of patients about reading ability is usually not
effective. How can you determine the reading ability of the patient? One
option is to use one of several instruments that have been developed to
assess patient literacy quickly. Some of the literacy assessment
instruments most commonly used in healthcare settings include the
Rapid Estimate of Adult Literacy in Medicine (Davis et al., 1993) and the
Wide Range Achievement Test (Jastak & Wilkinson, 1993).

One of the best ways to assess literacy is simply through careful
observation of your patient. Clues that might be observed in a patient
with low health literacy skills include forms that are filled out incompletely
or incorrectly, written materials that are handed to a person
accompanying the patient, and aloofness or withdrawal during provider
explanations. Additional clues might include surveillance of the behavior
of others in the same situation to copy their actions or a request for help
from staff or other patients. Verbal responses like “I will read this at
home” or “I can’t read this now because I forgot my glasses” are also
common (Bastable, 2006; Doak & Doak, 2002).

Health literacy tools continue to focus primarily on reading ability,
despite the IOM’s recommendation that the focus change to skills-based

health literacy tools that use a combination of skills that patients can use
to manage health, such as verbal, computer, or other skills (AHRQ,
2011). Because reading ability continues to be the prevalent focus, we
consider assessment of readability of materials next.

Assessing the Readability of Patient Education Materials
Many health-related teaching materials are written on a level that is
above the average patient’s literacy level and contain too much medical
jargon (National Center for Education Statistics, 2007). Written materials
can still be useful supplements for patients with low health literacy skills if
the written materials selected are appropriate to the reading level of the
patient. Print materials for most patient populations should be written
between the seventh- and eighth-grade reading levels. Print materials for
patients with low health literacy skills should be written at or below the
fifth-grade reading level (Doak & Doak, 2002).

CRITICAL THINKING QUESTIONS

Have you ever been assigned to read a book that had so many big
words in it that you had to keep the dictionary by your side? If it was
assigned for school, you probably struggled through it for the sake of
not failing the test, but what about if you were not being graded?
Would you bother to read it? If you did read it because you knew it
would help you, would you have enough understanding to actually
apply the information?

Several readability formulas are available to determine the grade
level of materials (Flesch, 1948; Fry, 1968; McLaughlin, 1969). One of
the easiest formulas to use is the SMOG formula, which predicts the
reading grade level of materials within 1.5 grades 68% of the time
(McLaughlin, 1969). The procedure for using the SMOG readability
formula for printed materials is outlined in Box 10-1. Readability of

BOX 10-1

1.

2.

3.

4.

5.

1.
2.
3.

materials available in an electronic format can be assessed using
formulas embedded in word processing programs and also for free via
several readability calculation websites on the Internet.

SMOG READABILITY FORMULA

Choose 10 consecutive sentences near the beginning, 10
consecutive sentences from the middle, and 10 consecutive
sentences from the end of the material.
In these 30 sentences, count the number of words containing three
or more syllables, including repetitions. Consider hyphenated words
as one word. Proper nouns are also counted. Numerals and
abbreviations should be counted as they would if the words were
written out. When a colon divides words, each portion of the
sentence is considered a separate sentence.
Estimate the square root of the number of polysyllabic words
counted.
Add three to the square root. This gives the SMOG grading, which is
the reading grade level that a person must have achieved to fully
understand the material.
The quickest way to assess reading grade level is to use the SMOG
conversion table. Simply compare the total number of words
containing three or more syllables in the 30 sentences with the
SMOG conversion table.

However, not all written patient education materials contain 30
sentences. To assess materials with fewer than 30 sentences:

Count all the polysyllabic words.
Count the number of sentences.
Find the average number of polysyllabic words per sentence.

4.
5.
6.

Multiply that average by the number of sentences short of 30.
Add that figure to the total number of polysyllabic words.
Find the square root of the number you obtained in step 5 and add
the constant of three. This procedure also gives you the SMOG
grading.

SMOG Conversion Table

Word Count Grade Level

0–2 4
3–6 5
7–12 6
13–20 7
21–30 8
31–42 9
43–56 10
57–72 11
73–90 12
91–110 13
111–132 14
133–156 15
157–182 16
183–210 17
211–240 18

Data from Harold C. McGraw, Office of

Educational Research, Baltimore County Schools,

Towson, Maryland.

KEY COMPETENCY 10-10

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Communication (Teaching/Learning):

Knowledge (K8e) Understands the concept of health literacy

Skills (S8a) Assesses factors that influence the patient’s and family’s
ability to learn, including readiness to learn, preferences for learning
style, and levels of health literacy

Attitudes/Behaviors (A8e) Accepts responsibility to insure the patient
receives health information that is understandable

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Low health literacy can be a barrier to effective patient education, but
the patient with low health literacy skills is capable of learning if the nurse
is willing to invest the extra time that is required. It is important for the
nurse to take extra care to present information in terms that the patient is
familiar with rather than using medical jargon; to use alternate formats,
such as pictographs, when possible; to restate information using simple
words; and to verify the patient’s understanding by having him or her
convey the information in his or her own words. The dividends for the
extra effort include the patient who is able to manage his or her own
illness, make informed health decisions, and make health-related
behavior changes as a result of a patient education process that has
accommodated for his or her weaknesses.

The Patient Education Process: Planning
The patient and the nurse share the planning process for patient
education, but it is the responsibility of the nurse to guide the process
using goals and objectives. Learning goals are derived from the learning
assessment, and nursing diagnoses and objectives are developed based
on goals in collaboration with the patient. The use of goals and objectives
helps the nurse to focus on what is important for the patient to learn and
to keep patient education centered on outcomes (Rankin & Stallings,
2001; Rankin et al., 2005).

Patient education is directed toward behavioral change; therefore, the
objectives for patient education are stated as behavioral objectives.
There are three components of behavioral objectives: performance,
conditions, and criteria (Mager, 1997). Performance refers to the activity
that the patient will engage in and answers this question: What can the
learner do? The condition refers to special circumstances of the patient’s
performance and answers this question: Under what conditions will the
learner perform the behavior? The criteria or evaluation component refers
to how long or how well the behavior must be performed to be acceptable
and answers this question: What is the performance standard? (Rankin &
Stallings, 2001; Rankin et al., 2005).

The learning objectives should be specific, measurable, and
attainable (Rankin, 2005; Rankin & Stallings, 2001; Rankin et al., 2005).
Learning objectives are also written in a manner that is learning-domain
specific. Recognizing the targeted domain of learning as cognitive,
psychomotor, or affective helps guide the process of writing behavioral
learning objectives and thus guides the selection of learning activities.

The Patient Education Process: Implementation
The next stage of the process involves the actual intervention. Whether

the teaching will occur in a group or with an individual patient, learning
activities need to be consistent with learning objectives.

Using various learning activities can make learning more fun and
more effective. Some common learning activities include lectures,
demonstrations, practice, games, simulations, role-playing, discussions,
and self-directed learning through computer-assisted instruction or self-
directed workbooks.

Patient education materials are frequently used in the implementation
stage of the patient education process. Patient education materials can
be designed to be used alone or to supplement other types of patient
education activities but should be previewed before use and used only if
consistent with learning objectives. There are many types of patient
education materials currently on the market, or you might opt to produce
your own materials.

Patient education materials generally include audiovisual materials,
computer programs, Internet resources, posters, flip charts, charts,
graphs, cartoons, slides, overhead transparencies, photographs,
drawings, patient education newsletters, or written patient materials, such
as handouts, brochures, or pamphlets. These materials, even if designed
to be used alone, should not be used without some explanation as to why
the patient is being instructed to view the video or read the brochure
(Falvo, 2004, 2011). In addition, the nurse should keep the door of
communication open by inviting questions that the patient might have as
a result of exposure to the teaching materials.

You must evaluate a variety of factors as you look at the
appropriateness of patient education materials. Three important criteria
for judging patient education materials are the following (Doak, Doak,
Gordon, & Lorig, 2001, p. 184):

The material contains the information the patient wants.

The material contains the information the patient needs.
The patient understands and uses the material as presented.

It is an expectation of the Joint Commission that the right educational
materials are used in patient and family education and that the materials
are accurate, age specific, easily accessible, and appropriate to patient
needs (Joint Commission, 2003). To address all these criteria, the nursre
must conduct a needs assessment before preparing or choosing patient
education materials.

Considerations: Patient Education with Older Adults
When caring for older adults, one of the primary considerations related to
the patient education process is accommodation for age-related barriers
to learning (Figure 10-5). The age-related barriers particularly important
in the patient education process include age-related changes in
cognition, vision, and hearing. Research has demonstrated that teaching
is not as effective if it does not accommodate age-related cognitive and
sensory changes (Donlon, 1993; Masters, 2001; Weinrich, Weinrich,
Boyd, Atwood, & Cervenka, 1994). Gerogogy in patient education has
been defined as the transferring of essential information that has been
designed, modified, and adapted to accommodate for the physiologic and
psychologic changes in elderly persons by taking into account the
person’s disease process, age-related changes, educational level, and
motivation (Pearson, 2012).

BOX 10-2

Figure 10-5 The nurse must accommodate for age-related cognitive and sensory changes in
older adults for teaching to be effective.

© Monkey Business Images/Shutterstock.

Age-related changes in cognitive function occur slowly and are
thought to begin at approximately 60 years of age in healthy adults
(Miller, 2004). Age-related visual changes are the most prevalent physical
impairments affecting older adults. Hearing impairment ranks as one of
the four most prevalent chronic conditions affecting the older population,
occurring in one-third of the U.S. population between the ages of 65 and
74 years and in 47% of the population 75 years of age or older (National
Institutes of Health, n.d.). Each of these age-related changes can have a
profound effect on the teaching and learning process. Specific age-
related changes in cognition, vision, and hearing are listed in Box 10-2.

AGE-RELATED BARRIERS TO LEARNING: COGNITIVE
AND SENSORY CHANGES

Cognitive
Changes in encoding and storage of information

BOX 10-3

Changes in the retrieval of information
Decreases in the speed of processing information

Visual
Smaller amount of light reaches the retina
Reduced ability to focus on close objects
Scattering of light resulting in glare
Changes in color perception resulting in difficulty distinguishing

colors, such as dark green, blue, and violet
Decrease in depth perception and peripheral vision

Hearing
Reduced ability to hear sounds as loudly
Decrease in hearing acuity
Decrease in the ability to hear high-pitched sounds
Decrease in the ability to filter background noise

Data from Merriam, S. B., & Caffarella, R. S. (1999). Learning in adulthood: A comprehensive

guide (2nd ed.). San Francisco, CA: Jossey-Bass; Merriam, S. B., Caffarella, R. S., &

Baumgartner, L. M. (2007). Learning in adulthood: A comprehensive guide (3rd ed.). San

Francisco, CA: Jossey-Bass; Miller, C. A. (2004). Nursing for wellness in older adults: Theory

and practice (4th ed.). Philadelphia, PA: Lippincott.

Specific strategies can be used during the patient education process
to help overcome the age-related learning barriers in cognition, vision,
and hearing. Some of these strategies are included in Box 10-3.

STRATEGIES TO ACCOMMODATE AGE-RELATED
BARRIERS TO LEARNING: COGNITIVE AND SENSORY
CHANGES

Cognitive
Slow the pace of the presentation.
Give smaller amounts of information at a time.
Repeat information frequently.
Reinforce verbal teaching with audiovisuals, written materials, and

practice.
Reduce distractions.
Allow more time for self-expression of the learner.
Use analogies and examples from everyday experience to illustrate

abstract information.
Increase the meaningfulness of content to the learner.
Teach mnemonic devices and imaging techniques.
Use printed materials and visual aids that are age specific

Visual
Make sure patient’s glasses are clean and in place.
Use printed materials with 14- to 16-point font and serif letters.
Use bold type on printed materials, and do not mix fonts.
Avoid the use of dark colors with dark backgrounds for teaching

materials; instead, use large, distinct configurations with high
contrast to help with discrimination.

Avoid using blue, green, and violet to differentiate type, illustrations,
or graphics.

Use line drawings with high contrast.
Use soft white light to decrease glare.
Light should shine from behind the learner.
Use color and touch to help differentiate depth.
Position materials directly in front of the learner.

Hearing

Speak distinctly.
Do not shout.
Speak in a normal voice or speak in a lower pitch.
Decrease extraneous noise.
Face the person directly while speaking at a distance of 3 to 6 feet.
Reinforce verbal teaching with visual aids or easy-to-read materials.

Data from Weinrich, S. P., Boyd, M., & Nussbaum, J. (1989). Continuing education: Adapting

strategies to teach the elderly. Journal of Gerontological Nursing, 15(11), 17–21; Oldaker, S. M.

(1992). Live and learn: Patient education for the elderly orthopaedic client. Orthopaedic

Nursing, 11(3), 51–56.

Cultural Considerations in Patient Education
Developing an educational program that is culturally appropriate is not
much different from creating any other patient education program. You
begin with a needs assessment; then you write objectives and design the
program. The difference is that you must be culturally sensitive and
incorporate cultural information that you have learned about the target
group into the patient education process (Bastable, 2006; Gonzalez &
Lorig, 2001; Lengetti, Ordelt, & Pyle, 2007).

How important is it that you incorporate cultural information into the
patient education process? Cultural awareness and sensitivity of nurses
can influence the ability of patients to receive and apply information
regarding their health care (Campinha-Bacote, Yahle, & Langenkamp,
1996). The way that information is communicated can influence a
patient’s perception of the healthcare system and affect adherence to
prescribed treatments. In a recent study, patients who received care from
nurses with cultural sensitivity training showed improvement not only in
use of social resources but also in overall functional capacity (Majumdar,
Browne, Roberts, & Carpio, 2004).

KEY OUTCOME 10-2

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential VII: Clinical Prevention and Population Health

7.5 Use evidence-based practices to guide health teaching, health
counseling, screening, outreach, disease and outbreak investigation,
referral, and follow-up throughout the lifespan (p. 24).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

In addition to the difference that it can make in relationship to patient
outcomes, the standards of practice are clear that the nurse is
responsible for using “health promotion and teaching methods in
collaboration with the healthcare consumer’s values, beliefs, health
practices, developmental level, learning needs, readiness and ability to
learn, language preference, spirituality, culture, and socieoeconomic
status” (ANA, 2015, p. 65). The Joint Commission standards also require
not only that the patient’s learning needs, abilities, and readiness to learn
are assessed but also that the patient’s preferences are assessed. This
assessment must consider cultural and religious practices as well as
emotional and language barriers (Joint Commission, 2003).

KEY OUTCOME 10-3

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential VII: Clinical Prevention and Population Health

7.7 Collaborate with other healthcare professionals and patients to
provide spiritually and culturally appropriate health promotion and
disease and injury prevention interventions (p. 24).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

How do you incorporate cultural information into the patient education
process? Gonzalez and Lorig (2001, p. 172) suggest the following:

Change the information into more specific or more relevant
terminology.
Create descriptions or explanations that fit with different people’s
understanding of key concepts.
Incorporate a group’s cultural beliefs and practices into the program
content and process.

In addition, any visual aids that are used should reflect the target
group or population. The use of culturally relevant analogies can also
help people to understand complex, abstract, or foreign concepts
(Gonzalez & Lorig, 2001).

The Patient Education Process: Evaluation
Evaluation determines worth by judging something against a standard.
The standard used in the patient education process is the learning
objective. Thus, the term evaluation as used here implies measuring the
outcomes resulting from systematically planned activities implemented as
a part of a patient education program or patient education process
against the learning objectives to determine whether learning occurred.

Initiation of the patient education evaluation process is the

responsibility of the nurse, and according to Rankin and Stallings (2001,
p. 326), the evaluation process should include the following:

Measuring the extent to which the patient has met the learning
objectives
Identifying when there is a need to clarify, correct, or review
information
Noting learning objectives that are unclear
Pointing out shortcomings in patient teaching interventions
Identifying barriers that prevented learning

Nurses commonly use several methods to evaluate patient learning.
These methods include direct observation, the teach-back method or
asking patients to explain something in their own words, situational
feedback to determine if the patient selects the appropriate behavior,
records of health-related behaviors that patients report, patient interviews
and questionnaires, and critical incidents, such as readmission,
emergency department visits, and mortality (McNeill, 2012).

KEY COMPETENCY 10-11

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Communication (Teaching/Learning):

Knowledge (K8g) Understands the purpose of health education

Skills (S8g) Evaluates patient and family learning

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Evaluation of Patient-Centered Care
The National Strategy for Quality Improvement in Health Care was
established by the secretary of the USDHHS to set priorities to guide the
nation to increase access to high-quality health care. One of the priorities
identified was the delivery of PCC and FCC (USDHHS, 2011). We know
that there is a link between PCC and high-quality health care, but
identifying specific measures of PCC is challenging.

The HCAHPS (pronounced H-CAPS) survey, also known as the
Consumer Assessment of Healthcare Providers and Systems (CAHPS)
Hospital Survey, was the first national, standardized, publicly reported
survey of patients’ perspectives of hospital care. The intent of the survey
is to provide a standard instrument to measure patient satisfaction with
the hospital experience. The survey asks a core set of questions to
assess patient satisfaction with the care provided by nurses, physicians,
and other members of the healthcare team; the responsiveness of the
hospital staff; pain management; communication about medications; and
the cleanliness and quietness of the environment. The standardized
questions allow for comparisons of patient care experiences.

A more recent addition to the CAHPS survey is the integration of a
supplemental item set related to health literacy. The primary goal of the
survey is to measure, from the patient’s perspective, how well health-
related information was communicated to them by health professionals
during their care. This survey is available in English and Spanish.
CAHPS supplemental item sets are also now available to assess cultural
competence, to assess technology use, and for the patient-centered
medical home (USDHHS, 2012).

Patient satisfaction with the care provided is recognized as a valid

quality indicator (Bankert et al., 2014). As consumers, patients provide
their perspectives on the quality of care, delivery of care, outcomes of
care, and the extent to which they were included as an active participant.
PCC requires that evaluation of the care experience include the
perspective of the patient (Walton & Barnsteiner, 2012).

1.

2.

3.

Conclusion
The patient relationship with healthcare professionals has changed
dramatically during the past few decades and continues to evolve. In just
one generation, we have moved from a healthcare system in which the
provider made all the decisions for the passive patient to a system where
our goal is full partnership with the patient. This shift requires nurses to
actively engage patients in all dimensions of their care while
communicating in a manner that conveys empathy and respect for patient
preferences.

CASE STUDY 10-1 ▪ MR. MARTIN

Mr. Martin, an 82-year-old African American patient, is ready for
discharge from the medical unit after a 3-day hospitalization resulting
from exacerbation of heart failure. Before discharge from the hospital,
the student nurse reviews the medication orders and provides Mr.
Martin with standard patient education materials related to control of
heart failure symptoms.

Case Study Questions

What else could the student nurse in the case study do to enhance
the effectiveness of the patient education process for Mr. Martin?

Do you have any suggestions for the student nurse related to
accommodating age-related changes of this patient?

Do you have any suggestions for the student nurse related to
cultural considerations as she educates this patient?

Classroom Activity 10-1

Provide students with a copy of printed patient education materials.
These can be obtained from a local healthcare organization or from
online sources, such as the American Heart Association. Ask students
to evaluate the materials for readability using the SMOG formula in Box
10-1. Next, ask students to evaluate the materials for use with older
adults using the information presented in Box 10-2 and Box 10-3.
Finally, have students evaluate the materials for use with a population
of a different culture. Ask students to share their findings during
informal presentations to classmates.

Classroom Activity 10-2

Divide the class into small groups and ask students to create a patient
education brochure that conforms to recommended reading levels,
considers age-related learning barriers, and accommodates cultural
differences. The group may choose a fictitious case scenario or an
actual scenario from a recent clinical experience. For this activity,
several students will need to bring laptops to class or the class will
need to have access to a computer lab. Alternately, this activity could
be assigned to students to complete outside of class to be shared with
the class or submitted for a grade.

Classroom Activity 10-3

Share highlights of the story of Lia Lee from Anne Fadiman’s book,
When the Spirit Catches You and You Fall Down. Next, share the
responses of Lia’s mother to Dr. Arthur Kleinman’s questions, available

at http://www.donnathomson.com/2012/11/eight-questions-that-can-
heal.html. Discuss the differing perspective of the issues once
someone asks the patient and/or family what they think.

Classroom Activity 10-4

Numerous classroom and clinical activities related to PCC are
available on the QSEN website at http://qsen.org/teaching-
strategies/strategy-search/. Choose activities from the website for
students to complete that meet objectives specific to your course.

References
Agency for Healthcare Research and Quality. (2011). Health literacy
interventions and outcomes: An updated systematic review
(Publication No. 11E-006). Rockville, MD: U.S. Department of Health
and Human Services.

American Association of Colleges of Nursing. (1998). The essentials of
baccalaureate education for professional nursing practice. Washington,
DC: Author.

American Association of Colleges of Nursing. (2008). The essentials of
baccalaureate education for professional nursing practice. Washington,
DC: Author.

American Nurses Association. (1973). Standards of nursing practice.
Kansas City, MO: Author.

American Nurses Association. (2015). Nursing: Scope and standards of
practice (3rd ed.). Silver Spring, MD: Author.

Anderson, L. W., & Krathwohl, D. R. (Eds.). (2001). A taxonomy for
learning, teaching and assessing: A revision of Bloom’s taxonomy of
educational objectives. New York, NY: Addison-Wesley.

Baker, D. W., Parker, R. M., Williams, M. V., & Clark, W. S. (1998). Health
literacy and the risk of hospital admission. Journal of General Internal
Medicine, 13, 791–798.

Baker, D. W., Parker, R. M., Williams, M. V., Pitkin, K., Parikh, N. S.,
Coates, W., & Imara, M. (1996). The health care experience of patients
with low literacy. Archives of Family Medicine, 5, 329–334.

Bandura, A. (1997). Self-efficacy: The exercise of control. New York, NY:
W. H. Freeman.

Bankert, E., Lazarek-LaQuay, A., & Joseph, J. M. (2014). Patient-

centered care. In P. Kelly, B. A. Vottero, & C. A. Christie-McAuliffe
(Eds.), Introduction to quality and safety education for nurses (pp. 161–
189). New York, NY: Springer.

Bartlett, G., Blais, R., Tamblyn, R., Clermont, R. J., & MacGibbon, B.
(2008). Impact of patient communication problems on the risk of
preventable adverse events in acute care settings. Canadian Medical
Association Journal, 178(12), 1555–1562.

Bastable, S. B. (2006). Essentials of patient education. Sudbury, MA:
Jones and Bartlett.

Bloom, B. (1956). Taxonomy of educational objectives. New York, NY:
Addison-Wesley.

Campinha-Bacote, J., Yahle, T., & Langenkamp, M. (1996). The
challenge of cultural diversity for nurse educators. Journal of
Continuing Education in Nursing, 27(2), 59–64.

Conner, M. (2004). Introduction to andragogy and pedagogy. Retrieved
from http://www.agelesslearner.com/intros/andragogy.html

Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J.,
Mitchell, P., . . . Warren, J. (2007). Quality and safety education for
nurses. Nursing Outlook, 55(3), 122–131.

Davis, T. C., Long, S. W., Jackson, R. H., Mayeaux, E. J., George, R. B.,
& Murphy, P. W. (1993). Rapid estimate of adult literacy in medicine: A
shortened screening instrument. Family Medicine, 25, 391.

Disch, J. (2012). Are we really ready for patient-centered care? Nursing
Outlook, 60(5), 237–239.

Doak, L. G., & Doak, C. C. (Eds.). (2002). Health literacy. Retrieved from
http://www.pfizerhealthliteracy.com

Doak, C., Doak, L., Gordon, L., & Lorig, K. (2001). Selecting, preparing,
and using materials. In K. Lorig (Ed.), Patient education: A practical
approach (3rd ed., pp. 183–197). Thousand Oaks, CA: Sage.

Doak, C. C., Doak, L. G., & Root, J. H. (1996). Teaching patients with low

literacy skills. Philadelphia, PA: Lippincott.
Donlon, B. C. (1993). The effect of practical education programming for
the elderly (PEPE) on the rehospitalization rate of older congestive
heart failure patients: A quasi-experimental study. Unpublished
doctoral dissertation, University of Southern Mississippi.

Falvo, D. (2004). Effective patient education: A guide to increased
compliance (3rd ed.). Sudbury, MA: Jones and Bartlett.

Falvo, D. R. (2011). Effective patient education: A guide to increased
adherence (4th ed.). Sudbury, MA: Jones & Bartlett Learning.

Flagg, A. J. (2015). The role of patient-centered care in nursing. Nursing
Clinics of North America, 50, 75–86.

Flesch, R. (1948). A new readability yardstick. Journal of Applied
Psychology, 32(3), 221–233.

French, K. (2015). Transforming nursing care through health literacy
ACTS. Nursing Clinics of North America, 50, 87–98.

Fry, E. (1968). A readability formula that saves time. Journal of Reading,
11, 513–517.

Gerteis, M., Edgman-Levitan, S., Daley, J., & Delbanco, T. L. (1993).
Through the patient’s eyes: Understanding and promoting patient-
centered care. San Francisco, CA: Jossey-Bass.

Gonzalez, V. M., & Lorig, K. (2001). Working cross-culturally. In K. Lorig
(Ed.), Patient education: A practical approach (3rd ed., pp. 163–182).
Thousand Oaks, CA: Sage.

Henneman, E. A., & Cardin, S. (2002). Family-centered critical care: A
practical approach to making it happen. Critical Care Nurse, 22(6), 12–
19.

Hochbaum, G. M. (1958). Public participation in medical screening
programs: A socio-psychological study (Public Health Service
Publication No. 572). Washington, DC: U.S. Government Printing
Office.

Hunter, R., & Carlson, E. (2014). Finding the fit: Patient-centered care.
Nursing Management, 45, 39–43.

Institute of Medicine. (2001). Crossing the quality chasm: A new health
system for the 21st century. Washington, DC: National Academies
Press.

Institute of Medicine. (2004). Health literacy: A prescription to end
confusion. Washington, DC: National Academies Press.

Jastak, S., & Wilkinson, G. S. (1993). Wide range achievement test:
Review 3. Wilmington, DE: Jastak Associates.

Joint Commission. (1995). Comprehensive accreditation manual for
hospitals (Vols. 1–2). Oakbrook Terrace, IL: Author.

Joint Commission. (2003). Joint Commission guide to patient and family
education. Oakbrook Terrace, IL: Author.

Joint Commission. (2010). Advancing effective communication, cultural
competence, and patient- and family-centered care: A roadmap for
hospitals. Oakbrook Terrace, IL: Author.

Kleinman, A. (1980). Patients and healers in the context of culture: An
exploration of the borderland between anthropology, medicine, and
psychiatry. Berkeley: University of California Press.

Knowles, M. (1970). The modern practice of adult education: Andragogy
versus pedagogy. New York, NY: Association Press.

Knowles, M., Swanson, R., & Holton, E. (1998). The adult learner: The
definitive classic in adult education and human resource development.
Houston, TX: Gulf.

Knowles, M., Swanson, R., & Holton, E. (2011). The adult learner: The
definitive classic in adult education and human resource development
(7th ed.). New York, NY: Elsevier.

Lengetti, E., Ordelt, K., & Pyle, N. (2007, November). Patient teaching
competency for staff. Patient Education Management, 123–124.

Lorig, K. (2001). Patient education: A practical approach (3rd ed.).

Thousand Oaks, CA: Sage.
Mager, R. (1997). Preparing instructional objectives (3rd ed.). Atlanta,
GA: Center for Effective Performance.

Majumdar, B., Browne, G., Roberts, J., & Carpio, B. (2004). Effects of
cultural sensitivity training on health care provider attitudes and patient
outcomes. Journal of Nursing Scholarship, 36(2), 161–166.

Massachusetts Department of Higher Education. (2016). Nurse of the
future: Nursing core competencies: Registered nurse. Retrieved from
http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Masters, K. (2001). The effect of education that is modified to
accommodate for age-related barriers to learning in older adult home
health patients with congestive heart failure. Unpublished doctoral
dissertation, Louisiana State University Health Sciences Center.

McLaughlin, G. H. (1969). SMOG grading—a new readability formula.
Journal of Reading, 12, 639–646.

McNeill, B. E. (2012, January–March). You “teach” but does your patient
really learn? Basic principles to promote safer outcomes. Tar Heel
Nurse, 9–16.

Merriam, S. B., & Caffarella, R. S. (1999). Learning in adulthood: A
comprehensive guide (2nd ed.). San Francisco, CA: Jossey-Bass.

Merriam, S. B., Caffarella, R. S., & Baumgartner, L. M. (2007). Learning
in adulthood: A comprehensive guide (3rd ed.). San Francisco, CA:
Jossey-Bass.

Miller, C. A. (2004). Nursing for wellness in older adults: Theory and
practice (4th ed.). Philadelphia, PA: Lippincott.

Miller, M. A., & Stoeckel, P. R. (2011). Client education: Theory and
practice. Sudbury, MA: Jones & Bartlett Learning.

National Center for Education Statistics. (2007). Literacy in everyday life:
Results from the 2003 National Assessment of Adult Literacy.
Retrieved from http://nces.ed.gov/pubsearch/pubsinfo.asp?

pubid=2007480
National Institutes of Health. (n.d.). Hearing loss: A common problem for
older adults. Retrieved from
http://nihseniorhealth.gov/hearingloss/hearinglossdefined/01.html

National Patient Safety Foundation. (2015). Ask me 3. Retrieved from
http://www.npsf.org/?page=askme3

Nightingale, F. (1969). Notes on nursing: What it is and what it is not.
New York, NY: Dover. (Original work published 1860)

Oldaker, S. M. (1992). Live and learn: Patient education for the elderly
orthopaedic client. Orthopaedic Nursing, 11(3), 51–56.

Pearson, M. (2012, June–August). Gerogogy in patient education—
revisited. Oklahoma Nurse, 12–17.

Picker Institute. (n.d.). Picker principles of patient-centered care.
Retrieved from http://cgp.pickerinstitute.org/?page_id=1319

Prohaska, T. R., & Lorig, K. (2001). What do we know about what works:
The role of theory in patient education. In K. Lorig (Ed.), Patient
education: A practical approach (3rd ed., pp. 21–55). Thousand Oaks,
CA: Sage.

Quality and Safety Education for Nurses. (2012). QSEN competencies:
Definitions and pre-licensure KSAS. Retrieved from
http://qsen.org/competencies/pre-licensure-ksas/

Rankin, S. H. (2005). Patient education in health and illness.
Philadelphia, PA: Lippincott.

Rankin, S. H., & Stallings, K. D. (2001). Patient education: Principles and
practice (4th ed.). Philadelphia, PA: Lippincott.

Rankin, S. H., Stallings, K. D., & London, F. (2005). Patient education in
health and illness (5th ed.). Philadelphia, PA: Lippincott.

Redman, B. K. (2001). The practice of patient education (9th ed.). St.
Louis, MO: Mosby.

Redman, B. K. (2003). Measurement tools in patient education (2nd ed.).

New York, NY: Springer.
Redman, B. K. (2006). The practice of patient education: A case study
approach (10th ed.). St. Louis, MO: Mosby.

Russell, S. S. (2006). An overview of adult-learning processes. Urologic
Nursing, 26(5), 349–352, 370.

Stephenson, P. L. (2007). Before teaching begins: Managing patient
anxiety prior to providing education. Clinical Journal of Oncology
Nursing, 10(2), 241–246.

U.S. Department of Health and Human Services, National Institutes of
Health, National Cancer Institute. (2004). Making health
communication programs work: A planner’s guide. Retrieved from
http://www.cancer.gov/publications/health-communication/pink-
book.pdf

U.S. Department of Health and Human Services. (2011). National
strategy for quality improvement in health care. Washington, DC:
Author.

U.S. Department of Health and Human Services. (2012). CAHPS health
literacy item sets. Retrieved from https://cahps.ahrq.gov/surveys-
guidance/item-sets/literacy/index.html

Walton, M. K., & Barnsteiner, J. (2012). Patient-centered care. In G.
Sherwood & J. Barnsteiner (Eds.), Quality and safety in nursing: A
competency approach to improving outcomes (pp. 67–89). West
Sussex, England: Wiley.

Weinrich, S. P., Boyd, M., & Nussbaum, J. (1989). Continuing education:
Adapting strategies to teach the elderly. Journal of Gerontological
Nursing, 15(11), 17–21.

Weinrich, S. P., Weinrich, M. C., Boyd, M. D., Atwood, J., & Cervenka, B.
(1994). Teaching older adults by adapting for aging changes. Cancer
Nursing, 17(6), 494–500.

Weiss, B. D. (1999). Twenty common problems in primary care. New

York, NY: McGraw-Hill.
Williams, M. V., Baker, D. W., Honig, E. G., Lee, T. M., & Nowlan, A.
(1998). Inadequate literacy is a barrier to asthma knowledge and self-
care. Chest, 114, 1008–1015.

© James Kang/EyeEm/Getty Images

CHAPTER 11

Informatics in Professional
Nursing Practice
Kathleen Masters and Cathy K. Hughes

Learning Objectives

After completing this chapter, the student should be able to:

1. Consider the role of informatics in nursing practice.
2. Discuss various informatics competencies for professional

nursing practice.
3. Consider security and privacy issues related to electronic health

records (EHRs).
4. Discuss basic computer competencies required for nursing

practice.
5. Discuss the information literacy skills needed to practice nursing.
6. Examine the role of information management in nursing practice.
7. Envision the future of healthcare information systems based on

current influences.

Key Terms and Concepts

Nursing informatics (NI)
Electronic health record (EHR)
Search engines
Database
Email
Listservs
Social media
Telehealth
EBSCO Publishing
Cumulative Index to Nursing and Allied Health Literature
(CINAHL)
Cochrane Library
Educational Resource Information Center (ERIC)
Health Source
MEDLINE
PsycINFO
Personal health record

Healthcare delivery depends on information for effective decision making.
Having entered the era of electronic health records (EHRs) and
telecommunication systems, informatics has become an indispensable
element in the practice of nursing. All professional nurses now use
informatics skills in their practice.

Informatics: What Is It?
Nursing informatics (NI) is both a field of study and an area of
specialization. In the mid-1900s, NI was first identified as the use of
information technology in nursing practice (Hannah, 1985). In 1992, the
American Nurses Association (ANA) first recognized NI as a nursing
specialty. The original ANA Scope and Standards of Nursing Informatics
Practice was published in 2001 and then revised in 2008 and 2014. A key
component of the definition is that nursing informatics is a specialty within
the profession of nursing that “integrates nursing science, computer
science, and information science” for the purpose of managing and
communicating data, information, and knowledge (ANA, 2008, p. 92).
Nursing informatics is useful in supporting decision making through
“information structures, information processes, and information
technology” (ANA, 2008, p. 92). Thus, the specialty of NI focuses on
developing and implementing solutions for the management and
communication of health information pertinent to providing better quality
patient care (Zykowski, 2003).

Clinical informatics is a broader term that includes nursing as well as
other medical and health specialties and addresses the use of
information systems in patient care. The domains of clinical informatics
include the three areas of health systems, clinical care, and information
and communication technologies and may include issues ranging from
decision support to EHR documentation to electronic order entry
(Alexander, 2015b). Health informatics is an even broader term that
encompasses the “the integration of health-care sciences, computer
science, information science, and cognitive science to assist in the
management of healthcare information” (Saba & McCormick, 2015, p.

232).

KEY COMPETENCY 11-1

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Informatics and Technology:

Knowledge (K2c) Describes the foundation of Nursing Informatics:
distinguishes between healthcare and nursing informatics and
describes Informatics Knowledge and its relationship to Regulations,
Human Factors, and Change Management

Skills (S2c) Uses informatics, and knowledge of larger healthcare
delivery system, to support and enhance patient care

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Informatics, the broadest of the terms, is the science of collecting,
managing, and retrieving information. The informatics discipline began
decades ago, but an Institute of Medicine (IOM) report published in 1991
brought national attention to the lack of use of information technology in
the healthcare industry as compared to other industries (IOM, 1997).
That report, along with subsequent IOM reports, became the impetus for
the transition to information systems to support the provision of health
care (Silsbee & Reed, 2014). In today’s healthcare systems, information
and computer technologies are major infrastructure components of
patient safety and integral tools used by healthcare providers (Walton,
2012).

The Effect of Legislation on Health
Informatics
Several IOM (1997, 1999, 2001) reports informed Congress about
legislation needed to bring about change in health care related to
informatics that resulted in the passage of several laws that have
expedited the health informatics agenda. Three primary laws have
affected health information management. The Health Insurance
Portability and Accountability Act (HIPAA) of 1996 contains provisions for
privacy and security of health information. The Health Information
Technology for Economic and Clinical Health (HITECH) Act of 2009
provided federal money in the form of grants to advance the use of health
information technology (HIT). The Patient Protection and Affordable Care
Act of 2010 also provides for funding of HIT (Silsbee & Reed, 2014).

KEY COMPETENCY 11-2

Examples of applicable Nurse of the Future: Nursing Core
Competencies
Informatics and Technology:

Knowledge (K6a) Describes patient access, rights and engagement as
pertains to EHRs.

Knowledge (K6b) Understands the principles of data integrity,
professional ethics and legal rights of patients

Skills (S6a) Utilizes strategies to protect data and maintains data
integrity

Skills (S6b) Upholds ethical standards related to data security,
regulatory requirements, confidentiality, and clients’ right to privacy

Attitudes/Behaviors (A6) Recognizes that greater patient engagement
contributes to better health outcomes

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

HIPAA and Health Information Privacy
Movement toward electronic information management in health care was
slow, in part because of concern over the lack of privacy of patient health
records in an electronic system. In 1996, Congress passed HIPAA to
improve the efficiency and effectiveness of the healthcare system by
encouraging the development of a health information system. Some
areas addressed by the act include simplifying healthcare claims,
developing standards for data transmission, and implementing privacy
regulations. The privacy regulations protect clients by limiting the ways
that health plans, pharmacies, hospitals, and other entities can use
clients’ personal medical information. The regulations protect medical
records and other individually identifiable health information, whether
communicated orally, on paper, or electronically. Accompanying the
privacy regulations are specific security rules that protect health
information in electronic form. To be in compliance, agencies must
ensure the confidentiality and integrity of all electronic health information
that is created, received, transmitted, or stored; protect against threats to
security; protect against disclosures of information; and ensure
compliance of their employees (Garner, 2003).

Protecting an individual’s personal and private information has
historically been a significant issue for nursing. Healthcare information is
a collection of data relating to personal aspects of an individual’s life.

Improper disclosure can cause devastating consequences. Patients
assume that information provided to a healthcare provider will not be
disclosed. It is not only possible but also probable that patients will not
disclose certain types of information essential to their care if they believe
the information is not confidential. The introduction of electronic
documentation and communication has increased the difficulty of
maintaining privacy. Improved access to healthcare information can and
does increase efficiency and improve patient care, but accompanying the
benefits are greater difficulties in maintaining privacy and confidentiality.
Preserving the security of the health information system is critical
because unauthorized access to the computerized health information
system compromises the privacy and confidentiality of patient health
records. Protection against unauthorized access can be achieved by
implementing a login process that verifies that the user has permission to
access the system. The majority of systems rely on a user ID and
password for verification. Passwords must be changed frequently to
protect against breach of security. Users should never divulge or share
passwords. Healthcare agencies have written policies regarding the
penalties of misuse of the system. Consequences are usually severe,
with many including termination of employment.

CRITICAL THINKING QUESTION

What is your role as a nurse in protecting patient healthcare
information?

HITECH
The HITECH Act provided money to providers and organizations to
encourage use of the electronic health record (EHR). Under the
HITECH Act there are two sets of standards to help providers meet

meaningful use criteria of EHRs and to ensure that EHRs meet
performance standards. The first standard outlined metrics that providers
and facilities had to achieve in order to meet meaningful use criteria and
merit the incentives available through the Centers for Medicare and
Medicaid Services (CMS) Incentive Program. Under this program,
healthcare providers and organizations could receive financial incentives
for meaningful use of certified EHRs through 2016. However, by 2015 a
provider that had not shown meaningful use of a certified EHR received
less reimbursement. A certified EHR is one that meets the requirements
of interoperability and formatting standards. The second set of standards
in the HITECH Act specify the standards that the technology vendors
must meet to certify their products as meaningful use-certified (TIGER
Initiative Foundation, 2014).

The HITECH Act outlined three phases of meaningful use, with each
stage within the phase building on the previous so that criteria and
objectives evolved each year, moving the healthcare industry with each
stage. Phase one involved data capture and sharing, such as using
information captured in a standardized format to track clinical conditions
or coordinate care. Phase two involved advanced clinical processes,
such as electronic transmission of patient care summaries across
multiple settings. Phase three involved improved outcomes, such as
improving quality, safety, and efficiency, leading to improved health
outcomes and population health (Alexander, 2015a; Silsbee & Reed,
2014; TIGER Initiative Foundation, 2014).

Nursing Informatics Competencies
The current expectation is that all nurses demonstrate proficiency in the
use of information and patient care technology; therefore, many of the
national nursing organizations have promulgated lists of expectations for
either nursing students or nurses related to informatics skills. Defined
levels of informatics competencies vary depending on the experience and
specialty of the nurse. For example, differing levels of expertise in
informatics are expected from the beginning nurse, experienced nurse,
informatics specialist, and informatics innovator (Hebda & Czar, 2009;
McGonigle & Mastrian, 2009; Staggers, Gassert, & Curran, 2001).

The entry-level professional nurse is expected to have computer
literacy and basic information management skills. Important technology
skills of the entry-level nurse include knowing how to use nursing-specific
software, such as computerized documentation; use of patient care
technologies, such as monitors, pumps, and medication dispensing; and
information management for patient safety (American Association of
Colleges of Nursing [AACN], 2008). In our world of electronic
communication and data management, maintaining privacy, security, and
confidentiality of patient information as mandated by HIPAA is an
expectation of all nurses, including nursing students.

Experienced nurses should be skilled in information management
and computer technology to sustain their specific area of practice. These
skills include making judgments based on trends of data in addition to
collaboration with informatics nurses in the development of nursing
systems. An informatics nurse specialist has graduate-level informatics
preparation and is prepared to assist the practicing nurse in meeting his
or her needs for information (ANA, 2008). The informatics innovator also

has graduate-level informatics preparation and possesses skills for
developing theory and conducting informatics research (Thede, 2003).
The focus of this chapter is on the generalist nurse rather than on the
informatics specialist or informatics innovator.

AACN Information Management and Application
of Patient Care Technology
The AACN (2008) includes information management and application of
patient care technology as an essential component of a baccalaureate
education in nursing in order to prepare the graduate to deliver safe and
effective care. The AACN names informatics and technology-related
outcomes for baccalaureate nursing graduates, including that the nurse
will demonstrate skills in using patient care technologies, information
systems, and communication devices that support safe nursing practice;
use telecommunication technologies to assist in effective communication
in a variety of healthcare settings; apply safeguards and decision-making
support tools embedded in patient care technologies and information
systems to support a safe practice environment for both patients and
healthcare workers; understand the issues of clinical information systems
to document interventions related to achieving nurse-sensitive outcomes;
use standardized terminology in a care environment that reflects
nursing’s unique contribution to patient outcomes; uphold ethical
standards related to data security, regulatory requirements,
confidentiality, and clients’ right to privacy; and recognize that redesign of
workflow and care processes should precede implementation of care
technology to facilitate nursing practice (AACN, 2008, pp. 18–19).

Quality and Safety Education for Nurses:
Informatics Competencies

Sponsored by the Robert Wood Johnson Foundation, Quality and Safety
Education for Nurses (QSEN) has the overall goal of preparing future
nurses who will have the knowledge, skills, and attitudes (KSAs)
necessary to continuously improve the quality and safety of the
healthcare systems within which they work (QSEN, n.d.). The purpose of
this initiative is to develop competencies of future nursing graduates in
six key areas: patient-centered care, evidence-based practice, quality
improvement, teamwork and collaboration, safety, and informatics. The
application of informatics in nursing practice is also a vital component in
the mastery of the other defined KSAs.

Informatics is defined in the QSEN (n.d.) initiative as the use of
information and technology to communicate, manage knowledge,
mitigate error, and support decision making (Figure 11-1). The entry-level
informatics skill domain competencies identified by QSEN include the
following:

Figure 11-1 The use of advanced technology enables communication and supports collaboration
in decision making to mitigate error and optimize patient outcomes.

© Carlos Amarillo/Shutterstock.

Seek information about how information is managed in care settings
before providing care.
Apply technology and information management tools to support safe
processes of care.
Navigate the EHR.
Document and plan patient care in an EHR.
Employ communication technologies to coordinate care for patients.
Respond appropriately to clinical decision-making supports and
alerts.
Use information management tools to monitor outcomes of care
processes.
Use high-quality electronic sources of healthcare information.

KEY COMPETENCY 11-3

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Informatics and Technology:

Knowledge (K1a) Understands basic computer science concepts

Knowledge (K1b) Identifies the basic components of the computer
systems

Skills (S1a) Demonstrates proficiency in concepts of information and
communication technology; foundations of basic computer systems
(i.e., software, operating systems, hardware, networks, peripheral
devices, computer systems, Internet and web-based application,
wireless technology)

Skills (S1b) Demonstrates proficiency in basic computer skills related
to personnel management (i.e., admin), education, and desktop
software

Attitudes/Behaviors (A1) Recognizes the importance of basic computer
competence to evolving nursing science

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Nurse of the Future Core Competencies:
Informatics and Technology
The Nurse of the Future Core Competencies for informatics uses the
2015 definition from the National Academies of Sciences, Engineering,
and Medicine, stating that “the Nurse of the Future will be able to use
advanced technology and to analyze as well as synthesize information
and collaborate in order to make critical decisions that optimize patient
outcomes” (Massachusetts Department of Higher Education, 2016, p.
26).

Technology Informatics Guiding Education
Reform Initiative
In 2004, the Technology Informatics Guiding Education Reform (TIGER)
initiative was formed to bring together various nursing stakeholders in
order to develop a shared vision, strategies, and specific actions for
improving nursing practice, education, and patient care delivery through
the use of information technology (Technology Informatics Guiding
Education Reform, 2009). The TIGER Informatics Competencies
Collaborative (TICC) developed informatics recomendations, and in 2011
the group published a landmark report titled Informatics Competencies
for Every Practicing Nurse: Recommendations from the TIGER
Collaborative (Transforming Health Through Information Technology,

2017).
The TIGER Informatics competencies for all practicing nurses and

graduating nursing students resulted in the TIGER Informatics
Competency Model, which has three components: basic computer
competencies, information literacy, and information management
(Technology Informatics Guiding Education Reform, 2009).

The organization of the remainder of this chapter reflects the three
components of the TIGER Competency Model as well as
recommendations in the TIGER Initiative Foundation (2014) publication
The Leadership Imperative: TIGER’s Recommendations for Integrating
Technology to Transform Practice and Education, that provides guidance
for incorporating technology into transformational practice changes to
enhance patient, family, and economic outcomes.

Basic Computer Competencies
Basic computer competencies include understanding the concepts of
information and communication technology, possessing skill in the use of
a computer, and managing files, word processing, spreadsheets, using
databases, presentations, Web browsing, and communication (TIGER,
2009). An overview of some of these skills is presented in the following
sections of the chapter.

Web Browsing
Not since the invention of the printing press has the speed with which
new information can be accessed changed so much as with the
development of the Internet. Search tools and search engines assist
users in finding specific topics on the Web by compiling a database of
Internet sites. In addition to search engines, there are metasearch
engines. A metasearch engine conducts a search of a variety of search
engines. Metacrawler (www.metacrawler.com), Google
(www.google.com), and Dogpile (www.dogpile.com) are examples of
metasearch engines. Each search engine queries different databases
using different search techniques (Bliss & DeYoung, 2002) and uses a
range of engines for retrieval of information.

Communication: Email
Email (electronic mail) can be sent to anyone in the world who has an
email address. In moments, messages can be sent across time zones,
allowing instant communication. For several reasons, attention must be
paid to the content of messages sent by email. Someone other than the

intended recipient can access a message while it is transmitted over the
Internet. In addition, messages containing sensitive information can
accidentally or purposefully be forwarded. Although email can be a way
of facilitating direct communication between consumers of health care
and healthcare providers, precautions must be taken to ensure that only
the intended recipient receives health-related email messages.

To send and receive email, a person must have an individual address
that consists of two main parts separated by an @ sign. The first part is
called a login name or a user ID. The part after the @ is the name of the
network or service provider used to access the Internet. The characters
after the last dot in an email address indicate the domain or main
subdivision of the Internet to which the computer belongs. Addresses
must be accurate for the intended recipient to receive the message.
Appropriateness must be considered when selecting your login name.
Professionals should not use suggestive or insensitive wording for their
login names.

Email is a special form of communication and carries its own form of
etiquette. Pagana (2007) suggests that nurses follow these guidelines
when sending a business or professional message:

Do not use all uppercase letters. Typing in all caps is deemed
shouting.
Include a specific subject line.
Sign your messages with text that includes your email address and
contact information.
Use the “reply to all” function appropriately. Not everyone is
interested in receiving your comments.
Avoid forwarding chain letters, and delete all unnecessary
information from forwarded messages.
Do not send confidential information, and check for correct recipients

before sending.
Use the spell-check and grammar functions.
Do not use email for thank-you correspondence.

KEY OUTCOME 11-1

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential I: Liberal Education for Baccalaureate Generalist Nursing
Practice

1.4 Use written, verbal, nonverbal, and emerging technology methods
to communicate effectively (p. 12).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

Communication: Listserv Groups and Mailing
Lists
Mailing lists and listservs are forms of group email that provide an
opportunity for people with similar interests to share information.
Subscribing to a list is usually free. Once subscribed, you can send and
receive messages to and from the list. The communication is
asynchronous, meaning it does not occur in real time. Someone posts a
question or comment to the list, and other members reply in time. List
groups are usually either layperson oriented or professional oriented.
There are numerous groups devoted to the topic of nursing. To find a list,
ask friends and colleagues or visit CataList, an official catalog of listservs
that includes a searchable database. You can access CataList at

www.lsoft.com/catalist.html.
Most listservs provide specific instructions on subscribing. Every

listserv has two addresses. One address is used to join, and the second
is used to send messages that can be read by the group. Listserv groups
can be open to anyone, or you might need permission to join. It is
important to remember that messages sent to the listserv are read by
everyone subscribed to the listserv. Posting a personal message to an
individual on a listserv is considered inappropriate. Do not send
attachments to the list. The list might have hundreds of members, and
some will not have computers that support sophisticated graphics or
large files. In addition, viruses can be transmitted in attachments.

Communication: Social Media
Social media are Internet-based applications that enable communication
and sharing of resources and information (Lindsay, 2011). Examples of
social media are YouTube, Facebook, LinkedIn, and Twitter as well as
blogs, wikis, and chat rooms. The many choices of how users can share
information on nursing-related resources can be found on the ANA
website (www.nursingworld.org).

KEY OUTCOME 11-2

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential IV: Information Management and Application of Patient Care
Technology

4.2 Use telecommunication technologies to assist in effective
communication in a variety of healthcare settings (p. 18).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

Growing participation in social networking sites poses challenges for
nursing. Although social networking aids with personal and professional
knowledge exchange and prompts interaction with others, it comes with
risks. Personal and patient privacy issues can be raised, and some
networking discussions might be viewed as “fact” and not validated. The
ANA has adopted the Principles for Social Networking, which include the
following:

Nurses must not transmit or place online individually identifiable
patient information.
Nurses must observe ethically prescribed professional patient–nurse
boundaries.
Nurses should understand that patients, colleagues, institutions, and
employers might view postings.
Nurses should take advantage of privacy settings and seek to
separate personal and professional information online.
Nurses should bring content that could harm a patient’s privacy,
rights, or welfare to the attention of appropriate authorities.
Nurses should participate in developing institutional policies
governing online contact (ANA, 2011a, 2011b).

KEY COMPETENCY 11-4

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Informatics and Technology:

Knowledge (K2d) Describes an understanding of electronic

communication strategies among healthcare providers in the
healthcare system

Skills (S2d) Utilizes electronic communication strategies (EHR,
mHealth, personal health records)

Attitudes/Behaviors (A2b) Appreciates the use of electronic
communications strategies in the delivery of patient care

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

The National Council of State Boards of Nursing (NCSBN) has also
adopted guidelines related to the responsible use of social media and
has endorsed the principles adopted by the ANA. The NCSBN (2011)
guidelines, available at www.ncsbn.org/Social_Media.pdf, address issues
of confidentiality and privacy; common myths and misunderstandings
related to social media; possible consequences in the use of social
media, including consequences with board of nursing implications; and
how to avoid problems. The guidelines also include seven scenarios
related to social media use by nurses with board of nursing implications.

According to the NCSBN (2011) white paper, depending on the
jurisdiction, the board of nursing might investigate reports of
inappropriate disclosures related to the use of social media on the
grounds of the following: unprofessional conduct, unethical conduct,
moral turpitude, mismanagement of patient records, revealing a
privileged communication, and breach of confidentiality. If allegations are
found to be true, the nurse could face disciplinary action by the board of
nursing that can include a reprimand, a sanction, an assessment of a
fine, or the temporary or permanent loss of licensure. In addition,
improper use of social media might violate state and federal laws,

resulting in civil or criminal penalties that carry with them fines or jail time.
Social networking can have both positive and negative

consequences. Negative consequences can affect not only nurses’
personal reputations but also their professional standing. Nurses should
consider that current or future employers might view their personal social
media pages.

On the other hand, social media can be used in disasters as a means
of disseminating information and as an emergency management tool.
Social media can be a source of information in a crisis as well as part of a
plan to mobilize responders. In disaster preparation, social media sites
can be used to publicize training events and dates (Lindsay, 2011).

KEY OUTCOME 11-3

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential I: Liberal Education for Baccalaureate Generalist Nursing
Practice

1.3 Use skills of inquiry, analysis, and information literacy to address
practice issues (p. 12).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

Future challenges of social media include the use of the technology
for the delivery of accurate and pertinent information by experts and
healthcare providers and by peers and the lay public. Healthcare
providers’ uses of social media technology may include public education
related to sources of information and monitoring the effect of social media

on health outcomes.

Communication: Telehealth
Telehealth is the use of electronic information and telecommunications
technologies to support long-distance clinical health care, patient and
professional health-related education, public health, and health
administration (U.S. Department of Health and Human Services
[USDHHS], n.d.-b). The use of this technology has many implications in
the provision of health care in the context of both access and quality. For
example, healthcare providers can monitor patients in their homes for
changes in health status. Images and other data can be transmitted for
consultation with other healthcare providers. Practitioners in
geographically remote areas or in a prison setting can connect to a large
hospital for consultations and second opinions without transporting the
patient to that site. From a motor vehicle crash site, the emergency
medical system response field team can transmit information and
documentation to the emergency department for direction on care of the
patient.

Information Literacy
Information literacy skills are prerequisites for the practice of evidence-
based nursing (TIGER, 2009). Information literacy builds on basic
computer competencies and includes such skills as being able to identify
information needed for specific purposes, locating pertinent information,
evaluating the information, and correctly applying the information. The
following section discusses information location and evaluation specific to
nursing and health care.

CRITICAL THINKING QUESTIONS

What needs of populations in your region or state could be addressed
with the use of telehealth? What ideas can you envision to assist in
the access to and delivery of healthcare services where you live or
work?

Electronic Databases
An increasing number of databases are available on the Internet and can
be accessed through local libraries or by subscription from a vendor,
such as EBSCO Publishing, which provides access to online databases
and e-journals. Most of the databases allow keyword searches and are
capable of advanced searching. Many full-text resources are available via
databases, making information available very quickly. Some of the most
beneficial databases to nursing include the following:

KEY COMPETENCY 11-5

Examples of applicable Nurse of the Future: Nursing Core
Competencies

Informatics and Technology:

Knowledge (K8) Describes the integration of research and evidence-
based practice into the EHR.

Skills (S8a) Conducts online literature searches

Skills (S8b) Provides for efficient data collection

Skills (S8c) Uses applications to manage aggregated data

Skills (S8d) Integrates evidence-based standards to support clinical
practice

Attitudes/Behaviors (A8) Values technology as a tool for generating
knowledge and guiding clinical practice

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

The Cumulative Index to Nursing and Allied Health Literature
(CINAHL) is a resource for nursing and allied health professionals,
students, educators, and researchers. This database provides
indexing and abstracting for more than 1,700 current nursing and
allied health journals and publications dating back to 1982, totaling
more than 880,000 records.
The Cochrane Library is an online collection of six databases with
“independent high-quality evidence for healthcare decision making”
(Cochrane Collaboration, n.d.). It is available at academic institutions
and is funded for free access in many countries and regions of the
world.
The Educational Resource Information Center (ERIC) is a national
information system supported by the U.S. Department of Education,
the National Library of Education, and the Office of Educational

Research and Improvement. It provides access to information from
journals included in the Current Index of Journals in Education and
Resources in Education Index. ERIC provides full text of more than
2,200 digests, along with references for additional information,
citations, and abstracts from more than 1,000 educational and
education-related journals.
Google Scholar (googlescholar.com), launched in 2004, contains
some full-text peer-reviewed journals, abstracts, links to subscription
journals, and articles for purchase as well as technical reports,
theses, and books.
Health Source, the Nursing Academic Edition, provides more than
550 scholarly full-text journals, including more than 450 peer-
reviewed journals focusing on many medical disciplines, including
nursing and allied health.
MEDLINE, created by the National Library of Medicine, is the largest
biomedical literature database and provides authoritative medical
information on medicine, nursing, dentistry, veterinary medicine, the
healthcare system, and preclinical sciences. In MEDLINE, users can
search abstracts from more than 4,600 current biomedical journals.
Included are citations from Index Medicus, International Nursing
Index, Index to Dental Literature, PREMEDLINE, AIDSLINE,
BIOETHICSLINE, and HealthSTAR.
PsycINFO contains nearly 2 million citations and summaries of
journal articles, book chapters, books, dissertations, and technical
reports, all in the field of psychology. It also includes information
about the psychological aspects of related disciplines, such as
medicine, psychiatry, nursing, sociology, education, pharmacology,
physiology, linguistics, anthropology, business, and law.

CRITICAL THINKING QUESTION

How can you locate online sources for more information on a new
treatment or medications for a health condition you discussed in a
nursing class or clinical this week?

KEY OUTCOME 11-4

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential III: Scholarship for Evidence-Based Practice

3.4 Evaluate the credibility of sources of information including but not
limited to databases and Internet resources (p. 16).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

Internet access to government organizations and nonprofit
organizations is also available. The U.S. National Library of Medicine
(www.nlm.nih.gov/hinfo.html) offers access to a myriad of health
information websites. PubMed and MedlinePlus permit searches of
multiple retrieval systems and provide excellent information. The
evaluation guidelines discussed in the following section should be applied
to all Internet sites before using the information in patient teaching
(Thede & Sewell, 2010).

Website Evaluation
The Internet has grown rapidly since its beginning, and information can
be published easily and inexpensively. An Internet website can be
created by anyone with the ability to create a webpage, and many
webpage templates are available for little or no cost, making this very

easy. Many sites are for commercial purposes; others simply publish the
opinions of the website owner. Websites are under no guidelines or
standards. In addition, no official organization is responsible for site
evaluation. As a result, a vast amount of information is available on the
Internet, but not all information is reliable. Applying the following
guidelines can assist you in evaluating resources on the Internet so that
the information you obtain is reliable:

Accuracy: Is the information accurate, reliable, and free from error?
Spelling and punctuation errors can indicate an untrustworthy site.
Authority or source: Look for the credentials of the author or the
reputation of the hosting organization. A good indication of authority
is peer review.
Objectivity: What are the goals and objectives of the site? What
biases are present? Is the site trying to present a specific or neutral
point of view?
Currency or timeliness: Look for publication and updated dates to
determine if the information is current. Dead links can indicate old
information.
Coverage or quality: Is the subject matter presented on the site of
appropriate quality for the intended audience?
Intended purpose: Does the site have choices for such users as the
public, healthcare providers, students, or educators?
Usability: Is the site designed for easy navigation? Are there
excessive graphics that require long download times? Are all links
current, and do they load easily? (Hebda & Czar, 2009; Thede &
Sewell, 2010)

CRITICAL THINKING QUESTION

What is your role as a nurse in the evaluation of information on the

Internet?

KEY OUTCOME 11-5

Example of applicable outcomes expected of the graduate from a
baccalaureate program

Essential IV: Information Management and Application of Patient Care
Technology

4.5 Use standardized terminology in a care environment that reflects
nursing’s unique contribution to patient outcomes (p. 18).

Reproduced from American Association of Colleges of Nursing. (2008). The essentials of

baccalaureate education for professional nursing practice. Retrieved from

http://www.aacnnursing.org/Portals/42/Publications/BaccEssentials08.pdf

Health Information Online
The number of people accessing health information online continues to
grow. This increase in numbers demonstrates how critically important it is
that healthcare websites provide reliable and credible information. Nurses
are responsible for assisting the public in evaluating health information
available on the Internet.

Whether nurses are developing online materials or using existing
online information, it is important for them to understand what makes the
information accessible to all people and to be able to make informed
recommendations about websites to individuals with disabilities
(Carmona, 2005; Smeltzer, Zimmerman, Frain, DeSilets, & Duffin, 2003).
Some websites that feature webinars and online programs have closed
captioning and copies of the scripts available on demand for these
programs. Language options are available on some websites for print

and audible programs (Thede & Sewell, 2010). Contents of sites should
be presented in a way that people with disabilities and with low-end
technology are able to navigate and use.

Vulnerable populations and underserved populations, which include
persons with lower socioeconomic status, with lower reading levels, in
rural areas, or with disabilities, have issues with access to care and
access to information about health care. For persons in these
populations, the term digital divide has typically been used to describe
decreased access to information technologies, particularly via the
Internet (Chang et al., 2004).

More people are using the Internet for finding health information.
Knowledgeable nurses need to assist patients and their families in
evaluating the quality of Internet resources. The Health on the Net
Foundation (HON), founded in 1995, is a nonprofit organization dedicated
to assisting people in obtaining reliable health information on the Internet
(HON, n.d.). To obtain certification, a website applies for registration. The
site is evaluated and, if approved, is qualified to display the HONcode
seal. The site is randomly checked for compliance. From the HON
website, Internet users can download the HON toolbar, which will be
added to their Web browser. When a certified site is accessed, the seal
will be illuminated on the user’s toolbar. The HONcode criteria in brief
include:

Authoritative: Indicate the qualifications of the authors.
Complementarity: Information should support, not replace, the
doctor–patient relationship.
Privacy: Respect the privacy and confidentiality of personal data
submitted to the site by the visitor.
Attribution: Cite the source(s) of published information; date medical
and health pages.

Justifiability: Back up claims relating to benefits and performance.
Transparency: Accessible presentation, accurate email contact.
Financial disclosure: Identify funding sources.
Advertising policy: Clearly distinguish advertising from editorial
content.

Several sites from the Office of the National Coordinator (ONC) for
Health Information Technology (ONC HIT, n.d.), such as HealthIT.gov,
have information on e-health tools for the public to review and use that
focus on health and wellness. Such sites as Health 2.0 Developer
Challenge (n.d.) hold innovation competitions and community action
programs to address solutions for key challenges in HIT.

KEY COMPETENCY 11-6

Examples of applicable Nurse of the Future: Nursing Core
Competencies
Informatics and Technology:

Knowledge (K2a) Describes Information Management concepts (i.e.,
communication theories)

Knowledge (K2b) Describes standardized terminology in a care
environment that reflects nursing’s unique contribution to patient
outcomes

Skills (S2a) Uses data, as presented through the EHR, to inform
clinical decision and deliver safe, quality health care

Skills (S2b) Uses data from nursing and all relevant sources, including
technology, to inform the delivery of care

Attitudes/Behaviors (A2a) Values the importance of nursing data to
improve nursing practice

Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future:

Nursing core competencies: Registered nurse. Retrieved from

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Information Management
Information management consists of collecting data, processing the data,
and presenting and communicating the processed data as information or
knowledge. A foundational concept in information management is wh