Chapter 1 Nursing Foundations PDF
Chapter 1 Nursing Foundations PDF
Chapter 1 Nursing Foundations PDF
c h a p t e r
Nursing Foundations
Words to Know
active listening
activities of daily living
advanced practice
art
assessment skills
capitation
caring skills
clinical pathways
comforting skills
counseling skills
cross-trained
Learning Objectives
discharge planning
empathy
managed care practices
multicultural diversity
nursing skills
nursing theory
primary care
quality assurance
science
sympathy
theory
Name one historical event that led to the demise of nursing in England
before the time of Florence Nightingale.
Identify four reforms for which Florence Nightingale is responsible.
Describe at least five ways in which early U.S. training schools deviated
from those established under the direction of Florence Nightingale.
Name three ways that nurses used their skills in the early history of
U.S. nursing.
Explain how art, science, and nursing theory have been incorporated into
contemporary nursing practice.
Discuss the evolution of definitions of nursing.
List four types of educational programs that prepare students for beginning levels of nursing practice.
Identify at least five factors that influence a persons choice of educational
nursing program.
State three reasons that support the need for continuing education in
nursing.
List examples of current trends affecting nursing and health care.
Discuss the shortage of nurses and methods to reduce the crisis.
Describe four skills that all nurses use in clinical practice.
NURSING ORIGINS
Nightingales Contributions
While Nightingale was providing nursing care for residents at the Institution for the Care of Sick Gentlewomen
in Distressed Circumstances, England found itself allied
with Turkey, France, and Sardinia in defending the
Crimea, a peninsula on the north shore of the Black Sea
(18541856). The British military suffered terribly, and
war correspondents at the front lines made public the dire
circumstances of the soldiers. Reports of high death rates
and complications among the war casualties caused outrage among the British people. As a result, the government
became the object of national criticism.
It was then that Florence Nightingale offered a strategic
plan to Sidney Herbert, Secretary of War and an old family friend. She proposed that the sick and injured British
soldiers at Scutari, a military barracks in Turkey, would
BOX 1-1
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Nursing Foundations
Educated
Neat, orderly, sober, and industrious, with a serious
disposition
Applicants also had to submit two letters of recommendation attesting to their moral character, integrity, and
capacity to care for the sick. Once selected, a volunteer
nurse was to dress plainly in brown, gray, or black and had
to agree to serve for at least 6 months (Donahue, 1985).
35 to 50 years of age
Matronly and plain-looking
TABLE 1.1
NIGHTINGALE SCHOOLS
FIGURE 1.2 Community health nurses circa late 1800s to early 1900s. (Courtesy of Visiting Nurse Association, Inc., Detroit, MI.)
FIGURE 1.3 A military nurse comforts a soldier during World War II.
(Courtesy of the National Archives, Washington, DC.)
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CONTEMPORARY NURSING
Defining Nursing
In an effort to clarify for the public, and nurses themselves, just what nursing encompasses, various working
definitions have been proposed. Nightingale is credited
Nursing Foundations
Two basic educational options are available to those interested in pursuing a career in nursing: practical (vocational) nursing and registered nursing. Several types of
programs prepare graduates in registered nursing. Each
educational track provides the knowledge and skills for a
particular entry level of practice. Some factors affecting
the choice of a nursing program include the following:
Career goals
Geographic location of schools
Costs involved
Length of programs
Reputation and success of graduates
Flexibility in course scheduling
Opportunity for part-time versus full-time enrollment
Ease of movement into the next level of education
TABLE 1.2
THEORIST
THEORY
Florence Nightingale
18201910
Environmental Theory
Man
Health
Environment
Nursing
Synopsis of Theory
Application to Nursing Practice
Virginia Henderson
18971996
Dorothea Orem
1914
Self-Care Theory
Man
Health
Environment
Nursing
Synopsis of Theory
EXPLANATION
Practical/Vocational Nursing
During World War II, many registered nurses enlisted in
the military. As a result, civilian hospitals, clinics, schools,
and other health care agencies faced an acute shortage of
trained nurses. To fill the void expeditiously, abbreviated
programs in practical nursing were developed across the
country to teach essential nursing skills. The goal was to
prepare graduates to care for the health needs of infants,
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to form the National Association for Practical Nurse Education and Service, Inc. This group worked to standardize
practical nurse education and to facilitate the licensure of
graduates. By 1945, eight states had approved practical
nurse programs (Mitchell & Grippando, 1997). In 1993,
enrollments in LPN/LVN nursing programs reached a
peak of 60,749 students. Since then, however, the numbers have declined gradually (Fig 1-4).
Despite the trend in enrollments, the Bureau of Labor
Statistics (2002) predicts that job opportunities in nursing are expected to increase 10% to 20% through 2010.
Career centers, vocational schools, hospitals, independent agencies, and community colleges generally offer
practical nursing programs, arranging clinical experiences at local community hospitals, clinics, and nursing
homes. The average length of a practical nursing program ranges from 12 to 18 months, after which graduates
are qualified to take their licensing examination. Because
this nursing preparatory program is the shortest, many
consider it the most economical.
Licensed graduates provide direct health care for
clients under the supervision of a registered nurse, physician, or dentist. To provide career mobility, many schools
of practical nursing have developed articulation agreements to help their graduates enroll in another school
that offers a path to registered nursing via associate or
baccalaureate degrees.
Registered Nursing
Students can choose one of three paths to become a registered nurse: a hospital-based diploma program, a program
that awards an associate degree in nursing, or a baccalaureate nursing program. All three meet the requirements
for taking the national licensing examination (NCLEX-
Nursing Foundations
T/C
FIGURE 1.4 Trends in LPN/LVN and
RN enrollments 19972001. Numbers are based on U.S. candidates
taking the NCLEX for the first time in
respective years, as reported by the
National Council of State Boards of
Nursing.
TABLE 1.3
Assessing
Diagnosing
Planning
Implementing
Evaluating
BACCALAUREATE NURSE
Identifies priorities
Directs others to carry out nursing
orders
* Note that each more advanced practitioner can perform the responsibilities of those identified previously.
T/C
question whether it was necessary for students in registered nursing programs to spend 3 years acquiring a basic
education. She believed that nursing education could be
shortened to 2 years and relocated to vocational schools
or junior or community colleges. The graduate from this
type of program would acquire an associate degree in
nursing, would be referred to as a technical nurse, and
would not be expected to work in a management position.
This type of nursing preparation has proven extremely
popular and now commands the highest enrollment
among all registered nurse programs. Despite the condensed curriculum, graduates of associate degree programs have demonstrated a high level of competence in
passing the NCLEX-RN.
Baccalaureate Programs
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BOX 1-2
Nursing Foundations
No basic program provides all the knowledge and skills needed for a lifetime career.
Current advances in technology make previous methods of practice obsolete.
Assuming responsibility for self-learning demonstrates personal accountability.
To ensure the publics confidence, nurses must demonstrate evidence of
current competence.
Practicing according to current nursing standards helps to ensure that
care is legally safe.
Renewal of state licensure often is contingent on evidence of continuing
education.
FUTURE TRENDS
Two major issues dominate nursing today. The first concerns methods of eliminating the shortage of nurses. The
second involves strategies for responding to a growing
aging population with chronic health problems.
Enrollment in all nursing programs and continuing
education will contribute to reducing the current and projected shortages of nurses. In 2001, the vacancy rate in
nursing positions was 13% (Tieman, 2002). The future
looks even more alarming. The Bureau of Labor Statistics
projects that one million nursing positions will be open by
2010 (http://www.nursingworld.org/gova/federal/news/
nrs.htm; American Association of Colleges of Nursing,
2002). Many of these positions are likely to remain unfilled, because the number of practicing nurses is forecasted to decrease by approximately 20% by that time
(ANA, 2001). According to the National Council of State
Boards of Nursing (2001), factors contributing to the
nurse shortage include the following:
Continuing Education
Continuing education in nursing is defined as any planned
learning experience that takes place beyond the basic
nursing program (ANA, 1974). Nightingale is credited
with having said, to stand still is to move backwards.
The principle that learning is a life-long process still
applies. Box 1-2 lists reasons why nurses, in particular,
pursue continuing education. Many states now require
nurses to show proof of continuing education to renew
their nursing license.
Governmental Responses
In 2002, the federal government attempted to address the
shortage of nurses by passing the Nurse Reinvestment
Act. This legislation authorizes the following:
1. Loan repayment programs and scholarships for
nursing students
2. Funding for public service announcements to
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Proactive Strategies
Rather than taking a wait-and-see position about the
nursing shortage and the ramifications of the Nurse Reinvestment Act, many nurses are proactively responding
TABLE 1.4
HEALTH CARE
The most underserved health care populations include older adults,
ethnic minorities, and the poor, who delay seeking early
treatment because they cannot afford it.
The number of uninsured has risen from 37 million in 1995 to
41.2 million in 2002. This figure could exceed 48 million
by 2009.
Medicare and Medicaid benefits are being modified and reduced.
Chronic illness is the major health problem.
Disease and injury prevention and health promotion are priorities.
Medicine tends to focus on high technology, which improves
outcomes for a select few.
Hospitals are downsizing and hiring unlicensed personnel to
perform procedures once in the exclusive domain of licensed
nurses for cost containment.
There are fewer primary care physicians in rural areas.
Changes in reimbursement practices have created a shift in
decision making from hospitals, nurses, and physicians to
insurance companies.
Health care costs continue to increase despite managed care
practices (cost-containment strategies used to plan and
coordinate a clients care to avoid delays, unnecessary services,
or overuse of expensive resources).
Capitation (strategy for controlling health care costs by paying a
fixed amount per member) encourages health providers to limit
tests and services to increase profits.
Hospitals, practitioners, and health insurance companies are being
required to measure, monitor, and manage quality of care.
NURSING
Enrollments and numbers of graduates from LPN/LVN and
RN educational programs are currently decreasing.
More licensed nurses are earning masters and doctoral
degrees.
There continues to be a shortage of nurses in various
health care settings because of decreased enrollments,
retirement, attrition, and cost-containment measures.
Hospital employment is decreasing.
Client-to-nurse ratios in employment settings are higher.
More high-acuity clients are in previously nonacute
settings such as long-term and intermediate health care
facilities.
Job opportunities have expanded to outpatient services,
home health care, hospice programs, community
health, and mental health agencies.
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Assessment Skills
Before the nurse can determine what nursing care a person requires, he or she must determine the clients needs
and problems. This requires the use of assessment skills
(acts that involve collecting data), which include interviewing, observing, and examining the client and in some
cases the clients family (family is used loosely to refer to
the people with whom the client lives and associates).
Although the client and the family are the primary
sources of information, the nurse also reviews the clients
medical record and talks with other health care workers
to obtain facts. Assessment skills are discussed in more
detail in Unit IV.
Caring Skills
Caring skills (nursing interventions that restore or maintain a persons health) may involve actions as simple as
assisting with activities of daily living (ADLs), the acts
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Counseling Skills
A counselor is one who listens to a clients needs, responds with information based on his or her area of expertise, and facilitates the outcome that a client desires.
Nurses implement counseling skills (interventions that
include communicating with clients, actively listening
during exchanges of information, offering pertinent
health teaching, and providing emotional support) in
relationships with clients.
To understand the clients perspective, the nurse uses
therapeutic communication techniques to encourage verbal expression. Therapeutic and nontherapeutic communication techniques are discussed in Chapter 7. The use of
active listening (demonstrating full attention to what is
being said, hearing both the content being communicated
and the unspoken message) facilitates therapeutic interactions. Giving clients the opportunity to be heard helps
them to organize their thoughts and to evaluate their situation more realistically.
Once the clients perspective is clear, the nurse provides pertinent health information without offering
specific advice. By reserving personal opinions, nurses
promote the right of every person to make his or her own
decisions and choices on matters affecting health and illness care. The role of the nurse is to share information
about potential alternatives, allow clients the freedom to
choose, and support the decision that is made.
While giving care, the nurse finds many opportunities
to teach clients how to promote healing processes, stay
well, prevent illness, and carry out ADLs in the best possible way. People know much more about health and
health care today, and they expect nurses to share accurate information with them.
Because clients do not always communicate their feelings to strangers, nurses use empathy (intuitive aware-
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Nursing Foundations
FIGURE 1.6 Example of recovery pathway in managed care. (Courtesy of Elkhart General Hospital, Elkhart, IN.)
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Comforting Skills
Nightingales presence and the light from her lamp communicated comfort to the frightened British soldiers. As
a result of that heritage, contemporary nurses understand
that illness often causes feelings of insecurity that may
threaten the clients or familys ability to cope; they may
feel very vulnerable. It is then that the nurse uses comforting skills (interventions that provide stability and
security during a health-related crisis) (Fig. 1-7). The
nurse becomes the clients guide, companion, and interpreter. This supportive relationship generally increases
trust and reduces fear and worry.
As a result of one womans efforts, modern nursing
was born. It has continued to mature and flourish ever
since. The skills that Nightingale performed on a very
grand scale are repeated today during each and every
nurseclient relationship.
FIGURE 1.7 This nurse offers comfort and emotional support. (Copyright B. Proud.)
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Kenney, P. A. (2001). Maintaining quality care during a nursing shortage using licensed practical nurses in acute care.
Journal of Nursing Care Quality, 15(4), 6068.
Mahaffey, E. H. (2002). The relevance of associate degree nursing: Past, present, future. Online Journal of Issues in Nursing,
7(2), 11p.
National Center for Chronic Disease Prevention and Health Promotion. (2002). Healthy aging for older adults. United States
Department of Health and Human Services. http://www.
cdc.gov/aging
National Council of State Boards of Nursing, Inc. (2001).
Licensure and examination statistics. Chicago.
National Council of State Boards of Nursing, Inc. (2001).
NCSBN position statement: Nurse shortage. http://www.
ncsbn.org/public/news/ncsbn_position_nurse_shortage.htm.
Accessed 9/24/02.
Nightingale, F. (1859). Notes on nursing: What it is, and what it
is not. London: Harrison.
Palmer, P. (2001). Ever upward: An innovative online college
offers an unusual solution to the nursing shortage: Helping
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