Introduction

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

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

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

Religion
Religion has also played a significant role in the development of nursing. Although many of the world's
religions encourage benevolence, it was the Christian value of "love thy neighbor as thyself" and Christ's
parable of the Good Samaritan that had a significant impact on the development of Western nursing.
During the third and fourth centuries, several wealthy matrons of the Roman Empire, such asFab iola,
converted to Christianity and used their wealth to provide houses of care and healing (the forerunner of
hospitals) for the poor, the sick, and the homeless. Women were not, however, the sole providers of
nursing services.

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

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

Early religious values, such as self-denial, spiritual calling, and devotion to duty and hard work, have
dominated nursing throughout its history. Nurses' commitment to these values often resulted in
exploitation and few monetary rewards. For some time, nurses themselves believed it was inappropriate to
expect economic gain from their "calling."
War

Throughout history, wars have accentuated the need for nurses. During the Crimean War (1854-1856), the
inadequacy of care given to soldiers led to a public outcry in Great Britain. The role Florence Nightingale
played in addressing this problem is well known. She was asked by Sir Sidney Herbert of the British War
Department to recruit a contingent of female nurses to provide care to the sick and injured in the Crimea.
Nightingale and her nurses transformed the military hospitals by setting up sanitation practices, such as
hand washing and washing clothing regularly. Nightingale is credited with performing miracles; the
mortality rate in the Barrack Hospital in Turkey, for example, was reduced from 42% to 2%.

During the American Civil War (1861-1865), several nurses emerged who were notable for their
contributions to a country torn by internal strife. Harriet Tubman and Sojourner Truth
provided care and safety to slaves fleeing to the North on the Underground Railroad. Mother
Biekerdyke and Clara Barton searched the battlefields and gave care to injured and dying soldiers. Noted
authors Walt Whitman and Louisa May Alcott volunteered as nurses to give care to injured soldiers in
military hospitals. Another woman leader who provided nursing care during the Civil War wasD orothea
Dix. She became the Union's Superintendent of Female Nurses responsible for recruiting
nurses and supervising the nursing care of all women nurses working in the army hospitals.

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

World War II casualties created an acute shortage of caregivers, and the Cadet Nurse Corps was
established in response to a marked shortage of nurses. Also at that time, auxiliary health careworkers became prominent.
"Practical" nurses, aides, and technicians provided much of the actual nursingcare under the instruction and supervision of better
prepared nurses. Medical specialties also arose at thattime to meet the needs of hospitalized clients.

During the Vietnam War, approximately 90% of the 11,000 American military women stationed in
Vietnam were nurses. Most of them volunteered to go to Vietnam right after they graduated from nursing
school. This made them the youngest group of medical personnel ever to serve in wartime (Vietnam
Women's Memorial Foundation, n.d.). Near the Vietnam Veterans Memorial ("The Wall") stands the
Vietnam Women's Memorial. This monument was established to "honor the women who
served and also for the families who lost loved ones during the war . . . to let them know about the women
who provided comfort, care and a human touch for those who were suffering and dying" (Vietnam
Women's Memorial Foundation, n.d.).

Societal Attitudes

Society's attitudes about nurses and nursing have significantly influenced professional nursing.

Before the mid-1800s, nursing was without organization, education, or social status; the prevailing attitude
was that a woman's place was in the home and that no respectable woman should have a career. The role
for the Victorian middle-class woman was that of wife and mother, and any education she obtained was
for the purpose of making her a pleasant companion to her husband and a responsible mother to her
children. Nurses in hospitals during this period were poorly educated; some were even incarcerated
criminals. Society's attitudes about nursing during this period are reflected in the writings of Charles
Dickens. In his book Martin Chuzzlewit (1896), Dickens reflected his attitude toward nurses through his
character Sairy Gamp. She "cared" for the sick by neglecting them, stealing from them, andphysically abusing them.This literary
portrayal of nurses greatly influenced thenegative image and attitude toward nurses up to contemporary times.
In contrast, the guardian angel or angel of mercy image arose in the latter part of the 19th century, largely
because of the work of Florence Nightingale during the Crimean War. After Nightingale brought
respectability to the nursing profession, nurses were viewed as noble, compassionate, moral, religious,
dedicated, and self-sacrificing.

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

During the past few decades, the nursing profession has taken steps to improve the image of the nurse. In
the early 1990s, the Tri-Council for Nursing (the American Association of Colleges of Nursing, the
American Nurses Association, the American Organization of Nurse Executives, and the National League
for Nursing) initiated a national effort (titled "Nurses of America") to improve the image of nursing. More
recently, the Johnson& Johnson corporation contributed $20 million in 2002 to launch a "Campaign for
Nursing's Future" to promote nursing as a positive career choice (Anonymous, 2003; Fitzpatrick, 2002). In
addition, nursing schools and hospitals are targeting men in their recruitment efforts.

Nursing Leaders

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

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

Nightingale was born to a wealthy and intellectual family. She believed she was "called by
God to help others . . . [and] to improve the well-being of mankind" (Schuyler, 1992, p. 4). She was
determined to become a nurse in spite of opposition from her family and the restrictive societal code for
affluent young English women. As a well-traveled young woman of the day, she visited Kaiserswerth in
1847, where she received 3 months' training in nursing. In 1853 she studied in Paris with the Sisters of
Charity, after which she returned to England to assume the position of superintendent of a charity hospital
for ill governesses.

When she returned to England from the Crimea, a grateful English public gave Nightingale an honorarium
of 4500. She later used this money to develop the Nightingale Training School for Nurses, whichopened in 1860. The school
served as a model for other training schools. Its graduates traveled to othercountries to manage hospitals and institute
nurse-training programs.
Nightingale's vision of nursing, which included public health and health promotion roles for nurses, wasonly partially addressed
in the early days of nursing. The focus tended to be on developing the professionwithin hospitals.
Barton (1812-1912)
Clara Barton was a schoolteacher who volunteered as a nurse during the American CivilWar. Her responsibility was to organize
the nursing services. Barton is noted for her role in establishingthe American Red Cross, which linked with the International Red
Cross when the U.S. Congress ratifiedthe Treaty of Geneva (Geneva Convention). It was Barton who persuaded Congress in
1882 to ratify thistreaty so that the Red Cross could perform humanitarian efforts in time of peace.

Richards (1841-1930)
Linda Richards was America's first trained nurse. She graduated from the New England
Hospital for Women and Children in 1873. Richards is known for introducing nurse's notes and doctor'sorders. She also initiated
the practice of nurses wearing uniforms (American Nurses Association, 2006a).She is credited for her pioneer work in
psychiatric and industrial nursing.

Mahoney (1845-1926)
Mary Mahoney was the first African American professional nurse. She graduated from the
New England Hospital for Women and Children in 1879. She constantly worked for the acceptance of
African Americans in nursing and for the promotion of equal opportunities (Donahue, 1996, p. 271). The
American Nurses Association (2006b) gives a Mary Mahoney Award biennially in recognition of
significant contributions in interracial relationships.

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

Dock (1858-1956)
Lavinia L. Dock was a feminist, prolific writer, political activist, suffragette, and friend of
Wald. She participated in protest movements for women's rights that resulted in the 1920 passage of the
19th Amendment to the U.S. Constitution, which granted women the right to vote. In addition, Doc
campaigned for legislation to allow nurses rather than physicians to control their profession. In 1893,
Dock, with the assistance of Mary Adelaide Nutting and Isabel Hampton Robb, founded the American
Society of Superintendents of Training Schools for Nurses of the United States and Canada, a precursor to
the current National League for Nursing.

Sanger (1879-1966)
Margaret Higgins Sanger public health nurse in New York, has had a lasting impact on
women's health care. Imprisoned for opening the first birth control information clinic in America, she is
considered the founder of Planned Parenthood. Her experience with the large number of unwanted
pregnancies among the working poor was instrumental in addressing this problem.

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

CONTEMPORARY NURSING PRACTICE

An understanding of contemporary nursing practice includes a look at definitions of nursing, recipients of
nursing, scope of nursing, settings for nursing practice, nurse practice acts, and current standards of
clinical nursing practice.

Definitions of Nursing

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

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

In the latter half of the 20th century, a number of nurse theorists developed their own theoretical
definitions of nursing. Theoretical definitions are important because they go beyond simplistic common
definitions. They describe what nursing is and the interrelationship among nurses, nursing, the client, the
environment, and the intended client outcome: health

Certain themes are common to many of these definitions:

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

Professional nursing associations have also examined nursing and developed their definitions of it. In
1973, the American Nurses Association (ANA) described nursing practice as "direct, goal oriented, and
adaptable to the needs of the individual, the family, and community during health and illness" (ANA,
1973,). In 1980, the ANA changed this definition of nursing to this: "Nursing is the diagnosis and
treatment of human responses to actual or potential health problems" (ANA, 1980,). In 1995, the
ANA recognized the influence and contribution of the science of caring to nursing philosophy and
practice. Their most recent definition of professional nursing is much broader and states: "Nursing is the
protection, promotion, and optimization of health and abilities, preventions of illness and injury,
alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care
of individuals, families, communities, and populations" (ANA, 2003).

Research to explore the meaning of caring in nursing has been increasing. For example, Coffman (2004)conducted a
metasynthesis of qualitative studies describing cultural caring in nursing practice. Likewise,Graber and Mitcham (2004) sought
to identify actions, interventions, and interpersonal relationships that
demonstrated caring and compassion.

Recipients of Nursing
The recipients of nursing are sometimes called consumers, sometimes patients, and sometimes clients. A
consumer is an individual, a group of people, or a community that uses a service or commodity. People
who use health care products or services are consumers of health care.
A patient is a person who is waiting for or undergoing medical treatment and care. The word patient
comes from a Latin word meaning "to suffer" or "to bear." Traditionally, the person receiving health care
has been called a patient. Usually, people become patients when they seek assistance because of illness or
for surgery. Some nurses believe that the wordpatient implies passive acceptance of the decisions and
care of health professionals. Additionally, with the emphasis on health promotion and prevention of
illness, many recipients of nursing care are not ill. Moreover, nurses interact with family members and
significant others to provide support, information, and comfort in addition to caring for the patient.

For these reasons, nurses increasingly refer to recipients of health care asclients. Aclien t is a person whoengages the advice or
services of another who is qualified to provide this service. The termclient presentsthe receivers of health care as collaborators in
the care, that is, as people who are also responsible for their own health. Thus, the health status of a client is the responsibility of
the individual in collaboration withhealth professionals. In this book,client is the preferred term, althoughcons um
er andpatient are used insome instances.

Scope of Nursing

Nurses provide care for three types of clients: individuals, families, and communities. Theoretical
frameworks applicable to these client types, as well as assessments of individual, family, and community
health.

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

Promoting Health and Wellness

Wellness is a process that engages in activities and behaviors that enhance quality of life and maximize
personal potential (Anspaugh, Hamrick,& Rosata, 2003, p. 490). Nurses promote wellness in clients who
are both healthy and ill. This may involve individual and community activities to enhance healthy
lifestyles, such as improving nutrition and physical fitness, preventing drug and alcohol misuse, restricting
smoking, and preventing accidents and injury in the home and workplace.

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

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

• Providing direct care to the ill person, such as administering medications, baths, and specific procedures
and treatments
• Performing diagnostic and assessment procedures, such as measuring blood pressure and examining
feces for occult blood
• Consulting with other health care professionals about client problems
• Teaching clients about recovery activities, such as exercises that will accelerate recovery after a stroke
• Rehabilitating clients to their optimal functional level following physical or mental illness, injury, or
chemical addiction

Caring for the Dying

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

Settings for Nursing

In the past, the acute care hospital was the main practice setting open to most nurses. Today many nurseswork in hospitals, but
increasingly they work in clients' homes, community agencies, ambulatory clinics,long-term care facilities, health maintenance
organizations (HMOs), and nursing practice centers

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

Nurse Practice Acts

Nurse practice acts, or legal acts for professional nursing practice, regulate the practice of nursing in the
United States and Canada. Each state in the United States and each province in Canada has its own act.
Although nurse practice acts differ in various jurisdictions, they all have a common purpose: to protect the
public. Nurses are responsible for knowing their state's nurse practice act as it governs their practice.

Standards of Nursing Practice

Establishing and implementing standards of practice are major functions of a professional organization.
The purpose of the ANA Standards of Practice is to describe the responsibilities for which nurses are
accountable. The American Nurses Association developed standards of nursing practice that are
generic in nature, by using the nursing process as a foundation, and provide for the practice of nursing
regardless of area of specialization. Various specialty nursing organizations have further developed
specific standards of nursing practice for their area. For nurses in Canada, each province or territory
establishes its own standards of practice. The ANA Standards of Professional Performance
describe behaviors expected in the professional nursing role.

ROLES AND FUNCTIONS OF THE NURSE

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

Caregiver
The caregiver role has traditionally included those activities that assist the client physically and
psychologically while preserving the client's dignity. The required nursing actions may involve full care
for the completely dependent client, partial care for the partially dependent client, and supportive-
educative care to assist clients in attaining their highest possible level of health and wellness. Caregiving
encompasses the physical, psychosocial, developmental, cultural, and spiritual levels. The nursing process
provides nurses with a framework for providing care. A nurse may provide care directly or delegate it to other caregivers.

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

In the role ofcommu n icator, nurses identify client problems and then communicate these verbally or in
writing to other members of the health team. The quality of a nurse's communication is an important factor
in nursing care. The nurse must be able to communicate clearly and accurately in order for a client's health
care needs to be met.
Teacher
As ateach er, the nurse helps clients learn about their health and the health care procedures they need to
perform to restore or maintain their health. The nurse assesses the client's learning needs and readiness to
learn, sets specific learning goals in conjunction with the client, enacts teaching strategies, and measures
learning. Nurses also teach unlicensed assistive personnel (UAP) to whom they delegate care, and they
share their expertise with other nurses and health professionals.

Standards of Practice for the Registered Nursedescribe a competent level of nursing care as
demonstrated by the nursing process.

1. Assessment
Collects comprehensive data pertinent to the patient's health or the situation.

2. Diagnosis
Analyzes the assessment data to determine the diagnoses or issues.

3. Outcomes Identification
Identifies expected outcomes for a plan individualized to the patient or the situation.

4. Planning
Develops a plan that prescribes strategies and alternatives to attain expected outcomes.

5. Implementation
Implements the identified plan.

5A. Coordination of care

5B. Health teaching and health promotion

5C. Consultation
The advanced practice registered nurse and the nursing role specialist provide consultation to influence
the identified plan, enhance the abilities of others, and effect change.

5D. Prescriptive authority and treatment

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

5E. Treatment and evaluation

6. Evaluation
Evaluates progress towards attainment of outcomes.
Standards of Professional Performancedescribe a competent level of behavior in the professional role.

7. Quality of practice
Systematically enhances the quality and effectiveness of nursing practice.

8. Education
Attains knowledge and competency that reflects current nursing practice.
9. Professional practice evaluation
Evaluates one's own nursing practice in relation to professional practice standards and guidelines, relevant
statutes, rules, and regulations.

10. Collegiality
Interacts with and contributes to the professional development of peers and colleagues.

11. Collaboration
Collaborates with patient, family, and others in the conduct of nursing practice.

12. Ethics
Integrates ethical provisions in all areas of practice.

13. Research
Integrates research findings into practice.

14. Resource utilization

Considers factors related to safety, effectiveness, cost, and impact on practice in the planning and delivery
of nursing services.

15. Leadership
Provides leadership in the professional practice setting and the profession

Client Advocate
A client advocate acts to protect the client. In this role the nurse may represent the client's needs and
wishes to other health professionals, such as relaying the client's wishes for information to the physician.
They also assist clients in exercising their rights and help them speak up for themselves.

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

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

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

Manager
The nurse manages the nursing care of individuals, families, and communities. The nursemanager also
delegates nursing activities to ancillary workers and other nurses, and supervises and evaluates their
performance. Managing requires knowledge about organizational structure and dynamics, authority and
accountability, leadership, change theory, advocacy, delegation, and supervision and evaluation.

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

Research Consumer
Nurses often use research to improve client care. In a clinical area, nurses need to (a) have some
awareness of the process and language of research, (b) be sensitive to issues related to protecting the rights
of human subjects, (c) participate in the identification of significant researchable problems, and (d) be a
discriminating consumer of research findings.

Expanded Career Roles

Nurses are fulfilling expanded career roles, such as those of nurse practitioner, clinical nurse specialist,
nurse midwife, nurse educator, nurse researcher, and nurse anesthetist, all of which allow greater
independence and autonomy.

CRITERIA OF A PROFESSION

Nursing is gaining recognition as a profession.Profes s ion has been defined as an occupation that requires
extensive education or a calling that requires special knowledge, skill, and preparation. A profession is
generally distinguished from other kinds of occupations by (a) its requirement of prolonged, specialized
training to acquire a body of knowledge pertinent to the role to be performed; (b) an orientation of the
individual toward service, either to a community or to an organization; (c) ongoing research; (d) a code of
ethics; (e) autonomy; and (f) a professional organization.

Two terms related to profession need to be differentiated: professionalism and professionalization.

Professionalism refers to professional character, spirit, or methods. It is a set of attributes, a way of life
that implies responsibility and commitment. Nursing professionalism owes much to the influence of
Florence Nightingale.Professionalization is the process of becoming professional, that is, of acquiring
characteristics considered to be professional.

Expanded Career Roles for Nurses

NURSE PRACTITIONER
A nurse who has an advanced education and is a graduate of a nurse practitioner program. These nurses
are certified by the American Nurses Credentialing Center in areas such as adult nurse practitioner, family
nurse practitioner, school nurse practitioner, pediatric nurse practitioner, or gerontology nurse practitioner.
They are employed in health care agencies or community-based settings. They usually deal with
nonemergency acute or chronic illness and provide primary ambulatory care.

CLINICAL NURSE SPECIALIST

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

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

NURSE MIDWIFE
An RN who has completed a program in midwifery and is certified by the American College of Nurse
Midwives. The nurse gives prenatal and postnatal care and manages deliveries in normal pregnancies. The
midwife practices in association with a health care agency and can obtain medical services if
complications occur. The nurse midwife may also conduct routine Papanicolaou smears, family planning,
and routine breast examinations.

NURSE RESEARCHER
Nurse researchers investigate nursing problems to improve nursing care and to refine and expand nursing
knowledge. They are employed in academic institutions, teaching hospitals, and research centers such as
the National Institute for Nursing Research in Bethesda, Maryland. Nurse researchers usually have
advanced education at the doctoral level.

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

NURSE EDUCATOR
Nurse educators are employed in nursing programs, at educational institutions, and in hospital staff
education. The nurse educator usually has a baccalaureate degree or more advanced preparation and
frequently has expertise in a particular area of practice. The nurse educator is responsible for classroom
and often clinical teaching.

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