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Unit 1 Exploring Contemporary Nursing

c h a p t e r

Nursing Foundations
Words to Know
active listening
activities of daily living
advanced practice
assessment skills
caring skills
clinical pathways
comforting skills
counseling skills

Learning Objectives
discharge planning
managed care practices
multicultural diversity
nursing skills
nursing theory
primary care
quality assurance

On completion of this chapter, the reader will:

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
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.

This chapter traces the historical development of nurs-

ing from its unorganized beginning to current practice.

Nurses in the 21st century owe a debt of gratitude to their
pioneering counterparts who served their clients on battlefields, in settlement houses in urban slums, in Bostons
harbor on a floating childrens hospital, and on horseback in the Appalachian frontier of Kentucky. Ironically,
nursing is returning to the original community-based
model of practice from which it originated.


Nursing is one of the youngest professions but one of the

oldest arts. It evolved from the familial roles of nurturing
and caretaking. Early responsibilities included assisting
women during childbirth, suckling healthy newborns, and

ministering to the ill, aged, and helpless within households

and surrounding communities. Its hallmark was caring
more than curing.
During the Middle Ages in Europe, religious groups
assumed many of the roles of nursing. Nuns, priests, and
brothers combined their efforts to save souls with a commitment to care for the sick. Despite their zeal, they were
overworked and overwhelmed as a result of their limited
numbers, especially during periods when plagues and
pestilence spread quickly among communities. Consequently, some convents and monasteries engaged conscientious penitent and disadvantaged lay people to assist
with the burden of physical care.
In England, the character and quality of nursing care
changed dramatically when religious groups were exiled
to Western Europe during the schism between King
Henry VIII and the Catholic Church. The management of

UNIT 1 Exploring Contemporary Nursing

parochial hospitals and the ill within them in England fell

to the state. Hospitals became poorhouses, which some
characterized more accurately as pesthouses. The English
state recruited the hospital labor force from the ranks of
criminals, widows, and orphans, who repaid the Crown
for their meager food and shelter by tending to the unfortunate sick. An example of the menial requirements
for employment appears in Box 1-1. Generally, nursing
attendants were ignorant, uncouth, and apathetic to the
needs of their charges. Without supervision, they rarely
performed even their minimal duties. Infections, pressure
sores, and malnutrition were a testimony to their neglect.


In the midst of the deplorable health care conditions,

Florence Nightingale, an Englishwoman born of wealthy
parents, announced that God had called her to become a
nurse. Despite her familys protests, she worked with
nursing deaconesses, a Protestant order of women who
cared for the sick in Kaiserwerth, Germany. After becoming suitably prepared through her nursing apprenticeship,
Nightingale embarked on the next phase of her career.

fare better if a team of women trained in nursing skills

could care for them (Fig. 1-1). With Herberts approval of
this plan, Nightingale selected women with reputations
beyond reproach. She realized intuitively that only people
with devotion and idealism could accept the discipline and
hard work necessary for the task before them.
To the British medical staff at Scutari, the arrival of
this group of women implied that they were incapable of
providing adequate care. Jealousy and rivalry caused
them to refuse any help from Nightingale and her 38 volunteers. When it became clear that the daily death rate,
which averaged about 60%, was not subsiding, the medical staff allowed Nightingales nurses to work. Under
Nightingales supervision, the women cleaned the filth,
eliminated the vermin, and improved ventilation, nutrition, and sanitation. They helped control infection and
gangrene and lowered the death rate to 1%.
Servicemen and their families alike were grateful, and
England adored Nightingale. To show their appreciation,
many donated funds to sustain the great work that she had
begun. Nightingale used this money to start the first training school for nurses at St. Thomas Hospital in England.
This school became the model for others in Europe and
the United States.

The Crimean War

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

Nightingale changed the negative image of nursing to a

positive one. She is credited with:

BOX 1-1

Training people for their future work

Selecting only those with upstanding characters as
potential nurses

Rules of Employment for Nursing


No dirt, rags, or bones may be thrown from the windows.

Nurses are to punctually shift the bed and body linen of patients, viz.,
once in a fortnight (2 weeks), their shirts once in four days, their drawers
and stockings once a week or oftener, if found necessary.
All nurses who disobey orders, get drunk, neglect their patients, quarrel
with men, shall be immediately discharged.

FIGURE 1.1 Florence Nightingale (center), her brother-in-law, Sir Harry

From Goodnow, M. (1933). Outlines of nursing history (5th ed., pp. 5758). Philadelphia
and London: W. B. Saunders.

Verney, and Miss Crossland, the nurse in charge of the Nightingale

Training School at St. Thomas Hospital, with a class of student nurses.
(Courtesy of The Florence Nightingale Museum Trust, London, England.)


Improving sanitary conditions for the sick and

Significantly reducing the death rate of British
Providing classroom education and clinical teaching
Advocating that nursing education should be lifelong

Nursing Foundations

Neat, orderly, sober, and industrious, with a serious
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).

Stop, Think, and Respond BOX 1-1

How did Florence Nightingale convince the English
and others that formal education of people who
cared for the sick and injured was essential?


U.S. Nursing Schools

The Civil War occurred around the same time as the

Nightingale reformation. Like England, the United States
found itself involved in a war with no organized or substantial staff of trained nurses to care for the sick and
wounded. The military had to rely on untrained corpsmen and civilian volunteers, often the mothers, wives,
and sisters of soldiers.
The Union government appointed Dorothea Lynde
Dix, a social worker who had proved her worth by
reforming health conditions for the mentally ill, to select
and organize women volunteers to care for the troops. In
1862, Dix followed Nightingales advice and established
the following selection criteria. Applicants were to be:

35 to 50 years of age
Matronly and plain-looking


After the Civil War, training schools for nurses began to

be established in the United States. Unfortunately, however, the standards of U.S. schools deviated substantially
from those of the Nightingale paradigm (Table 1-1).
Whereas planned, consistent, formal education was the
priority in the Nightingale schools, the training of U.S.
nurses was more an unsubsidized apprenticeship.
Eventually, the curricula and content of U.S. training
schools became more organized and uniform. Training
periods lengthened from 6 months to 3 full years. Graduate nurses received a diploma attesting to their successful
completion of training.

Expanding Horizons of Practice

Diplomas in hand, U.S. nurses began the 20th century
by distinguishing themselves in caring for the sick and
disadvantaged outside hospitals (Fig. 1-2). Some nurses
moved into communities and established settlement
houses where they lived and worked among poor




Training schools were affiliated with a few select hospitals.

Training hospitals relied on employees to provide client care.
Education costs were borne by students or endowed from the
Nightingale Trust Fund.
Training of nurses provided no financial advantages to the
Class schedules were planned separately from practical
Curricular content was uniform.

Any hospital, rural or urban, could establish a training school.

Students staffed the hospital.
Students worked without pay in return for training, which
usually consisted of chores.
Hospitals profited by eliminating the need to pay employees.

A previously trained nurse provided formal instruction,

focusing on nursing care.
The number of clinical hours during training was restricted.

At the end of training, graduates became paid employees or

were hired to train others.

No formal classes were held; training was an outcome of work.

Curricular content was unplanned and varied according to
current cases.
Instruction was usually informal, at the bedside, and from a
physicians perspective.
Students were expected to work 12 hours a day and to live in
or adjacent to the hospital in case they were needed
At the end of training, students were discharged and new
students took their places. Most graduates sought privateduty positions.

UNIT 1 Exploring Contemporary Nursing

FIGURE 1.2 Community health nurses circa late 1800s to early 1900s. (Courtesy of Visiting Nurse Association, Inc., Detroit, MI.)

immigrants. Other nurses provided midwifery services,

especially in the rural hills of Appalachia. The success of
such public health efforts in administering prenatal and
obstetric care, teaching child care, and immunizing children is well documented.
Like their counterparts in previous generations, nurses
continued to volunteer during wars. They offered their
services to fight yellow fever, typhoid, malaria, and dysentery during the Spanish-American War. They replenished
the nursing staff in military hospitals during World Wars
I and II (Fig. 1-3). They worked side by side with physicians in Mobile Army Service Hospitals (MASH) during
the Korean War, acquiring knowledge about trauma care
that later would help to reduce the mortality rate of U.S.
soldiers in the Vietnam conflict. More recently, nurses
answered the call during Operation Desert Storm. Whenever and wherever there has been a need, nurses have put
their own lives on the line.

FIGURE 1.3 A military nurse comforts a soldier during World War II.
(Courtesy of the National Archives, Washington, DC.)



Combining Nursing Art With Science

At first, the training of nurses consisted of learning the
art (ability to perform an act skillfully) of nursing. Students learned this art by watching and imitating the techniques performed by other nurses with more experience.
In this way, mentors informally passed nursing skills to
Contemporary nursing practice has added another
dimension: science. The English word science comes
from the Latin word scio, which means, I know. A science (body of knowledge unique to a particular subject)
develops from observing and studying the relation of one
phenomenon to another. By developing a unique body of
scientific knowledge, it is now possible to predict which
nursing interventions are most likely to produce desired

Integrating Nursing Theory

The word theory (opinion, belief, or view that explains
a process) comes from a Greek word that means vision.
For example, a scientist may study the relation between
sunlight and plants and derive a theory of photosynthesis that explains how plants grow. Others who believe
the theorists view to be true may then apply the theory
for their own practical use.
Nursing has undergone a similar scientific review.
People such as Florence Nightingale and others have
examined the relationships among humans, health, the
environment, and nursing. The outcome of such analysis becomes the basis for nursing theory (proposed
ideas about what is involved in the process called nursing). Nursing programs then adopt the theory to serve as
the conceptual framework or model for their philosophy,
curriculum, and most importantly approach to clients.
Similarly, psychologists have adopted Freuds psychoanalytic theory or Skinners behavioral theory and used
it as a model for diagnostic and therapeutic interventions
with clients.
Table 1-2 summarizes some nursing theories and discusses how each has been applied to nursing practice.
These are only a few of the many theories that exist;
additional information can be found in current 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

with the earliest modern definition: she defined nursing

as putting individuals in the best possible condition for
nature to restore and preserve health.
Other definitions have been offered by nurses who
have come to be recognized as authorities and therefore
qualified spokespersons on the practice of nursing. One
such authority is Virginia Henderson. Her definition,
adopted by the International Council of Nurses, broadened the description of nursing to include health promotion, not just illness care. She stated in 1966:
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 a peaceful
death) that he could 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.

Henderson proposed that nursing is more than carrying

out medical orders. It involves a special relationship and
service between the nurse and the client (and his or her
family). According to Henderson, the nurse acts as a
temporary proxy, meeting the clients health needs with
knowledge and skills that neither the client nor family
members can provide.
The most recent definition of nursing comes from the
American Nurses Association (ANA). In its 1980 report
Nursing: A Social Policy Statement, the ANA defines nursing as the diagnosis and treatment of human responses
to actual or potential health problems. The ANAs position is that in addition to traditional dependent and interdependent functions, nursing has an independent area of
practice. As the role of the nurse continues to change,
there will be further revisions to the definition of nursing
and the scope of nursing practice.


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

UNIT 1 Exploring Contemporary Nursing





Florence Nightingale

Environmental Theory
Synopsis of Theory
Application to Nursing Practice

Virginia Henderson

Basic Needs Theory

Synopsis of Theory
Application to Nursing Practice

Dorothea Orem

Self-Care Theory
Synopsis of Theory

Sister Callista Roy


Application to Nursing Practice

Adaptation Theory
Synopsis of Theory
Application to Nursing Practice


An individual whose natural defenses are influenced by a healthy or

unhealthy environment
A state in which the environment is optimal for the natural body
processes to achieve reparative outcomes
All the external conditions capable of preventing, suppressing, or
contributing to disease or death
Putting the client in the best condition for nature to act
External conditions such as ventilation, light, odor, and cleanliness can
prevent, suppress, or contribute to disease or death.
Nurses modify unhealthy aspects of the environment to put the client in
the best condition for nature to act.
An individual with human needs that have unique meaning and value
The ability to independently satisfy human needs composed of 14 basic
physical, psychological, and social elements
The setting in which a person learns unique patterns for living
Temporarily assisting a person who lacks the necessary strength, will,
and knowledge to satisfy one or more of 14 basic needs
People have basic needs that are components of health. The significance
and value of these needs are unique to each person.
Nurses assist in performing those activities that the client would perform
if he or she had strength, will, and knowledge.
An individual who uses self-care to sustain life and health, recover from
disease or injury, or cope with its effects
The result of practices that people have learned to carry out on their
own behalf to maintain life and well-being
External elements with which man interacts in the struggle to maintain
A human service that assists people to progressively maximize their selfcare potential
People learn behaviors that they perform on their own behalf to
maintain life, health, and well-being.
Nurses assist clients with self-care to improve or to maintain health.
A social, mental, spiritual, and physical being affected by stimuli in the
internal and external environments
A persons ability to adapt to changes in the environment
Internal and external forces in a continuous state of change
A humanitarian art and expanding science that manipulates and
modifies stimuli to promote and to facilitate mans ability to adapt
Man is a biopsychosocial being. A change in one component results in
adaptive changes in the others.
Nurses assess biologic, psychological, and social factors interfering with
health; alter the stimuli causing the maladaptation; and evaluate the
effectiveness of the action taken.

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,

children, and adults who were mildly or chronically ill or

convalescing so that registered nurses could be used more
effectively to care for acutely ill clients.
After the war, many registered nurses opted for parttime employment or resigned to become full-time housewives, and thus the need for practical nurses continued. It
became obvious that the role practical nurses were fulfilling in health care delivery would not be temporary. Consequently, leaders in practical nursing programs organized


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

RN). A person licensed as a registered nurse may work

directly at the bedside or supervise others in managing the
care of groups of clients.
Table 1-3 describes how educational programs prepare
graduates to assume separate but coordinated responsibilities. When hiring new graduates, however, many
employers do not differentiate between these educational
programs, arguing that a nurse is a nurse.

Hospital-Based Diploma Programs

Diploma programs were the traditional route for nurses
through the middle of the 20th century. Their decline
became obvious in the 1970s, and their numbers continue to dwindle (Fig. 1-5). The reason for their decline
is twofold: first, there has been a movement to increase
professionalism in nursing by encouraging education in
colleges and universities; second, hospitals can no longer
financially subsidize schools of nursing.
Diploma nurses were, and are, well trained. Because
of their vast clinical experience (compared with students
from other types of programs), they often are characterized as more self-confident and easily socialized into the
role requirements of a graduate nurse.
A hospital-based diploma program generally lasts
3 years. Many hospital schools of nursing collaborate with
nearby colleges to provide basic science and humanities
courses; graduates can transfer these credits if they choose
to pursue associate or baccalaureate degrees later.

Associate Degree Programs

During World War II, when qualified nurses were being
used for the military effort, hospital-based schools accelerated the education of some registered nursing students
through the Cadet Nurse Corps. After the war ended,
Mildred Montag, a doctoral nursing student, began to

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

UNIT 1 Exploring Contemporary Nursing











Gathers data by interviewing,

observing, and performing a basic
physical examination of people
with common health problems
with predictable outcomes
Contributes to the development of
nursing diagnoses by reporting
abnormal assessment data

Collects data from people with

complex health problems with
unpredictable outcomes, their
family, medical records, and
other health team members
Uses a classification list to write a
nursing diagnostic statement,
including the problem, its etiology, and signs and symptoms
Identifies problems that require
collaboration with the physician
Sets realistic, measurable goals
Develops a written individualized
plan of care with specific
nursing orders that reflects the
standards for nursing practice

Identifies the information

needed from individuals or
groups to provide an
appropriate nursing
Conducts clinical testing of
approved nursing diagnoses
Proposes new diagnostic
categories for consideration
and approval

Identifies priorities
Directs others to carry out nursing

Applies nursing theory to the

approaches used for
resolving actual and
potential health problems of
individuals or groups
Conducts research on nursing
activities that may be
improved with further study

Assists in setting realistic and

measurable goals
Suggests nursing actions that can
prevent, reduce, or eliminate
health problems with predictable
Assists in developing a written plan
of care
Performs basic nursing care under
the direction of a registered nurse

Shares observations on the progress

of the client in reaching
established goals
Contributes to the revision of the
plan of care

Evaluates the outcomes of nursing

care routinely
Revises the plan of care

Develops written standards for

nursing practice
Plans care for healthy or sick
individuals or groups in
structured health care
agencies or the community

* Note that each more advanced practitioner can perform the responsibilities of those identified previously.


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

FIGURE 1.5 Distribution of basic RN programs. Numbers are based on

educational programs of U.S. candidates taking the NCLEX-RN examination in 2001, as reported by the National Council of State Boards of

Although collegiate nursing programs were established at

the beginning of the 20th century, until recently they did
not attract large numbers of students. Their popularity
has been increasing, perhaps because of proposals by the
ANA and the National League for Nursing to establish


baccalaureate education as the entry level into nursing

practice. The deadline for implementation of this goal,
once set for 1985, has been postponed for three reasons:

The date coincided with a national shortage of

There was tremendous opposition from nurses
without degrees, who believed that their titles and
positions would be jeopardized.
Employers feared that paying higher salaries to personnel with degrees would escalate budgets beyond
their financial limits.

BOX 1-2

Consequently, the adoption of a unified entry level into

practice remains in limbo.
Although this preparatory program is the longest and
most expensive, baccalaureate-prepared nurses have the
greatest flexibility in qualifying for nursing positions, both
staff and managerial. Nurses with a baccalaureate degree
usually are preferred in areas where the need for independent decision-making is substantial, such as public health.
Currently, many nurses without degrees are returning
to school to earn baccalaureate degrees. Articulation has
been difficult for many because of problems transferring
credits for courses they took during their diploma or associate degree programs. To increase enrollment, some collegiate programs are offering nurses an opportunity to
obtain credit by passing challenge examinations. In
addition, many colleges and universities provide satellite
or outreach programs to accommodate nurses who cannot
go to school full-time or travel long distances.

Graduate Nursing Programs

Graduate nursing programs are available at both the masters and doctoral levels. Masters-prepared nurses fill
roles as clinical specialists, nurse practitioners, administrators, and educators. Nurses with doctoral degrees conduct research and advise, administer, and instruct nurses
pursuing undergraduate and graduate degrees. Although
a graduate degree in nursing is preferred, some nurses
pursue advanced education in fields outside nursing, such
as business, leadership, and education, to enhance their
nursing career.

Nursing Foundations

Rationales for Acquiring

Continuing Education

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


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 (
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:

Retirement rate of nurses that exceeds their replacement

Declining enrollment in nursing programs

Attrition of aging faculty, which restricts numbers
of student applicants

Increased aging population requiring health care

Job dissatisfaction as a result of stress and the unrelenting rigor of working in health care

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

encourage more people to enter nursing programs


UNIT 1 Exploring Contemporary Nursing

3. Career ladder programs to facilitate advancement

to higher levels of nursing practice

4. Best practice grants modeled after the ANA/American Nursing Credentialing Centers magnet program, which recognizes workplaces with positive
outcomes for clients (e.g., low mortality rates, short
lengths of stay) combined with increased satisfaction among employed nurses who demonstrate
quality care and work productivity
5. Grants to incorporate gerontology into the curricula of nursing programs
6. Loan repayment programs for nursing students who
agree to teach following graduation (http://www.
Before the provisions are set into motion, Congress must
approve appropriations to fund them.

to the trends affecting their role in health care (Table 1-4).

Nurses are dealing with the unique challenges of the 21st
century by:

Pursuing post-licensure education

Training for advanced practice roles (nurse prac-

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


titioner, nurse midwifery) to provide cost-effective

health care in areas in which numbers of primary
care physicians are inadequate
Becoming cross-trained (able to assume nonnursing jobs, depending on the census or levels of
client acuity on any given day). For example, nurses
may be trained to provide respiratory treatments
and to obtain electrocardiograms, duties that nonnursing health care workers previously performed.
Learning more about multicultural diversity
(unique characteristics of ethnic groups) as it affects
health beliefs and values, food preferences, language,
communication, roles, and relationships
Supporting legislative efforts toward national health
insurance that involves nurses in primary care
(the first health care worker to assess a person with
a health need)
Promoting wellness through home health care and
community-based programs


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.

Enrollments and numbers of graduates from LPN/LVN and
RN educational programs are currently decreasing.
More licensed nurses are earning masters and doctoral
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
Job opportunities have expanded to outpatient services,
home health care, hospice programs, community
health, and mental health agencies.


Helping clients with chronic diseases learn tech

niques for living healthier and, consequently, longer

Referring clients with health problems for early
treatment, a practice that requires the fewest resources and thus minimizes expenses
Coordinating nursing services across health care
settingsthat is, discharge planning (managing
transitional needs and ensuring continuity)
Developing and implementing clinical pathways,
standardized multidisciplinary plans for a specific
diagnosis or procedure that identify aspects of care
to be performed during a designated length of stay
(Fig. 1-6)
Participating in quality assurance (process of identifying and evaluating outcomes)
Concentrating on the knowledge and skills to manage the health needs of older Americans whose
numbers will reach 70 million by 2030, according to
the National Center for Chronic Disease Prevention
and Health Promotion (2002)


Although employment location and how they carry out

nursing skills (activities unique to the practice of nursing) differ according to educational preparation, all nurses
share the same philosophical perspective. In keeping with
Nightingales traditions, contemporary nursing practice
continues to include assessment skills, caring skills, counseling skills, and comforting skills.

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

Nursing Foundations


that people normally do every day. Examples of ADLs

include bathing, grooming, dressing, toileting, and eating.
More and more, however, the nurses role is expanding
to include the safe care of clients who require invasive or
highly technical equipment. This textbook introduces
beginning nurses to the concepts and skills needed to provide care for clients whose disorders have fairly predictable outcomes. Once this foundation has been established,
students may add to their initial knowledge base.
Traditionally, nurses always have been providers of
physical care for people unable to meet their own health
needs independently. But caring also involves the concern
and attachment that result from the close relationship of
one human being with another. Despite the close relationship that caring involves, the nurse ultimately wants
clients to become self-reliant. The nurse who assumes too
much care for clients, like a parent who continues to tie a
childs shoes, often delays their independence.

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-


UNIT 1 Exploring Contemporary Nursing

Nursing Foundations

FIGURE 1.6 Example of recovery pathway in managed care. (Courtesy of Elkhart General Hospital, Elkhart, IN.)



UNIT 1 Exploring Contemporary Nursing

ness of what the client is experiencing) to perceive the

clients emotional state and need for support. This skill
differs from sympathy (feeling as emotionally distraught
as the client). Empathy helps the nurse become effective
in providing for the clients needs while remaining compassionately detached.

1. Explain the reason for enacting the Nurse Reinvestment Act

in 2002.
2. Name four types of skills that all nurses perform when caring
for clients.

Comforting Skills

References and Selected Readings

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.

Stop, Think, and Respond BOX 1-2

Identify which of the following nursing actions is an
assessment skill, caring skill, counseling skill, and
comforting skill: (a) the nurse discusses with a family the progress of a client undergoing surgery;
(b) the nurse provides information on advanced
directives, which allows a client to identify his or
her end-of-life decisions; (c) the nurse asks a client
to identify his or her current health problems; (d)
the nurse provides medication for a client in pain.

FIGURE 1.7 This nurse offers comfort and emotional support. (Copyright B. Proud.)

Critical Thinking Exercises

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practical nurses to licensed practical/vocational nurses
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American Nurses Association. (2001). 2001 annual stakeholders
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American Nurses Association. (1980). Nursing: A social policy
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American Nurses Association. (1974). Standards for continuing
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Barber, J. L., Bland, C., Langdon, M. B., et al. (2000). LPN role
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Boden, L., & Smith, M. (2002). Debate. Is it really possible to
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Buerhaus, P. I. (1998). Is a nursing shortage on the way? Nursing, 28(8), 3435.
Buerhaus, P., & McCue, P. (2000). This nursing shortage will
be unprecedented. News & Views, Winter(1), 6.
Bureau of Labor Statistics. (2001). Occupational outlook handbook. Licensed practical and licensed vocational nurses. Washington, D.C.: U.S. Dept. of Labor (
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Curtin, L. (2002). Editorial opinion. Why stay in nursing today?
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Davidhizar, R., & Shearer, R. (2000). Your continuing education
topic #12000. Self-talk for the licensed practical/vocational
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Donahue, M. P. (1985). The finest art. St. Louis: Mosby.
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Nurses Associations first position on education for nurses.
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Duff, S. (2002). Nurses get funds to ease shortage. Modern
Healthcare, 32(23), 13.
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into practice proposalis it relevant today? Online Journal of
Issues in Nursing, 7(2), 3p.
Henderson, V. (1966). The nature of nursing. New York:
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32(1), LPN Education Directory: 34.
Joel, L. A. (2002). Education for entry into nursing practice:
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Kenney, P. A. (2001). Maintaining quality care during a nursing shortage using licensed practical nurses in acute care.
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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
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National Council of State Boards of Nursing, Inc. (2001).
Licensure and examination statistics. Chicago.
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NCSBN position statement: Nurse shortage. http://www.
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

Nursing Foundations


minority medical technicians, LPNs and others move up to

RN careers. Minority Nurse, Fall, 3237.
Redmond, G. M. (1997). LPN-BSN: Education for a reformed
health care system. Journal of Nursing Education, 36(3),
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