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Nursing Practice and the Nursing Process

Understanding basic concepts in nursing practice, such as roles of nursing, theories of nursing,
licensing, and legal issues, helps enhance performance.
Definition of Nursing

 Nursing is an art and a science.

 Earlier emphasis was on the care of sick patient; now the promotion of health is stressed.
 American Nurses Association definition, 1980: Nursing is the diagnosis and treatment of
human responses to actual and potential health problems.

Roles of Nursing
Whether in hospital-based or community health care setting, nurses assume three basic roles:

 Practitioner—involves actions that directly meet the health care and nursing needs of
patients, families, and significant others; includes staff nurses at all levels of the clinical
ladder, advanced practice nurses, and community-based nurses.
 Leader—involves actions such as deciding, relating, influencing, and facilitating that
affect the actions of others and are directed toward goal determination and achievement;
may be a formal nursing leadership role or an informal role periodically assumed by the
 Researcher—involves actions taken to implement studies to determine the actual effects
of nursing care to further the scientific base of nursing; can include all nurses, not just
academicians, nurse scientists, and graduate nursing students.

History of Nursing

 The first nurses were trained by religious institutions to care for patients; no standards or
educational basis.
 In 1873, Florence Nightingale developed a model for independent nursing schools to
teach critical thinking, attention to the patient's individual needs, and respect for the
patient's rights.
 During the early 1900s, hospitals used nursing students as cheap labor and most graduate
nurses were privately employed to provide care in the home.
 After World War II, technological advancements brought more skilled and specialized
care to hospitals, requiring more experienced nurses.
 Development of intensive and coronary care units during the 1950s brought forth
specialty nursing and advanced practice nurses.
 Since the 1960s, greater interest in health promotion and disease prevention along with a
shortage of physicians serving rural areas, helped create the role of the nurse practitioner.

Theories of Nursing

 Nursing theories help define nursing as a scientific discipline of its own.

 The elements of nursing theories are uniform—nursing, person, environment, and
health; also known as the paradigm or model of nursing.
 Nightingale was the first nursing theorist; she believed the purpose of nursing was to put
the person in the best condition for nature to restore or preserve health.
 More recent nursing theorists include:
o Levine—Nursing supports a person's adaptation to change due to internal and
external environmental stimuli.


o Orem—Nurses assist the person to meet universal, developmental, and health

deviation self-care requisites.
o Roy—Nurses manipulate stimuli to promote adaptation in four
modes—physiologic, self-concept, role function, and interdependence relations.
o Neuman—Nurses affect a person's response to stressors in the areas of
physiologic, psychological, sociocultural, and developmental variables.
o King—Nurses exchange information with patients, who are open systems to
attain mutually set goals.
o Rogers—Nurses promote harmonious interaction between the person and
environment to maximize health; both are four-dimensional energy fields.

Nursing in the Health Care Delivery System

 Technology, education, society values, demographics, and health care financing have an
impact on where and how nursing is practiced.
o By the year 2030, the over age 65 population will more than double to about 70
o Almost 50% of the U.S. population has one or more chronic conditions.
o The annual cost of medical care in the United States is greater than $900 billion
and growing at twice the rate of inflation.
 Current trends to use health care dollars for primary care of many, rather than specialized
care for a few, have shifted nursing care out of the acute care hospital and into the home
and outpatient setting.
 Inpatient staff nurses are now responsible for a greater number of patients who may be
older, more acutely ill, and hospitalized for shorter stays.
o Diagnosis-related groups (DRGs), implemented in 1983, set rates for Medicare
payment for inpatient services, fixing reimbursement based on diagnosis, not on
actual charges. This set the standard for shorter hospital stays and other cost-
cutting measures.
o During the 1990s, hospital mergers, reengineering efforts, and other cost-cutting
efforts led to a decrease in nursing care hours and registered positions, replacing
nurses with less-skilled personnel.
o From late 1990s through mid-2000, nursing school enrollment began to decline
and has yet to reverse. Health care employers are experiencing a shortage in the
supply of new nurses and the aging of the registered nurse workforce. By 2010,
the average age of the practicing nurse in the United States is projected to be age
o Research indicates that the number of registered nurses directly and positively
affects patient outcomes. Health care organizations are attempting to increase
nursing positions during a shortage.
 The concept of managed care has expanded for health maintenance organizations
(HMOs) and preferred provider organizations to case management and reimbursement
control for most insurance plans. Therefore, more nurses are working in utilization
management or for hospitals or insurance companies to determine the need for specialist
consultations, costly procedures, surgeries, and hospitalizations.
 More nurses are working for large outpatient centers run by hospitals or HMOs;
responsibilities include less “hands on― care, but more assessment and health
education for patients and their families.
 The nursing role has expanded to meet health care challenges more efficiently with
certification in a variety of specialties to provide direct care or support and educate other
nurses in their roles (see Box 1-1, page 4).