Basic Concepts in Nursing

Florence Nightingale, who wrote in 1858 that the goal of nursing was to put the patient in the best condition for nature to act upon him, nursing leaders have described nursing as both an art and a science. Social Policy Statement (2003), the American Nurses Association (ANA) defined nursing as the diagnosis and treatment of human responses to health and illness. ANA identifies the following phenomena as the focus for nursing care and research: Self-care processes Physiologic and pathophysiologic processes such as rest, sleep, respiration, circulation, reproduction, ac- tivity, nutrition, elimination, skin, sexuality, and communication Comfort, pain, and discomfort Emotions related to health and illness Meanings ascribed to health and illnesses Decision making and ability to make choices Perceptual orientations such as self-image and control over ones body and environments Transitions across the lifespan, such as birth, growth, development, and death Affiliative relationships, including freedom from oppression and abuse Environmental systems

The central figure in health care services is, of course, the patient. The term patient, which is derived from a Latin verb meaning to suffer, has traditionally been used to de- scribe a person who is a recipient of care.

Maslows Hierarchy

Maslow ranked human needs as follows: physiologic needs; safety and security; sense of belonging and affection; esteem and self-respect; and self-actualization, which includes self- fulfillment, desire to know and understand, and aesthetic needs. Lower-level needs always remain, but a persons abil ity to pursue higher-level needs indicates movement toward psychological health and well-being.

The health care system in the United States, which tradi- tionally has been disease oriented, is placing increasing em- phasis on health and its promotion

World Health Organization (WHO) defines health in the preamble to its constitution as a state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity (WHO, 2006 pg. 1).

On the healthillness contin- uum, even people with a chronic illness or disability may attain a high level of wellness if they are successful in meeting their health potential within the limits of their chronic illness or disability.

Wellness has been defined as being equivalent to health. Wellness involves being proactive and being involved in self-care activities aimed toward a state of physical, psycho- logical, and spiritual wellbeing (Clark, Stuifbergen, Got- tlieb, et al., 2006).
Cultural Diversity

An appreciation for the diverse characteristics and needs of people from varied ethnic and cultural backgrounds is im- portant in health care and nursing. Culture is defined as learned patterns of behavior, beliefs, and values that are shared by a particular group of people.

Demand for Quality Health Care

Quality Improvement and Evidence-Based Practice

In the 1980s, hospitals and other health care agencies im- plemented ongoing quality assurance (QA) programs. These programs were required for reimbursement for serv- ices and for accreditation by the Joint Commission (previously known as the Joint Commission for Accreditation of Healthcare Organizations [JCAHO]). Continuous quality improvement (CQI) was identified as a more effective mechanism for maintaining quality health care and its im- plementation was mandated in health care organizations in 1992.
Clinical Pathways and Care Mapping

Clinical pathways are tools for tracking a patients progress toward achieving positive outcomes within specified time frames. Clinical pathways based on current literature and clinical expertise have been developed for patients with certain diagnosis- related groups (DRGs) (eg, heart failure, ischemic stroke, fractured hip), for high-risk patients (eg, those receiving chemotherapy), and for patients with certain common health problems (eg, diabetes, chronic pain). The pathways indicate key events, such as diagnostic tests, treatments, ac- tivities, medications, consultation, and education, that must occur within specified times for patients to achieve the desired and timely outcomes.

Alternative Health Care Delivery Systems

The rising cost of health care over the past few decades has led to the use of managed health care and alternative health care delivery systems, including health maintenance organ- izations (HMOs) and preferred provider organizations (PPOs).
Managed Care

Managed care has contributed to a dramatic reduction in inpatient hospital days, continuing expansion of ambulatory care, fierce competition, and marketing strategies that ap- peal to consumers as well as to insurers and regulators.

Case Management

Case management is a system of coordinating health care services to ensure cost-effectiveness, accountability, and quality care. The premise of case management is that the re- sponsibility for meeting patient needs rests with one person or team whose goals are to provide the patient and

family with access to required services, to ensure coordination of these services, and to evaluate how effectively these services are delivered. The goals of case management are quality, appropriateness, and timeliness of services as well as cost reduction. Evi- dence-based pathways or similar plans are often used in case management of similar patient populations (Craig & Hu- ber, 2007; Huber & Craig, 2007).

Roles of the Nurse

Professional nurses who work in institutional, community-oriented, or commu- nity-based settings have three major roles: the practitioner role, which includes providing care, teaching, and collaborating; the leadership role; and the research role.

Practitioner Role
The practitioner role involves those actions taken by nurses to meet the health care and nursing needs of individual pa- tients, their families, and significant others. This role is a dominant one for nurses in primary, secondary, and tertiary health care settings and in home care and community nurs- ing. It is achieved through use of critical thinking, clinical judgment, and the nursing process, all of which are key tools for nursing practice.

Leadership Role
The leadership role is often viewed as a role assumed by nurses who have titles that suggest leadership and who are the leaders of large groups of nurses or related health care professionals. The leadership role involves those actions that nurses execute when they assume responsibility for the ac- tions of others directed toward determining and achieving patient care goals. Many staff nurses now work in settings where they are held accountable for the nursing care deliv- ered by unlicensed assistive personnel (UAPs) who work under their direct supervision. Nursing leadership involves four components: decision making, relating, influencing, and facilitating. Each of these components promotes change and the ultimate outcome of goal achievement. Basic to the entire process is effective communication, which determines the success of the process and achievement of goals

Research Role
The primary task of nursing research is to contribute to the scientific base of nursing practice. Studies are needed to de- termine the effectiveness of nursing interventions and nurs- ing care. The science of nursing grows through research, leading to the generation of scientifically based rationale for nursing practice and patient care. This process is the basis of EBP, with a resultant increase in the quality of patient care. research role is considered to be a responsibility of all nurses in clinical practice. Nurses are constantly alert for nursing problems and important issues related to patient care that can serve as a basis for the identification of re- searchable questions.

Models of Nursing Care Delivery

Several organizational methods or models that vary greatly from one facility to another and from one set of patient cir- cumstances to another may be used to carry out nursing care. These methods and models have changed over the years and have included functional nursing, team nursing, primary nursing, and patient-focused or patient-centered care. The models most commonly utilized today include pri- mary nursing, which is characterized by assigning one pri- mary nurse to accept overall responsibility for a given pa- tients individualized nursing care, and patient-focused care, which is

characterized by assigning a nurse to manage the care of a caseload of patients during a given shift, who may then delegate care activities to other nursing personnel, in- cluding UAPs.

Community health nursing, public health nursing, commu- nity-based nursing, and home health nursing may be dis- cussed together. However, although aspects of patient care in each type do overlap, these terms are distinct from one another. central idea of community- oriented nursing practice is that nursing intervention can promote wellness, reduce the spread of illness, and improve the health status of groups of citizens or the community at large. Its emphasis is on primary, secondary, and tertiary pre- vention. Nurses in these settings have traditionally focused on health promotion, maternal and child health, and chronic care.

Expanded Nursing Roles

Professional nursing is adapting to meet changing health needs and expectations. The role of the nurse has ex- panded to improve the distribution of health care services and to decrease the cost of health care. Nurses may re- ceive advanced education in such specialties as family care, critical care, coronary care, respiratory care, onco- logic care, maternal and child health care, neonatal in- tensive care, rehabilitation, trauma, rural health, and gerontologic nursing. In medical-surgical nursing, the most significant titles associated with an advanced spe- cialized education include nurse practitioner (NP) and clin- ical nurse specialist (CNS), and the more recent title of ad- vanced practice nurse (APN), which encompasses both NPs and CNSs. Certified nursemidwives (CNMs) and certified registered nurse anesthetists (CRNAs) are also identified as APNs. Nurses who function in these roles provide direct care to patients through independent prac- tice, practice within a health care agency, or collabora- tion with a physician. Specialization in nursing has evolved as a result of the recent explosion of technology and knowledge.

Interdisciplinary Collaborative Practice

This chapter has explored the changing role of nursing. Many references have been made to the significance of nurses as members of the health care team. As the unique competencies of nurses become more clearly articulated, there is increasing evidence that nurses provide health care services distinct to the profession. However, nursing con- tinues to recognize the importance of collaboration with other health care disciplines in meeting the needs of pa- tients. Some institutions use the collaborative practice model (Fig. 1-2). Nurses, physicians, and ancillary health person- nel function within a decentralized organizational structure, collaboratively making clinical decisions. A joint practice committee, with representation from all care providers, may function at the unit level to monitor, support, and foster collaboration. Collaborative practice is further enhanced with integration of the health or medical record and with joint patient care record reviews. The collaborative model, or a variation of it, promotes shared participation, responsi- bility, and accountability in a health care environment that is striving to meet the complex health care needs of the public.
Advanced Practice Nurse (APN): a title which encompasses the nurse practitioners (NPs), clinical nurse specialists (CNSs), certified nurse midwives (CNMs) and certified registered nurse anesthetists (CRNAs). Collaborative practice model: involves nurses, physicians, and ancillary health personnel functioning within a decentralized organizational structure and collaboratively making clinical decisions. Community-oriented nursing practice: nursing interven- tion that promotes wellness, reduces the spread of illness, and improves the health status of groups of citi- zens or the community at large with emphasis on primary, secondary, and tertiary prevention. Continuous quality improvement (CQI): the ongoing ex- amination of processes used to provide care, with the aim of improving quality by assessing and improving those processes that might improve patient care outcomes and patient satisfaction. Healthillness continuum: description of a persons health status as a range with anchors that include poor health or imminent death on one end of the continuum to high- level wellness on the other end.

OUESTIONS
On completion of this chapter, the learner will be able to: 1. 1 Define health and wellness. 2. 2 Describe factors causing significant changes in the health care delivery system and their impact on health care and the nursing profession. 3. 3 Describe the practitioner, leadership, and research roles of nurses. 4. 4 Describe nursing care delivery models. 5. 5 Discuss expanded nursing roles.

Community-Based Nursing Practice

On completion of this chapter, the learner will be able to: 1. 1 Discuss the changes in the health care system that have increased the need for nurses to practice in community- based settings. 2. 2 Compare the differences and similarities between com- munity- and hospital-based nursing. 3. 3 Describe the discharge planning process in relation to home care preparation. 4. 4 Explain methods for identifying community resources and making referrals. 5. 5 Discuss how to prepare for a home health care visit and how to conduct the visit. 6. 6 Identify personal safety precautions a home care nurse should take when making home visits. 7. 7 Describe the various types of nursing functions provided in ambulatory care facilities, in occupational health and school nursing programs, in community nurse managed centers, in hospice care settings, and in facilities that provide services to the homeless.

community-based nursing: nursing care of individuals and families that is designed to (1) promote and maintain health and (2) prevent disease. It is provided as patients transition through the health care system to health- related services outside of the hospital setting primary prevention: health care delivery focused on health promotion and prevention of illness or disease secondary prevention: health care delivery centered on health maintenance and aimed at early detection of dis- ease, with prompt intervention to prevent or minimize loss of function and independence tertiary prevention: health care delivery focused on mini- mizing deterioration associated with disease and improv- ing quality of life through rehabilitation measures

The shift in health care delivery from inpatient to outpatient settings is a result of multiple factors, including new population trends. Changes in fed- eral legislation, tighter insurance regulations, decreasing hospital revenues, and alternative health care delivery sys- tems have also affected the ways in which health care is de- livered. The growing number of older adults in the United States increases the demand for medical, nursing, and social services within the public health system. Hospitals and other health care providers are reimbursed at a fixed rate for patients who have the same diagnosis as defined by diagno- sis-related groups (DRGs). Under this system, hospitals and other health care providers can reduce costs and earn in- come by carefully monitoring the types of services they pro- vide and discharging patients as soon as possible. Conse- quently, patients are being discharged from acute care facilities to their homes or to residential or long-term care facilities in early stages of recovery.

Community-Based Care
Community-based nursing is a philosophy of care in which the care is provided as patients and their families move among various service providers outside of hospitals. This nursing practice

focuses on promoting and maintaining the health of individuals and families, preventing and minimiz- ing the progression of disease, and improving quality of life (Stanhope & Lancaster, 2008). Nurses in community-based practice provide preventive care at three levelsprimary, secondary, and tertiary. Pri- mary prevention focuses on health promotion and preven- tion of illness or disease, including interventions such as teaching about healthy lifestyles. Secondary prevention centers on health maintenance and is aimed at early detec- tion and prompt intervention to prevent or minimize loss of function and independence, including interventions such as health screening and health risk appraisal. Tertiary pre- vention focuses on minimizing deterioration and improving quality of life, including rehabilitation to assist patients in achieving their maximum potential by working through their physical or psychological challenges. Home care nurses often focus on tertiary preventive nursing care, al- though primary and secondary prevention are also ad- dressed.

Home Health Care

Home care nursing is a unique component of community- based nursing.

Ambulatory Settings
Ambulatory health care is provided for patients in commu- nity- or hospital-based settings. The types of agencies that provide such care are medical clinics, ambulatory care units, urgent care centers, cardiac rehabilitation programs, mental health centers, student health centers, community outreach programs, and nursing centers.

Occupational Health Programs

Federal legislation, especially the Occupational Safety and Health Act (OSHA), has been enacted to ensure safe and healthy work conditions. A safe working environment re- sults in decreased employee absenteeism, hospitalization, and disability, as well as reduced costs.

School Health Programs

School health programs provide services to students and may also serve the schools community. School-age children and adolescents with health problems are at major risk for underachieving or failing in school.

Community NurseManaged Centers

Community nursemanaged centers are a relatively new concept in community-based nursing, having appeared only in recent decades.

Care for the Homeless

Homelessness is a growing problem. The homeless popula- tion is heterogeneous and includes members of both dys- functional and intact families, the unemployed, and those who cannot find affordable housing.

assessment: the systematic collection of data to determine the patients health status and any actual or potential health problems collaborative problems: specific pathophysiologic manifestations that nurses monitor to detect onset or changes in status

critical thinking: a process of insightful thinking that utilizes multiple dimensions of ones cognition to develop conclusions, solutions, and alternatives that are appropriate for the given situation deontologic or formalist theory: an ethical theory main- taining that ethical standards or principles exist independently of the ends or consequences ethics: the formal, systematic study of moral beliefs evaluation: determination of the patients responses to the nursing interventions and the extent to which the outcomes have been achieved implementation: actualization or carrying out of the plan of care through nursing interventions moral dilemma: situation in which a clear conflict exists between two or more moral principles or competing moral claims moral distress: conflict that arises within oneself when a person is aware of the correct course of action but insti- tutional constraints stand in the way of pursuing the cor- rect action moral problem: competing moral claim or principle; one claim or principle is clearly dominant moral uncertainty: conflict that arises within a person when he or she cannot accurately define what the moral situation is or what moral principles apply but has a strong feeling that something is not right morality: the adherence to informal personal values nursing diagnoses: actual or potential health problems that can be managed by independent nursing interven- tions nursing process: a deliberate problem-solving approach for meeting peoples health care and nursing needs; common components are assessment, diagnosis, plan- ning, implementation, and evaluation planning: development of goals and outcomes, as well as a plan of care designed to assist the patient in resolving the diagnosed problems and achieving the identified goals and desired outcomes teleologic theory or consequentialism: the theoretical basis of ethics, which focuses on the ends or consequences of actions, such as utilitarianism utilitarianism: a teleologic theory of ethics based on the concept of the greatest good for the greatest number

On completion of this chapter, the learner will be able to: 1. 1 Define the characteristics of critical thinking and critical thinkers. 2. 2 Describe the critical thinking process. 3. 3 Define ethics and nursing ethics. 4. 4 Identify several ethical dilemmas common to the med- ical-surgical area of nursing practice. 5. 5 Specify strategies that can be helpful to nurses in ethical decision making. 6. 6 Describe the components of the nursing process. 7. 7 Develop a plan of nursing care for a patient using strate- gies of critical thinking.

Critical Thinking
Critical thinking is a multidimensional skill, a cognitive or mental process or set of procedures. It involves reasoning and purposeful, systematic, reflective, rational, outcome- directed thinking based on a body of knowledge, as well as examination and analysis of all available information and ideas.

Critical thinking leads to the formulation of conclu- sions and alternatives that are the most appropriate for the situation. Although many definitions of critical thinking have been offered in various disciplines, some consistent themes within those definitions are (1) a strong formal and informal foundation of knowledge; (2) willingness to pursue or ask questions; and (3) ability to develop solutions that are new, even those that do not fit the standard or current state of knowledge or attitudes. Willingness and openness to various viewpoints are inherent in critical thinking, and it is also important to reflect on the current situation (Ban- ning, 2006). Critical thinking includes metacognition, the examination of ones own reasoning or thought processes, to help refine thinking skills. Independent judgments and de- cisions evolve from a sound knowledge base and the ability to synthesize information within the context in which it is presented. Nursing practice in todays society requires the use of high-level critical thinking skills. Critical thinking enhances clinical decision making, helping to identify pa- tient needs and the best nursing actions that will assist pa- tients in meeting those needs.

Components of Critical Thinking

Certain cognitive or mental activities are key components of critical thinking. Critical thinkers: Ask questions to determine why certain develop- ments have occurred and to see whether more infor- mation is needed to understand the situation accurately Gather as much relevant information as possible to consider as many factors as possible Validate the information presented to make sure that it is accurate (not just supposition or opinion), that it makes sense, and that it is based on fact and evidence Analyze the information to determine what it means and to see whether it forms clusters or patterns that point to certain conclusions Draw on past clinical experience and knowledge to explain what is happening and to anticipate what might happen next, acknowledging personal bias and cultural influences Maintain a flexible attitude that allows the facts to guide thinking and take into account all possibilities Consider available options and examine each in terms of its advantages and disadvantages Formulate decisions that reflect creativity and inde- pendent decision making Critical thinking requires going beyond basic problem solving into a realm of inquisitive exploration, looking for all relevant factors that affect the issue, and being an out - of-the-box thinker. It includes questioning all findings un- til a comprehensive picture emerges that explains the phe- nomenon, possible solutions, and creative methods for proceeding (Wilkinson, 2007). Critical thinking in nursing practice results in a comprehensive plan of care with maxi- mized potential for success. ethics and morality are used to describe beliefs about right and wrong and to suggest appropriate guidelines for action. In essence, ethics is the formal, systematic study of moral beliefs, whereas morality is the adherence to infor- mal personal values. Because the distinction between ethics and morality is slight, the two terms are often used inter- changeably.
Autonomy This word is derived from the Greek words autos (self) and nomos (rule or law), and therefore refers to self-rule. In contemporary discourse it has broad meanings, including in- dividual rights, privacy, and choice. Autonomy entails the abil- ity to make a choice free from external constraints. Beneficence Beneficence is the duty to do good and the active promotion of benevolent acts (eg, goodness, kindness, charity). It may also include the injunction not to inflict harm (see nonmalefi- cence). Confidentiality Confidentiality relates to the concept of privacy. Information obtained from an individual will not be disclosed to another unless it will benefit the person or there is a direct threat to the social good. Double Effect This is a principle that may morally justify some actions that produce both good and evil effects. All four of the following criteria must be fulfilled:

1. 2.

3. 4. 5. Fidelity Fidelity is promise keeping; the duty to be faithful to ones commitments. It includes both explicit and implicit promises to another person. Justice From a broad perspective, justice states that like cases should be treated alike. A more restricted version of justice is distributive justice, which refers to the distribution of social benefits and burdens based on various criteria that may include the following: EqualityIndividual need Individual effort Societal contribution Individual merit Legal entitlement Retributive justice is concerned with the distribution of pun- ishment. Nonmaleficence This is the duty not to inflict harm as well as to prevent and remove harm. Nonmaleficence may be included within the principle of beneficence, in which case nonmaleficence would be more binding. Paternalism Paternalism is the intentional limitation of anothers autonomy, justified by an appeal to beneficence or the wel- fare or needs of another. Under this principle, the prevention of evil or harm takes precedence over any potential evil caused by interference with the individuals autonomy or liberty. Respect for Persons Respect for persons is frequently used synonymously with autonomy. However, it goes beyond accepting the notion or attitude that people have autonomous choices, to treat- ing others in such a way that enables them to make choices. Sanctity of Life This is the perspective that life is the highest good. Therefore, all forms of life, including mere biologic existence, should take precedence over external criteria for judging quality of life. Veracity Veracity is the obligation to tell the truth and not to lie or de- ceive others.

The action itself is good or morally neutral. The agent sincerely intends the good and not the evil effect (the evil effect may be foreseen but is not intended). The good effect is not achieved by means of the evil effect. There is proportionate or favorable balance of good over evil.

Confidentiality

All nurses should be aware of the confidential nature of in- formation obtained in daily practice. If information is not pertinent, they should question whether it is prudent to doc- ument it in a patients record. In the practice setting, discus- sion of patients with other members of the health care team is often necessary. However, these discussions should occur in a private area where it is unlikely that the conversation will be overheard. Nurses should also be aware that the use of family members as interpreters for patients who are not fluent in the English language or who are deaf violates pa- tients rights of confidentiality. Translation services should be provided for nonEnglishspeaking patients and inter- preters should be provided for those who use sign language.

American Nurses Association Code of Ethics for Nurses

1. The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by consid- erations of social or economic status, personal attributes, or the nature of health problems. 2. The nurses primary commitment is to the patient, whether an individual, family, group, or community.

3. The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.

4. The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurses obligation to provide optimum patient care.

5. The nurse owes the same duties to self as to others, in- cluding the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth. 6. The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action. 7. The nurse participates in the advancement of the profes- sion through contributions to practice, education, adminis- tration, and knowledge development.

8. The nurse collaborates with other health professionals and the public in promoting community, national, and I nterna- tional efforts to meet health needs. 9. The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.

Assessment: The systematic collection of data to determine the patients health status and
any actual or potential health problems. (Analysis of data is included as part of the assessment. Analysis may also be identified as a separate step of the nursing process.)

Diagnosis: Identification of the following two types of patient problems:

Nursing diagnoses: Actual or potential health problems that can be managed by independent nursing interventions Collaborative problems: Certain physiologic compli-cations that nurses monitor to detectonset or changes in status. Nurses manage collaborative problems using physicianprescribed and nurse-pre- scribed interventions to minimize the complications of the events (Carpenito-Moyet, 2008 pg. 19).

Planning: Development of goals and outcomes, as well as a plan of care designed to assist the
patient in re- solving the diagnosed problems and achieving the identified goals and desired outcomes

Implementation: Actualization of the plan of care through nursing interventions Evaluation: Determination of the patients responses to the nursing interventions and the
extent to which the outcomes have been achieved

ASSESSMENT
1. 2. 3. 4. 5. Conduct the health history. Perform the physical assessment. Interview the patients family or significant others. Study the health record. Organize, analyze, synthesize, and summarize the collected data.

Diagnosis
Nursing Diagnosis 1. 2. 3. 4. Identify the patients nursing problems. Identify the defining characteristics of the nursing problems. Identify the etiology of the nursing problems. State nursing diagnoses concisely and precisely.

Collaborative Problems 1. Identify potential problems or complications that require collaborative interventions. 2. Identify health team members with whom collaboration is essential.