Professional Documents
Culture Documents
Nursing Foundation
Nursing Foundation
Nursing Foundation
B. Sc., (Nursing)
Subject:
NURSING FOUNDATION
NURSING FOUNDATION
S.No
Content
1.
Unit I
- Development of Nursing as a
profession
- Development of nursing education
in India and Trends in Nursing
education.
- Professional organization
- Code of ethics
Unit II
- Ethical and legal aspects of
Nursing
- Concept of health and illness
- Stress and adaptation
- Theory of nursing practice
Unit III
- Nursing process
- Assessment
- Planning
- Implementation and
- Evaluation
Unit IV
- Quality Assurance
- Nursing standard
- Nursing audit
Unit V
- Primary health care concept
- Community oriented nursing
- Holistic Nursing
- Primary nursing
3.
4.
5.
Page
No
NURSING FOUNDATION
COURSE DESCRIPTION
This course will help students develop an understanding of the philosophy, objectives and
responsibilities of nursing as'' a profession. The purpose of the course is to orient to the
current concepts involved in the practice of nursing and developments in the nursing
profession.
OBJECTIVES
At the end of the course, the student will
1. identify professional aspects of nursing.
2. explain theories of nursing.
3. identify ethical aspects of nursing profession.
4. utilize steps of nursing process.
5. identify the role of the nurse in various levels of health services.
6. appreciate the significance of quality assurance in nursing.
7. explain current trends in health and nursing,
COURSE CONTENTS
*Development of nursing as a profession
.-its philosophy
-objectives and responsibilities of a graduate nurse.
UNIT I
NURSING TODAY
OBJECTIVES
Mastery of content in this chapter will enable the student to:
to deliver care artfully with compassion, caring, and a respect for i; each client's
dignity and personhood. As a science, nursing is based upon a body of knowledge
that is always changing with new discoveries and innovations. When nurses
integrate the science and art of nursing into their practice, .the quality of care
provided to clients is at a level of excellence that benefits clients in innumerable
ways.
At the center of a nurse's practice is the client, which includes the individual,
family, and /or community. Clients enter a health care facility with a wide variety of
health care problems, experiences, vulnerabilities, and expectations. But that is what
makes nursing both challenging and rewarding. Making a difference in a client's life can
be very fulfilling: helping a dying client find relief from pain, helping a young child and
her parents learn to adjust to a disability, finding ways for an older adult to remain in the
home to manage his or her own daily care. Nursing offers personal and professional
rewards every day. This chapter presents a contemporary approach to the evolution of
nursing and nursing practice. This approach presents to the reader elements of the
historical, practical, social, and political influences on the discipline of nursing.
The following definition was developed by the American Nurses Association (ANA):
Nursing is the protection, promotion, and optimization of health and abilities, prevention
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).
This definition asserts the prominence and importance nursing holds in providing
health care to people of our global community.
Expert clinical nursing practice is a result of a commitment to the application of
knowledge and clinical experience. The expertise required to interpret clinical situations
and make complex decisions is the essence of nursing care and is the basis for the
advancement of nursing practice and the development of nursing science (Benner, 1984;
Carnevali and Thomas, 1998). Critical thinking skills are essential to nursing (see
Chapter 14). When providing nursing care, the nurse makes clinical judgments about the
5
care needed for clients based on fact, experience, and standards of care (Alfaro-LeFevre,
1995). Knowledge, expertise, and lifelong learning are gained through the continual
process of critical thinking.
Nursing has responded to and always will continue to respond to the needs of its
clients. In times of war, nursing has responded by meeting needs of the wounded in the
combat zones and in military hospitals in the United States and abroad. When
communities face health care crises, such as those that occur from infectious diseases or
a lack of health care resources, nursing is there to establish community-based
immunization and screening pro- grams, treatment clinics, and health promotion
activities.
Our clients are most vulnerable when they are injured, sick, or dying. Historically
nursing has been there and will continue to be there not only to meet the needs of the
client, but also to assist in meeting the needs of the client's friends and families.
Nurses are active in social policy and political. Nurses and their professional
organizations lobby for health care legislation to meet the needs of clients, particularly
the medically underserved. For example, nurses in communities provide home visits to
newborns of high- risk mothers (e.g., adolescent, poorly educated mothers, or medically
underserved). The results of these visits document fewer emergency department visits,
fewer new- born infections, and reduced infant mortality. Changes in health care
legislation allow these services to be paid by public and private insurance. Nurses are
active in local government planning to ensure that health care re- sources are available in
all clients' communities.
Throughout the nursing profession's history, nurses have studied and tested new
and better ways to help their clients, their families, and their communities. Nurses have
been leaders in expanding knowledge in nursing and other health care disciplines through
health care research. Early in nursing history during the Crimean War, Florence
Nightingale studied and implemented methods to improve battlefield sanitation, which
ultimately reduced illness, infection, and mortality. Today nurses are active in
determining the best practices for skin care management, pain control, nutritional
management, and care of older adults, to cite just a few examples.
Florence Nightingale
The founder of modern nursing/ Florence Nightingale, established the first nursing
philosophy based on health maintenance and restoration in Notes on Nursing: What It Is
and What It Is Not (Nightingale/ 1860). Her views on nursing were derived from a
spiritual philosophy/ developed in her adolescence and adulthood (Macrae 1995), and
reflected the changing needs of society. She saw the role of nursing as having 'charge of
somebodys health based on the knowledge of how to put the body in such a state to be
free of disease or to recover from disease" (Nightingale/ 1860). During the same year, she
developed the first organized program for training nurses, the Nightingale Training
School for Nurses at St. Thomas' Hospital in London.
Nightingale was the first practicing nurse epidemiologist (Cohen, 1984). Her
statistical analyses connected poor sanitation with cholera and dysentery. She viewed
nursing as a search for truth in finding answers to health care questions or discovering
and using God's laws of healing in nursing practice (Macrae, 1995). In 1853 Nightingale
went to Paris to study with the Sisters of Charity and was later appointed superintendent
of the English General Hospitals in Turkey. During this period she brought about major
reforms in hygiene, sanitation, and nursing practice and reduced the mortality rate at the
Barracks Hospital in Scutari, Turkey, from 42.7% to 2.2% in 6 months (Woodham Smith, 1983; Donahue, 1996).
1100.1200
Formation of charitable institutions to care for the aged, sick, and poor.
These included the I
Hospital Brothers of St. Anthony's, Brothers of Misericordia (Italy), and
the Alexian Brothers.
11633
1809
i 1836
1846
1860
1860
1860-1865
1874
1882
United States ratified the American Red Cross, founded by Clara Barton.
1884
1890
1893
First community health service for the poor: Henry Street Settlement
opened by Lillian Wald and
Harriet Brewster.
1894
Isabel Hampton Robb, RN, was the first superintendent of the Johns
Hopkins Training School in
Baltimore, Maryland.
1897
1901
1901
1902
Sigma Theta Tau, National Honor Society of Nursing, was formed by six
student nurses from
Indiana University.
1907
1908
1911
1920
1923
1926
1948
Brown Report: Dr. Esther Lucille Brown. concluded that all nursing
education programs should be affiliated with universities and have their
own bud- gets. She recommended a broad academic education within a
university and 2 years of nursing education focused on technical skills.
1949
1952
1953
1960
1965
1969
1975
Oncology Nursing Society formed. NLN required theory-based
curriculum for ac. creditation.
1985
1994
1996
The Pew Report: Looking at future nursing needs and shortages. Institute
of Medicine (IOM) Report. Parallel to the Pew Report.
Of the female nurses of the Union Army, Dix organized hospitals, appointed nurses, and
oversaw and regulated supplies to the troops. Mother Bickerdyke organized ambulance
services, supervised nurses, and walked abandoned battlefields at night, looking for
wounded soldiers. Harriet Tubman was active in the Underground Railroad movement
and assisted in leading over 300 slaves to freedom (Donahue, 1996).
The first African-American professional nurse was Mary Mahoney, RN. She was
concerned with relation- ships between cultures and races, and as a noted nursing leader,
she brought forth an awareness of cultural diversity and respect for the individual,
regardless of back- ground, race, color, or religion.
Isabel Hampton Robb, a graduate of St. Catherine's in Ontario, was the first
superintendent of the Johns Hopkins Training School in Baltimore, Maryland, in 1894.
As one of her many contributions to nursing, she helped found the Nurses' Associated
Alumnae of the United States and Canada in 1896. This organization became the
American Nurses Association (ANA) in 1911. She authored many nursing textbooks,
including Nursing: Its Principles and Practice for Hospital and Private Use (1894),
Nursing Ethics (1900), and Educational Standards for Nurses (1907), and was one of the
original founders of the American Journal of Nursing (AJN) (Donahue, 1996). Today, the
AJN continues to present current insights into nursing practice and professional issues.
Nursing in hospitals expanded in the late nineteenth century. However, nursing in
the community did not increase significantly until 1893, when Lillian Wald and Mary
Brewster opened the Henry Street Settlement, which focused on the health needs of poor
people who lived in tenements in New York City (Donahue, 1996). Nurses working in
this settlement were some of the first to demonstrate autonomy in practice because they
frequently encountered situations that required quick and innovative problem solving and
critical thinking without the supervision or direction of a physician. The poor people also
needed nursing therapies aimed at maintaining wellness through proper nutrition,
10
hygiene, and shelter. Wald described her activities with the Henry Street Settlement in the
textbooks The House on Henry Street (1915) and Windows on Henry Street (1934).
Twentieth Century
In the early twentieth century a movement toward a scientific, research-based
defined body of nursing knowledge and practice was evolving. Nurses began to assume
expanded and advanced practice roles. Mary Adelaide Nutting, a member of the first
graduating class at Johns Hopkins Hospital and successor to Isabel Hampton Robb as
superintendent of the Johns Hopkins Training School, was instrumental in the affiliation
of nursing education with universities. She became the first professor of nursing at
Columbia University Teachers College in 1907 (Donahue, 1996). In addition, a landmark
report, the Goldmark Report, concluded that nursing education needed increased financial
support and suggested that the money be given to university schools of nursing.
As nursing education developed, nursing practice also expanded. In 1901 the
Army Nurse Corps was established, followed in 1908 by the Navy Nurse Corps. By the
1920s nursing specialization was developing. Graduate nurse-midwifery programs were
initiated, and in the late 1940s and early 1950s specialty nursing organizations, such as
the Association of Operating Room Nurses, American Association of Critical Care
Nurses, and Oncology Nursing Society, were formed.
Twenty-first Century
Nursing practice and education must continue to evolve to meet the needs of society. In
1990 the American Nurses Association established the Center for Ethics and Human
rights. The Center provides a forum to address the complex ethical and human rights
issues confronting nurses and designs activities and programs to increase ethical
competence in nurses (ANA, 2001). Nursing code of ethics was revised in 2001 to reflect
current ethical issues affecting health care and nursing practice.
Today the profession is faced with multiple challenges. Nurses and nurse
educators are revising nursing practice and school curricula to meet the ever-changing
needs of society, including bioterrorism, emerging infections, and disaster management.
Advances in technology, the rising acuity of hospitalized clients, and early discharge
from health care institutions require nurses in all settings to have a strong and current
knowledge base from which to practice. In addition, nursing along with the Robert Wood
Johnson Foundation, through the Last Acts Campaign, is taking a leadership role in
11
developing standards and policies for end-of-life care. The End-of-Life Nursing
Education Consortium (ELNEC) offered collaboratively by the American Association of
Colleges of Nursing (AACN) and the City of Hope Medical Center has brought end-oflife care and practices into the nursing curricula (ANA, 2002d).
Nursing practice can now be found in multiple care settings, including health care
institutions and foundations, the community, and the home. In addition, nurses are active
in political and lobbying groups, social and not-for-profit agencies, and work on
establishing social health care policies. These' activities increase nursing 's public
viability and, at the same time, increase the public's awareness of professional nursing.
The challenge now is to prepare professional nurses to deliver complex, multifaceted care
in the client's home.
SOCIETAL INFLUENCES ON NURSING
There are many external forces that affect nursing. These include demographic changes
of the population, human rights, increasing numbers of medically underserved,. and the
threat of bioterrorism.
Demographic Changes
Demographic changes affect the population as a whole. Changes that have influenced
health care in recent decades include the population shift from rural areas to urban
centers; the increasing life span; the higher incidence of chronic, long-term illness; and
the increased incidence of diseases such as alcoholism and lung cancer. Nursing as a
profession responds to such changes by exploring new methods for providing care, by
changing educational emphases, and by establishing practice standards in new areas.
Women's Health Care Issues
The women's movement has brought about many changes in society as women have
increasingly sought economic, political, occupational, and educational equality. As a
result, there is greater sensitivity to the health care needs of women and the role of
women in health care research. There are and continue to be emerging health care
specialties dealing with the needs of women.
These new specialties expand on the traditional obstetrical specialty. These new
specialties address issues ranging from well women's examinations, to ontological sub
specialties, and management of menopause. In addition, health care researchers
acknowledge the prior lack of female subjects in biomedical research, and now the
12
federal government mandates that women must be routinely included in research, unless
specific exception criteria are met. For example, research focusing on management of
prostatic cancer is such an exception.
Nursing is responding in two ways to women's health care issues and the women's
movement. Because most nurses are "women, they are increasingly asserting their equal
rights as human beings, employees, and health care professionals. The women's
movement has encouraged nurses to seek greater autonomy and responsibility in
providing care. The women's movement has caused female clients to seek more
responsibility for and control for their bodies, health, and lives in general. As women
become more aware of their own unique needs and qualities, they seek health care that
can help them meet those needs and reach their full potential.
Human Rights Movement
The human rights movement is changing the way society views the rights of all of its
members, including minorities, clients with terminal illness, pregnant women, and older
adults. Many groups have special health care needs, and nursing has responded by
respecting all clients as individuals with a right to quality care and by supporting basic
human rights. Nurses advocate the rights of all clients, but they have also recognized the
special needs of some groups and thus have created bills of rights for dying, hospitalized,
and pregnant clients, as well as other groups, to ensure that quality care is provided
without sacrificing these rights.
Medically Underserved
The rising rates of unemployment, homelessness, and health care costs all contribute to
an increase in the medically underserved population. The medically under- served
population may be poor and on Medicaid or may be part of the working poor in that they
cannot afford their own insurance but make too much money to qualify for Medicaid. In
addition, there is an increase in the mentally ill population who have little or no access to
health care. Nurses work in many rural, neighborhood, and community-based settings
providing health promotion and disease management (Masson, 2001). Frequently these
nurses have advanced preparation and function as advanced practice nurses, giving them
the capability to provide direct health care. This area of nursing is rapidly expanding as
more nurses are seeking to work with this population in need.
Threat of Bioterrorism
13
The world is a changing place; the treats of bioterrorism are no longer fictitious. Many
health care agencies and communities have educational programs for nurses to prepare
them in the event of nuclear, chemical, or biological attack. Nurses are active in disaster
preparedness. For example, nurses work in conjunction with community disaster
preparedness groups and hospitals to determine what specific nursing activities are
needed before the disaster. This activity may range from participating in vaccine research,
decontamination in the event of biological attack, triage for mass casualty, to crisis
response units. It should also be remembered that if a disaster were to occur nurses would
also be essential in evaluating the strengths and weaknesses of any disaster plan that was
implemented.
programs in the community such as health fairs and wellness programs; educational
programs for specific diseases; and client and family teaching activities in hospitals,
clinics, primary care facilities, and other health care settings. Health promotion activities
are an important part of the role of a nurse.
Influence of Today's Health Care Delivery System
Today's health care delivery system is a complex and highly regulated system. Nurses
working in the system must be aware of their roles in containing health care costs,
providing the best evidenced-based practice, and participating in nursing and biomedical
research. In addition, today's health care system is further challenged by the nursing
shortage.
Rising Health Care Costs
Skyrocketing health care costs present challenges to the nursing profession, consumer,
and the health care delivery system as well. Nursing responsibility is to provide the
consumer with the best-quality care in an efficient and economically sound manner.
Nurses are challenged to use health care and client resources wisely. For example, clients
may be taught to perform procedures in the home with clean versus sterile equipment.
This does not compromise care because clients are in their home environments, which are
cleaner, and without the risks of nosocomial infections. However, nurses heed to
clinically evaluate each client to determine which clients can perform procedures safely
using clean technique. Nurses also playa role in managing health care costs by
participating in product evaluation. Most health care institutions invite nurses to
participate in product re- view committees to select the most clinically effective,
reasonable-cost items for clinical use.
Evidenced-Based Practice
Consumers of health care are more informed than ever, and with the Internet consumers
have access to more health care and treatment information. As a result consumers expect
and should receive the most current effective, state-of-the-art care in a rapidly changing
health care system. As providers of health care, nurses are faced with the challenge of
providing safe, effective care. One way to achieve this goal is to provide evidence-based
practice. Evidence-based practice is defined as "the integration of best research evidence
with clinical expertise and patient values" (Sackett and others, 2000). Evidence- based
15
nursing practice involves accurate and thoughtful decision making about health care
delivery for clients.
Nursing and Biomedical Research
Nursing knowledge, scientific knowledge, and research findings have rapidly expanded
over the last few years. Nurses share a "commitment to the advancement of nursing
science and the ethical conduct of nursing science" (ANA, 1997). The scientific
knowledge base for professional practice is developed through scholarly inquiry of
nursing and biomedical research literature, utilization of research findings, and
conducting research. Through nursing research, nurses base their care on scientific
sfindings, rather than tradition. The beneficiary of this care is the client. Through
research, nursing practice changes to provide the highest-quality state- of-the-art nursing
care.
Nursing Shortage
Although there is much in the professional and public media about the nursing shortage,
this shortage also represents challenges and opportunities for the profession. Vast health
care dollars are being invested in strategies aimed at recruiting a well-educated, critically
thinking, motivated, and dedicated nursing work force (Boychuk, 2001). Research
documents the direct link between nursing care and positive client outcomes, reduced
complication rate, and a more rapid return of the client to the pre illness state (Roming
2001; Blendon and others, 2002; Consumer Reports, 2003).
Like it or not, the nursing shortage affects the needs of the consumer (Roming, 2001;
Consumer Reports, 2003). With fewer nurses in the workplace, nurses must use their
client contact time efficiently and professionally. Time management, therapeutic
communication, client education, and compassionate implementation of psychomotor
skills are just a few of the essential skills needed for the provision of quality nursing care.
For example, using a well-organized approach to prepare a client to self- administer
blood pressure medication at home results in a scenario in which the client adheres to
medication, blood pressure remains within the target range, and most importantly the
client leaves the health care setting with a positive image of nursing and a feeling that
quality care was provided. The client should never feel rushed or that he or she was one
of many clients or tasks for the nurse. If a certain aspect of client care requires 15 minutes
of contact, it will take the same time to deliver the care in an organized manner as it
would in a rushed, harried manner. However, the impression left with the client will be
16
far different. As nurses we all have the opportunities and obligation to present our
profession and practice in the best possible manner.
Nursing as a profession
Nursing is not simply a collection of specific skills, and the nurse is not simply a person
trained to perform specific tasks. Nursing is a profession. No one factor absolutely
differentiates a job from a profession, but the difference is important in terms of how
nurses practice. When we say a person acts "professionally," for example, we imply that
the person is conscientious in actions, knowledgeable in the subject, and responsible to
self and others. Professions possess the following primary characteristics:
*
.*
.*
The practice of professional nursing and nursing knowledge has been developed over
time through development of nursing theories and research. Theoretical models serve as
frameworks for nursing curricula and clinical practice. Nursing research in- creases the
scientific basis of nursing practice through the systematic inquiry into health care
problems and issues.
Standards of Professional Performance
The ANA Standards of Professional Performance describes a competent level of behavior
in the professional role, including activities related to quality of care,
Quality of
practice.
The registered
nurse sys- of
practice
systematically
enhances the
quality and
effectiveness
of nursing
17
18
Education
Professional
practice
evaluation
The registered
nurse
interacts with
and contributes to the
professional
development
of
peers and
colleagues.
Participate
nurse's
signature
Outcomes,"
"Nursing
20
communicate your
of standard medical
abbreviations.
4. Be specific. Because nurses are now working
shifts of different lengths, some working l2-hour
shifts, and some working 8-hour shifts, it is even
more important to be specific about expected
timing of an intervention. If the order reads
"change incisional dressing shift," it could mean
either twice in 24 hours, or three times in 24 hours,
de-
pending
on
the
shift
time.
This
21
The registered
nurse
collaborates
with patient,
family, and
22
others in
the conduct of
nursing
practice
XII: Ethics
23
XIII: Research
The registered
nurse
integrates
research
findings into
practice
24
utilization
25
safety,
registered nurse:
effectiveness,
cost, and
impact on
plans of care.
practice in the
planning and
delivery of
nursing
services
nurse pro-
vides
builder.
leadership in
the
professional
international communities.
practice set-
profession.
measure progress.
Demonstrates a commitment to continuous,
lifelong learning for self and others.
26
comprehensive
pertinent
to
situation.
28
The registered nurse Additional Measurement Criteria for the Advanced Practice
analyzes
the Registered Nurse: The advanced practice registered nurse:
assessment
data
determine
diagnoses or issues.
examination,
and
diagnostic
procedures
in
identifying diagnoses.
Assists staff in developing and maintaining competency in the
diagnostic process.
29
3: Outcomes
Identification
diagnoses.
The registered nurse Considers associated risks, benefits, costs, current scientific
identifies
expected evidence, and clinical expertise when formulating expected
outcomes for a plan outcomes.
individualized to the
patient
situation.
or
the
of-expected
outcomes.
Develops
expected
patient
satisfaction,
and
continuity
and
an
individualized
plan
considering
patient
in
the
design
and
development
of
outcomes
are
not
achieved.
---
Additional
32
33
nursing
specialist
consultation
influence
identified
Prescriptive Authority
and Treatment
evidence-based
treatments,
therapies,
and
34
ongoing,
and
criterion-based
35
Nursing Education:
As a profession, nursing requires that its members possess. A significant amount of
education. The issue of standardization of nursing education and entry into practice remains a major controversy. In 1965 the ANA published a position paper on nursing
education that emphasizes the role of education in the profession. Most nurses agree that
nursing education is important to practice and that it must respond to changes in health
care created by scientific and technological advances. There are various education
preparations for the registered nurse. In addition, there is graduate nurse education and
continuing and in-service education for the practicing nurse.
Professional Registered Nurse Education:
36
There are various educational routes for becoming a professional registered nurse (RN).
Initially, hospital schools of nursing were developed to educate nurses to work within
those institutions. As nursing increasingly defined its own body of knowledge, formalized
educational processes developed to ensure a consistent level of education in institutions.
Such consistency was also necessary for RN licensure.
Currently in the United States the most frequent route an individual can choose to
become an RN is through completion of an associated degree or baccalaureate degree
program. Graduates of both programs are eligible to take the National Council Licensure
Examination for Registered Nurses (NCLEX-RN) to become registered nurses in the
state in which they will practice.
The associate degree program in the United States is a 2-year program that is usually
offered by a university or junior college. This program focuses on the basic sciences and
theoretical and clinical courses related to the practice of nursing. Graduates of this type of
program take the state board examination for RN licensure.
The baccalaureate degree program usually encompasses 4 years of study in a college or
university. The program focuses on the basic sciences and on theoretical and clinical
courses, as well as courses in the social sciences, arts, and humanities to support nursing
theory. In Canada the degree of Bachelor of Science in Nursing BSc (N) or Bachelor in
Nursing (BN) is equivalent to the degree of Bachelor of Science in Nursing (BSN) in the
United States. The AACN published the Essentials of Baccalaureate Education for
Professional Nursing: A Final Report (1998). This document delineated essential
knowledge, practice and values, attitudes, personal qualities, and professional behavior
for the baccalaureate-prepared nurse and guides faculty on the structure and evaluation of
the curriculum and the performance of the graduate (American Association of Colleges of
Nursing, 1998).
Nursing is a helping profession and, as
such, provides services which contribute to
the health and well-being of people.
Nursing is of vital consequence to the
individual receiving ser- vices; it fills needs
which cannot be met by the person, by the
family, or by other persons in the
37
community.
The demand for services of nurses will
continue to increase. The professional
practitioner is responsible for the nature
and quality of all nursing care that clients
licensed.
Graduate Education:
Master's Education. After obtaining a baccalaureate degree in nursing, a nurse can pursue
further education in any number of graduate fields, including nursing. A nurse completing
a graduate program can receive the degree of Master of Arts (MA) in nursing, Master in
Nursing (MN), or Master of Science in Nursing (MSN). The graduate degree provides the
advanced clinician with strong skills in nursing science and theory with emphasis in the
basic sciences and research-based clinical practice. A master's degree in nursing can be
valuable for nurses seeking roles of nurse educator, clinical nurse specialist, nurse
administrator, or nurse practitioner.
Doctoral Preparation: Professional doctoral programs in nursing (DSN or DNS c)
emphasize the application of re- search findings to clinical nursing. Other programs
emphasize more basic research and theory and award the degree of Doctor of Philosophy
(PhD) in nursing. The need for nurses with doctorate degrees is rising. Expanding clinical
roles, new areas of nursing such as nursing informatics, and rapidly advancing
technology are just a few reasons for increasing the number of doctorally prepared
nurses. It is important to continue to do research in areas such as nursing theory" basic
science and clinical practice to expand nursing knowledge. Doctorally prepared nurses
are needed to educate the beginning nurse and those seeking advanced academic and
clinical preparation.
38
Nursing practice defined nursing as the diagnosis and treatment f human responses to
actual or potential health problems (ANA, 1980, 1995). This definition illustrates the
consistent orientation of nurses to the provision of care) promote the well-being of their
clients. Today the nursing profession remains committed to the care and nurturing of both
healthy and ill people, individually or 1 groups and communities (ANA, 1995).
Nurse Practice Acts : all states in the United States, Nurse Practice Acts regulate the
licensure and practice of nursing. Each state or province defines for itself the scope of
nursing practice, But most have similar practice acts. The definition of nursing practice
published by the ANA is in some ways representative of the scope of nursing practice as
defined 1 most states. In the last decade, however, many states have revised their Nurse
Practice Acts to reflect nursing's growing autonomy and the expanded roles of nurses in
practice.
Licensure and Certification: censure. In the United States, RN candidates must pass Ie
NCLEX.RN, which is administered by the individual state Boards of Nursing. Regardless
of educational preparation, the examination for RN licensure is exactly the same in every
state in the United States. This provides a standardized minimum knowledge base for the
client population nurses serve.
Certification. Beyond the NCLEX-RN, the nurse may choose to work toward
certification in a specific area of nursing practice. Minimum practice requirements are
set, based on the certification the nurse is seeking. National nursing organizations, such
as the ANA, have many types f certification that the nurse can work toward. After passing
the initial examination, the nurse maintains certification by ongoing continuing education
and clinical or administrative practice.
Science and Art of Nursing Practice: Nursing is a multidimensional profession.
Nursing reflects the needs and values of society, implements the standards of professional
performance and the standards of care, meets the needs of each client, and integrates current research and evidence-based findings to provide the highest level of care. Although
nursing has a specific body of knowledge, socialization into the profession and practice
are essentials components of the discipline. Clinical expertise takes time and
commitment. According to Benner (1984), an expert nurse passes through five levels of
proficiency when acquiring and developing generalist or specialized nursing skills.
40
Nurses use the competencies of critical thinking to integrate information from the
scientific and nursing knowledge bases, derive knowledge from past and present
experiences, apply critical thinking attitudes to a clinical situation, and implement
intellectual and professional standards. Providing well thought out care with the
compassion and caring attributes of the profession enables nurses to provide eacl1 client
the best of the science and art of nursing care.
Novice: Beginning nursing student, or any nurse entering a situation in which there is no
previous level of experience, for example, an experienced operating room nurse chooses
to now practice in home health. The learner learns via a specific set of rules or
procedures, which are usually stepwise and linear.
Advanced Beginner-A nurse who has had some level of experience with the situation.
This experience may only be observational in nature. But the nurse is able to identify
meaningful aspects or principles of nursing care.
Competent-A nurse who has been in the same clinical position for 2-3 years. This nurse
understands the organization and the specific care required by the type of clients, e.g.,
surgical, oncology, or orthopedic clients. This nurse is a competent practitioner who is
able to anticipate nursing care and establish long-range goals. In this phase, the nurse has
usually had experience with all types of psychomotor skills required by this specific
group of clients.
Proficient-A nurse with greater than 2-3 years of experience in the same clinical position.
This nurse perceives a client's clinical situation as a whole, is able to assess an en- tire
situation, and can readily transfer knowledge gained from multiple previous experiences
to a situation. This nurse focuses on managing care as opposed to managing and
performing skills.
Expert-A nurse with diverse experience who has an intuitive grasp of an existing or
potential clinical problem. This nurse is able to zero in on the problem and focus on
multiple dimensions of the situation. This nurse is skilled at identifying client-centered
problems, as well as problems related to the health care system or perhaps the needs of
the novice nurse.
Professional Responsibilities and Roles: Contemporary nursing requires that the nurse
possess knowledge and skills for a variety of professional roles and responsibilities. In
the past, the principal role of nurses was to provide care and comfort as they carried out
41
specific nursing functions. However, changes in nursing have expanded the role to
include increased emphasis on health promotion and illness prevention, as well as
concern for the client as a whole.
Autonomy and Accountability: Autonomy is an essential element of professional
nursing. Autonomy means that a person is reasonably independent and self-governing in
decision making and practice. In the case of nursing, there are independent nursing
measures a nurse can initiate without medical orders. A professional nurse also actively
collaborates with health professionals to pursue the best treatment plan for a client.
Nurses attain increased autonomy through higher levels of education. In the changing
health care system, advanced practice nurses are increasingly taking on independent roles
in nurse-run clinics, collaborative practice, and advanced nurse practice settings.
With increased autonomy come greater responsibility and accountability. Accountability
means that the nurse is responsible, professionally and legally, for the type and quality of
nursing care provided. The nurse is account- able for keeping current and competent in
technical skills and informed of the knowledge needed to perform nursing care. The
nursing profession itself regulates accountability through nursing audits and standards of
practice.
Caregiver: As caregiver, the nurse helps the client regain health through the healing
process. Healing is more than just curing a specific disease, although treatment skills that
promote physical healing are important to caregivers. The nurse addresses the holistic
health care needs of the client, including measures to restore emotional, spiritual, and
social well-being. The caregiver helps the client and families set goals and meet those
goals with a minimal cost of time and energy.
Advocate: In the role of client advocate, the nurse protects the client's human and legal
rights and provides assistance in asserting those rights if the need arises. The nurse
advocates for the client, keeping in mind the client's religion and culture. For example,
the nurse may provide additional information for a client who is trying to decide whether
or not to accept a treatment, or the nurse may assist with communication within the
family. The nurse may also defend clients' rights in a general way by speaking out against
policies or actions that might endanger their well-being or conflict with their rights.
42
Educator: As an educator, the nurse explains to clients concepts and facts about health,
demonstrates procedures such as self- care activities, determines that the client fully
under- stands, reinforces learning or client behavior, and evaluates the client's progress in
learning. Some client teaching can be unplanned and informal, such as when a nurse
responds to a question about a health issue in casual conversation. Other teaching
activities may be planned and more formal, such as when the nurse teachers client with
diabetes to self-administer insulin injections. The nurse uses teaching methods that match
the client's capabilities and needs and incorporates other resources, such as the family, in
teaching plans.
Communicator: The role of communicator is central to all nursing roles and activities.
Nursing involves communication with clients and families, other nurses and health care
professionals, resource persons, and the community. Without clear communication, it is
impossible to give care effectively, make decisions with clients and families, protect
clients from threats to well-being, coordinate and man. age client care, assist the client in
rehabilitation, offer comfort, or teach. The quality of communication is a critical factor in
meeting the needs of individuals, families, and communities.
Manager: As a manager, the nurse coordinates the activities of other members of the
health care team, such as nutritionists and physical therapists, when managing care for a
group of clients. To effectively manage a single client or group of clients the nurse
implements solid clinical decision- making skills. As a clinical decision maker, the nurse
uses critical thinking skills throughout the nursing process to provide effective care.
Before undertaking any nursing action, whether it is assessing the client's condition,
giving care, or evaluating the results of care, the nurse plans action by deciding the best
approach for each . The nurse makes these decisions alone or in collaboration with the
client and in each of these situations, the nurse collaborates and consults with other
health care professionals (Keeling and Ramos, 1995).
Career Development: Innovations in health care, expanding health care systems and
practice settings, and the increasing needs of clients have been a stimulus for hew nursing
roles. Today nurses need to commit to lifelong learning and career development in order
to provide clients with the state-of- the-art care they need.
43
95.7%
Female
4.3%
Male
Race
90% 4%
White/Caucasian
3.4%
44
African-American
1.4%
Asian/pacific Islanders
0.4%
Hispanics
American Indian/Alaska Natives
Age
<30 years
30-49 years
11% >
60%
<15%
Education
59%
Diploma program
Associate degree Bachelor's degree
31%
Master's degree
7.5%
Doctorate
0.5%
Site of Employment
Hospitals
46
The geriatric nurse practitioner (GNP) is an ANP with specialization in care of the
older adult. GNPs are trained in the special needs of the aging adult, with emphasis on
health promotion, health maintenance, and functional status. The GNP works with the
client and family to manage existing health problems so as to pro- mote independence
and self-care. The client population is usually age 65 and older.
Certified Nurse-Midwife
A certified nurse-midwife is an RN who is also educated in midwifery and is certified
by the American College of Nurse-Midwives. The practice of nurse-midwifery involves
providing independent care for women during normal pregnancy, labor, and delivery, as
well as care for the newborn. It may include some gynecological services such as routine
Papanicolaou (pap) smears, family planning, and treatment for minor vaginal infections.
A CNM practices with a health care agency that provides medical consultation,
collaborative management, and referral)
Certified Registered Nurse Anesthetist:
47
competency, safety training, and instruction about new equipment or procedures. These
nursing educators often participate in the development of nursing policies and
procedures.
The primary focus of the nurse educator in an agency's apartment of client education is to
teach ill or disabled clients and their families how to provide care in the home. These
nurse educators may be specialized and certified, such as a certified diabetic educator
(CDE) or an os- )my care nurse, and see only a discrete population of clients, In most
health care agencies, however, the budget does not permit a separate client education
department therefore the responsibility usually falls to the staff nurse
plan and provide client and family education.
Nursing Administrator: A nurse administrator manages client care and the delivery of
specific nursing services within a health care agency. Nursing administration begins with
positions such as the charge nurse or assistant nurse manager. Experience and additional
education may d to a middle-management position, such as nurse manager of a specific
patient care area(s) or house super- or, or to an upper management position, such as assist
or associate director or director of nursing services. Nurse manager's positions usually
require at least a baccalaureate degree in nursing, and director and nurse executive
positions generally require a master's degree. Chief nurse executive and vice president
positions in large health care organizations often require preparation at the doctorate
level. Nurses may have advanced degrees such a master's degree in business
administration (MBA), hospital administration (MHA), or public health (MPH).
In today's health care organizations, directors may have responsibility for more than
nursing personnel responsibilities may include a particular service or product line, such
as medicine or cardiology, and include supportive functions and personnel such as
medicine clinics, cardiac diagnostics, or outpatient services such as cardiac the
catheterization. In addition, the director may be responsible for ancillary personnel such
as cardiology technicians, respiratory therapists, social workers, and dietitians.
Vice presidents of nursing or chief nurse executives of have responsibilities for all
clinical functions within the hospital. This may include all ancillary personnel who
provide and support patient care services. The nursing administrator needs to be skilled in
business and management, as well as understand all aspects of nursing d client care.
48
49
Some professional organizations focus on specific areas such as critical care, nursing
administration or research, or nurse-midwifery. These organizations seek to improve the
standards of practice, expand nursing roles, and foster the welfare of nurses within the
specialty areas. In addition, professional organizations present education programs and
publish journals.
Future Trends in Nursing: This chapter has emphasized that nursing is not a static,
unchanging profession but is continuously growing and evolving as society changes, as
health care emphases and methods change, as lifestyles change-and as nurses themselves
change. To speak of nursing at all is to speak of nursing as it is at a given time, and in this
sense, this chapter is about trends in nursing.
The current philosophies and definitions of nursing demonstrate the holistic trend in
nursing-to address the whole person in all dimensions, in health and illness, and in
interaction with the family and community. Nursing continues to draw on the social
sciences and other fields as the focus of nursing care expands.
Expansion of Employment Opportunities: Nursing practice trends include a growing
variety of employment settings in which nurses have greater independence, autonomy,
and respect as members of the health care team. Nursing roles continue to expand and
develop, broadening the focus of nursing care and providing a more holistic and allencompassing domain. Nursing therapies are not only drawing from traditional nursing
and medicine, spiritual, and emotional realms, but also expanding into alternative
therapies such as healing touch, massage therapy, and use of natural herbs and vitamins:
Nursing's Public Perception: Any member of society who has been ill, hospitalized, or
visited an emergency department has experienced nursing care; as an ANA campaign
noted, "Everybody needs a Nurse." The Johnson and Johnson Foundation has developed
a compelling, attention-getting media campaign on the nursing profession. These media
clips show nursing practice, and the nurses featured in the advertisements describe their
satisfaction with the profession.
Nursing is a pivotal health care profession; as frontline health care providers, nurses
practice in all health care settings and constitute the largest number of professionals.
50
Nurses are essential to provide skilled, specialized, knowledgeable care; to improve the
health status of the public; and to ensure safe, effective quality care (ANA, 2002c). In
addition, the American public rated nurses high in honesty and ethics in their professional
role.
Nursing's Impact on Politics and Health Policy:
The ability to influence or persuade an individual holding a government office to exert
the power of that office to affect a desired outcome is known as political power or
influence. Nurses' involvement in politics is receiving greater emphasis in nursing
curricula, professional organizations, and health care settings. Professional nursing
organizations have employed lobbyists to urge state legislatures and the U.S. Congress to
improve the quality of health care.
The ANA works for the improvement of health standards and the availability of health
care services for all people, fosters high standards of nursing, stimulates and promotes the
professional development of nurses, and advances their economic and general welfare.
The purposes are unrestricted by considerations of nationality, race, creed, lifestyle, color,
sex, or age. The ANA employs RNs as lobbyists at the federal level, and state nursing
organizations also hire lobbyists and legislative specialists to work on state nursing issues
and assist with federal efforts. Finally, lobbyists working on behalf of nursing are
employed in Washington, D.C., by professional organizations such as the American
Federation of Teachers,
51
needs, and generous contributors of time and money to nursing and their organizations
and to candidates working for universal good health care, then the future is bright indeed.
Nurses are becoming more involved in health care reform. Nursing's Agenda for Health
Care Reform supports the creation of a health care system that ensures access, quality,
and services at affordable costs. The plan for reform focuses on primary health care
services and the pro- motion, restoration, and maintenance of health. Healthy People
2010 (USDHHS, 2002) is a document for public health policy for the new millennium
(see Chapter 6). It outlines goals for vulnerable populations, such as low-income groups,
minorities, and persons With disabilities (Lancaster, 1999).
Political activism and commitment are a part of professionalism, however, and politics
are an important aspect of the delivery of health care. Therefore nurses should view
politics as a reality that includes the arts of influence, compromise, and social interaction.
Nurses have been involved in a different sort of politics in schools of nursing and in
health care settings when seeking additional resources, more self-direction, and
accountability with authority. The skills gained in such experiences can be transferred to
the politics of health care policy making.
As long as nurses maintain involvement in health care policy and practice, misinformed
outsiders cannot attempt to impose their Will on nursing and nursing practice. Non
nursing groups, often led by other health care providers, have made attempts to impose
institutional licensure, mandatory continuing education, curtailment of advanced nursing
practice, and other constraints on the nursing profession. Nursing should have its own
voice in decisions made in these and numerous other areas affecting the practice and
quality of nursing care. Although nurses have often successfully prevented infringement
on the profession's self-governance, the future of nursing requires that nurses individually
and collectively seek a greater influence on health care polices affecting nursing practice.
Historical Development of Nursing Education in India:
In 1871, training for midwives were given for a period of six' months with
supervised nursing practice.
In 1918, first Lady Health Visitors course was started in Lady Reading
52
Later diploma in General Nursing and Midwifery course was started with 3
years 9 months and later it was condensed to 3 years duration.
In 1959, the first master's programme in nursing was started at RAK College
of Nursing, New Delhi.
MSc (N) with any speciality (after BSc nursing with 2 years of experience and 2
years duration).
PhD. in nursing (after MSc nursing 3 yearsduration-regular; after M Phil nursing2 years duration).
53
enjoined the care of the sick and the helpless. Charaka and Susruta leading
authorities on the ancient Hindus system of Ayurveda (the science of life) though
lived in the Christian era, they were not influenced by the Christianity. The
following reference is found regarding the nurse in Charaka. Samhita:
Nurse: Knowledge of the manner in which drugs should be prepared and
compounded for administration, cleverness, devotedness to the. patient waited upon,
and purity (both of mind and body) are the four qualifications of the attending nurse.
Subsequently, monastic' orders further emphasized knowledge based health and nursing
care. Nuns, monks had to acquire special knowledge and skills before being assigned to
take care of the sick. The renounced Roman Matrons, Fabiola, Marceba and Paula stand
out as early intellectuals associated with organisation of hospitals and nursing. Later, the
many Christian religious orders emphasized the special knowledge needed by caregivers.
Modern Scientific Nursing: Nightingale's
Model of Nursing Education
Florence Nightingale emphasized on cognitive knowledge and skills (1909).
Preparation of nurses in Florence Nightingale's school of nursing at St. Thomas
hospital included a years training with instruction by the Matron, the ward sister and
the physician before assignment for 2-year hospital apprenticeship experience, during
which students were granted stipends. These students were called 'ordinary
probationers'. Those who did not receive stipend, but paid tuition for the first year
were educated for higher positions and were called 'lady nurses'. Nightingale model of
nursing education, the hospital based diploma school appears to have been the first
model in almost all countries.
.
The most conspicuous and widespread modification of the Nightingale system had
occurred, in the United States and Canada and this is referred to as 'American system' or
professional model in contrast to the British or Nightingale's apprenticeship model. A
span of 60 odd years since nursing schools were first established in US divides itself into
three periods of about 20 years each.
.
1. A pioneering period: 1873.1898
The immediate problem was not to build a finished educational structure but to clear the
ground, to provide decent conditions for both patients and nurses, and to lay the
54
1940s-1960s: This period is considered as basic science era. Brown (1948) a social
anthropologist, reassessed nursing education at the request of national nursing council
for war service, supported Winslow-Gold Mark report stressing on inadequacies in
nursing education and stated that within 50 years, the education of nurses should
occur in collegiate settings.
Indian Nursing Council:
The Indian Nursing Council was established under an Act of Parlian1ent, known as the
Indian Nursing Council Act, 1947 following a recommendation made by the Shore
Committee in 1946. The Act was subsequently amended in 1950 and 1957.
The Indian Nursing Council was constituted in 1949. Section 3(1) of the Indian
Nursing Council Act describes the constitution and composition of the council.
55
There are 25 elected members through different registration councils and institutions, 26 ex-offices members including superintendent of nursing service and
Directors of Health Services of various states, 4 nominated members of the
Government of India and 3 elected members of Parliament, making a total of 55
members. The 55 members include 31 nurses, 19 doctors and 5 others. The
President and Vice-Presidents are elected by the Council. Secretary is usually the
nursing adviser of the Directorate General of Health Services.
The Executive Committe consists of 7 elected members of the council. The
President and Vice-President are ex-officio men1bers. The official address of the
Indian Nursing Council is: Indian Nursing Council, Combined Councils Building,
Temple Lane, Kotla Road, New Delhi. The council meets once a year, and the
executive more frequently.
The functions of the council are:
1. Prescribing minimum syllable for the training of nurses,
56
under take responsibility to exert general supervision over the performance of the nurses
within their jurisdiction. This includes checking substandard nursing service, negligence
of duty and unethical behaviour of registered nurses. State councils act in close cooperation with the State Governments.
57
d. To elevate nursing education and to raise the standard of I training. e. To strive to bring
about a more uniform system of education, examination, certification and registration.
f. To donate can subscribe to, an otherwise and any institution on organisation in, or
outside, India connected with nursing.
g. To promote and provide for welfare of, and to give relief by grants of money on other
aid, on otherwise as the association may thing fit.
Achievements
Some of the important achievements of the TNAI are (1) raising the standard of training,
of both general and midwifery training, (2) the establishment of nurse registration
councils in many states, (3) the establishment of the college of nursing in Delhi, (4)
formation of the Health Visitor's, League, the Midwives Association and the Student
Nurses Association. A detailed account of the TNAI will be found in the booklet TNAI
handbook, the TNAI in the only professional association of nurses devoted to work for
the welfare of nurses throughout the country on a national level.
International Council 'of Nurses:
The International Council of Nurses (ICN) was founded in 1899 by Mrs. Bedford
Fenwick, an Englishwoman. The ICN is the oldest international association of
professional women. Membership is open' to all self-governing national nurses
associations. The Indian Nursing Council was affiliated to the ICN in 1912. The
headquarters of the ICN are located in Geneva, Switzerland. Currently, the ICN is a
federation of 95 National Nurse Association representing over a million nurses
throughout the world.
Nurses of national association are automatically members of the ICN. Under the
auspices of the ICN, nurses from national association may attend international
conferences visit other countries for study, employment. On observation the rough the
ICN exchange of privileges programme obtain advice an assistance through the ICN
headquarters and may draw on the resources of the ICN information centre. The
international council of nurses 'is in official relationship with the WHO, UNICEF, ILO
and other international bodies. The ICN publishers a quarterly journal, the International
Nursing Review. An international conference of ICN is held every four years. May 12
is usually celebrated around the world as International Nurses Day, as on this day
Florence Nightingale, founder of modern nursing was born But the national association
58
are free to choose another date of special significance to the nursing profession within
their own country.
59
Ethics:
Ethics is the study of good conduct, character, and motives. It is concerned with
determining what is good or valuable for all people. Acts that are ethical often reflect a
commitment to standards beyond personal preferences-standards on which individuals,
professions, and societies agree.
Basic Terms
To discuss ethics, it is helpful to establish a basic vocabulary. Although the terms may
have a certain meaning in a larger context, they provide specific meanings within the
context of ethics that further the understanding and discussion about ethical matters.
These basic terms include autonomy, beneficence, non maleficence, justice, and fidelity.
In his essay Autonomy under duress, Leonard harris (1992).Challenges the notion that
respect for autonomy guarantees respect for all persons. Most researchers investigating
the concept of autonomy focus on appreciating culture differences. For example,
investigators on a Navajo reservation identified a cultural tradition where thought and
language are considered to have the power to shape reality. As a result, the discussion of a
poor prognosis, often considered a duty out of respect for autonomy, can have a
devastating effect for a client who is from a Navajo tradition. Harris is also concerned
that the definition of autonomy is influenced by the culture of the people using the term.
His concerns, however, led him to conclude that there can be limits in other more subtle
ways to the value of respect for autonomy. His argument is based on his experience as an
African-American. If race-targeted advertising such as cigarette and alcohol" advertising
elicits less social consternation than we might hope, one reason may be that the target is
not invested by physicians and society in general with ties of affection, compassion, and
value among those empowered to create change. II Society may claim respect for
autonomy, I and health care providers specifically commit to this respect in their
professional practices. Nonetheless, Harris argues, certain groups of poor or historically
underserved peoples , may not enjoy equal respect for autonomy. The respect they enjoy
is lessened as a result of racial prejudice. Respect for autonomy applied in this way
60
promotes harm. Harris does not argue to abandon the concept of autonomy. He does
warn, " however, that an honest appraisal of its use is critical.
Implications for Practice:
Harris recommends a thorough self-examination to ensure that when the term autonomy
is applied, it is applied with respect, compassion, and value, as though no differences
existed between classes or races of people.
Autonomy.
Autonomy refers to a person's independence. As a standard in ethics, autonomy
represents an agreement to respect another's right to determine a course of action. Respect
for another's autonomy is fundamental to the practice of health care. It serves to justify
the inclusion of clients in all aspects of decision making regarding their health care. The
agreement to respect autonomy involves the recognition that clients are "in charge of
their own destiny in matters of health and illness" (O'Neil, 1995). For example, the
purpose of the preoperative con- sent that clients must read and sign before surgery is the
assurance in writing that the health care team respects the client's independence by
obtaining permission to proceed.
The consent process implies that a client may refuse treatment, and in most cases the
health care team must agree to follow the client's wishes. Health care professionals agree
to abide by a standard of respect for the clients autonomy.
Beneficence refers to taking positive actions to help others. The practice of beneficence
encourages the urge to do good for others. Commitment to beneficence helps to guide
difficult decisions wherein the benefits of a treatment may be challenged by risks to the
client's well-being or dignity. A child's immunization may cause discomfort during
administration, but the benefits of protection from disease, both for the individual and for
society, outweigh the temporary discomforts. The agreement to act with beneficence also
requires that the best interests of the client remain more important than self-interest. For
example, a nurse will not simply follow medical orders but will act thoughtfully to
understand client needs and then work actively to help meet those needs.
Nonmaleficence:
61
Maleficence refers to harm or hurt; thus non maleficence is the avoidance of harm or
hurt. In health care ethics it is important to remember that ethical practice involves not
only the will to do good, but also the equal commitment to do no harm. The health care
professional tries to balance the risks and benefits of a plan of care while striving to do
the least harm possible. This principle is often helpful in guiding discussions about new
or controversial technologies. For example, a new bone marrow transplant procedure may
promise a chance at cure. The procedure, however, may require long periods of pain and
suffering. These discomforts should be considered in light of the suffering that the disease
itself might cause, and in light of the suffering that other treatments might cause. The
commitment to provide least harmful interventions illustrates the term non- maleficence.
The standard of non maleficence promotes a continuing effort to consider the potential for
harm even when it may be necessary to promote health. ,
Justice:
Justice refers to fairness. Health care providers agree to strive for justice in health care.
The term often is used during discussions about resources. What constitutes a fair
distribution of resources may not always be clear. In these cases national discussion about
just distribution of resources often helps to clarify methods for achieving fairness. For
example, in the United States the number of candidates awaiting liver transplants is
approximately 3 times larger than the number of available organs for transplantation.
Decisions about who should receive available organs are always difficult. Criteria set by
a national multidisciplinary committee strive for justice by ranking recipients according
to need. These criteria are preferable to resorting to selling organs for profit, which would
favor recipients with the most money, and preferable to distributing them by lottery,
which would result in random distribution without regard to justice.
Fidelity
Fidelity refers to the agreement to keep promises. A commitment to fidelity explains the
reluctance to abandon clients, even when disagreement arises about decisions that a client
may make. The standard of fidelity also includes an obligation to follow through :with
care offered to clients. For example, if a nurse assesses a client for pain and then offers a
plan to manage the pain standard of fidelity encourages the nurse to monitor the client's
response to the plan. Professional behavior by the nurse includes revision of the plan as
necessary to keep the promise to reduce pain.
62
Professional Nursing
Code of Ethics. A code of ethics is a set of ethical principles that are accepted by all
members of a profession. A profession's ethical code is a collective statement about the
group's expectations and standards of behavior. Codes serve as guidelines to assist nurses
and other professional groups when questions arise about correct practice or behavior.
The nursing code of ethics, as in other 'professions, sets forth ideals of conduct. The
American nurses Association (ANA) and the International Council 'of nurses (ICN) have
established widely accepted codes professional nurses attempt to follow. These codes
differ somewhat in specific emphasis, but they reflect the same basic principles, including
responsibility, accountability, advocacy, confidentiality, and veracity. Nurses agree to
responsibility for specific actions and accountability for the consequences. To practice
responsibly, professional nurses also agree to maintain competence in their practice and
to use competence the application of judgment.
Accountability:
Accountability refers to the ability to answer for one's own actions. The nurse balances
accountability to the client, the profession, the employer, and society. For example, a
nurse may know that client who will be discharged soon remains confused about how to
administer insulin. The action that a nurse takes in response to this situation will be
guided by the sense of accountability. The client, the institution, and society rely on the
good judgment of the nurse and trust that the nurse will take action in response to this
situation. The nurse may request more hospitalization to provide further teaching or
arrange home care to continue teaching at home. The goal is the prevention of injury to
the client. The nurse's sense of accountability guides actions '1'thatachieve this goal.
To remain accountable to society, nursing professionals agree to evaluate practices and
actions and to take action to preserve nursing excellence the joint commission on
accreditation association, recommends standards for the delivery of nursing care. These
standards provide a basic structure against which nursing care is objectively measured.
Accountability is best ensured and measured. When quality of care has been defined.
National organizations such as the JCAHO and ANA provide these definitions and offer
standards of practice to achieve quality as well as a structure for evaluation of continuing
practice a CAHO, 2002). The following activities serve to : support standards of the
JCAHO and ANA in the nursing professions:
63
The nurse, in all professional relationships, practices with compassion and respect for the
inherent dignity, worth and uniqueness of every individual, unrestricted by considerations
of social or economic status, personal attributes, or the nature of health problems.
The nurse's primary commitment is to the patient, whether an individual, family, group,
or community.
The nurse promotes, advocates for, and strives to protect the health, safety, and rights of
the patient. The nurse is responsible and accountable for individual nursing practice and
determines the appropriate delegation of tasks consistent with the nurse's obligation to
provide optimum patient care.
The nurse owes the same duties to self as to others, including the responsibility to
preserve integrity and safety, to maintain competence, and to continue personal and
professional growth.
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.
The nurse participates in the advancement of the profession through contributions to
practice, education, administration, and knowledge development.
The nurse collaborates with other health professionals and the public in promoting
community, national, and inter- national efforts to meet health needs.
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.
64
Responsibility.
The term responsibility refers to the characteristics of reliability and dependability. The
term implies an ability to distinguish between right and wrong. In professional nursing,
responsibility includes a duty to perform actions well and thoughtfully. When
administering a medication, for example, a nurse is responsible for assessing the client's
need for the drug, for giving it safely and correctly, and for evaluating the response to it.
By agreeing to act responsibly, the nurse gains trust from clients, colleagues, and society.
Confidentiality.
The concept of confidentiality in health care enjoys widespread acceptance in the United
States. Federal legislation known as HIPAA (Health Insurance Portability and
Accountability Act of 1996) requires it. The legislation defines the rights and privileges
of clients for protection of privacy without diminishing access to quality care. In addition
to a requirement for education of all employees in health care about the HIPAA
protections, the legislation establishes fines for infractions (HHS fact sheet, 2002).
Medical records may not be copied or forwarded without a client's consent. Health care
information, including laboratory results, diagnosis, and prognosis, is not shared with
others without specific client consent. This practice even includes preventing other family
members or friends of the client from acquiring health care information. Conflicting
obligations may arise when a client wants to keep information from insurance companies
to preserve coverage or from employers to preserve a job. The commitment to
confidentiality is particularly challenged as medical records become computerized.
Preservation of confidentiality is often in competition with the need to facilitate access to
information. In the case of computer access, health care institutions work to protect
confidentiality by using special access codes that limit what certain employees can find
on a computer system.
Nurses
have
four
nurse
uses
judgment
regarding
.when accepting
Nurses render health services to the 1be nurse at all. times maintains standards
individual, the family, and the community of personal conduct which reflect well on
and coordinate their services with those of the profession
confidence;
related groups.
and
enhance
public
The nurse's primary responsibility is to The nurse assumes the major role in
determining and implementing acceptable
those people requiring nursing care.
In providing care, the nurse promotes an standards of critical nursing practice,
environment in which the human rights, management, research, and education.
values, customs, and spiritual beliefs of the The nurse is active in developing a core of
individual, family, and community are research-based professional knowledge.
The nurse, acting through the professional.
respected.
The nurse ensures that the individual organization, participates in creating and
receives sufficient in- formation on which maintaining equitable social and economic
to base consent for care and related working conditions in nursing.
information.
The nurse holds in confidence personal
nurse
shares
with
society
the
other fields.
responsibility for initiating and supporting The nurse takes appropriate action to
action to meet the health and social needs safeguard individuals when their care Is
of the public, in particular those of endangered by a co-worker or any other
person.
vulnerable populations.
The nurse also shares responsibility to
sustain and protect the natural environment
from depletion, pollution, degradation and
destruction.
66
Older people may not be as familiar with the concept of autonomy as people from
younger generations. As a result, older adults may be uncomfortable disagreeing
with doctors or nurses. They may view assertiveness as a violation of trust.
.As people age, they may develop clinical conditions that affect the
communication process: hearing deficits; memory impairments, chronic illness,
isolation. Clients may become incapacitated by stroke or disease. Most older
adults take multiple medications, some of which may affect cognitive skills in
subtle ways. It is important to evaluate the competence of a client to make
decisions, and to provide assistance where necessary, especially when treatment
choices, consent, or ethical issues arise.
.Consensus about medical goals for clients ; the geriatric population can be hard
to achieve. When is a position so diminished by old age that a treatment plan not
orily prolongs life, it also prolongs suffering? Working to ensure dignity and
comfort can be as important as achieving medical success.
Veracity.
A part of the ANA code of conduct addresses the issue of veracity, another aspect of
reliability. Veracity in general means accuracy or conformity to truth. As a part of the
nursing code of ethics, veracity guides nurses to practice truthfulness. Although in most
circumstances veracity is an odious asset, the practice of truthfulness may be challenged
during the delivery of health care. A nurse may have to balance competing interests in
certain cases. For example, a spouse may make an urgent plea that a client not be given
news of a poor prognosis. In this case, principles generally in effect that may take
precedence over the spouse's wishes include respect for the client's autonomy and the
principle of veracity. In some in may be tempting to tell a child that a medicine when it
does not or that a procedure will not it probably will, to achieve a level of compliance
codes of ethics guide the nurse to tell however, and it is a rare circumstance where other
principles would support another behavior.
67
Professional nurses must understand the legal limits influencing their daily practice. This,
coupled with good judgment and sound decision making, ensures safe and appropriate
nursing care.
Sources of Law
The legal guidelines that nurses must follow are derived from statutory law, regulatory
law, and common law. Statutory law is created by elected legislative bodies such as state
legislatures and the U.S. Congress. An example of state statutes are the Nurse Practice
Acts found in all 50 states. These nurse practice acts describe and define the legal
boundaries nursing practice within each state, An example of a federal statute enacted by
the U.S. Congress is the Americans with Disabilities Act (ADA) (1995). This statute
products the rights of handicapped individuals in the work place, in educational
institutions, and throughout our society, Regulatory law, or administrative law, is created
by administrative bodies such as State Boards of nursing when they pass rules and
regulations. An example regulatory law is the duty to report incompetent or un ethical
nursing conduct to the State Board of Nursing common law is created by judidal
dedsions made in courts when individual legal cases are decided. An example common
law is informed consent and the client's right to refuse treatment.
Statutory law is either civil or criminal. Criminal laws prevent harm to society and
provide punishment for crimes (Black, 1999). There are two classifications of crime. A
felony is a crime of a serious nature that has a penalty ally of imprisonment for greater
than 1 year or even death. A misdemeanor is a less serious crime that has a penalty of a
fine or imprisonment for less than 1 year an example of criminal conduct for nurses
would be misuse of a controlled substance.
Civil laws protect the rights of individual persons within our society and encourage fair
and equitable treatment among people (Black, 1999). Generally, violations of civil laws
cause harm to an individual or property. The damages for civil laws involve the payment
of money, unlike criminal laws, which are punished by imprisonment however under
many federal and state laws, sanctions for violations may include both civil and criminal
penalties.
Standards of Care:
68
Standards of care are the legal guidelines for nursing practice, Nursing standards of care
are defined in the nurse practice. Acts and by the State Board of Nursing of each state,
by the federal and state laws regulating hospitals and other health care institutions, by the
professional
perform their duties. These internal standards of care are quite specific and should be
accessible on all nursing units. For example, a policy/procedure outlining the steps that
should be taken when changing a dressing or administering medication provides specific
information about how nurses are to perform these tasks. Some hospitals are also now
using commercially published procedural textbooks to reference the institution's general
policy and procedures. Nurses must know the polices and procedures of their employing
institution because the same standard of care should be used by all nurses in the health
care institution institutional policies and procedures must conform to state and federal
laws, as well as community standards, and cannot conflict with legal guidelines that
defines acceptable standards of care.
In a lawsuit for malpractice or nursing negligence, a nursing expert is called to testify to
the jury about the standards of nursing care as applied to the facts of the case. The
standards of care are used by the jury to determine whether the nurse acted appropriately.
Nurse experts must base their opinions on existing standards of practice established by
Nurse practice Act,
federal and state hospital licensing laws, standards of the JCAHO, job descriptions, and
current nursing re- search literature.
Usually, general duty nurses are responsible for meeting the same standards as other
general duty nurses in similar settings. However, specialized nurses such as nurse
anesthetists, OR nurses, intensive care nurses, or certified nurse midwives are held to
standards of care and skill exercised by those in the same specialty as defined by
applicable standards. All nurses should know the standards of care that they are expected
to meet within their specific specialty and work setting. Ignorance of the law or of
standards of care is not a defense against malpractice. However, at the time of trial the
standard of care is what the nurse experts testify that standard to be and ultimately what
the jury believes.
Petition-element\"
of
the
claim:
plaintiff outlines what the defendant nurse establish the essential legal elements of the
did wrong and how as a result of that case against the defendant. The defendant
alleged negligence the plaintiff was injured. selects
70
'experts
to
establish
the
Answer: The nurse admits or denies each appropriateness of the nursing care.
allegation in the petition. Anything that is
Trial Usually occurs at least 2 to 3 years,
Proof of Negligence
The nurse owed a duty to the client.
Medical records: The defendant obtains all The nurse did not carry out the duty or
of the plaintiff's relevant medical records breached the duty (failure to use that degree
for treatment before and after the incident.
Witnesses'
depositions:
Questions
posed to the witness under oath to obtain members of his or her profession).
all relevant, non privileged information The client was injured: Medical bills, lost
about the case.
(doctor,
nurse,
Other witlessness: Factual witnesses, both for" the breach of duty the client would not
neutral and biased, are deposed to obtain have been injured).
information and their version of the case.
This may include family members on the
plaintiff's side and other medical personnel
(e.g., nurses) on the defendant's side.
Treating physicians' depositio/1S: Before
subsequent
treating,
physicians"
One of the first and most important cases to discuss a nurse's liability was Darling v
Charleston Community Memorial Hospital. This 1966 Illinois Supreme Court case has
been adopted in almost every state. It involved an 18 year old man with a fractured leg.
The emergency department physician applied a cast with insufficient padding. The man's
toes became swollen and discolored, and he developed decreased sensation. He
complained to the nursing staff many times. Although the nurses recognized the
symptoms as signs of impaired circulation, they failed to tell their supervisor that the
physician did not respond to their calls or the client's needs. Gangrene developed, and the
man's leg had to be amputated. Although the physician was held liable for incorrectly
applying the cast, the nursing staff was also held liable for failing to adhere to the
standards of care for monitoring and reporting the client's symptoms. Even though the
nurses attempted to contact the physician, this case holds that when the physician fails to
respond, the nurse must go over the physician's head to make sure that the client is
appropriately treated.
The nurse is obligated to seek appropriate treatment for the client not only ethically but
legally. The nurse bears a fiduciary relationship to the client. A fiduciary relation- ship is
one in which a professional, the nurse, provides services which by their nature cause the
recipient, the client, to trust in the specialized knowledge, the integrity, and the fidelity of
the professional. The nurse is obligated in the fiduciary relationship to provide
knowledgeable, safe care to the client. The nurse is obligated to behave honestly and
truthfully with regard to the client. Last, the nurse must be faithful to provide care in the
best interests of the client.
The best way for nurses to keep up with the current legal issues affecting nursing practice
is to read the nursing literature in their practice area. Current nursing literature deals with
the changing obligations and standards of care for nurses, explains pertinent state and
federal laws, and keeps the nurse up to date on any new rules or regulations and case law.
Federal Statutory Issues in Nursing Practice
Americans With Disabilities Act:
The Americans with Disabilities Act (ADA) (1995) is a very broad-reaching civil rights
statute. It protects the rights of disabled people. It is also the most extensive law on how
employers must treat health care workers and clients infected with the human
72
immunodeficiency virus (HIV). The Supreme Court ruled in 1998 in Bragdon v Abbott
that even asymptomatic HIV constitutes a disability within the meaning of the ADA. This
means that the HIV-positive individual who does not have acquired immunodeficiency
syndrome (AIDS) is still protected by the ADA. The ADA regulations protect the privacy
of infected people by giving individuals the opportunity to decide whether to disclose
their disability. However, several cases have held that the health care provider may be
obligated to disclose the fact that he or she is infected with HIV. Despite these rulings.
health care workers with disabilities, such as HIV Infection, are protected in the
workplace under the ADA. :likewise, health care workers may not discriminate. against
HIV-positive clients.
73
Potentially suicidal clients are admitted to psychiatric units. If the client's history and
medical records indicate suicidal tendencies, the client must be kept under supervision.
Lawsuits result from clients' attempts at suicide within the hospital. The allegations in the
lawsuits are that he health care provider failed to provide adequate supervision and failed
to safeguard the facilities documentation of precautions against suicide is essential.
Advance Directives:
There are two basic advance directives: living wills and durable powers of attorney for
health care. Many clients have living wills or have signed a durable power of attorney for
health care. The Patient Self-Determining Act (PSPA) (1991) requires health care
institutions to provide written information to clients concerning the clits rights under state
law to make decisions, including the right to refuse treatment and formulate advance
directives. Under the act, it must be documented in the client's record whether the, client
has signed an advance directive. The hospital is also required to ensure that state law is
followed and provide education: for the staff and the public concerning living wills and'
durable powers of attorney. It is especially important understand clients' cultural beliefs
when explaining advance directives. Regulatory mandates to benefit the public are based
on the dominant value in American society of self determination. This may be in conflict
with a client's cultural heritage (In order for living wills or durable powers of attorney for
health care to. be enforceable, the client must be legally incompetent or lack decisional
capacity to make decisions regarding health care treatment (Furrow and others, 1991).
The determination of legal competency is made by a judge, and the determination of
decisional capacity is usually made by the physician and family. Therefore the
implementation of the advance directive is done within the context of the health care
team and the health care institution. The nurse should be familiar with the institution's
policies complying with the act.
74
Living Wills. Living wills are written documents that direct treatment in accordance with
a client's wishes in the event of a terminal illness or condition Living wills may be
difficult to interpret and not clinically specific in unforeseen circumstances. Each state
providing for living wills has its own requirements for executing them. Generally, two
witnesses, neither of whom can be a relative or physician, are needed when the client
signs the document. If health care workers follow the directions of the living will, they
are immune from liability.
A durable power of attorney for health care designates an agent, surrogate, or proxy to
make health care decisions if and when the client is no longer able to make decisions on
his or her own behalf. This agent is appointed to make health care treatment decisions
based on the client's wishes
Addition to federal statutes, the ethical doctrine of autonomy ensures the client the right
to refuse medical treatment. This right to refuse medical treatment was up held in the
Bouvia v superior court case in 1986. That case allowed the discontinuation of the client's
tube feedings at her request. The courts have also upheld the right of a legally competent
client to refuse medical treatment for religious reasons. Christian Scientists refuse
medical treatment based on religious beliefs, and Jehovah's Witnesses accept medical
treatment but refuse blood transfusions for religious beliefs. In the absence of a truly
compelling reason otherwise, the right to make those choices are protected. The U.S.
Supreme Court stated in the Cruzan v Director Missouri Department of Health case in
1990 that "we assume that the U.S. Constitution would grant a constitutionally protected
competent person the right to refuse lifesaving hydration and nutrition." In cases
involving the client's right to refuse or withdraw medical treatment, the courts balance the
client's interest with the state's interest in protecting life, preserving medical ethics,
preventing suicide, and protecting innocent third parties. Children are generally
considered innocent third parties. Although the courts will not force adults to undergo
treatment that is refused for religious reasons, they will grant an order al- lowing
hospitals and doctors to treat children of Christian Scientists or Jehovah's Witnesses who
have denied consent for treatment of their minor children.
Where clients are legally incompetent and are unable to make health tare decisions, the
courts balance the state's interest with what the client would have wanted. The courts
attempt to substitute their judgment as to what the client would have chosen if the client
75
were competent. The Supreme Court held in the Cruzan case that states had the right to
require "clear and convincing evidence" of a legally incompetent client's prior wishes
when making determinations to discontinue life-sustaining treatment. In that case
nutrition and hydration were recognized as life-sustaining medical treatment that could be
withdrawn.
Every state now requires "clear and convincing" evidence of the client's choice, but
individual states differ as to what standard satisfies the amount of evidence required. If
there is no evidence of the client's prior choice, most states allow treatment to be stopped
based on other factors, including the best interest of the client balanced with the state's
interest.
In addition to client refusals of treatment, the nurse will frequently encounter the DNR
order. DNR means "do not resuscitate" or "no code." The DNR order was first developed
in 1976 and marks an important change in health care because it was the first order to
withhold treatment instead of deliver treatment (Bums and others, 2003). A DNR order
should be written, not given verbally. The physician should routinely review DNR orders
in case the client's condition warrants a change. "Slow codes" or "partial" codes may be
defined differently by various institutions and may be interpreted as not performing
resuscitative procedures as a competent person would. If resuscitative procedures are
performed more slowly than recommended by the American Heart Association, they may
be interpreted as being below the standard of care and therefore become the basis for a
lawsuit.
Cardiopulmonary resuscitation (CPR) is an emergency treatment that is provided without
client consent. It is a procedure that is performed on an appropriate client un- less a DNR
order is written in the client's chart. Since 1988; when New York first adopted legislation
regarding DNR orders, over 20 states have drafted similar statutes (New York DNR
Statute, 1988). The statutes assume that all clients will be resuscitated unless there is a
written DNR order in the chart. Legally competent adult clients may consent to a DNR
order verbally or in writing after being given the appropriate information by the
physician. A verbal consent requires two witnesses, one of whom must be a physician
affiliated with the hospital. A written consent requires two adult witnesses. If the client
lacks the decisional capacity to give consent, a surrogate may give consent for the client
76
if two physicians say that within reasonable medical certain the client has a terminal
condition, the client is terminally unconscious, resuscitation would be medically futile, or
resuscitation would impose extraordinary burden on the client in light of the client's
medical condition and the expected out- come of resuscitation. If no surrogate is available
to give consent, the DNR order can still be written but only if the physician is reasonably
medically certain that the resuscitation would be futile. The statutes provide that the attending physician must review the DNR orders every 3 days for hospitalized clients or
every 60 days for client residential health facilities.
Uniform Anatomical Gift Act:
An individual who is at least 18 years of age may make an anatomical gift or organ
donation (defined as a "donation of all or part of a human body to take effect upon or
after death"). The gift must be made in writing and signed by the donor. If the donor
cannot sign, the document must be signed by another individual and two witnesses. In
many states adults may sign the back of their driver's license, indicating consent to organ
donation. Pursuant to the Uniform Anatomical Gift Act of 1987, which has been adopted
in nearly 20 states, unless the gift is revoked by the donor before death, no further consent is required after the donor's death.
In most states Required Request laws mandate that at the time of admission to a hospital,
a qualified health care provider must ask each client over 18 whether they are an organ or
tissue donor. If the answer is affirmative, a copy of the document should be obtained. If
the answer is negative and the attending physician consents, the option to make or refuse
an anatomical gift should be discussed. Documentation should be placed in the client's
medical record. Required Request laws came about be- cause of the shortage of suitable
organs for transplantation. Required requested laws are also part of the Uniform
Anatomical Gift Act (1987), which addresses many issues involving organ donation,
including the rights and duties at death. The physician who certifies death shall not be
involved in the removal or transplantation of organs.
The National organ Transplant Act of 1984 prohibits the purchase or sale of organs. The
act also provides civil and criminal immunity to the hospital and physician who acts in
accordance with the act. The act also protects the donor's estate from liability for injury or
dam- age that may result from the use of the gift. Organ transplantation is extremely
expensive. Clients ill end-stage renal disease are eligible for Medicare coverage for a
77
kidney transplant, but other transplants have to be paid for by private insurance. The
United Network for Organ Sharing has a contract with the federal government and sets
policies and guidelines for the procurement of organs. Most clients who require organ
transplantation have to be placed on a waiting list for an organ in their geographical area.
Recently, the geographical system has changed to give priority to clients who
demonstrate the greatest need. Nurses must be familiar with their employing institution's
policies and procedures regarding organ donation.
Health Insurance Portability and Accountability Act:
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) limits the
extent to which health plans may impose preexisting condition limitations and prohibits
discrimination in health plans against individual anticipants and beneficiaries based on
health status. One of the ways that insurance companies keep costs down is y not insuring
certain preexisting conditions that clients are when they obtain group health insurance
coverage for example, if a client has heart disease, an insurer may to be provide health
insurance for the client for all medical problems except heart disease. HIPAA requires
Insurers to only limit coverage for a preexisting condition for 12 months in most cases.
This means that if an employee has group health insurance coverage with his job for at
least 12 months and then changes jobs, the second employer cannot impose preexisting
condition exclusion n the individual. The advantages of HIPAA are that employees can
change jobs without losing coverage as a result of preexisting coverage exclusion as long
as they have had .12 months of continuous group health insurance coverage.
HIPAA also contains a section that sets standards regarding the electronic exchange of
private and sensitive health information. Known as the Privacy Standards Rosati, 2002),
these rules create client rights to consent J use and disclose protected health information,
to in- pert and copy one's medical record, and to amend mistaken or incomplete
information. In addition, the standards require all hospitals and health agencies to have
specific policies and procedures in place to ensure compliance with the standards. These
policies and procedures must provide reasonable safeguards to protect written and verbal
communications about clients. Student nurses ,who visit patient care units before caring
for clients usually prepare by reading clients' charts. However, no part If the chart can be
copied. Although HIPAA will not require such measures as soundproof rooms in
hospitals, it does mean that nurses and all health care providers should avoid discussing
clients in public hallways and. should provide reasonable levels of privacy in
78
comminuting with and about clients in any manner. Message boards used in clients'
hospital rooms to post daily nursing care information can no longer contain information
revealing the client's medical condition. HIPAA viola- ions have civil and criminal
sanctions. All nurses must understand the HIPAA policies of their organization.
Restraints
The Resident's Rights section of the Medicaid Statute: 1988) regulates the use of physical
or chemical restraints n nursing facilities. In addition, the FDA has set forth Guidelines
for the use of restraints (U.S. Department of health and Human Services, 1992). The
statutes provide hat restraints may be imposed (1) only to ensure the physical safety of
the resident or other residents and (2) only on the written order of a physician that
specifies the duration (usually 24 hours) and circumstances until such an order could
reasonably be obtained). The most frequent indications for restraints are as follows.
1. Unanticipated risk of injury to self falls or others, 2/ interference with treatment, and 3.
clinically disruptive or disturbing behavior. (Martin 2002). The nurse must know when
and how to use restraints correctly. After a client is restrained, the nurse is required to
make frequent client assessments and to periodically release restraints. Liability for
improper or unlawful restraint, as well as liability for client injury from unprotected falls,
lies with the nurse and the health care institution.
State Statutory Issues in nursing practice:
Licensure:
All registered nurses are licensed by the State Board of nursing of the state in which they
practice. The requirements for licensure vary among states, but most states have
minimum education requirements and require a licensure examination. All states use the
National Council Licensure examinations for registered nurse and licensed practical nurse
examinations. Licensure permits persons to offer special skills to the public, but it also
provides legal guidelines for protection of the public.
A license can be suspended or revoked by the state board of nursing if a nurses conduct
violates provisions in the licensing statute based on administrative law rules that
implement and enforce the statute. For example controlled substances jeopardize their
license status. Because a license is viewed as a property right, due process must be
followed before a license can be suspended or revoked. Due process means that nurses
must be notified of the charges brought against them and that the nurses have an
79
80
Every state with child abuse legislation requires that. suspected child abuse or neglect
must be reported. Health care professionals such as nurses are mandated to report
suspected cases. To encourage reports of suspected cases, states provide legal immunity
for the reporter if the report is made in good faith. Health care professionals who do not
report suspected child abuse or neglect may be held liable for civil or criminal legal
action.
As in all areas of nursing practice, negligence involving pediatric clients is possible, and
the nurse is responsible for preventing a child in his or her care from accidentally coming
to harm. Cribs, which sometimes have a restraining device over the top, are designed to
keep infants and toddlers from climbing out of bed and injuring themselves. All
poisonous substances and sharp objects should be kept out of the reach of small children.
When possible, small children should be kept under constant watch to minimize
opportunities for accidental harm.
81
order of priority for the giving of consent for autopsies, such as (1) decedent, in writing;
(2) durable power of attorney; (3) surviving spouse; and (4) surviving child, parent,
brother, or sister in the order named (Autopsy Consent, 1998). It is important to know a
client's cultural heritage. In some cultures, the accepted family social hierarchy may
differ from what is expected by law. Nurses must help clients under- stand the law and
what, if any, options are available. Death is to be reported and investigated by the coroner
when there are reasonable grounds to believe that the person died as a result of violence,
homicide, suicide, accident, or death occurring in any unusual or suspicious manner. The
coroner should be also be contacted if a client's death is unforeseen and sudden and the
client has not been seen by a physician in over 36 hours.
Physician Assisted Suicide
In 1994 the State of Oregon passed the Oregon Death with Dignity Act, which was the
first statute that permitted physician-assisted suicide. The statute provided that a
competent individual with a terminal disease defined as an "incurable and irreversible
disease that has been medically confirmed and will, within reasonable medical judgment,
produce death within 6 months" could make an oral and written request for medication to
end his or her life in a humane and dignified manner. The written request had to be signed
and witnessed by two individuals. The attending physician had to refer the individual to a
consulting physician and refer the individual for counseling, if appropriate. The attending
physician also had to have the individual notify his or her next of kin and provide
information regarding the medication so that an informed decision could be made. There
was a day waiting period between the initial oral request and the writing of the
prescription and no less than a 48-hour waiting period between the written request and
the writ- ing of the prescription. The individual had a right to rescind the request at any
time and had to be able to self- administer the medication. Despite efforts by the Oregon
state legislature and the U.S. attorney general, the Oregon Death with dignity Act went
into effect in November 1997. However, it remains the object of several challenges in
federal court.
In Compassion in Dying v Washington (1996) and Quill Vacco (1996), challenges to state
statutes that made assist- ing in suicide a criminal act in Washington and New York,
respectively, were filed with the courts. The lower courts both held that the criminal
statutes were unconstitutional. The cases were heard by the Supreme Court, and on June
26, 1997, the Supreme Court held in Washington
82
fundamental constitutional right to assisted suicide. In making its ruling, the Supreme
Court did not preclude the states from passing legislation legalizing assisted suicide. The
Supreme Court also relied on the fact that there are no legal barriers to obtaining pain
medication and that dying persons in Washington and New York could "obtain palliative
care, even when doing so would hasten their deaths."
Other states have proposed similar legislation. Legally, nurses must know their State
Nurse Practice Act and their state laws regarding physician-assisted suicide. The
American Nurses Association has stated that nurses should not participate in assisted
suicide because it is an act that violates the Code for Nurses and the ethical traditions of
the profession.
83
appendectomy and the physician performs a tonsillectomy, battery has occurred. Once
again, the key issue is the client's consent.
In some situations consent is implied. For example, if a client gets into a wheelchair or
transfers to a stretcher after being advised that it is time to be taken for an x-ray
procedure the client has given implied consent to the procedure. If the client learns that
an x-ray film of the head instead of the foot is to be taken and the client refuses to have
the x-ray film taken, the consent has been revoked or withdrawn.
Invasion of Privacy.
The tort of invasion of privacy protects the client's right to be free from unwanted
intrusion into his or her private affairs. The four types of invasion of privacy torts are
intrusion on seclusion, appropriation of name or likeness, publication of private or
embarrassing facts, and publicity placing one in a false light.
Clients are entitled to confidential health care. For example, in a classic case, reporters
published photographs of a female client in her hospital room without her consent. A
claim for invasion of privacy was upheld. This case is an example of intrusion on
seclusion publication of private, embarrassing facts.
Another form of invasion of privacy is the release of a client's medical information to an
unauthorized person, such as a member of the press or the client's employer. The
information that is contained in a client's medical record is a confidential communication.
It should be shared with health care providers for the purpose of medical treatment only.
client's medical record is confidential. The nurse should not disclose the client's
confidential medical information without the client's consent. For example, a nurse
should respect a wish not to inform the client's family of a terminal illness. Similarly, a
nurse should not assume that a client's spouse or family members know all of the client's
history, particularly with respect to private issues such as mental illness, medications,
pregnancy, abortion, birth control, or sexually transmitted diseases.
An individual's right to privacy may conflict with the public's right to know. In one case a
married couple was filmed by a television crew while attending a hospital program in
84
which they participated. The couple had previously told no one but their immediate
family that they were involved in the in vitro fertilization program and had been assured
that there would be no publicity or public exposure. After the newscast they were
subjected to phone calls and embarrassing questions. The couple filed a lawsuit. The
court held that the husband and wife stated a claim for invasion of privacy and that even
though the in vitro fertilization program may have been of public interest, the identity of
the plaintiffs was a private matter.
Many states, through their respective public health departments, require that certain
infectious or communicable diseases be reported. Sometimes the client is a public figure
whose physical condition is considered newsworthy. There are also cases in which
information is given out about a scientific discovery or a major medical breakthrough, as
with the first heart transplant case or the first artificial heart recipient. If an event falls
into any of these categories, information should be channeled through the public relations
department of the institution to ensure that invasion of privacy does not occur. The nurse
should not independently attempt to decide the legality of disclosing information.
Nursing standards for what constitutes confidential in- formation are based on
professional ethics and the common law. The ideals of privacy and sensitivity to the
needs and rights of clients who may not choose to have nurses intrude on their lives, but
who depend on nurses for their care, guide the nurse's judgment. The nurse's fiduciary
duty requires that confidential information not be shared with others.
Defamation of Character.
Defamation of character is the publication of false statements that result in damage to a
person's reputation. The statements must be published with malice in the case of a public
official or public figure. Malice means that the person publishing the information knows
it is false and publishes it anyway or that it is published with reckless disregard as to the
truth or falsity of the statement. If the statement is presented orally, it is called slander. If
the statement is made in writing, it is called libel. For example, if a nurse tells people
erroneously that a client has venereal disease and the disclosure affects the client's
business, the nurse could be held liable for slander.
Unintentional Torts
85
Negligence negligence is conduct that falls below the standard of care. The standard of
care is established by law for the protection of others against an unreasonably great risk
of harm. For example, if a driver of a car acts unreasonably in failing to stop at a stop
sign, it is negligence. In general, courts define negligence in car accident cases and other
negligence cases as that degree of care that an ordinarily careful and prudent person
would use under the same or similar circumstances.
Malpractice.
Malpractice is one type of negligence; it is referred to as professional negligence. Nursing
malpractice results when nursing care falls below the standard of care. Nurses can be
found liable for malpractice if the following criteria are established: (1) the nurse
(defendant) owed a duty to the client (plaintiff) (2) the nurse did not carry out that duty;
(3) the client was injured; and (4) the nurse's failure to carry out the duty caused the
injury. Even though nurses do not intend to injure clients, if nurses give care that does not
meet the appropriate standards, they may be held liable for negligence. Negligence may
involve failing to check a client's arm band and then administering medication to the
wrong client. Negligence may also involve administering a medication to a client even
though it has been documented that the client has an allergy to that medication. In
general, courts define nursing negligence as the failure to use that degree of skill or
learning ordinarily used under the same or similar circumstances by members of the
nursing profession (Missouri Approved Instructions.
The best way for nurses to avoid being liable for negligence is to follow standards of
care, give competent health care, communicate with other health care providers, develop
a caring rapport with the client, and document assessments, interventions, and evaluations
fully. If a nurse is brought into a lawsuit, careful, complete, and thorough documentation
is one of the best defenses. Nurses should also know the current nursing literature in their
areas of practice. They should know and follow the policies and procedures of the
institution in which they work. Nurses should be sensitive to common sources of client
injury, such as falls and medication errors. Finally, nurses must communicate with the
client, explain the tests and treatment to be performed, document that specific
explanations were provided to the client, and listen to the client's concerns about the
treatment. Any significant changes in the client's condition must be reported to the
physician and documented in the chart. Timely and truthful documentation is important to
86
provide the communication necessary among the health care team members. Good
documentation also keeps other health care providers up-to-date on the most recent
treatments received by the client so that ongoing care can be safely provided. Nurses
must be certain that documentation is legible and signed.
A number of courts have stated that when a health care provider negligently alters or
loses medical records relevant to a malpractice claim, the health care provider must
demonstrate why these events occurred. An institution has a duty to maintain nursing
records. These duties are established by statutes and accreditation regulations. Nursing
notes contain substantial evidence needed to understand the care received by a client. If
records are lost or incomplete, there is a presumption that the care was negligent and
.therefore the cause of the client's injuries. In addition, incomplete or illegible records
undermine the credibility or believability of the health care provider.
Consent
A signed consent form is required for all routine treatment, hazardous procedures such as
surgery, some treatment programs such as chemotherapy, and research involving clients A
client signs general consent forms when admitted to the hospital or other health care
facility. Separate special consent or treatment forms must be signed by the client or a
representative before specialized procedures or treatments are performed.
State statutes provide the designation of individuals who are legally able to give consent
to medical treatment. Nurse should know law in their own states be familiar with the
policies and procedures of their employing in situation regarding consent.
87
and values of the client may be very different from those own cultural values on the
client. Insensitivity toward concern. A conscious awareness of the different values and
beliefs held by various cultures is essential for sensitive nursing care.
Chromosome
analysis
:0
(InItial)
B.
Alpha-fetoprotein
(Initial)
C.
Acetylcholinesterase (Initial)
(If indicated) D (Initial)
II. I consent to the performance of an ultrasound examination for the purpose of dating
the pregnancy, locating the placenta and selecting a site for placement of the needle.
III. I understand that
88
A. the procedure of amniocentesis involves a small risk to both mother and fetus and
that these risks include; discomfort at the site where the needle was inserted. cramping,
bloody spotting, leakage of amniotic fluid, intrauterine Infection and miscarriage.
B. there is a possibility that growing the fetal cells may not be successful and that
repeat amniocentesis would then be required.
C. although the likelihood of an error is considered to be extremely small, a complete
and correct diagnosis of the condition of the fetus based on the test(s) performed
cannot be guaranteed.
D. the results provided of normal chromosomes or normal biochemical status of the
fetus does not eliminate the possibility that the child may have birth defects and/or
mental retardation because of other disorders.
E. in the case of twins, the results may apply to only one of the pair.
F. in some Rh negative mothers Rh sensitization has occurred following amniocentesis.
IV. I have had my questions answered and understand and accept the risks and
limitations of this test.
Signed: (patient)
(Spouse)
(Witness)
Date:
Sample consent form for a special procedure.
Abortion Issues
In 1973 in the case of Roe
fundamental right to privacy, which includes a woman's decision to have an abortion. The
court ruled that during the first trimester a woman could end her pregnancy without state
regulation because the risk of natural mortality from abortion is less than with normal
childbirth. During the second trimester the state has an interest in protecting maternal
health, and the state may enforce regulations regarding the person per- forming the
abortion and the abortion facility. By the third trimester, when the fetus becomes viable,
the state's interest is to protect the fetus, so the state can therefore prohibit abortion except
when necessary to save the mother.
89
In 1989 in the case of Webster v Reproductive Health Services, the court substantially
narrowed the Roe
abortions if the fetus is thought to be over 28 weeks' gestational age. States may also
require a minors parental consent or a judicial decision that 'the minor is mature and can
self-consent.
In the case of Planned Parenthood of Southeastern Pennsylvania Casey (1992), informed
consent was up-held in that the physician must present the woman with a description of
the nature of the abortion procedure, the health risk related to abortion and childbirth, the
probable gestational age of the fetus, and the availability of state-published material
about medical assistance, adoption agencies, and child support from the father. The court
also upheld a mandatory 24-hour waiting period between when the materials are provided
to the client and when the abortion is performed. An emendated mi- nor must get
informed consent of one parent or a judicial determination that the minor is mature and
can give her own informed consent.
Student Nurses
Student nurses are liable if their actions cause harm to clients. If a client is harmed as a
direct result of a nursing student's actions or lack of action, the liability for the in- correct
action is generally shared by the student, instructor, hospital or health care facility, and
university or educational institution. Student nurses should never be assigned to perform
tasks for which they are unprepared, and they should be carefully supervised by
instructors as they learn new skills. Although student nurses may not be considered
employees of the hospital, the institution has a responsibility to monitor the acts of
student nurses. Student nurses are expected to perform as professional nurses would in
providing safe client care. Faculty members are usually responsible for instructing and
observing students, but in some situations staff nurses serving as preceptors may share
these responsibilities. Every nursing school should provide clear definitions of preceptor
and faculty responsibility.
When students are employed as nursing assistants or nurses' aides when not attending
classes, they should not perform tasks that do not appear in a job description for a nurses'
aide or assistant. For example, even if a student has learned to administer intramuscular
medications in class, this task may not be performed by a nurse's aide. If a staff nurse
overseeing the nursing assistant or aide knowingly assigns work without regard for the
90
person's ability to safely conduct the task defined in the job description, the staff nurse
will also be liable. If students employed as nurse's aides are requested to perform tasks
that they are not prepared to safely complete, this information should be brought to the
supervisor's attention so that the needed help can be obtained.
Malpractice Insurance
between the nurse and the insurance company. Malpractice insurance provides for a
defense when a nurse is sued for professional negligence or medical malpractice as port
of the insurance contract, the insurance company pays for any judgment or settlement of
the case and also pays for the attorney's fees generated in the t representation of the nurse.
Nurses employed by health t care institutions generally are covered by that institution's
insurance and do not need to purchase any supplemental insurance unless the nurse plans
to practice nursing outside of the employing institution. The employing Institutions
insurance, however, only covers nurses while; they are working within the scope of their
employment. : Because nurses are professionals and it is often difficult to separate their
private lives from their professional skills, they should 'consider purchasing individual
professional liability insurance, even if the employing institution has coverage. A nurse
who is called on by neighbors and" friends to provide nursing care on a volunteer basis
would not be covered by the hospital's policy if the neighbor or friend filed suit.
Nurses should consult their lawyers on what types of I policies to purchase and what
rights or duties; if any, exist , 1st under the policy. If the employing institution and the
nurse are sued in a professional liability case, even though the nurse has insurance with
the hospital, the nurse should notify his or her private insurance carrier of " the lawsuit. If
both the hospital policy and the private. Policy are considered primary and the hospital
loses as a result of the nurse's acts, theoretically the hospital could sue the nurse's private
insurer to recover its losses. Most private insurance policies for nurses, however, are
considered excess policies and only begin covering the nurse after all of the primary
hospital insurance coverage has been exhausted. Because the hospital insurance coverage
is generally much greater than the private insurance coverage, hospitals very rarely sue
nurses' private insurers.
Abandonment and Assignment Issues:
Short Staffing. During nursing shortages or staff down- sizing periods, the issue of
inadequate staffing may arise. The ]CAHO (2003) requires institutions to have guide91
lines for determining the number (staffing ratios) of nurses required to give care to a
specific number of clients. Legal problems may arise if there are not enough nurses to
provide competent care. If nurses are, assigned to care for more clients than is reasonable,
they should bring this information to the attention of the nursing supervisor. If nurses are
required to accept assignments, they should make written protests to nursing
administrators. Although these protests may not relieve nurses of responsibility if a client
suffers an injury because of inattention, it would show that the nurses were attempting to
act reasonably. Whenever a written protest is made, nurses should keep a copy of this
document in their own personal file. Most administrators recognize that knowledge of a
potential problem shifts some of the responsibility to the institution. Nurses should not
walk out when staffing is inadequate, because charges of abandonment could be made. A
nurse who refuses to accept an assignment may be considered insubordinate and clients
will not benefit from having even less staff available. It is important to know the
institution's policies and procedures on how to handle such reports before the situation
arises.
Floating:
Nurses are sometimes required to "float" from the area in which they normally practice
to other nursing units. In one case a nurse in obstetrics was assigned to an emergency
department. A client entered the emergency department and complained of chest pain.
The client was given an incorrect dosage of lidocaine by the obstetrical nurse and died
after suffering irreversible brain damage and cardiac arrest. The nurse lost the malpractice
lawsuit who float should inform the supervisor of any lack of experience in caring for the
type of clients on the nursing. They should also request and be given orientation to the
unit. A supervisor can be held liable if a staff nurse is given an assignment he or she
cannot safely handle. In the case of Winkelman Beloit Memorial Hospital the court
remarked that if an employer wishes to rotate nurses to areas outside of their. usual area
of expertise the employer should provide the training and education to prepare nurses to
work in an area outside of their normal assignment. Before accepting employment nurses
should find out the institutors policies regarding floating and have an understanding as to
what is expected. For example, nurses should not be floated to areas
where they have not been adequately cross trained.
Physicians' Orders.
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The physician is responsible for directing medical treatment. Nurses are obligated to
follow physicians' orders unless they believe the orders are or in error would harm
clients. Therefore all orders must be assessed, and if one is found to be erroneous or
harmful, further clarification from the physician is necessary. If the physician confirms
the order and the nurse still believes it is inappropriate, the supervising nurse should be
informed. A nurse should not proceed to perform a physician's order if it is foreseeable
that harm will come to the client. The nursing supervisor should be informed and given a
written memorandum detailing the events in chronological order; the reasons for refusing
to carry out the order should also be written to protect the nurse from disciplinary action.
The supervising nurse should help re- solve the questionable order. A medical consultant
may be called in to help clarify the appropriateness or inappropriateness of the order. A
nurse carrying out an inaccurate or inappropriate order may be legally responsible for any
harm suffered by the client.
In a malpractice lawsuit against a physician and a hospital, one of the most frequently
litigated issues is whether the nurse kept the physician informed of the client's condition.
To inform a physician properly, nurses must per- form a competent nursing assessment of
the client to determine the signs and symptoms that are significant in relation to the
attending physician's tasks of diagnosis and treatment. Nurses must be certain to
document that the physician was notified and document his or her response, the nurse's
follow-up, and the client's response.
The physician should write all orders, and the nurse must make sure that they are
transcribed correctly. Verbal orders are not recommended because they increase the
possibilities for error. If a verbal order is necessary (e.g., during an emergency), it should
be written and signed by the physician as soon as possible, usually within 24 hours. The
nurse should be familiar with the institution's policy and procedures regarding verbal
orders.
Risk Management:
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sponge count and the client suffers an injury be- cause of a retained sponge, the hospital
is liable because the nurse charted a correct count when it was not correct.
Every piece of equipment must be carefully used to prevent injury to the client. There can
also be liability for nurses because of incorrect positioning or insufficient padding placed
when positioning the client. All nurses need to be risk managers.
Professional Involvement
Nurses must be involved in their professional organizations and on committees that
define the standards of care for nursing practice. If current laws, rules and regulations, or
policies under which nurses must practice do not reflect reality, nurses must become
involved as advocates to see that the scope of nursing practice is accurately de- fined.
Nurses must be willing to represent nursing and the client's perspective in the community
as well. The voice of nursing can be powerful and effective when the organizing focus is
the protection and welfare of the public entrusted to their care.
CONCEPT OF HEALTH
Health is a common theme in most cultures. In fact, all communities have their concepts
of health, as part of their culture. Among definitions still used, probably the oldest is that
health is the "absence of disease". In some cultures, health and harmony are considered
equivalent, harmony being defined as "being at peace with the self, the community, god
and cosmos". The ancient Indians and Greeks shared this concept and attributed disease
to disturbances in bodily equilibrium of what they called "humors".
Modern medicine is often accused for its preoccupation with the study of disease, and
neglect of the study of health. Consequently, our ignorance about health continues to be
profound, as for example, the determinants of health are not yet clear; the current
definitions of health are elusive; and there is no single yardstick for measuring health.
There is thus a great scope for the study of the "epidemiology" of health.
Health continues to be a neglected entity despite lip service. At the individual level, it
cannot be said that health occupies an important place; it is usually subjugated to other
needs defined as more important, e.g., wealth, power, prestige, knowledge, security.
Health is often taken for granted, and its value is not fully understood until it is lost. At
the international level, health was "forgotten" when the covenant of the League of
Nations was drafted after the First World War. Only at the last moment, was world health
95
brought in. Health was again '!forgotten" when the charter of the United Nations was
drafted at the end of the Second World War. The matter of health had to be introduced ad
hoc at the United Nations Conference at San Francisco in 1945 (1).
However, during the past few decades, there has been a reawakening that health is a
fundamental human right and a world -wide social goal; that it is essential to the
satisfaction of basic human needs and to an improved quality of life; and, that it is to be
attained by all people. In 1977, the 30th World Health Assembly decided that the main
social target of governments and WHO in the coming decades should be "the attainment
by all citizens of the world by the year 2000 of a level of health that will permit them to
lead a socially and economically productive life", for brevity, called "Health for All" (2).
With the adoption of health as an integral part of socio-economic development by the
United Nations in 1979 (3), health, while being an end in itself, has also become a major
instrument of overall socio-economic development and the creation of a new social order.
CHANGING CONCEPTS
An understanding of health is the basis of all health care. Health is not perceived the
same way by all members of a community including various professional groups (e.g.,
biomedical scientists, social science specialists, health administrators, ecologists, etc)
giving rise to confusion about the concept of health. In a world of continuous change,
new concepts are bound to emerge based on new patterns of thought. Health has evolved
over the centuries as a concept from an individual concern to a world -wide social goal
and encompasse{i the whole quality of life. A brief account of the changing concepts of
health is given below:
1. Biomedical concept
Traditionally, health has been viewed as an "absence of disease", and if one was free from
disease, then the person was considered healthy. This concept, known as the "biomedical
concept" has the basis in the "germ theory of disease" which dominated medical thought
at the turn of the 20th century. The medical profession viewed the human body as a
machine, disease as a consequence of the breakdown of the machine and one of the
doctor's task as repair of the machine (4). Thus health, in this narrow view, became the
ultimate goal of medicine.
The criticism that is levelled against the biomedical concept is that it has minimized the
96
role of the environmental, social, psychological and cultural determinants of health. The
biomedical model, for all its spectacular success in treating disease, was found inadequate
to solve some of the major health problems of mankind (e.g., malnutrition, chronic
diseases, accidents, drug abuse, mental illness, environmental pollution, population
explosion) by elaborating the medical technologies. Developments in medical and social
sciences led to the conclusion that the biomedical concept of health was inadequate.
2. Ecological concept
Deficiencies in the biomedical concept gave rise to other concepts. The ecologists put
forward an attractive hypothesis which viewed health as a dynamic equilibrium between
man and his environment, and 'disease a maladjustment of the human organism to
environment. Dubos (5) defined health saying: "Health implies the relative absence of
pain and discomfort and a continuous adaptation and adjustment to the environment to
ensure optimal function". Human ecological and cultural adaptations do determine not
only the occurrence of disease but also the availability of food and the population
explosion. The ecological concept raises two issues, viz. imperfect man and imperfect
environment. History argues strongly that improvement in human adaptation to natural
environments can lead to longer life expectancies and a better quality of life - even in the
absence of modern health delivery services (6).
3. Psychosocial concepts
Contemporary developments in social sciences revealed that health is not only a
biomedical phenomenon, but one which is influenced by social, psychological, cultural,
economic and political factors of the people concerned (6). These factors must be taken
into consideration in defining and measuring health. Thus health is both a biological and
social phenomenon.
4. Holistic concept
The holistic model is a synthesis of all the above concepts. It recognizes the strength of
social, economic, political and environmental influences on health. It has been variously
described as a unified or multidimensional process involving the well-being of the
whole person in the context of his environment. This view corresponds to the view held
by the ancients that health implies a sound mind, in a sound body, in a sound family, in
sound environment. The holistic approach implies that all sectors of society have an
effect on health, in particular, agriculture, animal husbandry, food, industry, education,
97
housing, public works, communications and other sectors (7). The emphasis is on the
promotion and protection) of health.
CONCEPT OF DISEASE There have been many attempts to define disease. Webster
defines disease as "a condition in which body health is impaired, a departure from a state
of health, an alteration of the human body interrupting the performance of vital
functions". The Oxford English Dictionary defines disease as "a condition of the body or
some part or organ of the body in which its functions are disrupted or deranged". From an
ecological point of view, disease is defined as a maladjustment of the human organism to
the environment" (80). From a sociological point of view, disease is considered a social
phenomenon, occurring in all societies (81) and defined and fought in terms of the
particular cultural forces prevalent in the society. The simplest definition is, of course,
that disease is just the opposite of health - i.e., any deviation from normal functioning or
state of complete physical or mental well-being - since health and disease are mutually
exclusive. These definitions are considered inadequate because they do not give a
criterion by which to decide when a disease state begins, nor do they lend themselves to
measurement of disease.
The WHO has defined health but not disease. This because disease has many shades
("spectrum of disease" ranging from in apparent (sub clinical) cases to severe manifest
illness. Some diseases commence acutely (e.g., fool poisoning), and some insidiously
(e.g., mental illness rheumatoid arthritis). In some diseases, a "carrier" state occur in
which the individual remains outwardly healthy, and is able to infect others (e.g.,
typhoid fever). In some instances, the, same organism may cause more than one clinical
manifestation (e.g., streptococcus). In some cases, the same disease may b; caused by
more than one organism (e.g., diarrhoea). Some diseases have a short course, and some a
prolonged course. I is easy to determine illness when the signs and symptoms an
manifest, but in many diseases the border-line between normal and abnormal is
indistinct as in the case of diabetes hypertension and mental illness. The end-point or
final outcome of disease is variable - recovery, disability or death of the host.
Distinction is also made between the words disease, illness and sickness which are not
wholly synonymous. The tern "disease" literally means "without ease" (uneasiness) disease, the opposite of ease - when something is wrong with bodily function. "illness"
refers not only to the presence of specific disease, but also to the individual's perceptions
98
and behaviour in response to the disease, as well as the impact 0 that disease on the
psychosocial environment (82). "Sickness' refers to a state of social dysfunction. Susser
(83) has suggested the following usage.
Disease is a physiological/psychological dysfunction; Illness is a subjective state of the
person who feels aware of not being well.
Sickness is a state of social dysfunction, i.e., a role that the individual assumes when ill
("sickness role").
The clinician sees people who are ill rather than the disease! which he must diagnose and
treat (84). However, it is possible to be victim of disease without feeling ill, and to be ill
withou1 signs of physical impairment. In short, an adequate definition of disease is yet to
be found - a definition that is satisfactory 01 acceptable to the epidemiologist, clinician,
sociologist and the statistician.
THEORY NOURSING PRACTICE
The Domain of Nursing:
Any science has a domain, which is the view or perspective of the discipline. The domain
contains the subject, central concepts, values and beliefs, phenomena of interest, and the
central problems of the discipline. The domain of
including
knowledge
development,
experience practice, and literature identified with the profession (Alligood and MarrinerTomey, 2002). Nursing identified its domain in a paradigm that includes four linkages the
person, health, environment situation, and nursing. person refers to the recipient of
nursing care, including individual clients, families, and the community. The person is
central to the care being provided. Because the person's needs are multidimensional, it is
important that nursing provides care that is individualized to the client's needs.
99
Health is defined in different ways by the client, the clinical setting, and the health care
profession . It is the goal of nursing care. The American Association (ANA) (1995)
defines health as dynamic state of being which the developmental and behaviour potential
of the individual is realized to the t extent possible." Health is dynamic and continuously
changing. The nurse is challenged to provide can based on the client's individualized
level of health and the care needs at the time of care delivery.
Environment situation includes all possible conditions affecting the client and the
setting in which health care needs occur. For example, a client's level of health and health
care needs can be influenced by factors the home, school, workplace, or community. An
adolescent girl with immune-mediated (or type 1) diabetes may need to adapt her care
regimen to physical activities of school, to the demands of a part-time job, and to the
timing of social events, such as her. There is continuous interaction between the client
and the environment. This interaction can have positive and negative effects on the
person's level of health and health care. Nursing has a unique focus in helping clients ~in
all situations achieve a stable or improved level of health.
Nursing is the "diagnosis and treatment of human responses to actual or potential health
problems" For example, a nurse does not medically diagnose client's heart condition but
instead assesses the client response to the disease and develops nursing diagnosis of
fatigue, change in body image, and altered ing. From these nursing diagnoses, the nurse
creates individualized plan of care. Nurses use cal thinking skills to integrate knowledge,
experience, attitudes, and standards into the individualized plan of for each client.
Theory:
A theory is a set of concept definitions relationships, and assumptions that project a
systematic View of phenomena. For example, Orem's self-care deficit theory defines
nursing as a helping service, a creative effort to help people (Fawcett, 1995). In addition,
Orem's theory suggests that the goal of nursing is to help people to meet their own
therapeutic self-care demands. From this theoretical view, nursing assists clients by
acting for, doing, or guiding physical and/or psychological support. Orem's theory
contains a detailed framework of self-care concepts that are linked in such a way as to
explain, describe, or predict the type of nursing care that will assist clients to achieve a
100
better level of health. A theory is a way of seeing through a "set of relatively concrete and
specific concepts and the propositions that describe or link the concepts" (Fawcett, 1999).
A nursing theory is a conceptualization of some aspect of nursing communicated for the
purpose of describing, explaining, predicting, and/or prescribing nursing care (Meleis,
1997). For example, Orem's theory (2001) explains the factors within a clients' living
situation that support or interfere with the client's self-care ability. It is important to note
that this theory has value in helping nursing design nursing interventions to pro- mote the
client's self-care in managing an illness such as diabetes or arthritis.
Theories constitute much of the knowledge of a discipline, and theory and inquiry are
vital linkages to each other (Fawcett and others, 2001). Nursing theories pro- vide nurses
with a perspective to view client situations, a way to organize data, and a method to
analyze and interpret information. When a nurse uses Orem's theory in practice, the nurse
assesses and interprets the data to determine the client's self-care needs, self-care deficits,
and self-care abilities in the management of a disease. The theory then guides the nurse to
design individualized nursing interventions. Application of nursing theory in practice
depends on the nurse's knowledge of nursing and other theoretical models, how these
models relate to each other, and the use of these models in designing nursing
interventions.
Nursing is a learned profession, a science, and an art (Rogers, 1990). Nurses need a
theoretical base to exemplify the science and art of the profession when they pro- mote
health and wellness for their clients, whether the client is an individual, a family, or a
community.
Components of a Theory :
As previously stated, a theory is a set of concepts, definitions, and assumptions or
propositions to explain a phenomenon. The theory explains how these elements are
uniquely related in the phenomenon. It is developed after extensive research, which
allows the re- searcher to see a clear perspective of all components of a phenomenon. For
example, Kristin Swanson studied the phenomenon of caring by conducting extensive
inter- views with clients and their professional caregivers (Swanson, 1991). Swanson's
theory of caring defines five components of caring: knowing, being with, doing for,
enabling, and maintaining belief. These components provide a foundation of knowledge
for the direction and delivery of caring nursing practice. Swanson's theory provides a
101
basis for identifying nurse, caring behaviors, which can then be tested, to determine to if
caring can improve client health outcomes.
Concepts
Definition
`
Phenomenon
Assumptions
or
Propositions
102
a normal range of responses; stressors attack flexible lines of defense followed by the
normal lines of defense; and nurse's actions are focused on primary, secondary, and
tertiary prevention (Neuman, 1972).
Identify domain and goals of nursing.
Provide knowledge to improve nursing administration, practice, education, and
research.
Guide research to establish empirical knowledge base for nursing.
Identify area to be studied.
ldentify research techniques and tools that will be used to validate nursing
interventions.
.Identify nature of contribution that research will make to advancement of
knowledge.
Formulate legislation governing nursing practice, research, and education.
Formulate regulations interpreting nurse practice acts so that nurses and others
better understand laws.
Develop curriculum plans for nursing education.
Establish criteria for measuring quality of nursing care, education} and
research.
Guide development of nursing care delivery system.
Provide systematic structure and rationale for nursing activities.
Phenomenon. Nursing theories focus on the phenomena of nursing and nursing care. A
phenomenon is an aspect of reality that can be consciously sensed or experienced
(Meleis, 1997). Examples of phenomena of nursing include caring, self-care, and client
responses to stress. In Neuman Systems Model (1972), phenomena include all client
responses, environmental factors, and nursing actions. Within a specific discipline,
phenomena are part of the domain of the discipline. In nursing, phenomena reflect the
domain of nursing practice.
Types of Theory:
The general purpose of a theory is important because it specifies the context and situation
in. which the theory applies (Chinn and Kramer, 1999). Theories have different purposes
and may be classified by levels of abstraction (grand theories versus middle-range
103
theories) or the goals of the theory (descriptive or prescriptive). Theories may describe,
predict, or prescribe activities for the phenomena of interest.
Grand theories are broad in scope and complex and therefore require further
specification through research before they can be fully tested. A grand theory is not
intended to provide' guidance for specific nursing interventions, but to provide the
structural framework for broad, abstract ideas about nursing.
Theories that have more limited scope, less abstraction, address specific phenomena or
concepts and reflect practice (administration, clinical, or teaching) are considered
middle-range theories. The phenomena or concepts tend to cross different nursing fields
and reflect a wide variety of nursing care situations, such as uncertainty, incontinence,
social support, quality of life, and for example, Mishel's theory of uncertainty in illness
(1988, 1990) focuses on the experience of clients with cancer while living with continua;
uncertainty. The theory provides a basis for nurses to assist in appraising and adapting to
the uncertainty and the illness response.
Descriptive theories are the first level of theory development. They describe phenomena,
speculate on why phenomena occur, and describe the consequences of phenomena. They
have the ability to explain, relate, and in some situations predict nursing phenomena
(Meleis, for example, theories of growth and development describe the maturation
processes of an individual at various ages. Descriptive theories do not di- specific nursing
activities, but may help to explain client assessments.
Prescriptive theories address nursing interventions predict the consequence of a specific
nursing intervention. In nursing, a prescriptive theory should designate the prescription
(i.e., nursing interventions), the conditions under which the prescription should occur,
and consequences (Meleis, 1997). Prescriptive theories are on oriented, which tests the
validity and predictability a nursing intervention. These theories guide nursing recharch
to develop and test specific nursing interventions. For example, Mishel's theory of
uncertainty predicts that increasing the coping skills of clients gynecological cancer
assists their ability to deal with uncertainty of the cancer diagnosis and treatment. Thus
the theory provides a framework to design interventions that support and bolster clients'
coping resources.
104
Theoretical Models:
A theoretical model refers to global ideas about the individuals, groups, situations, or
events of interest to a specfic discipline from the view of the theorist. Theories focus
more specifically on the events and phenomena of discipline and are specific enough to
contribute to a d basis for nursing. Development of theory enhances ing science, which
involves the generation of knowledge.
knowledge from other disciplines, it is designed to advance and support nursing practice
and health care.
There are multiple nursing theories, some of which are presented in this and other
chapters in the text. It is important to understand the influence of theories from other
disciplines and their effects on nurses' clinical practice and client care and to use them in
developing innovative nursing interventions.
Relationship Of Theory
to the Nursing Process
and Client Needs
Historically, nursing theories were studied in an isolated academic environment
independent of nursing practice. Many nurses argued that theories were not relevant to
what occurs in clinical practice. There is, however, a contemporary move toward nursing
science or evidence based practice in which theories are tested and used to describe or
predict client outcomes of nursing care. For nursing to grow as a profession, knowledge
is needed to predict with confidence the types of nursing interventions that will improve
client outcomes. Nursing concepts and theories have evolved since Florence Nightingale,
who, in establishing the discipline of nursing, spoke with firm conviction about the nature
of nursing as a profession that required knowledge distinct from medical knowledge. The
overall goal of this knowledge has been to explain the practice of nursing as different and
distinct from the practice of medicine, psychology, and social work.
Theory generates nursing knowledge for use in practice. The integration of theory into
nursing practice is the basis for professional nursing. Nurses use the nursing process as a
means to determine the individual needs of clients. The nursing process is central to the
domain of nursing. However, the nursing process is not a theory it provides the process
for the delivery of nursing care, not the knowledge component of the discipline. The
105
process is a systematic approach for nursing care that allows a nurse to apply theory. For
example, a theory of caring influences what to assess, how to determine client needs, how
to plan care, how to select individualized nursing interventions, and how to evaluate
client outcomes. Useful theories are adaptable to different clients and all care settings.
Interdisciplinary Theories
To practice in today's health care systems, nurses need a strong scientific knowledge base
from nursing and other disciplines, such as the physical social, and behavioral sciences.
Knowledge from these other disciplines includes relevant theories that explain
phenomena. An interdisciplinary theory explains a systematic view of a phenomenon
specific to the discipline of inquiry, such as Erickson's development_theory.
Systems Theory:
A system is made up of separate components. The parts rely on one another, are
interrelated, share a common purpose, and together form a whole. A system has a specific
purpose or goal and uses a process to achieve that goal. The content is the product and
information obtained from the system.
Input is the information that enters the system. Output is the end product of a system.
Feedback is the process through which the output is returned to the system. Systems can
either be open or dosed. An open system interacts with its environment, exchanging
information between the system and the environment. Factors that change the
environment can also have an impact on the system. A closed system is one that does not
interact with the environment. An example of a closed system is a chemical reaction
occurring under specific conditions.
One example of an open system is the nursing process. The purpose of the nursing
process is to provide systematic and individualized client care. The process is the five
components assessment, nursing diagnosis, planning, implementation, and evaluation.
The content is the information obtained and used from each component. The nursing
process is an open system because the nurse applies the process to interact with the client
care environment. The nursing process continually changes as the client's nursing needs
Change. Input to the system comes from the client's assessment data (e.g., how the client
interacts with the environment). The output is re- turned as feedback to the system (e.g.,
106
the client's response to nursing interventions designed to assist the client to successfully
or unsuccessfully function in the environment).
using theories may have a systems model as the theoretical base. For example, Neuman
(1972, 1995) defines total-person model of wholism and an open systems aproach. As an
open system, the person interacts with the environment. The environment is both external
and internal, and the person interacts with stressors from the environment that affect the
system.
1952 Hildegard E. Peplau 1960 Faye G. Interpersonal process is maturing force
Abdellah Irene L. Beland Almeda Martin
for
personality.
Client's
problems
energy
fields
negentropically.
that
Self-care
evolve
maintains
wholeness.
Transactions
provide
frame
of
is
universal
and
varies
transculturally.
Caring is moral ideal: mind-body-soul
engagement with another. Disease is a
clue
to
preexisting
life
patterns.
107
INPUT
client interaction with
environment including
interactions from the
SYSTEM
OUTPUT
Nursing process
Assessment
Evaluation
environment
following domains.
Phychological
Nursing
Implementation
diagnosis
Physiological
DEvelomental
Planning
Sociocultural
Spiritual
Feedback
Client successfully or
unsuccessfully functions
in the environment
Basic Human Needs:
Maslow's hierarchy of needs is an interdisciplinary theory at is useful for designating
priorities of care. The hierarchy of basic human needs includes five levels of priority.
108
most basic, or first, level includes physiological needs, such physical and psychological
security. The third level contains love and belonging needs, including friendship, social
relationships, d sexual love. The fourth level encompasses esteem and Self esteem and
needs, which involve self-confidence, usefulness achievement, and self-worth. The final
level is the need for self-actualization, the state of fully achieving potential and having
the ability to solve problems and cope realistically with life's situations. Maslow's
hierarchy is extremely useful to nurses who must continually prioritize agent's nursing
care needs. Basic physiological and safety are usually the first priority, especially when a
client severely dependent physically. However, the nurse may counter situations in which
a client has no emergent physical or safety needs. Instead, high priority is given to e
psychological, socio cultural, developmental, or spiritual needs of the client.
Clients entering the health care system generally ve unmet needs. For example, a person
brought to an emergency department experiencing acute pneumonia an unmet need for
oxygen, the most basic physiological need. An older woman in a high crime area may be
concerned about physical safety and, while hospitalized have a need for psychological
security because of fear that her home will be burglarized. A widowed homemaker whose
children have moved away may feel that she does not belong or is not loved. Nurses in all
practice settings strive to help clients and their families meet these needs.
The hierarchy of needs is a useful way for nurses to plan individualized care for a client.
One need may take priority over another (such as restoration of an adequate airway
before the nurse educates the client in adjusting to in emotional conflict). The nurse uses
priorities to organize nursing diagnoses, develop goals and expected out- comes, and
select nursing interventions.
Health and Wellness Models:
Health and wellness theoretical models are designed to help health care professionals
understand the relationship between these two concepts and the client's attitudes toward
health and health practices. Knowledge of models assists nurses in understanding and
predicting the client's health behaviors, including use of health services and adherence to
recommended therapies . An understanding of these models is important when meeting
the health promotion and disease prevention needs of the client.
Stress and Adaptation:
109
Stress and adaptation are universal and dynamic. Everyone experiences stress and
attempts to adapt to life stressors. Stressors and stress responses are physiological and
behavioral. As a result, the models that explain the stress response are usually bio
behavioral and provide the framework for care of clients experiencing stress. Chapter 30
explains the more prominent theories and demonstrates how these models are used in
nursing practice.
Developmental Theories:
Human growth and development is an orderly predictive process that begins with
conception and continues through death. There are a variety of well-tested theoretical
models that describe and predict behavior and development at various phases of the life
continuum.
Psychosocial Theories:
Nursing is an eclectic discipline that strives to meet the holistic needs of clients in their
physiological, psychological, socio cultural, developmental, and spiritual do- mains.
There are theoretical models that explain and/or predict client responses in each of these
domains.
110
data collection, she linked the client's health status with environmental factors and
initiated improved hygiene and sanitary conditions during the Crimean War.
Nightingale 1860
Client's
To facilitate "the body's
reparative
Peplau 1952
processes"
manipulating
by
client's
environment
manipulated
to
include
light,
comfort,
develop
Nurses
participate
structuring
Abdellah 1960
is
Henderson 1955
environment
health
in
care
on-
workers
going
(Marriner- humans
tendency
to
of
develop
help
client
to
Henderson's
14
needs
(Henderson,
King 1971
To
provide
service
to
individuals, families,
Neuman 1972
Leininger 1978
This
theory
Abdellah's
problems
21
involves
nursing
(Abdellah
and
others, 1960).
service
(Marriner- "Unitary
man"
evolves
"humanistic science
This
theory.
is
self-care
deficit
Nursing
care
biological,
psychological,
developmental,
To use communication to
help
client
positive
reestablish
adaptation
to
environment
or
social
between
nurse,"
individuals, client, and health care sysfamilies, and groups in tem (King, 1981).
attaining and maintaining Stress reduction is goal of
maximal level of total systems model of nursing
To
assist
wellness
by
interventions
To
identify
types
demands placed on
of psychological, sociological,
and
dependence-
adaptive
client, assess adaptation to independence
demands, and help client modes (Roy, 1980).
This
adapt
theory
involves
caring
is
process
To promote health, restore interpersonal
client to health, and prevent comprising in- interventions
illness
112
and
enables
Nightingale provided basic concepts and propositions that could be supported and used
for practice in nursing. Nightingale's "descriptive theory" provides nurses with a way to
think about nursing with a frame of reference that for causes on clients and the
environment. Nightingale's letters and writings direct the nurse to act on behalf of the
client. Her principles were visionary and encompassed the areas of practice, research, and
education. Most important, her concepts and principles shaped and delineated nursing
practice. Nightingale taught and used the nursing process, noting that ('vital observation
[assessment] ...is not for the sake of piling up miscellaneous information or curious facts,
but for the sake of saving life and in- creasing health and comfort."
Peplau's Theory
Hildegard Peplau's theory (1952) focuses on the individual, the nurse, and the interactive
process; the result is the nurse-client relationship (Yamashita, 1997). According to this
theory, the client is an individual with a felt need, and nursing is an interpersonal and
therapeutic process, nursing goal is to educate the client and family and to help the client
reach mature personality development. The nurse strives to develop nurse-client
relationship in which the nurse serves as a resource person, counselor, and surrogate.
For example, when the client seeks help, the nurse and t first discuss the nature of the
problem and the e explains the services available. As the nurse-client relationship
develops, the nurse and client mutually de- the problem and potential solutions. The
client gains this relationship by using available services to meet , and the nurse assists the
client in reducing anxiety related to the health care problem. Peplau's theory is unique in
that the collaborative nurse-client relationship creates a "maturing force" through which
interpersonal effectiveness meets the client's needs. When the client's original needs have
113
been resolved, new needs may emerge. The nurse-client interpersonal relationship is
characterized by the following overlapping phases orientation identification, explanation,
and resolution.
Henderson/s Theory :
Virginia henderson defines nursing as "assisting the individual, sick or well, in the
performance of those activities that will contribute to health, recovery, or a peaceful death
and that the individual would perform unaided if he or she had the necessary strength,
will, or knowledge". The process of nursing strives to do this as rapidly as possible, and
the goal is independence. Henderson organized in to the theory 14 basic ``needs of the
whole person and includes phenomena from the following domains of the client
Physiological, psychological, socio cultural, spiritual, and developmental. together the
nurse and client work in unison to meet these needs and attain client-centered goals.
Abdellahs Theory:
Nursing theory developed by Faye Abdellah and others (1960) emphasizes delivering
nursing care for the whole person to meet the physical, emotional, intellectual social, and
spiritual needs of the client and family. when using this approach, the nurse needs
knowledge and skills in interpersonal relations, psychology, growth development,
communication, and sociology, as well as a knowledge of the basic sentences and specific
nursing skill. The nurse is a problem solver and decision maker the nurse formulates an
individualized view of the client's , need which may occur in the following four areas:
1. Comfort, hygiene, and safety
2. physiological balance
3. Psychological and social factors
4. Sociological and community factors
Johnson /s Theory
Dorothy Johnson's theory of nursing (1968) focuses on how the client adapts to illness
and how actual or potential stress can affect the ability to adapt. The goal of nursing is to
reduce stress so that the client can move more easily through recovery. According to
Johnson, the nurse assesses the client's needs in behavioral subsystems. Under normal
conditions tile client functions effectively in the environment. When stress disrupts
normal adaptation, however, behavior becomes erratic and less purposeful. The nurse
114
identifies this inability to adapt and provides nursing care to resolve problems in meeting
the client's needs.
Rogers' Theory
Martha Rogers (1970) considered the individual (unitary human being) as an energy field
coexisting within the universe. The individual is in continuous interaction with the
environment and is a unified whole, possessing personal integrity and manifesting
characteristics that are more than the sum of the parts (Rogers, 1970). The unitary human
being is a "four dimensional energy field identified by pattern and manifesting
characteristics that are specific to the whole and which cannot be predicted from the
knowledge of parts". The four dimensions used in Rogers' theory-energy fields, openness,
pattern and organization, and dimensionality-are used to derive principles related to
human development.
Orem's Theory
Dorothea Orem (1971) developed a definition of nursing that emphasizes the client's selfcare needs. Orem defines self-care as a learned, goal-oriented activity directed to- ward
the self in the interest of maintaining life, health, development, and well-being. The goal
of Orem's theory is to help the client perform self-care. According to Orem, nursing care
is necessary when the client is unable to fulfill biological, psychological, developmental,
or social needs. The nurse determines why a client is unable to meet these needs, what
must be done to enable the client to meet them, and how much self-care the client is able
to perform. The goal of nursing is to increase the client's ability to independently meet
these needs.
Neuman's Theory
Betty Neuman's theory (1995) defines a total-person model for nursing, incorporating a
wholistic concept and an open-systems approach . Neuman believes"that nursing is
concerned with the whole person. The goal of nursing is to assist individuals, families,
and groups in attaining and maintaining a maximal level of total wellness (Neuman and
Young, 1972). The nurse assesses, manages, and evaluates client systems. Nursing
focuses on the variables affecting the client's response to the stressor.
Nursing actions in dude the primary, secondary, and tertiary levels of prevention. Primary
prevention focuses on strengthening a line of defense through the identification of actual
or potential risk factors associated with stressors. Secondary prevention strengthens
115
internal defenses and resources by establishing priorities and treatment plans for
identified symptoms, and tertiary prevention focuses on readaptation. The principal goal
in tertiary prevention is to strengthen resistance to stressors through client education and
to assist in preventing a recurrence of the stress response Alligood and Marriner-Torney.
Leininger's Theory:
Leininger's cultural care diversity and universality theory states that care is the essence of
nursing and the, dominant, distinctive, and unifying feature of nursing. Human caring
varies among cultures in its expressions processes, and patterns. To provide care to clients
of unique cultures the nurse selects interventions from one of the following:
King's Theory:
Flmogene King's goal attainment theory focuses on three dynamic interacting systems:
personal, interpersonal, and social. A personal relationship forms between client and
nurse. The nurse-client relationship is the vehicle for the delivery of nursing care, which
King defines as a dynamic interpersonal process in which the nurse and client are
affected by each other's behavior, l as well as by the health care system. The nurse's goal
is to use communication to assist the client in reestablishing or i maintaining a positive
adaptation to the environment.
Roy's Theory
Sister Callista Roy's adaptation theory views the client as an adaptive system. According
to Roy's model, the goal of nursing is help the person adapt to changes in physiological !
needs, self-concept, role function, and interdependent relations during health and illness.
The need for nursing care arises when the client cannot adapt to internal and external
environmental demands. All individuals must adapt to the following demands:
1. Meeting basic physiological needs
2. Developing a positive self-concept
3. Performing social roles
4. Achieving a balance between dependence
116
independence
i The nurse determines what demands are causing problems for a client and assesses how
well the client is adapt- ing to them. Nursing care is then directed at helping the client
adapt. For example, a postoperative client who has a significant blood loss and now has a
low hematocrit value needs nursing interventions designed to assist the client in adapting
to the associated fatigue. The nurse I may design interventions to allow sufficient rest.
Watson's Theory:
Jean Watson's philosophy of transpersonal caring defines the outcome of nursing activity
in regard to the humanistic aspects of life. The action of nursing is directed at
understanding the interrelationship between health, illness, and human behavior. Nursing
is concerned with promoting and restoring health and preventing illness.
Watson's model is designed around the caring process, assisting clients in attaining or
maintaining health or in dying peacefully. This caring process requires that the nurse be
knowledgeable about human behavior human responses to actual or potential health
problems, individual needs, how to respond to others, and strengths and limitations of
the client and family, as well as those of the nurse. In addition, the nurse comforts and
offers compassion and empathy to clients and throw families. Caring represents all of the
factors the nurse uses to de- liver health care to the client.
Benner and Wrubel's Theory:
The primacy of caring is a model proposed by Patricia Benner and in this model, caring is
central. Caring creates possibilities for coping; enables possibilities for connecting with
and concern for others, and allows for the giving and receiving of help. As defined in this
theory, caring means that persons, events, projects, and things matter to people. Caring
itself presents a connection (Edwards, 2001). Caring represents a wide range of
involvement (e.g., caring about one's family, caring about one's friend- ships, and caring
about one's clients). Benner and Wrubel see the personal concern as an inherent feature of
nursing practice. In caring for one's clients, nurses help clients recover by noticing those
interventions that are successful and that can guide future care giving (Edwards, 2001).
Chapter 7 describes this theory and other theoretical perspectives on caring within the
nursing context.
Application of nursing theory in practice depends on nurses having knowledge of the
theories, as well as an understanding of how the theories relate to one another. Theories
117
are the organizing frameworks for the science of nursing and the substantive approaches
for nursing care. They provide critical thinking structures to guide clinical reasoning and
problem solving.
The Link Between Theory and Knowledge Development in Nursing
Nursing has its own body of knowledge that is both theoretical and practical. Theoretical
knowledge includes and "reflects on the basic values, guiding principles, elements, and
phases of a conception of nursing" (Meleis, 1997). The goals of theoretical knowledge
stimulate thinking and create a broad understanding of the "science" and practices of the
nursing discipline.
Practical knowledge is not organized in the same manner as theoretical knowledge.
Practical knowledge or the "art" of nursing is based on nurses' experience in providing
care to clients. It is achieved through personal know- ing gained through reflection on
care experiences, synthesis, and integration of the art and science of nursing.
An earlier discussion in this chapter described the types of nursing theories and indicated
that theories provided direction to nursing research. The relationships of components in a
theory help to drive the research questions for understanding nursing phenomena. For
example, the relationship of components within Orero's self- care deficit theory has led
nurse researchers to test approaches for their efficacy in improving self-care. The
relationship between nursing theory and nursing research helps to build the discipline's
knowledge base. As more research is conducted, the discipline learns to what
" extent a given theory can be useful in providing knowledge that improves client care.
note that one view of the relationship between research and theory is a spiral
This spiral represents the interaction between theory and research and an underlying
assumption that research increases nursing's knowledge base. Research is linked to theory
in two ways: generation of theory and testing of theory Theory-generating research is
designed to discover and
preconceived notions (e.g., hypotheses) of what the phenomena under study mean (Chinn
and Kramer, 2004).
In theory-generating research, the investigator makes observations with an open mind in
order to view a phenomenon in a new way. For example, a researcher may want to
understand end-of-life surrogate dedsion making. In this example, the researcher
118
interviews surrogate decision makers. From these interviews, the researcher would make
objective observations about the surrogate decision making process, resulting in an initial
theory of surrogate decision making.
Theory testing research is used to determine how accurately a theory describes a nursing
phenomenon. The investigator has some preconceived notions as to how the phenomenon
is described and generates research questions or hypotheses to test the assumptions of the
theory. Using the previous example of surrogate decision making, the researcher may test
elements of the theory. For example, interviews of decision makers indicated that more
knowledge about end of life care expectations was needed. The researcher may then
initially test an educational pro- gram on end-of-life care for groups of surrogate
caregivers. No one study can test all components of a theory; the theory is tested through
a variety of research activities.
The result of theory-generating or theory-testing research is to increase nursing's
knowledge base. As a result, nurses are able to incorporate research-based interventions
into the practice of the discipline. As these research activities continue, not only does the
knowledge and science of nursing increase, but also clients are the recipients of best
evidence-based nursing practice.
As an art, nursing relies on knowledge gained from practice and reflection of past
experiences. As a science, nursing draws on scientifically tested knowledge that is
applied in the practice setting. But it is the "expert nurse" who transports the art and
science of nursing into the scientific realm of creative caring.
119
To identify a client's health status and actual or potential health care problems or
needs
The components of the nursing process follow a logical sequence, but more than one
component may be involved at anyone time
Figure 4
In 1961, the nursing process was defined at the Cartholic University of America. It was
developed as a template for thinking that was exclusively for nursing. Although the
process was designed with registered nurses in mind, use of the nursing process provides
a common way of thinking for all licensed nurses. All licensed nurses collect data for
assessment. They plan, implement, and evaluate. Through the data they collect and
through their ongoing evaluation of the client, contribute to the nursing diagnoses that
RNs are responsible for making.
120
nurse using the process are similar. An overview of the five-phase nursing process is
shown in
Table 4
The system is open and flexible to meet the unique needs of client, family,
group, or community.
It is cyclic and dynamic. Because all phases are interre- lated, there is no
absolute beginning or end.
It is planned.
It is goal directed.
It permits creativity for the nurse and'client in devising ways to solve the
stated health problem.
The nursing process "provides the framework in which nurses use their knowledge and
skills to express human caring" and to help clients meet their actual and potential health
problems. The nursing process has unique properties that enable it to respond to the
changing health status of the client.
Role of the Nurse in Nursing Process
Nurse is one of the important members of the health care team, should be familiar with
all aspects of the nursing process. They should be specially educated in those aspects that
fall within their scope of practice. Within each step of the nursing process, there will be
functions performed by the nurse, functions carried out in collaboration with or under the
direction of the RN, and functions implemented by the RN. The importance of
understanding the entire process cannot be overemphasized.
121
the
planned
Assessment
Assessment is the systematic collection, organization, validation (proving or supporting),
and documentation of data information. All phases of the nursing process depend on urate
and complete data collection. Nursing assessments focus on a client's responses to a
health problem. The joint commission on Accreditation of Healthcare Organizations
(JCAHO, 2001) recommended that each client receive a documented assessment on
admission to an agency. The initial assessment is usually done by the RN.
122
In some situations, ongoing assessments are also done only by RNs. This may be stated in
the nurse practice act of state or may be a management decision of a particular facility.
The nurse is responsible for contributing by collecting data. The nurse is also responsible
for reading the assessment prior to beginning care of assigned clients.
The assessment process involves four closely related activities collecting data, organizing
data, validating data, documenting data.
Collecting Data
Data collection is the process of gathering information about a client. It must be both
systematic and continuous, and it must reflect a client's changing health status.
A client's database (baseline data) includes information from many sources: (1) The
nursing health history, (2) nurse's physical assessment, (3) the physician's history and
physical examination, (4) results of laboratory and diagnostic tests, and (5) information
contributed by other health personnel. (See Components of a Nursing Health History
in)
Client data should include past history as well as current. problems. For example, a
history of an allergic reaction to penicillin is a vital piece of historical data. Current data
relate to present circumstances, such as pain, nausea, or sleep pat- terns. To collect data
accurately, both the client and nurse must participate actively.
TYPES OF DATA
Data can be subjective or objective. Subjective data, also referred to as symptoms, are
apparent only to the person affected. Itching, pain, and feelings of worry are examples of
subjective data. Subjective data include the client's sensations, feelings, values, beliefs,
attitudes, and perception of personal health status and life situation. Information supplied
by family members and significant others is also considered subjective.
Objective data, also referred to as signs, are detectable by an observer or can be tested
against an accepted standard. They can be seen, heard, felt, or smelled. For example, a
discoloration of the skin or a blood pressure reading are objective data. During the headto-toe assessment, the nurse obtains the objective data needed to validate subjective data.
A complete data- base of both subjective and objective data provides a baseline for
comparing the client's responses to nursing and medical interventions.
Biographic Data ,
Client's name, address, age, sex, marital status, occupation, religious preference, health
123
Scale of pain: 1 to 10
Timing: when it began, how long it lasts, and how often it occurs
Past History
Childhood illnesses
Medication: all currently used prescription and over- the-counter medication, such
as aspirin, nasal spray, vit- amins, or laxatives
Lifestyle
Diet
Sleep/rest patterns
Activities of daily living (ADLs): any difficulties in per- forming the basic
activities
Recreation/hobbies
Social Data
Ethnic affiliation
124
Health insurance
Psychological Data
Major stressors .
Communication style
Sources of Data
The client is the primary source of data. All sources other than the client are considered
secondary sources. The nurse should indicate on the nursing history when the data are
obtained from a secondary source (a parent, a cousin, a friend).
Client Records -:
The nurse must always consider the information in client records in light of the present
situation. For example, if the most recent medical record is 10 years old, it is likely that
the client's health practices and coping behaviors have changed.
Data Collection Methods
The primary methods used to collect data are observing, inter- viewing, and examining.
Observation occurs whenever the nurse is in contact with the client or support persons.
Interviewing is used mainly while taking the nursing health history.
Observing
Observation is gathering data by using the senses. Although nurses observe mainly
through sight, most of the senses are engaged during careful observations. Examples of
client data observed through four of the five senses are shown in Table 4-2 .
Subjective
125
Client states he has a cramping pain in his abdomen, States, "I feel sick to my
stomach,"
Objective
,
Active bowel sounds auscultated in all four quadrants .Lung sounds clear
bilaterally; diminished in right lower lobe
Vision
Smell
Hearing
Touch
126
Interviewing
An interview is a planned communication or a conversation l purpose. In interviews, the
nurse gets or gives information; identifies problems of mutual concern; evaluates change;
teaches; and provides support, counseling, or therapy. Interviewing is a process the nurse
applies in most phases of the 19 process. During the assessment phase, however, the try
purpose of the interview is to gather data. One example of the interview is the admission
questionnaire.
Examining
The physical examination or physical assessment is a systematic data-collection method
that uses the senses of sight, 19, smell, and touch to detect health problems. To conduct
the examination, the nurse uses techniques of inspection, auscultation, palpation, and
percussion .
I
DOCUMENTING DATA:
To complete the assessment phase, the nurse records client Accurate documentation is
essential and should include all data collected about the client's health status. Data are led
in a factual manner and not interpreted by the nurse. (ample, the nurse records the client's
breakfast intake objective data) as "coffee 240 ml, juice 120 ml, 1 egg, and 1 )f toast," not
as "appetite good" (a judgment). A judgment or conclusion such as "appetite good" or
"normal appetite" may have different meanings for different people.
To increase accuracy, the nurse records subjective data in the client's own words.
Restating what someone says increases the chance of changing the original meaning.
Diagnosis
Diagnosis is the second phase of the nursing process. In this phase, nurses use criticalthinking skills to interpret assessment data and identify client strengths and problems. As
mentioned, this phase is the responsibility of the RN. The nurse discusses the collected
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data with the RN. The RN identifies appropriate nursing diagnoses for the client and
initiates the nursing care plan.
A nursing diagnosis is a statement about an alteration in the client's health status. It refers
to a condition that nurses are licensed to treat. A medical diagnosis is made by a
physician and refers to a condition that only a physician can treat. Table 4-3 compares
medical and nursing diagnoses, and collaborative problems.
The identification and development of nursing diagnoses began formally in 1973, and the
First Canadian- Conference took place in 1977. In 1982, the conference group accepted
the name North American Nursing Diagnosis Association (NANDA), recognizing the
participation and contributions of nurses in the United States and Canada. NANDA
updates its list of nursing diagnoses every two years.
Definitions
In 1990, NANDA adopted an official working definition of nursing diagnosis: "Nursing
diagnosis is a clinical judgment about individual, family, or community responses to
actual and potential health problems/life processes. Nursing diagnoses provide the basis
for selection of nursing interventions to achieve outcomes for which the nurse is
accountable."
Linda Carpenito provided a definition of nursing diagnosis which is perhaps easier to
understand. According to her, nursing diagnoses are" actual or potential health problems
which nurses, by virtue of their education and experience, are capable and licensed to
treat".
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Registered nurses are responsible for making nursing diagnoses. Nurses and other
nursing personnel contribute data to the process of diagnosing, and implement
specified nursing care.
The domain of nursing diagnosis includes only those health states that nurses are
educated and licensed to treat. For example, nurses are not educated to diagnose
or treat diseases like diabetes mellitus. This task is legally within the practice of
medicine. Yet nurses can diagnose and treat Deficient Knowledge, Ineffective
Individual Coping, or Imbalanced Nutrition, all of which may accompany
diabetes mellitus.
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Components of a NANDA:
Nursing Diagnosis
A nursing diagnosis has three components: the problem, qualifier(s), and etiology.
Problem (Diagnostic Label)
The problem statement, or diagnostic label, describes the client's health problem or
response for which nursing theory is given in clear, concise terms. The purpose of the
nursing diagnosis is to direct the formation of client goals and desired outcomes. It may
also suggest some nursing interventions.
Defining characteristics are the cluster of manifestations (signs and symptoms) that
indicate the presence of a particular diagnostic statement.
Qualifiers
When a NANDA label is followed by the word "(specify)", the nurse states the area in
which the problem occurs. For example, Deficient Knowledge (medications) or Deficient
Knowledge (dietary adjustments) specify the particular area in which teaching is needed.
Qualifiers are added to some NANDA statements to give additional meaning to the
diagnostic statement. For example:
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RN adds words to indicate the problem more specifically. For example, "Noncompliance
(specify)" might become "Non- compliance (diabetic diet)" related to denial of having
disease.
Basic three-part statements are used for actual problems. The basic three-part nursing
diagnosis statement is called the PES format and includes:
1. Problem (P): Statement of the client's response (NANDA label).
2. Etiology (E): Factors contributing to or probable causes of the response.
3. Signs and symptoms (S): Defining characteristics manifested by the client.
Problem
Situational Low Self-Esteem related to (r/t)
Etiology
Rejection by husband as manifested by (a.m.b.)
Signs and Symptoms
Hypersensitivity to criticism; states, "1 don't know if I can manage by myself" and rejects
positive feedback
Planning
Planning is the third step in the nursing process. Planning is a systematic phase of the
nursing process that involves decision making and problem solving. In planning, the
nurse refers to the client's assessment data and diagnostic statements for direction in
formulating client goals. All planning is aimed at preventing, reducing, or eliminating the
client's health problems. The product of the planning phase is a client care plan.
The input of the nurse and support persons is essential if a plan is to be effective. Nurses
do not plan for the client, but encourage the client to participate as actively as possible in
shaping a plan. In a home setting, the client's sup- port people and caregivers are the ones
who implement the plan of care. Its effectiveness depends largely on them.
According to the NCLEX-PN test plan, the Nurse role in the planning phase is to do
the following:
1. Assist in the formation of the goals of care:
Communicate client needs that may require alteration of the goals of care
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Involve the client and healthcare team members in the selection of nursing
interventions.
Plan for the client's safety, comfort, and maintenance of optimum functioning.
Select nursing interventions for delivery of client's care (Anderson 2000, 233.)
Types of Planning
Planning begins with the first client contact and continues until the nurse-client
relationship ends, usually when the client is discharged from the health care agency.
Initial Planning:
The RN who performs the admission assessment usually develops the initial
comprehensive plan of care. Planning should be initiated as soon as possible after the
initial assessment, especially because of the trend toward shorter hospital stays. The nurse
can assist with data collection.
Ongoing Planning
Ongoing planning is done by all nurses who work with the client. As nurses obtain new
information and evaluate the client's responses to care, they can individualize the initial
care plan further.
Discharge Planning:
Discharge planning involves anticipating and planning for needs after discharge. It is a
crucial part of comprehensive health care and should be addressed in each client's care
plan. Although many clients are discharged to other agencies (e.g., nursing homes),
follow-up care is increasingly being delivered in the home. Effective discharge planning
begins at first client contact and involves comprehensive and ongoing assessment to
obtain information about the client's ongoing needs. For more about discharge planning.
Etiology
Desired Outcomes
Nursing
identify
Frequency)
Monitor intake and output
order
Depression
Fatigue, weakness
Urine
specific
Difficulty swallowing
1.005+ 1.025
Other
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gravity
or
+
increased Serum Na normal
metabolic rate
Diaphoresis
Vomiting
Diarrhea
Burns
Other
Defining Characteristics
Insufficient intake
other
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Standardized care plans specify the nursing care for the groups of clients with common
needs (e.g., all clients with , myocardial infarction). Individualized care plans are tailored
to meet the unique needs of a specific client-needs that are not addressed' by the
standardized plans.
Care plans include the actions nurses must take to address the client's nursing diagnoses
and produce the desired outcomes and a timeline for accomplishing the goal. The
complete plan of care for a client is made up of several different documents.
Kardex Care Plans:
Kardex is a trade name for a system in which client information and instructions for some
of the client's.care are kept on a large card in a central file, making information quickly
accessible. The Kardex usually contains information about diet, activity levels, self-care
hygiene needs, treatments, and procedures. Kardex information may change frequently. It
is usually recorded in pencil so that the Kardex can be changed and kept up to date. It is a
temporary record for ongoing care, and it does not become part of the client's medical
record.
Computerized Care Plans
Computers are increasingly being used to create and store nursing care plans. The
computer can also generate both standardized and individualized care plans. Nurses
access the client's stored care plan from a centrally located terminal at the nurses' station
or from terminals in client rooms. Examples of a computerized student care plan can be
found on the companion website. Regardless of whether care plans are handwritten,
computerized, or standardized, nursing care must be individualized to fit the unique needs
of each client. The nurse uses standardized care plans for predictable, commonly
occurring problems and an individual plan for unusual problems or problems that need
special attention.
Student Care Plans
Because student care plans are a learning activity as well as a plan of care, they may be
more lengthy and detailed than care plans used by working nurses. To help students learn
to write a care plan, educators generally require that it be individualized. They may also
require a column be included for "Rationale" after the nursing intervention column. A
rationale is the scientific principle given as the reason for selecting a particular nursing
intervention. Table 4-4 shows how such a care plan would be made.
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Ensure that the plan contains orders for ongoing assessment of the client (e.g.,
"Inspect incision q8h").
8. Include collaborative and coordination activities in the plan. For example, the
nurse might ask a nutritionist or physical therapist about specific aspects of the
client's care.
9. Include plans for the client's discharge and home care needs. It is often necessary
to consult and make arrangements with the community health nurse, social
worker, and specific agencies that supply client information and needed
equipment.
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THE'PLANNING PROCESS
Setting Priorities Priority setting is the process of identifying nursing diagnoses and
interventions in order from most important or critical to least important. Life-threatening
problems, such as loss of respiratory or cardiac function, are given highest priority.
Health-threatening problems, such as pain and decreased cop- ing ability, are assigned
medium priority because they may result in delayed development or cause destructive
physical or emotional changes.
Desired Outcomes
Evaluatio
Nursing orders
Rationale
a.Monitor
espiratory
status q4h rate depth
effort
skin
color
mucous
membranes,
amount and color of
sputum.
b. Monitor results of
blood gases chest x-ray
studies and incentive
spirometer volume as
available
c. Monitor level of
consciousness
A,b,c,d.To identify
progress toward or
deviations
from
goal
ineffective
airway clearance
leads
to poor
oxygenation
evidenced
by
pallor
cyanosis,
lethargy,
drowsiness retain
nursing orders to
continue
to
identify progress.
Goal
status
indicates problem
not resolved.
e.Inadequate
oxygenation
causes increased
pulse
rate.
Respiratory rate
may be decreased
by
narcotic
analgesics
or
increased
by
deyspnea
and
anxiety.
Does not need to
be reinstructed as
client
demonstrates
statements
Demonstrates
adequateair
exchange as
evidenced by
1. Absence of pallor
and
cyanosis(skin
andmucous
membranes)
Goal
partially
met.skin
and
mucous
membranes
not
cyanotic but still
pale.
Usingcorrect
breathing/coughing
techniqueafter
instruction
Productive cough
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Loss
of
respiratory
functioning is a lifethreatening problem.
nurse's primary concern
must be to promote the
client's
oxygenation by addressing
the etiologies of this
problem.
137
extreme
anxiety
could
further
compromise
oxygenation by causing her
to breathe ineffectively and
increasing the rate at which
she uses oxygen. these are
not a threat to life. Also,
treatment of her highpriority
roles problem, Ineffective
Airway Clearance, will
relieve one of the etiologies
of this problem (dyspnea).
Meanwhile, the nurse
Imbalanced Nutrition: Less Low priority
than Body Requirements
related to decreased ,
appetite,
nausea,
and
increased
metabolism
secondary
to
disease
process.
This
problem is
not
currently health threatening,
but it could be if it were to
persist. It will almost
certainly resolve in a day or
two as the medical problem
is treated. If the medical
problem does not resolve
quickly, this will change to a
medium priority.
138
139
Explain
Share
Assemble
Help
Sit
140
Breathe
Identify
Sleep
Choose
Inject
State
Compare
List
Talk
Define
Move
Transfer
Demonstrate
Name
Turn
Describe
Prepare
Verbalize
Differentiate
Report
Discuss
Select
1. Write goals/outcomes in terms of client responses, not nurse activities. Begin each
goal statement with "the client will" to focus on client behaviors and responses.
Avoid statements that start with enable, facilitate, allow, let, or permit, which
indicate what the nurse hopes to accomplish, not what the client will do. Correct:
Client will drink 100 cc of water per hour (client behavior). Incorrect: Maintain
client hydration (nursing action).
2. Be sure that desired outcomes are realistic for the client's capabilities, limitations,
and designated time span, if it is indicated. Limitations include finances,
equipment, family support, social services, physical and mental condition, and
time. For example, the outcome "Measures insulin accurately" may be unrealistic
for a: client who has poor vision due to cataracts.
3. Ensure that the goals/desired outcomes are compatible with the therapies of other
professionals. For example, the outcome "Will increase the time spent out of bed
by 15 minutes each day" is n9t compatible with a physician's prescribed therapy
of bed rest.
4. Make sure that each goal is derived from only one nursing diagnosis. For
example, the goal "The client will increase the amount of nutrients ingested and
show progress in the ability to feed self" is derived from two nursing diagnoses:
Feeding Self-Care Deficit and Imbalanced Nutrition: Less than Body
Requirements.
5. Use observable, measurable terms for outcomes. Avoid words that are vague and
require interpretation or judgment by the observer. Phrases like "increase daily
exercise" and "improve knowledge of nutrition" can mean different things to
different people. They are not clear and specific enough to guide the nurse when
evaluating client responses.
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6. Make sure the client considers the goals important and I values them. 'The nurse
must actively listen to the client '... to determine personal values, goals, and
desired outcomes in relation to current health concerns. Clients are usually
motivated to reach goals they consider important. They may resist goals they feel
they are told they "should do."
Table 4-6 shows how outcomes are derived from nursing diagnoses.
Nursing Diagnosis
Opposite
response
(Goals)
Impaired physical mobility: Improved mobility ability
inability to bear weight on to bear weight on left leg.
left
leg,
related
to
inflammation of knee joint.
Ineffective
Airway Effective airway clearance
clearance related to poor
cough effort, secondary to
incision pain and fear of
damaging sutures.
Implementation :
Implementation is the fourth step of the nursing process, in which selected nursing
interventions and activities occur. Nursing interventions are the actions that are initiated
by the nurse to achieve client goals. The specific strategies should focus on eliminating or
reducing the cause of the nursing diagnosis.
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Indirect care: An intervention performed away from but on ': behalf of the
client, such as obtaining a referral for physical therapy.
complication. For example, physician might order physical therapy to teach the client
crutch-walking. The nurse would be responsible for informing the physical therapy
department and for coordinating the client's care to include the physical therapy sessions.
When the client returns to the nursing unit, the nurse would assist with crutch-walking
and collaborate with the physical therapist to evaluate the client's progress.
The nurse is responsible for explaining, assessing the need for, and administering the
medical orders. The RN writes nursing orders to individualize the medical order based on
the client's status. For example, for a medical order of "Progressive ambulation, as
tolerated," the nursing orders might be: 1. Dangle for 5 min, 12 h post-op
2. Stand at bedside 24 h post-op; observe for pallor, dizziness, and weakness.
3. Check pulse before and after ambulating. Do not progress if pulse 110.
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Usually, several possible interventions can be identified for each nursing diagnosis. The
nurse's task is to choose those that are most likely to achieve the desired client outcomes.
Implementing Skills
Nurses employ a wide variety of skills in providing client care:
Cognitive:(intellectual) skills include problem solving decision making, critical thinking,
and creative thinking. They are crucial to safe, intelligent nursing care.
Interpersonal skills are all the verbal and nonverbal activities people use when
communicating directly with one another. The effectiveness of a nursing action often
depends largely on the nurse's ability to communicate with others. Even when giving
medication to a client, the nurse needs to understand the client and in turn be understood.
A nurse who is delegating a nursing action also needs to be understood.
Interpersonal skills: are necessary for all nursing activities. Caring, comforting,
referring, counseling, and support- ing are just a few. They include conveying knowledge,
attitudes, feelings, interest, and appreciation of the client's cultural values and lifestyle.
Technical skills: are "hands-on" skills such as manipulating equipment, giving injections,
doing dressing changes, moving, lifting, and repositioning clients. These tasks, called
procedures or psychomotor skills, always require communicating with the client.
However, they also require knowledge and, frequently, manual dexterity. The number of
technical skills expected of a nurse has greatly increased in recent years because of the
increased use of technology, especially in acute care hospitals.
Basic Procedures For Nursing Interventions
All procedures follow a basic format. You need to perform several steps whenever you
begin a procedure. These steps provide safeguards for the client and aid in your
organization. Procedure Basic Procedure Steps and Admission Information, demonstrates
the use of the procedure template.
The nurse should develop an understanding of the rationale (scientific reasoning) for each
intervention. You will find rationales in italics for many steps of the procedures.
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.The nurse is unable to implement the nursing strategies safely alone (e.g., turning
an obese client in bed).
.Assistance would reduce stress on the client (e.g., turning a person who
experiences acute pain when moved).
.The nurse lacks the knowledge or skills to implement a particular nursing activity
(e.g., a nurse who is not familiar with a particular model of oxygen mask needs
assistance the first time it is applied).
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assigned the task. Delegating does not relieve the nurse of the ultimate responsibility for
the task. When in doubt, the nurse and the unlicensed person should work together until
the unlicensed person's understanding of the assigned task d ability to perform it are
confirmed.
Documenting Nursing Actions:
After carrying out the nursing orders, the nurse completes the implementing phase by
recording the interventions and client responses in the nursing progress notes. These are a
part of the agencies
recorded in advance because, on reassessment, the nurse may find that the action should
not or cannot be implemented for example, a nurse is authorized to inject 10 mg of
morphine the sulfate subcutaneously to a client, but the nurse finds that the clients
respiratory rate is 4 breaths per minute. This finding contraindicates the administration of
morphine (a respiratory depressant). The nurse withholds the morphine and reports the
clients respiratory rate to the nurse in charge and! or physician.
The nurse may record routine or recurring activities (e.g.; mouth care) at the and of a
shift. In the meantime, the nurse maintains a personal record of these interventions. Many
agencies have special forms for this type of recording.
In some instances, it is important to record a nursing action immediately after it is
implemented. Recorded data about a client must be up to date, accurate, and available to
other nurses and health care professionals. This is particularly true of the administration
of medications and treatments.
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UNIT IV
QUALITY CONTROL
INTRODUCTION
Controlling is the function of management that involves, setting standards ,measuring
performance against those standards ,reposting the results and taking action. Employees
who feel they can influence their environment have
147
,thus increasing job satisfaction and motivation. Organization also need some control
over productivity, innovation and quality outcomes.
Quality control is a specific type of controlling, refers to activities that evaluate, monitor
or regulate services rendered to consumers. In nursing, the goal of quality care would be
to ensure quality while meeting intended goals. Quality control when viewed
simplistically can be broken down into three basic steps:
1. Criterion or standard is determined
2. Information is collected to determine if the standard has been met.
3. Educational or corrective action is taken if the criterion has not been met.
To understand quality control, the nurse manager must become familiar with the process
and the terminology used and quality assurance and quality improvement as follows
Philosophy is a system of motivating belief and principles that direct actions of a
particular group during goal pursuit. The philosophy of a nursing department determines
goals oft/1 nursing workforce, which in turn influence patient care objectives established
by each nurse,
Accountability is the obligation to provide a reasoning for one's actions to the per who
delegate authority for that action. The conscientious nurse exhibits accountability to ward
her his employer, the patient, and government agency or insurance company that pays/
the patient's health care.
A Nursing care outcome is the end result of nursing interventions, a measurable change
in the state of a patient's health that is occasioned by nursing action.
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A norm is current level of performance of a selected work group with reference to a given
criterion.
An objective is a goal towards which effort is directed. To be effective a goal should be
expressed in observable, measurable terms and should include a target date for fulfilment.
A critical clinical indicator is a quantitative measure that can be used as a guide to
monitor and evaluate the quality of important patient care activities.
Measurement is the objective process of determining capacity, quantity or dimension of
an object; phenomenon, or outcome.
Evaluation is a subjective judgment based on objective measurement.
Feedback is the information about system performance that is reflected back into the
system on a basis for monitoring system operation.
Quality health care is the appropriate application of medical science knowledge to patient
care, while balancing the hazards associated with each intervention with the benefits
resulting from the intervention.
Communication is an enabling process that allows information to be transfered and I
ideas to be translated into action.
Continuous quality improvement is the ongoing process of monitoring structure, process,
and outcome indicators in order to identify signal events, significant trends, and
opportunities for change that will guide health care professionals in preventing patient
care problems and improving already satisfactory patient services.
149
150
institution itself, e.g., each organization develops a policy and procedure manual that
outlines its specific standards. These standards will minimize or maximized in terms of
the quality of service expected. Standards of practice allow the organization to measure
more objectively unit and individual performance. The recommended relationship
between the nursing department and other departments in a health agency are structural
standards, because they refer to the organizational structure in which nursing is
implemented. Criteria that specify desired methods for specific nursing intervention are
process standard, because they refer to the process or series of events through which care
is administered. Descriptive statement of desired patient care results are outcome
standards, because patients results are outcomes of nursing interventions.
Koont and Weitrich (1988) have identified the following eight types of standards the most
organization must establish:
1. Physical standards, which include patient activity ratings to establish nursing care
hours per patient day.
2. Cost standards, which include the cost per patient day.
3. Capital standards, which include the review of monetary investment or new
programmes.
1.
4 Revenue standards, which include the revenue per patient day for nursing care.
All these standards provides the yardstick for measuring quality care, e.g. outcome
standards are defined in terms of what the patient will know, do, express or experience
and reflect nursing also for physiological, emotional and mental well-being. These
outcome measures to be the most valid indicators of quality care, and recently evaluation
of hospital care have focused on structure and process standards also. The structure
standards which are often set by licensing and according bodies ensure a safe and
effective environment but do not address the actual care provided. The process standards
151
process of analysing data about the nursing process of patient outcomes to evaluate the
effectiveness of nursing interventions. The audits most frequently used in quality control
include outcome, process and structure audits.
1. Outcome audit Outcomes are the end results of care; the changes in the patients
health status and can be attributed to the delivery of health care services.
Outcome audits determine what results if any occurred as result of specific
nursing intervention for clients.
These audits assume the outcome accurately and demonstrate the quality of care
that was
of hospital care include mortality, its morbidity, and length of hospital stay.
2. Process audit Process audits are used to measure the process of care or how the
care was carried out. Process audit is task oriented and focuses on whether or not
practice standards are being fulfilled. These audits assume that a relationship
exists between the quality of the nurse and quality of care provided.
3.
Structure audit Structure audit monitors the structure or setting in which patient
care occurs, such as the finances, nursing service, medical records and
environment. This audit assumes that a relationship exists between quality care
and appropriate structure. These above audits can occur retrospectively,
concurrently and prospectively.
Rules
1. Encourages followers to be actively involved in the quality control process.
152
Selects and uses process, outcome and structure audits appropriately as quality
control tools.
Keeps abreast of current government and licensing regulations that affect quality
control.
agency. '
154
6. Each department should generate statistical measurement data that shall empower
employees to improve work processes.
7. Data collection of quality assessment occurs at the employee level. Employees
participate with quality assessment personnel in data analysis.
8. A collaborative approach is used to integrate all suppliers into the TOM process.
9. Team work is needed to foster problem solving and eliminate barriers between
specialty areas and roles.
10. Corporate culture must change, by establishing long-term goals to support quality,
maintaining performance standards overtime, empowering employees, openly
demon. starting quality monitoring and developing problem solving circles at
organizational level.
In 1994, Glasser argues that five basic conditions must be met if workers are to do quality
work as follows:
1. The work environment must be warm and supportive. The workers must trust
management.
2.
Workers should be asked to do only useful or purposeful work. They should feel
that they are contributing to a worthwhile need.
He also says that all lead managers must learn what quality actually is, teach it to all in
the organization, and then listen carefully to any worker who has an idea of how it may
be further improved.
Simpson (1994) argues that the cost of the quality care made up of the aggregate cost of
non-conforming plus the cost of conforming to customer requirement. The five elements
that make up the cost of quality are:
1. Cost of preventing mistakes (Employee training)
155
2. The cost of appraisal (auditing and quality assurance) .The cost of failure (errors
and omissions)
3. The cost of exceeding requirements (Producing information nobody needs).
4. The cost of lost opportunities (lost market share and reduced revenues).
Ideally, everyone in the organization should participate in quality control because each
individual benefits from it, quality control gives employees feedback about their current
quality care and how their care can be improved.
As a direct care giver, staff nurses are in an excellent position to monitor nursing practice
by identifying problems and implementing corrective actions that have the greatest
impact on patient care. The primary purpose of the nursing profession is to provide ever
high quality care to patients and clients. Moreover, the nurses are the major provider of
health care, and must assum )leadership role when measuring the quality of their services
and documenting their cost
NURSING AUDIT:
The world trend of professional accountability to an enlightened public can no longer be
ignored by nursing. We nurses easily use the words "Quality Nursing" but have we
defined what we mean by Quality? Do we know our deficiencies? Are we ready to admit
our deficiencies to our peers? Are we taking steps to remedy them? Only by such self
regulation we can retain our identity with the health professional as nature partners.
Meaning of terms:
1. Quality A judgment of what constitutes good or bad.
2. Audit-A systematic and critical examination to examine or verify.
3. Nursing audit-(a) It is the assessment of the quality of nursing care, (b) uses a
record as an aid in evaluating the quality of patient care.
Brief History of Nursing Audit:
Nursing audit is an evaluation of nursing service. Before 1955 very little was known
about lie concept. It was introduced by the industrial concern and the year 1918 was the
beginning medical audit.
156
George Groword, pronounced the term physician for the first time medical audit. Ten
years later Thomas R Pondon MD established a method of medical audit based on
procedures used by financial account. He evaluated the medical care by reviewing the
medical records.
First report of nursing audit of the hospital published in 1955. For the next 15 years,
nursing audit is reported from study or record on the last decade. The programme is
reviewed from record nursing plan, nurses notes, patient condition, nursing care. .
Nursing Care Audit
Audit related to the planning, delivery and evaluation of care. It is an important
component: of nursing care.
Medical audit. The systematic, critical analysis of the quality of medical care, including
the procedures for diagnosis and treatment, the use of resources, and the resulting
outcome and quality of life for the patient.
Definition of Nursing Audit
1. According to Elison "Nursing Audit refers to assessment of the quality of clinical
nursing
2. According to Goster Walfer
a. Nursing Audit is an exercise to find out whether good nursing practices are
followed,
b. The audit is a means by which nurses themselves can define standards from
their point of
157
Nurses must be informed about the process and the results of the programme,
Quality data should be analysed and used by nursing personnel at all levels.
158
159
A group discussion to see how the group rates the care received using the notes of
a patient who has been discharged; these should be anonymous and should reflect
a total period of care not exceeding two weeks in length.
Each individual auditor should then undertake the same exercise as above. This is
followed by a meeting of the whole committee who compares and discuss its
findings, and finally reach a consensus of opinion on each of 1he components.
Retrospective audit is a method for evaluating the quality of nursing care by examining
the nursing care as it is reflected in the patient care records for discharged patients. In this
type of audit specific behaviours are described then they are converted into questions and
the examiner looks for answers in the record.
For example the examiner looks through the patient's records and asks:
a. Was the problem solving process used in planning nursing care
b. Whether patient data collected in a systematic manner
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Importance of Standard
A standard is a practice that enjoys general recognition and conformity among
professionals n authoritative statement by which the quality of practice, service or
education can be judged. One of the determinants of profession is that members of the
161
162
Nursing audit is the process of analysing data about the nursing process or patient
outcomes to evaluate the effectiveness of nursing intervention.
A standard is a performance model that results from integrating criteria with norms and
used to judge quality of nursing objectives, orders and methods. One method of nursing
quality improvement is nursing audit, in which patient outcomes are measured against
nursing standards and performance criteria to determine the efficacy of nursing actions.
Purposes of Standards
No profession in the coming decades can afford to be isolated from the reality of being
accountable for efficiency and effectiveness of the services provided by its members. To t
accountable is to be answerable for quality. Each profession faces the need to establish its
value in the field of health care, in terms of availability, quality, cost and effectiveness.
Professional accountability is thus a vital part of nursing management.
In order to provide a high quality of care, it is necessary that nurses develop standard c
care and appropriate evaluation tools so that professional aspect of assurance and
attention will be given to the individual needs and response to clients. Setting standard is
the firs step in structuring evaluation system. The following are some of the purposes of
standards
1. Standards give direction and provide guidelines for performance of nursing staff.
2.
Standards provide a baseline for evaluating quality of nursing care, ranging frorr
excellent care to unsafe care.
3. Standards help improve quality of nursing care, increase effectiveness of care and
improve efficiency.
4. Standards may help to improve documentation of nursing care provided, i.e.
maintaining record of care.
5. Standards may help to determine the degree to which standards of nursing care
maintained and take necessary corrective action in time.
6. Standards help supervisors to guide nursing staff to improve performance.
7. Standards may help to improve basis for decision-making and devise alternative
system for delivering nursing care.
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Nursing standards improve nursing care quality by focusing the nurses efforts toward
appropriate goals and heightening their motivation for goal achievement. Standards can
decrease care costs by eliminating non-essential nursing activities. Establishing nursing
negligence consist of determining that there is a standard of care governing the client
situation and that harm could be foreseen if the standard was not met; proving that nurse
failed to meet the relevant standard; and determining that the nurse's failure to meet the
standard caused harm to the patient.
Nursing is a service profession. Services rendered by nurses are essential to clients and
welfare. Therefore, the profession as whole is accountable for the quality of care
delivered by individual nurses.
Characteristics of Standard
The characteristics of standards which undo that standard:
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may be directed towards an ideal, i.e. optional standards or may only specify the
minimal care that must be attained, i.e. minimum standard.
And one must remember that standards that work are objective, acceptable, achievable
and flexible.
Sources of Nursing Care Standards:
It is generally accepted that standards should be based on agreed up achievable level of
performance considered proper and adequate for specific purposes. The standards can be
established, developed, reviewed or enforced by variety of sources as follows:
Government units at National, State and Local Government units. Individual e.g.
personal standards.
Classification of Standards
There are different types of standards used to direct and control nursing actions.
Standards can be normative or empirical. Normative standards describe practices
considered 'good' or 'ideal' by some authoritative group. Empirical standards describe
practices actually observed in a large number of patient care settings. Here the normative
standards describe a higher quality of performance than empirical standards. Generally
professional organizations (TNAI, ANA or NAI) promulgate normative standards where
as low enforcement and regulatory bodies (INC/MCI) promulgate empirical standards.
Nursing care standards can be divided into ends and means standards. The ends standards
are patient-oriented; they describe the change as desired in a patient's physical status or
behaviour. The means standards are nursing oriented, they describe the activities and
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behaviour designed to achieve the ends standards. Ends (or patient outcome) standards
require information about the patients. A means standard calls for information about the
nurses performance. Standards are expected to understandable, achievable and
measurable. Standards established for whatever sources and however developed, must be
available to members of the nursing staff on the patient care units.
Standards can be classified and formulated according to frames of references (used for
setting and evaluating nursing care services) relating to nursing structure, process and
outcome, because standard is a descriptive statement of desired level of performance
against which to evaluate the quality of service structure, process or outcomes.
Structure Standard
A structural standard involves the 'set-up' of the institution. The philosophy, goals and
objectives, structure of the organization, facilities and equipment, and qualifications of
employees are some of the components of the structure of the organization, e.g.
recommended relationship between the nursing department and other departments in a
health agency are structural standards, because they refer to the organizational structure
in which nursing is implemented. It includes people money, equipment, staffing policies
etc. and the evaluation of structure is designed to find out the effectiveness in terms of the
degree to which goals are achieved and efficiency in terms of the amount of effort needed
to achieve the goal.
The structure is related to the framework, that is care providing system and resources that
support for actual provision of care. Evaluation of care concerns nursing staff, setting and
the care environment. The use of standards based on structure implies that if the structure
is adequate, reliable and desirable, standard will be met or quality care will be given.
Process Standard Process standards describe the behaviours of the nurse at the desired
level of performance.
intervention are process standards. A process standard involves the activities concerned
with delivering patient care. These standards measure nursing actions or lack of actions
involving patient care. The standards are stated in action-verbs, that is in observable and
measurable terms, e.g. "the nurse assesses", "the patient demonstrates". The focus is on
what was planned, what was done and what was communicated or recorded. Therefore,
the process standards assist in measuring the degree of skill, with which technique or
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procedure was carried out, the degree of client participation or the nature of interaction
between nurse and client.
In process standard there is an element of professional judgment, i.e. determining, the
quality or the degree of skill. It includes nursing care techniques, procedures, regimens,
Processes.
Outcome Standards Descriptive statements of desired patient care results are outcome
standards, because patient's results are outcomes of nursing interventions. Here outcome
as a frame of reference for setting of standards refers to description of the results of
nursing activity in terms of the change that occurs in the patient. An outcome standard
measures change in the patient health status. This change may be due to nursing care,
medical care or as a result of variety of services offered to the patient. Outcome standards
reflect the effectiveness and results rather than the process of giving care.
n quality assurance outcomes are stated in positive terms as the nursing goal is to
improve the health status of client. "Quality assurance" is assuring excellence. It
encompasses necessary changes or improvements to ensure survival. It involves
identifying standards for excellence, evaluating care against those standards and then
taking action to correct deficiencies and achieve the standards. "Excellence" is a variable
on a continuum that will differ from institution to institution or person to person. It is a
value judgment made by the health care provider with many factors being considered
such as type of institution and the consumer. The three essential elements of quality
assurance are standards, surveillance and corrective action. In order to assure quality,
standards must be first established, or the definition of excellence, then standards are
monitored and evaluated for achievement and feedback from the evaluation is utilized for
corrective action.
Thus, structural standards are agency or group-oriented, process standards are nurseoriented, and outcome standards are patient-oriented. For example the nursing department
formal table or organization is a structural standard; a nursing care objective (if written in
the form of patient behaviour) is an outcome standard.
In order to provide a higher quality of care however, it is necessary that nurses develop
standards of patient care and appropriate evaluation tools, so that professional aspects of
167
nursing involving intellectual and interpersonal activities will be ensured and attention
will be given to the individual needs and responses to patients.
As stated earlier, formulation of standards is the first step towards evaluating the nursing
care delivery. The standards serve as a base by which the quality of care can be judged.
This judgment may be according to a rating or other data that reflect the conformity of
existing practice with the established standards. The standards must be written, regularly
reviewed and well-known by the nursing staff.
Standards can be established to appraise care according to many approaches. The most
common approaches are based on structure, process and outcome. The nursing
organization or structure is usually evaluated according to structure standards, the
activities or delivery of care are evaluated by process standards and the patients status is
evaluated by outcome standards. But all those type standards are interrelated and can be
used to evaluate various aspects in a nursing care.
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which he alone is responsible. Similarly in the absence of a dietician and a medico social
worker the nurse may take on both these duties. The major functions and activities of the
nurses and classified as follows:
Those dealing with organization and control of the patient's environment and to
secure for him maximum mental and physician comfort.
Those performed under the direction and in co-operation with the physician.
activities sometimes leads to conflict and clash of personalities. The functional authority
of physician requires the nursing officer to carry out his instructions for treatment of the
patients whereas he has no authority to relieve her of the patients whereas he has no
authority to relieve her of her duties or change her if she does not perform her functions
adequately. That is the responsibility of the matron or the CO. Similarly in ward
management there might be orders and counter orders originating from two sources of
authority over her 10wledge and a thorough understanding of each others responsibilities
to manage a ward efficiently. Some of the important duties of a head nurse are listed
below:
General cleanliness and upkeep of the ward and its surrounding areas to provide
neat and cheerful environments for the patients.
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Keeping the ward equipment in optimum state of readiness by prompt repairs and
replacement through condemnation boards.
Assignment or duties for patients care to the staff working is the ward taking into
consideration the capabilities of each.
t. Indenting the collection of various items of medical and OM and other stores.
Ensuring that all specimens are sent to the laboratory in time and results collected
when due.
Requisition of diet as per instructions of the medical officer and ensuring that the
diets and extras are distributed to patients as per the requisition.
Overall supervision of all that happens in the ward is to ensure that the patients
treatment and recovery is as smooth and pleasant as possible.
3-3Y2 hours
b. Maternity
4 hours
C. New born
2-2Y2 hours
d. Infants
5-5Y2 hours
e. Older children
4-5Y2 hours
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f. Communicable disease
4Y2-5 hours
g. Important patients
5Y2-6Y2
hours
h. Intensive care patients
7 -17Y2 hours
For planning purposes it may be convenient to work on 3 hours per day per patient in our
Indian conditions.
Nurse Patient Ratio:
The consensus of nursing leaders and hospital administrators indicates that there is no
reliable method by which a general standard can be applied to determine the ratio of
nurses to the patients. There are a number of factors which influence the same:
a. Size and layout of the ward-open or partitioned.
b. Types of cases-acute, chronic, mental, children.
c. Type of hospital-teaching, non-teaching or research.
d. Number of important patients
e. Type of equipment-modern labour service devices, central services or obsolete methods
.f. Amount of domestic and house keeping work carried on staff nurses/nursing aids.
g. Amount of paper work and documentation carried out by nurses.
h. Length of stay of patients.
Assignment of Duties:
As already stated in this book there are three patterns of assignment of duties among the
nursing staff available in a ward unit.
a. Functional method
b. Case method
c. Team method
Functional Method
In this method various basic nursing functions is TPR, medicines, injections, treatment
procedures and so on are divided amongst the available staff allotting one or two nurses
per function for the entire word. The advantages are saving of equipment; the individual
nurses become skilled in their particular function, best utilsation of aptitudes, saving of
time and so no. The disadvantages are: that the patient is compartmentalized, he feels
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insecure as he is tended by a number of nurses, there is hardly any opportunity for staff
development and the work becomes repetitive and monotonous.
Case Method:
A few patients are completely assigned to each staff nurse and she carries out the total
nursing care of her group of patients. It has the advantage that the patients are
emotionally secured, the nurse gots the satisfaction of seeing the patient through all
stages of diseases and management. But this method requires large number of nurses.
Team Method
An experienced staff nurse is made responsible for the care of a group of patients with the
help of a set of junior nurses and nursing aids. She gets the nursing done under the
supervision in addition carrying out the important duties and procedures her. The nurse
acts as a head nurse for a limited number of patients and as a leader of a team. This
method satisfied the emotional needs of the patient as well as development and job
satisfaction of entire nursing team.
Documentation of Records
There are various records maintained by the head nurse. These may be administrative
nature or other clinical records concerned, with the medical and nursing care of the
patient. A list of records/documents maintained in the worked is given below. Specimen
headings of some of the records are given in Appendix B.
a. Day and night report book.
b. Temperature, pulse and respiratory recording book.
c. Treatment book/injection book. d. Sponge book.
e. Duty roster for the staff.
f. Instructions book which the head nurse carries with her when she accompanies the
medical officer on his daily ward rounds.
g. Controlled and local purchase drugs accounting book separate register is maintained
for dangerous drugs.
h. SIL and OIL register
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i. Despatch book.
j. Inventories of various stores items held in her charge.
k. Breakage book.
I. Memo book or medical officers call book specially for CMO in case his attention in
required in the ward outside normal working hours.
m. Telephone message book specially meant for receiving laboratory results of serious
patients when required urgently.
n. Intake and output chart record.
o. Demand books for various stores, like medical stores, dry and wet dispensary, quarter
master stores and red cross stores.
p. Out pass book for male wards.
q. Urine test report and weight record specially for medical cases.
r. ESR and weight record register for tuberculosis patients. S. Complaint book for
maintenance and repairs.
t. Suggestions books for officers and officers family ward only
.u. Admission and discharge book.
v. Scale of hospital diets and extras
Ww. Standing orders for patients.
x. Fire officers.
y. Instructions for special radiological' examination like VP, barium meal, barium enema,
cholicystography and soon. )
UNIT V
Community-Based Nursing
Community-based nursing involves the acute and chronic care of individuals and
families that enhances their capacity for self-care and promotes autonomy in decision
making (Ayers, Bruno, and Langford, 1999). Care takes place in community settings
173
such as the home or a clinic; however, the focus is nursing care of the individual or
family. The nurse's competence is based on critical thinking and decision making at the
level of the individual client-assessing health status, selecting nursing interventions, and
evaluating outcomes of care. Because direct care services are provided where clients
live, work, and play, it is important for community-based nursing to remain individual
and family oriented and to appreciate the values of a community (Zotti, Brown, and
Stotts, 1996).
The philosophical foundation for community-based nursing is the human ecological
model, which conceptualizes human systems as open and interactive with the
environment (Chalmers and others, 1998). In an ecological model the individual is
viewed within the larger systems of family, community, culture, and society. The social
interaction units seen in Figure 3-2 depict four circles: the inner circle of the client and
the immediate family, the second circle of people and settings that have frequent contact
with the client and family, the third circle of the local community and its values and
policies, and the outer circle of larger social systems such as government and church
(Ayers, Bruno, and Langford, 1999). A nurse in a community-based practice must
understand the interaction of all of the units while caring for the client and family in their
natural environment. The nurse will typically become involved in the domain of the first
three circles when providing health care. For example, a home health nurse working with
a newly diagnosed diabetic client will work closely with the client and family to establish
a comprehensive plan for the client's health. The nurse may become involved in knowing
the habits or lifestyle patterns when the client is with friends and co
workers to anticipate ways to plan the client's exercise schedule and meal routines.
Knowing the resources available in the community (e.g., medical supply shops for
glucose monitoring supplies and local diabetes association support groups) enables the
nurse to provide comprehensive support for the client's needs.
With the individual and family as the clients, the context of community-based nursing
is family-centered care within the community. This focus requires the nurse to have a
strong knowledge base in family theory, principles of communication, group dynamics,
and cultural diversity. The nurse learns to partner with clients and families so that ultimately the client and family assume responsibility for their health care decisions. The
family becomes involved in planning, decision making, implementation, and evaluation
of health care approaches. )
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Holistic nursing
Holistic nursing regards and treats the mind-body-spirit f the client. Nurses use holistic
nursing as relaxation therapy, guided imagery, music therapy, simple touch, massage, and
prayer. Such interventions affect the whole person (mind-body-spirit) and are effective,
economical, noninvasive, non pharmacological complements to medical care. Holistic
interventions can be used to augment standard treatments, to replace interventions that
are ineffective or debilitating, and to promote or maintain health (Dossey, Keegan, and
Guzzetta, 2000). The American Holistic Nursing Association maintains Standards of
Holistic Nursing Practice that define and establish the scope of holistic practice and dl
level of care expected from a holistic nurse Holistic Nurses' Association, 1998).
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Team nursing was developed in 1950s (under grant from the WK Kellogg foundation)
directed by Eleanor Lambertson at Teachers College, Columbia University in New York
city. It has been developed in an effort to decrease the problems associated with the
functional organization of patient care. Majority of people felt that despite a continued
shortage of professional nursing staff, a patient care system had to be developed that
reduced the fragmented care that accompanied functional nursing.
Team nursing was designed to accommodate several categories of personnels in meeting
the comprehensive nursing needs of a group of clients. Team nursing is based on
philosophy in which a group of professional and nonprofessional personnels work
together to identify, plan, implement and evaluate comprehensive client-centered care.
The key concept is a group that works together toward a common goal, providing
qualitative 1 comprehensive nursing care.
In team nursing ancillary personnel collaborate in providing care to a group of patients
under the direction of a professional nurse. Actually the team nursing involves
decentralization of a nursing unit and professional head nurses authority, in which the
unit divided into teams. Each team composed of team leader, team members and patients.
Staff and clients are usually divided evenly, often written unit proximity such as a wing
of floor. Comprehensive care for the client is the responsibility of the entire team, but is
led by the team leader who should be a registered nurse. Assignments are made according
to the capabilities of the members and respond to the needs of the group of clients.
In team nursing team leader, the nurse is responsible for knowing the condition and needs
of all the patients assigned to the team and planning individual care. The team leader
duties vary depending on the patients' needs and workload. These duties may include
assisting team members, giving direct personal care to patients, teaching and coordinating
patient care activities.
Merits:
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Every team member has the opportunity to learn from and teach colleagues
The client is able to identify personals who are responsible for his care
Demerits:
Establishing the team concept taken time, I effort and constancy of personnel.
Merely assigning people to a group does not make them a 'group' or 'team'
The team leader must have complex skills and knowledge, i.e. communication,
leadership organization, nursing care, motivation and other skills
Team nursing usually associated with democratic leadership. Group members are given
as much autonomy as possible when performing assignment
tasks, although
responsibility and accountability are shared by the team collectively he need for excellent
communication and coordination skills makes implementing team nursing organization
difficult and requires great self discipline on the part of the team members. Team nursing
allows each member to contribute their special expertise, or skills. recognizing the
177
individual worth of all employees and giving team members autonomy result 1 high job
satisfaction.
Progressive/ patient care
Progressive client care is a method in which client-care areas or units provide various
levels f care, e.g. (i) intensive care unit for the critically I, (ii) post intensive care unit,
(iii) regular care nits, (iv) convalescent unit, (v) self care unit.
Here the clients are evaluated with respect to level (intensity) of care needed. As they
progress towards increased self care (as they become ethically ill or in need of intensive
care or monitoring), they are marked to units/wards staffed to best provide the type of
care needed he merits and demerits of progressive patient ire as follows.
Merits:
Clients are in the best place to receive the care they require
use of nursing skills and expertise are maximized due to different staffing patterns
of each unit
Clients are moved towards self care independence is fostered where indicate
Demerits:
Primary nursing:
Primary nursing, developed in the early 1970s, uses some of the concepts of case method.
It involves total nursing care, directed by a nurse. on a 24-hour basis as long as the client
178
is under care. As originally designed, this method requires a nursing staff comprised
totally of registered. staff nurses. Here one specific nurse is the client's nurse, at all times
directing, planning evaluating and teaching. The primary nurse is essentially, on call all
the time and arranged coverage when away. Actually, the primary nurse assumes 24-hour
I responsibility for planning the care of one or more patients from admission or the start
of treatment to discharge or the treatments end. During work hours the primary nurse
provides total direct care for that patient. When the primary nurse is not on duty, care is
provided by other junior nurses who follow the care plan established by the primary
nurse, that means, even though the primary nurse is the director of care for clients,
segments of care are often delegated.
As stated earlier, it uses some concepts of case method leads to confusion. The difference
exists in the fact that case method involves a specified segment of time, i.e. shift where as
the primary nursing is 24-hour responsibility for as long as care needed by the client.
Although this method is designed for use in hospitals, this structure lends itself well to
home health nursing, hospital nursing and other health care delivery enterprise.
An integral responsibility of the primary nurse is to establish clear communication
between the patient, the doctor, the associate nurses and other team members.
Although the primary nurse establishes the nursing care plan, feedback in sought from
others in coordinating the patient care. The combination of clear interdisciplinary groups
communication and consistent, direct patient care by relatively few nursing staff allows
for holistic, high quality patient care. It gives job satisfaction, once nurse develop skill in
primary nursing care delivery, they feel challenged and rewarded.
Merits:
There is opportunity for the nurse to see the client and family as one system
The nurse is able to use a wide range of skills, knowledge and expertise
This method potentates creativity by the nurse; work satisfaction may increase
significantly
.The scene is set for increased trust and satisfaction by the client and nurse.
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Demerits :
The role and functions of the nurse manager and in organizing groups for patient care are
as follows:
as
1. Periodically evaluates the effectiveness of the organizational structure for the
delivery of patient care.
2. Determines if adequate resources and support exist before making any changes in
3. the organization of patient care.
4. Examines the human element in work redecision and support personnel during
adjustment to changes.
5. Uses committees to facilitate group goals, not to delay decision.
6. Teaches group members how to avoid group think.
7. Inspires the work group toward a team effort.
8. Organizes work activities to attain organizational goals.
9. Group activities in a manner that facilitates coordination within and between
department.
10. Uses a patient care delivery system that maximizes resources people, material and
time.
11. Organizes work in a manner that facilitates communication.
12. Uses committees structure to increase the quality and quantity of work
accomplished.
13. Uses knowledge of group dynamics for goal attainment.
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INFECTION CONROL:
A client entering a healthcare setting is at risk for acquiring infections because of lowered
resistance to infection, microorganisms and invasive procedures. The nurse comes in
contact with a variety of microorganisms and thus must practice 'infection control'
techniques to avoid spreading them to clients. The nurse is responsible for teach- ing
clients about infection, mode of transmission, reasons for susceptibility, and infection
control.
Infection Process:
An infection is an invasion of the body by pathogens, or microorganism capable of
producing disease. The development of an infection occurs in a cyclical process that
depends on the following six elements
An infectioIfwil1 develop if this cyclical chain remains intact. To prevent the spread of
micro- organism, the cycle must be interrupted. Nurses use respective practices to break
the chain, so that infection will not occur.
Infection Agent :
The pathogenic organisms include bacteria, viruses, fungi and protozoa and more
prevalent agents that are capable of causing infection. The most common pathogen and
their infections are given..
Reservoir:
The reservoir for growth and multiplication of microorganism is the natural habitant of
the organism. The possible reservoir that supports organism pathogenic to humans
includes other human (e.g. TB syphillis, HIV, HBV), animals (Rabies-dog), food (CI
botulinum) water, milk and inanimate object e.g. soil, gas gangrene, tetanus).
181
Portal of Exist:
The exist from the reservoir is the point of escape for the organism. The organism cannot
extend its influence unless it moves away from its original source. There usually a
primary exist route for each type of organism. In human common escape routes are as
follows:
1. Skin and mucus membrane, e.g. S. aureus, cause yellowish drainage. P. aeruginde
causes greenish drainage.
2. Respiratory tract e.g. Mycobacterium tubercle causes tuberculosis.
3. Gastro urinary tract. 4. GI tract.
4. Reproductive tract, e.g. STDs, HIV.
5. Blood -serum hepatitis.
Modes of Transmission:
An organism may be transmitted from its reservoir by various means of routes. Some
organisms can be transmitted by more than one route.
Contact
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.Direct contact, e.g. Staphylococcus, T. palladium, herpes simplex .Indirect contact, e.g.
Measles virus, HBV, Enterococcus and pseudomonal organisms. .Droplet contact, e.g.
influenza virus. M tuberculosis.
Air:
.Droplet nuclei, e.g. influenza virus, Pneumococcus, V-Z virus .Dust, e.g. Aspergillus
organisms.
Vehicles:
Liquids
water, e.g. Vibrio cholerae
drugs solution, e.g. Pseudomonas organism
blood, e.g. hepatitis B virus
food, e.g. Salmonella, Staphylococcus, Enterobacter, etc. and Klebsiella
organism.
Vectors
Portal of Entry:
The portal of entry is the point at which organism enters the host. The entry route often is
the same as the exist route. The urinary, respiratory, gastro- intestinal,-reproductive tract
and the skin are common entry points.
Susceptible Host:
For microorganism to continue to exists, they must find a source that is acceptable (a
host) and overcome any resistance mounted by the host defenses. Susceptibility is the
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Length and intimacy of the contact between a person and the microorganisms .
Course of Infection:
An understanding of the course of infection by stages in the development of an infection
is necessary if the nurse is to intervene and disrupt the infection cycle. An infection
progresses through the different phases which includes, incubation period, prodromal
stage, full stage of illness, convalescent phase.
Incubation Period:
Incubation period is the interval between the invasion of the body by the pathogen or
entrance of pathogen into the body and the appearance of the first symptoms of infection,
e.g. chickenpox 2-3 weeks, common cold 1-2 days, tetanus 2 to 21 days. .
Prodromal Stage:
A person is most infectious during this stage. It is an internal from onset of nonspecific
signs and symptoms (malaise, low grade fever, fatigue) to more specific symptoms;
During this time, micro- organisms grow and multiply; and client is more capable of
spreading disease to others.
Full Stage of illness:
Full stage of illness is an interval when client manifests signs and symptoms specific
type of I infection. The presence of specific signs and] symptoms indicates the full stage
of illness. The types of infection determine the length of illness and the severity of
manifestations. Symptoms that are limited or restricted to a discrete area are I referred to
184
Urinary Tract
185
The flushing action of urine flow washes away microorganism on lining of bladder and
urethra. An infect multilayered epitheliums of the tract provide barrier to microorganism.
The factors which may alter defense here are obstruction to normal flow by any means.
Gastrointestinal Tract
Here the acidity of the gastric secretions chemically destroys microorganisms incapable
of surviving low pH. The rapid peristalsis in small intestine prevents retention of bacterial
content. The factors which alter defense here are administration of antacids, delayed
motility resulting from impaction of fecal content in large bowel or mechanical
obstruction by masses.
Vagina
At puberty, normal flora causing vaginal secretion to achieve low pH, which inhibits
growth of many microorganisms. Antibiotics and oral contraceptives disrupting normal
flora, which alter defence.
In addition the inflammatory response is a protective vascular and cellular reaction that
neutralizes pathogens and repairs body cells. Normal flora, body system defenses and
inflammation are all non specific defenses that protect against microorganisms regardless
of prior exposure. The immune system is composed of separate cells and molecules
resistant to disease. Certain responses of the immune system are non- specific, whereas
others are specific defenses against specific pathogens. If any of the body's defense fails,
an infection can quickly progress to a serious health problem. The factors which affecting
immunological defense mechanism are as follow:
Increasing age
Stress
Poor nutrition
Inherited condition
Environments.
Nosocomiallnfections:
The term nosocomial is taken from the Greek word nosocomium meaning healthcare
facility. A nosocomial infection is one that is acquired in a hospital or other health agency.
This is a far- reaching and serious problem. A hospital is one of the most likely places for
186
Medical asepsis Medical asepsis or clean technique includes procedures used to reduce
the number of microorganisms and prevent their spread. changing a clients bed linen
daily, hand washing and using clean medicated cups are example of medical asepsis. The
practicing basic principles of medical asepsis in client care are as follows:
Wash hands frequently but especially before handling foods, before eating, after
using a handkerchief, after going to the toilet, before and after each client contact,
and after removing gloves.
187
Keep solid items and equipment from touch- ing the clothing, carry soiled linen or
other used articles so that they do not touch the uniform
Do not place solid bed linen or any other items on the floor, which is grossly
contaminated, it increases contamination of both surfaces
Avoid having clients, cough, sneezing, or breath directly on others. Provide them
with disposable tissues, and instruct them as indicated to cover their mouth and
nose to prevent spread by airborne droplet
Move equipment away from you when brush- I ing, dusting or scrubbing articles.
This helps prevent contaminated particles from settling on the hairs, face and
uniform.
Avoid raising dust use a specially treated cloth or a dampened cloth. Do not shake
linens. Dust and thin particles constitute a , vehicle, by which organisms may be
trans ported from one area to another .
Clean the least soiled areas first and then the more soiled ones. This helps preyent
having the cleaner areas soiled by the dirtier areas
Dispose of soiled or used items directly into appropriate containers. Wrap items
that are moist from body discharge or drainage in water proof containers such as
plastic bags, before discarding into the refuse holder so that handler will not come
in contact with them.
Pour liquids that are to be discarded, such as bath water, mouth rinse and the like
directly into the drain so as to avoid splattering in the sink and on to you
Sterilize items that are suspected of containing pathogen. After sterilization, they
can be managed by clean technique
Use practices of personal grooming that help prevent spready microorganism, i.e.
sham- pooling, nail cutting, avoid wearing rings, etc.
Surgical asepsis:
Surgical asepsis or sterile technique, includes procedures used to eliminated
microorganisms from an area. Sterilization destroys all microorganisms, and their spores
sterile techniques is practiced by nurses in the operating room and treatment areas, where
sterile instruments and supplies are used, i.e. care of surgical wounds, urinary catheter
insertion, invasive procedures and surgery.
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Only a sterile object can touch another sterile object, unsterile touching sterile
means conta- mination has occurred
Open the sterile packages so that the first edge of the wrapper is directed away
the worker to avoid the possibility of a sterile surface touching unsterile clothing.
The outside of the sterile package is considered contaminated
Avoid spilling any solution on a cloth or paper used as a field for a sterile set up.
The moisture penetrates through the sterile cloth or paper and carries organism by
capillary action so contaminate the field. The wet field is considered contaminated
if the surface immediately below it is not sterile
.Hold sterile objects above the level of the waist. This will help ensure keeping
the object within sight and prevent accidental contamination
Avoid talking, coughing, sneezing or reaching over a sterile field or object. This
helps prevent contamination by droplets, from the nose and the mouth or by
particles dropping from the worker's arms
Never walk away from or turn your back on a sterile field. This prevents possible
contamination while the field as out of the worker's view
All items brought into contact with broken skin, or used to penetrate the skin in
order to inject substances into the body, or to enter normally sterile body cavities,
should be sterile. These items include dressing used to cover wounds and
incisions, needles for injections and tubes, catheter used to drain urine from the
bladder, etc.
Use dry, sterile, forceps when necessary, forceps soaked in disinfectant are not
considered sterile
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Prepare food at temperature sufficiently high to ensure that they are safe to eat
Use care with cutting boards and utensils and wash hands, before and after
handling raw meat
Use individual personal care items, such as wash cloths, towels, tooth brushes.
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Use tongs to lift food from common service trays in caterings food stores, and
salad bars.
The community reinforces medical aseptic practices in several ways which includes
the following:
To prevent medical personnel from contaminating the patient 'who has a disease
affecting the immune system.
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Donning Gloves :
Nurses or healthcare personnel wear/don gloves if there is any possibility of contact with
infectious material. Nurses wear gloves for all types of patient care for the following
reasons:
To protect the patient from the nurse, who may be considered a contaminator to
the patient
The supply needed for donning gloves is a 'pair of gloves'. The steps of the
donning gloves are discussed in Table 5.3.
Donning a Mask
A mask should be worn for the following purposes:
To discourage that wearer from touching the mouth, ) use, or eye and from
transmitting infection material.
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Double Bagging :
A single bag is adequate if the contaminated articles can be placed in the bag without
contamination of the outside of the bag. Double bagging is recommended when it is
impossible to keep the outer surface of the single bag, free from contamination. The
second bag should be labeled for color coded to alert nursing personnel and to prevent
contamination of housekeeping personnels when handling contaminated material.
Double bag can be used for safe remove of any article from room. Double bagging has
purposes, i.e. to prevent spread of microorganism to the surrounding area and to prevent
potential accidental exposure of personnel to contaminated article. The supplies and
equipment needed for double bagging are as follows:
The steps to be followed for double bagging are given in the Table.
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Isolation Technique
The type of isolation technique followed will depend on transmissibility of the pathogen.
The use of environmental barriers will keep pathogens in a confined care, i.e. private
room, isolation room, closed door, protective gown, masks and gloves and shoe covers.
The nurse follows isolation technique to prevent the transmission of infection from
micro- organisms by preventing pathogens from leaving the room of the infected patient
or from entering the room of a highly susceptible patient.
The supplies and equipment needed for isolation technique are as follows:
Clean linen
Paper towels
Running water
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The step to be followed in preparing for disinfection and sterilization are enlisted in the
Table.
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Before contact with clients who are susceptible to infections, e.g. newborn
infants, clients with leukemia, organ transplant recipients and HIV+ve cases, in
order to prevent the spread of microorganisms.
5.
After touching organic material, i.e. after performing any duties involving
contaminated articles such as bedpans, surgical dressings, soiled tissues or dirty
linen.
6.
7.
8.
Encountering problem
Data collection
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The trial and error method of problem solving involves testing and number of solutions
until one is found that works for that particular problem. This method is not efficient for
the nurse and can be dangerous to the client, it is therefore, not recommended as guide for
nursing practice and can be moved to scientific method.
The scientific method of problem solving in a testable, systematic process for solving
problems. There are seven steps to this method, which are used in clinical practice when
the nurse wants to investigate specific nursing intervention or phenomenon are as follows
Hypothesis formulation
Testing hypothesis
Interpretation of results
The use of the scientific method enables nurses to do clinical research to expand the
scientific basis for nursing practice.
The nursing process is a method of organizing and delivering nursing care. To understand
its functions, components and interactions, the nurse should have a working knowledge
of the nature of the process. A process is a series of steps or components leading to
achievement of a goal, which includes the following:
Assessment
Diagnosing
Planning
Implementation
Evaluation
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establishes the data base, which includes nursing history, physical assessment,
review of the client record and nursing literature and consultation with the clients
support people and healthcare professionals
Diagnosing it is the analysis of client data to identify client strengths and health problems
that independent nursing action can prevent or resolve. When data analysis reveals an
actual or potential health problem that nursing interventions can prevent or resolve, the
problem if termed as 'nursing diagnosis'. The purpose of diagnosing is to develop a
prioritized list of nursing diagnosis. During the step the nurses activities includes the
following:
Carrying out the plan of care. Continuing data collection and modifying the plan
of care as needed
Documenting care.
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Evaluating: It is measuring the extent to which the client has achieved the goal specified
in the plan of care, identifying factors that positively or negatively influenced the goal
achievement; revise plan of care if necessary. The purpose of evaluation is to continue,
modify or terminate nursing care. In this step nurse does the following:
Measure how well the client has achieved desired goals/ objectives
When the nursing process is used to organize and deliver nursing care, the client becomes
an active participant in an individualized healthcare process. The client receives
comprehensive and consistent care. When used properly, the nursing process achieves for
the client scientifically based holistic, individualized care; the opportunity to work
collaboratively with nurses and continuity of care. Nurses who use the nursing process in
a thoughtful and systematic way achieve a clear and efficient plan of action by which the
entire nursing team can achieve results for clients; the satisfaction that they are receing is
out of an important difference in the lives of their clients; and the opportunity to grow
professionally, as nurses evaluate the effectiveness of intervention.
REFERENCE:
(i)
(ii)
(iii)
Dugas
(iv)
(v)
KNpark 2005 Text book of preventive and social medicine 18th edition.
M/S. Banasidas Bhanot Publishers, Jabulpul
(vi)
Nancy
(vii)
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