Nursing Now Today's Issues Tomorrows Trends 8th Edition

CATALANO Today's Issues, iiii::~~-Tomorrow's Trends

NURSING NOW Today’s Issues, Tomorrow’s Trends EIGHTH EDITION



Joseph T. Catalano, PhD, RN Program Consultant, Author, Professor Emeritus East Central University Ada, Oklahoma

F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2020 by F. A. Davis Company Copyright © 1996, 2000, 2003, 2006, 2009, 2015 by F. A. Davis Company. All rights reserved. is book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in the United States of America Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Acquisitions Editor: Jacalyn Sharp Manager of Project and eProject Management: Catherine Carroll Content Project Manager: Amanda Minutola Design & Illustrations Manager: Carolyn O’Brien As new scienti c information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. e author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. e author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. e reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Library of Congress Cataloging-in-Publication Data Names: Catalano, Joseph T., author. Title: Nursing now : today’s issues, tomorrow’s trends / Joseph T. Catalano. Description: Eighth edition. | Philadelphia, PA : F.A. Davis Company, [2020] | Includes bibliographical references and index. Identi ers: LCCN 2019014915 | ISBN 9780803674882 (pbk.) | ISBN 9780803674899 (e-book) Subjects: | MESH: Nursing—trends | Nursing Care—trends Classi cation: LCC RT82 | NLM WY 16.1 | DDC 610.7306/9—dc23 LC record available at https://lccn.loc.gov/2019014915 Authorization to photocopy items for internal or personal use, or the internal or personal use of speci c clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Report- ing Service, provided that the fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. e fee code for users of the Transactional Reporting Service is: 978-0-8036-7488-2/19 0 + $.25.

Dedication To the Sisters of St. Francis who teach not only the science and skills of being an RN but also the caring and kindness that make for a great RN. Caritas Benigna Est



Preface Although the storms of major political and social The chapter on the NCLEX examination was upheaval have swept over the landscape of American moved to the end of the book (Chapter 28) to corre- society the last few years, the profession of nursing spond with the topic’s usual order in most nursing has stood as an immovable rock founded on its curricula. It was also updated to reflect the recent guiding beliefs and dedication to ethical and high- changes by the National Council of State Boards quality nursing care. Yet the profession continues to of Nursing, including samples of the new alterna- progress and evolve at a rapid rate, and the eighth tive format questions. All other chapters have been edition of Nursing Now: Today’s Issues, Tomorrow’s updated with new content and resources. For exam- Trends is keeping up with that progress by includ- ple, this edition includes new information regarding ing loads of new information and the latest topics! the care of transgender individuals, current issues We believe you will be more than delighted with in genetics, elder care, the nursing huddle, and the rendition of this text, as it remains truly unique several new roles for nurses. Chapter 17, “Nursing among issues and trends books. The eighth edition Informatics,” and Chapter 19, “The Health-Care retains the eye-appealing and user-friendly format Debate,” underwent complete revision, and almost that made previous editions so popular along with 300 new NCLEX-style questions have been added to instructor and student resources found online. the text. The transformations in health care continue at a Graduates from today’s nursing programs have rapid rate. Demographic shifts have become the new opportunities for professional practice and advance- norm as the baby boomer bulge reaches the heart ment that could only be dreamed of a few years ago. of retirement age and new immigrants gain politi- Yes, the demands are many, but the rewards are cal savvy and power. Despite concerted efforts to great. Today’s nursing students must learn more, disable and destroy the Affordable Care Act (ACA), do more, and be more. Students entering nursing large portions of it remain in effect as the poor and schools today come from increasingly diverse cul- disadvantaged still seek it as a source of health insur- tural, personal, and educational backgrounds. They ance. Nurses, as always, lead the vanguard in direct- must master a tremendous amount of information ing and managing the many new evolutions in health and learn a wide variety of skills so that they can pass care. Quality of care rather than the number of ser- the licensure examination and become highly skilled vices provided is becoming the outcome measure for registered nurses. the provision of health care at all levels. The eighth edition of Nursing Now offers students Thanks to our readers’ suggestions, we moved one a starting point to influence the future of health care of the online bonus chapters—Chapter 23, “Client in the United States. We are very excited about the Education: A Moral Imperative”—back into the text. revised text and believe its quality and content meet With the ACA’s and other regulatory groups’ empha- the high standards demanded by our readers. sis on client education and the need for improved transition of care to prevent readmissions, this The book’s primary purpose remains the same as chapter is now in the right place at the right time. in past editions. It presents an overview and synthesis It has been revised extensively with an eye to new of the important issues and trends that are basic to the regulations. development of professional nursing and that affect nursing both today and into the future. Our readers vii

viii Preface served as their source of strength. Even more so than tell us that the book can be used both at the beginning in the past, nurses need to look to each other for the of the student’s educational process as an Introduc- inspiration and strength that allow them to succeed. tion to Nursing course and toward the end of the pro- Professional organizations still serve as the single- cess as an Issues and Trends course. Some instructors most powerful force for nurses, and membership in even use it throughout their programs, incorporating professional organizations is becoming increasingly chapters as the content is reflected in their course important. presentations. Nursing students remain the primary intended audience for Nursing Now. However, prac- It is our belief that this book will help future ticing nurses have reported there is a sufficiently wide nurses become familiar with the important issues and range of current issues and topics covered in enough trends that affect the profession and health care. The depth to be useful for their practice. nursing profession needs highly skilled nurses who can be civil, teach, do research, solve complicated A dichotomy that nurses face on a daily basis is client problems, provide highly skilled care, obtain the ability to hold on to key unchanging principles advanced degrees, and influence the political realm while working in a constantly changing environment. that so affects all aspects of health care. The leaders Simply stated, a nurse’s ability to adapt to changes in of the profession will come from those students who the health-care system while remaining focused on have a clear understanding of what it means to be a providing high-quality care is the basis for a success- professional nurse and are willing to invest effort in ful professional practice. The only way that nurses attaining their goals. will be able to effectively practice their profession in a demanding health-care system is to remain firmly Joseph T. Catalano, PhD, RN rooted in those values and beliefs that have always

Acknowledgments I would like to acknowledge my editors at F.A. Davis who, while adding many new trials to my life and increasing my virtues of patience and persistence, have also enhanced the overall quality of the eighth edition. ix



Reviewers Janet Espiritu-Pia, MSN, RN, CCRN Nursing Instructor Carol Ann Amann, PhD, RN-BC, FNGNA Covenant School of Nursing Assistant Professor Lubbock, Texas Gannon University Susan Golden, MSN, RN Erie, Pennsylvania Nursing Faculty Kristin Benavidez, MSN-L, RN Eastern New Mexico University–Roswell Nursing Instructor Roswell, New Mexico Clovis Community College Karen D. Groller, PhD, RN-BC, CMSRN Clovis, New Mexico Assistant Professor Marielle A. Blizzard, MSN, RN Moravian College, Helen Breidegam School of Nursing Instructor Wayne Community College Nursing Goldsboro, North Carolina Bethlehem, Pennsylvania Jordan Bosse, MS, RN Kandi Ann Hudson, EdD/CI, MSN, CMSRN, CNE Research Associate Professor of Nursing CleanSlate Centers Community College of Baltimore County University of Massachusetts Baltimore, Maryland Amherst, Massachusetts Peggy B. Lee, EdD, MS, RN, BC Mary Carrico, MSN, RN Assistant Professor of Nursing Eleanor Mann School Professor of Nursing West Kentucky Community and Technical of Nursing University of Arkansas-Fayetteville College Fayetteville, Arkansas Paducah, Kentucky Dane E. Menkin, NP-C, AAHIVM Jennifer Dunlap, MS, RN Family Nurse Practitioner Nursing Instructor Mazzoni Center and Simmons University St. Elizabeth College of Nursing Philadelphia, Pennsylvania Utica, New York Joseph Molinatti, EdD, RN Maybeth Elliott, PhD, RN Associate Professor Assistant Chair and Professor College of Mount Saint Vincent Pensacola Christian College Bronx, New York Pensacola, Florida xi

xii Reviewers Nancy Steffen, MSN, RN, CNE Denise Neill, PhD, RN, CNE Nursing Instructor Director and Associate Professor Century College Sam Houston State University White Bear Lake, Minnesota The Woodlands, Texas Kay Tosto, MSN, RN-BC Karen Rojenko, MSN, RNC Associate Degree Nurse Faculty Nursing Faculty Carteret Community College Arapahoe Community College Morehead City, North Carolina Littleton, Colorado Mary Elizabeth Wilber, BSN, MSN, PhD(c) Nancy L. Sarpy, PhD, RN Associate Professor/Faculty and Co-Director Assistant Professor of Nursing Doherty Center for Aviation and Health Research Loma Linda University Lewis University Loma Linda, California Romeoville, Illinois Mary J. Stedman, EdD, MS, RN, ANP Professor Farmingdale State College Farmingdale, New York

Contributors Mary Abadie, RN, MSN, CPNP Joseph T. Catalano, PhD, RN Assistant Professor, Retired Program Consultant, Author Southern University and A&M College Professor Emeritus School of Nursing Ada, Oklahoma Baton Rouge, Louisiana Tonia Aiken, RN, BSN, JD Sarah T. Catalano President and CEO Graphic Designer Aiken Development Group The Chickasaw Nation New Orleans, Louisiana Ada, Oklahoma Sharon M. Bator, PhD, RN Associate Professor Captain Dr. Leah S. Cullins, MSN, APRN, FNP-BC Denver College of Nursing Assistant Professor Denver, Colorado Southern University School of Nursing Barbara Bellfield, MS, RNP-C, RN Undergraduate & Graduate Programs Family Nurse Practitioner Southern University and A&M College Oxnard, California Baton Rouge, Louisiana Cynthia Bienemy, RN, PhD Director, Louisiana Center for Nursing Lydia DeSantis, RN, PhD, FAAN Louisiana State Board of Nursing University of Miami Baton Rouge, Louisiana School of Nursing Doris Brown, MEd, MS, RN, CNS Miami, Florida Public Health Executive Director Robert Wood Johnson Nurse Fellow Joan Anny Ellis, RN, PhD Faculty Development Specialist 2006–2009 Chamberlain University Baton Rouge, Louisiana Baton Rouge, Louisiana Sandra Brown, RN, DNS, APRN, FNP-BC CNE, Mary Evans, JD, RN ANEF, FAAN Colorado Springs, Colorado Professor Director of NP and DNP Program Betty L. Fomby-White, RN, PhD Woman’s Hospital Endowed Professor Professor, Retired Southern University and A&M College Southern University and A&M College School of Nursing School of Nursing Baton Rouge, Louisiana Baton Rouge, Louisiana Donna Gentile O’Donnell, RN, MSN Health Research Advisory Committee Thomas Jefferson University Philadelphia, Pennsylvania xiii

xiv Contributors Roberta Mowdy, PMHNP-BC Anita H. Hansberry, RN, MS Chickasaw Nation Division of Health Assistant Professor, Retired Ada, Oklahoma Southern University and A&M College Joseph Mulinari, PhD, RN School of Nursing College of Mount Saint Vincent Baton Rouge, Louisiana Department of Nursing Nicole Harder, RN, BN, MPA Bronx, New York Coordinator, Learning Laboratories Linda Newcomer, RN, MSN Helen Glass Centre for Nursing Instructor Faculty of Nursing East Central University University of Manitoba Department of Nursing Winnipeg, Manitoba, Canada Ada, Oklahoma Jacqueline J. Hill, RN, PhD Robert Newcomer, PhD Associate Professor Assistant Professor, Retired Interim Dean of College of Nursing and Allied East Central University Ada, Oklahoma Health Janet S. Rami, RN, PhD Southern University A&M College Professor Emeritus Baton Rouge, Louisiana Southern University and A&M College Edna Hull, PhD, RN, CNE School of Nursing Associate Professor, Retired Baton Rouge, Louisiana Southern University and A&M College, Baton Rouge Diane Ream, DNP, RN Associate Editor Director of Finance and Operations Teaching and Learning in Nursing All for Kids Home Health Senior Contributing Faculty Member Denver, Colorado Walden University Viki Saidleman, MS, RN Sharon W. Hutchinson, PhD, MN, RN, CNE Instructor Chair and Professor East Central University Dillard University Department of Nursing College of Nursing Ada, Oklahoma New Orleans, Louisiana Nancy C. Sharts-Hopko, RN, PhD, FAAN Cindy Krentz, DNP, RN Professor Assistant Professor of Nursing Villanova University Assistant Chairperson of the Nursing Department Villanova, Pennsylvania Metropolitan State College Enrica K. Singleton, RN, PhD Denver, Colorado Professor, Retired Joyce Miller, BSN, CPE, CCM Southern University and A&M College Medical Case Manager School of Nursing KorVel Corporation Baton Rouge, Louisiana Baton Rouge, Louisiana Karen Mills, MSN, RN Nurse Family Partnership State Nurse Consultant, Retired Louisiana Office of Public Health Baton Rouge, Louisiana

Wanda Raby Spurlock, DNS, RN, BC, CNS, Contributors xv FNGNA Karen Tomajan, MS, RN, NEA-BC Director of the Nursing Practice/Magnet Program Associate Professor John Muir Health Center Southern University and A&M College American Nurses Credentialing Center Magnet School of Nursing Baton Rouge, Louisiana Recognition Program Melissa Stewart DNS, RN, CPE Concord, California Assistant Professor Esperanza Villanueva-Joyce, EdD, CNS, RN National Consultant, Health Literacy Theorist Nurse Consultant Louisiana State University, Eunice Karen Lynn Webb, MSN, RN, PhDc Baton Rouge, Louisiana Assistant Professor Cheryl Taylor, PhD, RN, FAAN Appalachian State University Chairperson, Graduate Nursing Programs (MSN, Department of Nursing Boone, North Carolina PhD, & DNP) Kathleen Mary Young, RN, C, MA Associate Professor of Nursing Instructor Southern University and A&M College Western Michigan University Jewel L. and James Prestage Endowed Professor/Kellogg Kalamazoo, Michigan National League for Nursing Consultant to the National Student Nurses’ Association FNINR, National Institute of Nursing Research, Ambassador Jonas Scholar Mentor Baton Rouge, Louisiana



Contents U n i t 1 The Growth of Nursing 1 1 The Development of a Profession 3 2 Historical Perspectives 18 3 Theories and Models of Nursing 36 4 The Process of Educating Nurses 72 5 The Evolution of Licensure, Certification, and Nursing Organizations 103 U n i t 2 Making the Transition to Professional 121 6 Ethics in Nursing 123 7 Bioethical Issues 148 8 Nursing Law and Liability 183 9 Reality Shock in the Workplace 213 U n i t 3 Leading and Managing 245 10 Leadership, Followership, and Management 247 302 11 Communication, Negotiation, and Conflict Resolution 277 12 Understanding and Dealing Successfully With Difficult Behavior 13 Health-Care Delivery Systems 348 14 Ensuring Quality Care 372 15 Delegation in Nursing 391 16 Incivility: The Antithesis of Caring 408 17 Nursing Informatics 428 18 The Politically Active Nurse 456 U n i t 4 Issues in Delivering Care 485 19 The Health-Care Debate: Best Allocation of Resources for the Best Outcomes 487 20 Spirituality and Health Care 515 21 Diversity 540 22 Impact of the Aging Population on Health-Care Delivery 569 23 Client Education: A Moral Imperative 585 24 Nursing Research and Evidence-Based Practice 606 25 Integrative Health Practices 638 26 Preparing for and Responding to Disasters 668 27 Developments in Current Nursing Practice 700 28 NCLEX: What You Need to Know 717 Online Bonus Chapters 29 How to Take and Pass Tests BC-1 30 Governance and Collective Bargaining BC-19 Answers to NCLEX-Style Questions 740 xvii Glossary 778 Index 804



1 The Growth of Nursing



The Development 1 of a Profession Joseph T. Catalano Learning Objectives INTRODUCTION After completing this chapter, Since the time of Florence Nightingale, each generation of nurses, the reader will be able to: in its own way, has fostered the movement to professionalize the image of nurses and nursing. The struggle to change the • Define the terms position, job, status of nurses—from that of female domestic servants to one of occupation, and profession high-level health-care providers who base their protocols on scientific principles—has been a primary goal of nursing leaders for many years. • Compare the three approaches to defining a profession At some levels in nursing, the question of professionalism takes on immense significance.1 However, to the busy staff nurse—who is • Analyze those traits defining trying to allocate client assignments for a shift, distribute the medica- a profession that nursing has tions at 9 a.m. to 24 clients, and supervise two aides, a licensed practi- attained cal nurse (LPN) or licensed vocational nurse (LVN), and a nursing student—the issue may not seem very significant at all. • Evaluate why nursing has failed to attain some of the traits that Indeed, when nurses were first developing their identity separately define a profession from that of physicians, there was no thought about their being part of a profession.2 Over the years, as the scope of practice and responsibili- • Correlate the concept of ties have expanded, nurses have been recognized as the professionals power with its important they are. characteristics This chapter presents some of the current thoughts concerning nursing as a profession. WHAT IS A PROFESSION? For almost 100 years, experts in social science have been attempting to develop a “foolproof” approach to determining what constitutes a pro- fession but with only minimal success.3 3

4 U n i t   1 The Growth of Nursing On the other hand, as health care has advanced and made great strides in technology, pharmacol- What Do You Think? ogy, and all branches of the physical sciences, a high level of intellectual functioning is required for even Do you care if nursing is considered a profession? How relatively simple nursing tasks, such as taking a cli- will it affect the way you practice nursing? ent’s temperature or blood pressure using automated equipment. On a daily basis, nurses use assessment Of the many researchers and theorists who have skills and knowledge, have the ability to reason, and attempted to identify the traits that define a profes- make routine judgments based on clients’ conditions. sion, Abraham Flexner, Elizabeth Bixler, and Eliza Without a doubt, professional nurses must function Pavalko are most widely accepted as the leaders in at a high intellectual level. the field. These three social scientists have deter- mined that the following common characteristics are Patient comfort during the important: Civil War had additional meaning. • High intellectual level • High level of individual responsibility and High Level of Individual Responsibility and Accountability accountability Not too long ago, a nurse was rarely, if ever, named • Specialized body of knowledge as a defendant in a malpractice suit. In general, the • Knowledge that can be learned in institutions of public did not view nurses as having enough knowl- edge to be held accountable for errors that were higher education made in client care. This is not the case in the health- • Public service and altruistic activities care system today. Nurses are often the primary, and • Public service valued over financial gain frequently the only, defendants named when errors • Relatively high degree of autonomy and indepen- are made that result in injury to the client. Nurses must be accountable and demonstrate a high level dence of practice of individual responsibility for the care and services • Need for a well-organized and strong organization they provide.5 representing the members of the profession and The concept of accountability has legal, ethical, controlling the quality of practice and professional implications that include accept- • A code of ethics that guides the members of the ing responsibility for actions taken to provide client profession in their practice care and for the consequences of actions that are • Strong professional identity and commitment to the development of the profession • Demonstration of professional competency and possession of a legally recognized license4 NURSING AS A PROFESSION How does nursing compare with other professions when measured against these widely accepted profes- sional traits? The profession of nursing meets most of the criteria but falls short in a few areas. High Intellectual Level In the early stages of the development of nursing practice, this criterion did not apply. Florence Night- ingale raised the bar for education, and graduates of her school were considered to be highly educated compared with other women of that time. However, by today’s standards, most of the tasks performed by these early nurses are generally considered to be menial and routine.

C h a p t e r 1 The Development of a Profession 5 not performed. Nurses can no longer state that “the for information about the success of treatments, deci- physician told me to do it” as a method of avoiding sions about health care, and outcomes for clients. responsibility for their actions. Nursing education now requires nursing students to perform research for papers and projects so that by Specialized Body of Knowledge the time of graduation, they feel comfortable access- Most early nursing skills were based either on ing a wide range of the best and most current infor- traditional ways of doing things or on the intui- mation through electronic sources. Of course, one of tive knowledge of the individual nurse. As nursing the key limiting factors of EBP is the quality of the developed into an identifiable, separate discipline, a information on which the practice is based. Evaluat- specialized body of knowledge called nursing science ing the quality of information on the Internet can be was compiled through the research efforts of nurses difficult at times. with advanced educational degrees.6 As the body of The first step in developing an EBP is to identify specialized nursing knowledge continues to grow, exactly what the intervention is supposed to accom- it forms a theoretical basis for the best practices plish. Once the goal or client outcome is identified, movement in nursing today. As more nurses obtain the nurse needs to evaluate current practices to advanced degrees, conduct research, and develop determine whether they are delivering the desired philosophies and theories about nursing, this body of client outcomes. If the current practices are unsuc- knowledge will increase in scope and quantity. cessful or if the nurse feels they can be more efficient with fewer complications, research sources need Evidence-Based to be collected. These Practice ing today, there is an can be from published In professional nurs-increasing emphasis on journal articles (either evidence-based practice Evidence-based practice is the practice electronic or hard copy) of nursing in which interventions and from presentations “(EBP). Almost all of the are based on data from research that at research or practice demonstrates that they are appropriate conferences, which currently used nursing and successful.  often present the most theories address this issue current information. ”of nursing in which interventions are based on data in some way. Simply Then a plan should be stated, EBP is the practice developed to imple- ment the new findings. This process can be applied from research that demonstrates that they are appro- to changing policy and procedures or developing priate and successful. It involves a systematic process training programs for facility staff. The most current of uncovering, evaluating, and using information research data should always be used when initiating from research as the basis for making decisions about new practices or modifying old ones. For more detail and providing client care.7 Many nursing practices on EBP, go to Chapter 24. and interventions of the past were performed merely because they had always been done that way (accus- Public Service and Altruistic Activities tomed practice) or because of deductions from physi- When defining nursing, almost all major nursing ological or pathophysiological information. Clients theorists include a statement that refers to a goal have become more adept in the use of information of helping clients adapt to illness and achieve their technology, and as a result, many now have a higher highest level of functioning. The public (variously level of knowledge about their illnesses than in the referred to as consumers, patients, clients, individu- past. This increase in knowledge levels, use of online als, or humans) is the focal point of all nursing mod- health-care information, and demand for higher- els and nursing practice. The public-service function quality care constitute one of the driving forces of nursing has always been recognized and acknowl- behind the use of EBP. edged by society’s willingness to continue to educate The development of information technology has nurses in public, tax-supported institutions and in made EBP in nursing a reality. In the past, nurses private schools. In addition, nursing has been viewed relied primarily on units within their own facilities universally as an altruistic profession composed of

6 U n i t   1 The Growth of Nursing welfare. Today, nurses are found in remote and often selfless individuals who place the lives and well-being hostile areas, providing care for the sick and dying, of their clients above their personal safety. In the working 12-hour shifts, being on call, and working earliest days, dedicated nurses provided care for vic- rotating shifts. tims of deadly plagues with little regard for their own Issues Now Websites: Friends or Foes? Have a paper or report to do for class? Need information on pheochromocytoma, Smith- Strang disease, Kawasaki disease? No problem, look it up on the Web, right? Well, yes and no. Without question, there is a tremendous amount of information about almost any subject available just a few mouse clicks away. But the bigger question is, how good is that information? Anyone can post almost anything online these days, and there are no organizations or agencies that oversee or review the information for quality, accuracy, or objectivity. So how are you supposed to know what is credible and what is not? Although there is no foolproof method for determining the quality of any given website, some telltale markers can point you in the right direction when you are rating the quality of the informa- tion you seek. Marker 1: Peer Review All major professional journals have a peer-review process that requires any manuscript submitted to be reviewed by two or three professionals who are considered experts, or at least knowledgeable, in the subject matter. Peer review is one of the key elements in ensuring the accuracy of the information in the manuscript. When considering an Internet source, look for a clear statement of the source of the information and how that informa- tion is reviewed. If the information is from an established source, such as a recognized professional journal, it has been peer reviewed and has a higher degree of accuracy. Examine the format and writing style of the document. If it seems to be very choppy, or if the style, tone, or point of view changes throughout the article, it is an indication that it was not well edited and probably was not peer reviewed. Use the information with caution. Marker 2: Author Credentials The name of the author and his or her titles and credentials should be listed. Be cautious if no author or publisher is listed. Of course, anyone can use another person’s name as the author, but it is relatively easy to cross-check authors’ names through other databases, such as those found in libraries. Before accepting the information as gospel, it is probably worth looking up the author and seeing what other articles or books he or she has written. Another key to determining author credentials is to establish who owns the website. In general, per- sonal website pages are less likely to contain authoritative information. You can also look at the last three letters in the domain name of the Web address. Domain names ending in .gov, .org, or .edu tend to have higher-quality information. Also, see whether the information has a copyright. If the information is copyrighted, the person felt strongly enough about what he or she was posting to go to the effort of making sure that others could not use it as their origi- nal information.

C h a p t e r 1 The Development of a Profession 7 I s s u e s N o w (continued) Marker 3: Prejudice and Bias Although there is almost always a small degree of prejudice and bias in all written mate- rial, most legitimate authors strive to be as objective as possible. Many times, if you read a document with a critical eye, you can discern obvious prejudicial viewpoints. See if the author has a vested interest in the content of the document. For example, an article about the effects of tobacco use on the respiratory system written by a scientist who was hired by a tobacco company would probably have a decidedly different viewpoint than an article written by a scientist who was employed by the National Health Infor- mation Center. See if contact information is provided by the author and who the spon- sor or publisher of the document is. If these are not provided, be suspicious about the information. Marker 4: Timeliness Of course, all of us want the most recent information we can find and sometimes mistakenly assume that because it is on the Web, it is new. Some information on the Internet has been around since Tim Berners-Lee invented the World Wide Web in 1989, so some of the mate- rial can be very outdated. See if you can determine when the site was last updated and how extensively the information was revised. It is also a good practice to look to other sources (e.g., Internet, journals, books) to compare the material for currency. Many websites have links where you can access other related information. If those links have messages such as “Page not found” or “Link no longer available,” be extremely cautious with the information. Good links should connect you to other reliable sites. Marker 5: Presentation Although the old saying is that you can’t judge a book by its cover, experienced Internet users can often tell a lot about a website by its presentation. Some look well developed and professional, and others look very amateurish. There is no guarantee that the slick-looking websites are better, but it is one factor to consider in the overall evaluation of the informa- tion you are seeking. Take a look at the graphics. They should be balanced with the text and help explain or demonstrate information in the text. If the graphics seem to be just decora- tive, it should raise a red flag about the content of the site. Some sites use a compressed format that requires special programs such as Adobe Acrobat to view them. If you do not have access to these programs, the information in the site is unusable. Move on to the next site. In summary, the Internet can be a valuable source of information about a wide variety of subjects. However, each source needs to be evaluated carefully. Following the five markers discussed here will place you on the path to deciding the quality of the information pre- sented in any website. Sources: D. Gerberi, Predatory journals: Alerting nurses to potentially unreliable content, American Journal of Nursing, 118(1):62–65, 2018; National Center for Complementary and Integrative Health, Finding and evaluat- ing online resources, 2018, retrieved from https://nccih.nih.gov/health/webresources; East Carolina University Library, Evidence-based practice for nursing: Evaluating the evidence, 2018, retrieved from http://libguides .ecu.edu/c.php?g=17486&p=97640.

8 U n i t   1 The Growth of Nursing compared. The nurses’ code of ethics and its implica- tions are discussed in greater detail in Chapter 6. Few individuals enter nursing to become rich and Competency and Professional License famous. It is likely that those who do so for these Nurses must pass a national licensure examination to reasons quickly become disappointed and move on demonstrate that they are qualified to practice nurs- to other career fields. Although the pay scale has ing. Nurses are allowed to practice only after passing increased tremendously since the early 2000s, nurs- this examination. The granting of a nursing license ing, at best, provides a middle-class income. Surveys is a legal activity conducted by the individual state among students entering nursing programs continue under the regulations contained in that state’s nurse to indicate that the primary reason for wishing to practice act. become a nurse is to “help others” or “make a dif- ference” in someone’s life and to have “job security.” WHEN NURSING FALLS SHORT Rarely do these beginning students include “to make OF THE CRITERIA a lot of money” as their motivation.7 Autonomy and Independence of Practice Well-Organized and Strong Representation The nursing profession took its first steps toward Professional organizations represent the members of autonomy of practice and away from medical prac- the profession and control the quality of professional tice with Florence Nightingale’s radically new ideas practice. The National League for Nursing (NLN) about a separate educational setting for nurses. She and the American Nurses Association (ANA) are believed that nurses have a practice of health care the two major national organizations that represent that is independent from the practice of physicians. nursing in today’s health-care system. The NLN is To her, nursing practice had an intellectual compo- primarily responsible for regulating the quality of nent as well as a skill component that required differ- the educational programs that prepare nurses for ent education to master.10 the practice of nursing, whereas the ANA is more concerned with the quality of nursing practice in the Historically, there was a widely accepted belief that daily health-care setting. These and other organiza- nurses were the handmaidens or even servants to the tions are discussed in more detail in Chapter 5. physician.11 It was based on several factors, including social norms. For example, women became nurses, Both these groups are well organized, but nei- whereas men became physicians; women were sub- ther can be considered powerful when compared servient to men, the nature of the work being such with other professional organizations, such as the that nurses cleaned and physicians cured. In terms of American Hospital Association (AHA), the Ameri- the relative levels of education of the two groups, the can Medical Association (AMA), or the American average nursing program lasted for 1 year, whereas Bar Association (ABA). One reason for their lack of physician education lasted for 6 to 8 years. strength is that fewer than 10 percent of all nurses in the United States are members of any professional Unfortunately, despite efforts to expand nurs- organization at the national level.8 Many nurses do ing practice into more independent areas through belong to specialty organizations that represent a updated nurse practice legislation, nursing still specific area of practice, but these lack sufficient retains much of its subservient image to the public. political power to produce changes in health-care In reality, nursing is both an independent and an laws and policies at the national level. interdependent discipline. Nurses in all health-care settings must work closely with health-care provid- Nurses’ Code of Ethics ers, hospital administrators, pharmacists, and other Nursing has several codes of ethics that are used to groups in the provision of care. In some cases, nurses guide nursing practice. The ANA Code of Ethics for in advanced practice roles, such as nurse practi- Nurses, the most widely used in the United States, tioners, can and do establish their own independent was first published in 1971 and updated in 1985, 2001 practices. Most state nurse practice acts allow nurses and 2015. The current 2015 ANA Code of Ethics, more independence in their practice than they real- while maintaining the integrity found in earlier ver- ize. To be considered a true profession, nursing must sions, is now more relevant to current health-care and nursing practices.9 This code of ethics is recognized by other professions as a standard with which others are

be recognized by other disciplines as having practi- C h a p t e r 1 The Development of a Profession 9 tioners who practice nursing independently. Professional Identity and Development increased demand for nurses who are educated to The issue of job versus career is the question here. A deliver care in the community setting and in long- job is a group of positions, similar in nature and level term health-care settings rather than in the hospital. of skill, that can be carried out by one or more individ- There has also been a need for nurse case managers uals. There is relatively little commitment to a job, and who are prepared to coordinate care for vulnerable many individuals move from one job to another with populations requiring costly services over extended little regard to the long-term outcomes. A career, in periods. Nursing education programs are attempting contrast, is usually viewed as a person’s major lifework, to meet these needs by preparing individuals who can which progresses and develops as the person grows practice independently and autonomously, network, older. Careers and professions have many of the same collaborate, and coordinate services. These programs characteristics, including a formal education, full-time also offer more clinical experiences in rehabilitation, employment, requirement for lifelong learning, and nursing home, and community settings. a dedication to what is being achieved. Although an increasing number of nurses view nursing as their life’s What Do You Think? work, many still treat nursing more as a job. List and rate several of your recent experiences with the The problem becomes circular. The reason nurses health-care system. In what roles did you observe regis- lack a strong professional identity and do not con- tered nurses functioning? sider nursing as a lifelong career is that nursing does not have full status as a profession.12 Until nurses are Advanced Practice Nurses fully committed to the profession of nursing, identify For individuals who are unfamiliar with the health- with it as a profession, and are dedicated to its future care delivery system, it is sometimes difficult to development, nursing will probably not achieve pro- understand the similarities and differences between fessional status. nursing titles and roles. This confusion is particularly evident in the case of clinical nurse specialists (CNSs) MEMBERS OF THE HEALTH-CARE TEAM and nurse practitioners (NPs), who are sometimes collectively referred to as advanced practice regis- The health-care delivery system employs large num- tered nurses (APRNs).13 bers of diagnosticians, technicians, direct care pro- viders, administrators, and support staff (Table 1.1). The Nurse Practitioner and Certified Nurse Midwife It is estimated that more than 300 job titles are used In general, NPs are prepared to provide direct client to describe health-care workers. Among these are care in primary care settings, focusing on health pro- nurses, nurse practitioners, physicians, physician motion, illness prevention, early diagnosis, and treat- assistants, social workers, physical therapists, occu- ment of common health problems. Their educational pational therapists, respiratory therapists, clinical preparation varies, but in most cases, individuals psychologists, and pharmacists. All these individuals successfully complete a graduate nurse practitioner provide services that are essential to daily operation program and are certified by the American Nurses of the health-care delivery system in this country. Credentialing Center (ANCC) or an appropriate professional nursing organization. Depending on the Of particular importance among this array of individual state nurse practice act, NPs have a range health-care workers are various types of nurses: reg- of responsibilities for diagnosing diseases and pre- istered nurses, licensed practical (vocational) nurses, scribing both treatments and medications. A growing nurse practitioners, case managers, and clinical number of states now grant NPs direct third-party nurse specialists. Each of these requires a different reimbursement for their services without a physician. type of educational background, clinical expertise, and, sometimes, professional credentialing. In gen- Certified nurse midwives have similar advanced eral, all nurses make valuable contributions within practice education except that it focuses on the care the health-care delivery system. There has been an of pregnant women before, during, and after the birth process. They also have extensive education in the care of newborn infants.

10 U n i t   1 The Growth of Nursing Table 1.1 Other Key Health-Care Team Members Title Credential Practice Physician (MD) License—medical Medical—limited only by specialization; some serve as primary care providers. Physician (DO) License—osteopath Medical, with focus on body movement and holistic Physician (DC) License—chiropractor health—similar to MD. Can serve as primary care Physician (DPM) providers. Physician assistant License—podiatry Limited—focus on spinal column and nervous system. LPN/LVN Certification—no Unable to prescribe medications. Social worker individual license Limited—foot health. Can prescribe medications, License perform foot surgery. License Practices on physician’s license. Practice limited by medical practice act and wishes of supervising Physical therapist License physician. Respiratory therapist License Nursing—limited; basic nursing practice skills under the direction of a higher-level provider. Clinical psychologist License Pharmacist License Increasingly important as health care becomes more complex. Resolves financial, housing, psychosocial, and employment problems; does discharge planning and assists clients in transfer between facilities. May serve in case management roles to coordinate services. Focuses on helping clients maintain or regain the highest level of function possible after strokes, spinal cord injury, arthritis, or residual effects of traumatic accidents. Helps prevent physical decline and regain the ability to groom, eat, and walk through individualized range-of-motion and exercise programs. Therapy occurs in hospitals, clinics, or the community. Strives to restore normal or as near to normal as possible pulmonary functioning by conducting diagnostic tests and administering treatments that have been prescribed by a physician. Helps clients to manage mental health problems. Private practice, clinics. Distributes prescribed and over-the-counter medications, educates clients, monitors appropriate medication selections, detects interactions and untoward responses in community pharmacies and institutional settings. Valuable resource for nurses. The Clinical Nurse Specialist practitioners are comfortable working in high-tech Clinical nurse specialists usually practice in environments with seriously ill individuals and their secondary- or tertiary-care settings and focus on families. Because of the nature of their work, they care of individuals who are experiencing an acute are excellent health-care educators and physician illness or an exacerbation of a chronic condition. collaborators. In general, they are prepared at the graduate level and are ANCC certified.14 These highly skilled Attempts have been made to combine the roles of the CNS and NP so that the best qualities of both

C h a p t e r 1 The Development of a Profession 11 roles are preserved. The goal of this combination shouldered by nurses combined with a relatively would be to provide high-quality care to individu- small amount of control over their practice. This als in a wide array of health-care settings who have imbalance between authority and responsibility is the a wide range of health problems. Advocates of this source of disempowerment. Even in today’s society, movement include the NLN, the American Associa- with its concerns about equal opportunity, equal pay, tion of Colleges of Nursing (AACN), and the ANA. and collegial relationships, some nurses still seem Titling for this new blended role is unconfirmed, uncomfortable with the concepts of power in and and state legislatures may make the final decisions control of their practice. Their discomfort may arise through their licensing laws.14 As such, titling, educa- from the belief that nursing is a helping and caring tional preparation, and practice privileges will prob- profession whose goals are separate from issues of ably vary from one state to another. power. Although power and empowerment usually go Case Managers hand in hand, they are slightly different in con- One argument for the blended NP–CNS role is the cept. While empowerment helps the nurse to take need for case managers who possess the expertise of action and perform those activities that promote both levels of preparation. Case managers coordinate patient care, power is associated with control and services for clients with high-risk or long-term health authority. problems who require access to the full continuum of Historically, nurses were mostly powerless, and health-care services. Case managers provide services previous attempts at gaining power and control over in various settings, such as acute care facilities, reha- their practice were met with much resistance. Nev- bilitation centers, and ertheless, all nurses use They also work for man- aged care companies, insurance companies, “and private case man- agement agencies. Their roles vary according community agencies. an authoritative voice in their daily practice, even Depending on the individual state if they do not realize it. nurse practice act, NPs have a range of Nurses can understand responsibilities for diagnosing diseases the sources of their and prescribing both treatments and influence, learn how to medications.  increase it, and use it in ”however, their overall goal is to coordinate the use providing client care. to the circumstances of their employment; The Nature of Power of health-care services in the most efficient and cost- The term power has many meanings. From the effective manner possible.15 standpoint of nursing, power is probably best defined Case management is the glue that holds health- as the ability or capacity to exert influence over care services together across practitioners, agencies, another person or group of persons.16 In other words, funding sources, locations, and time. Titling, edu- power is the ability to get other people to do things cational preparation, and certification of nurse case even when they do not want to do them. Although managers are now available. The ANCC has devel- power in itself is neither good nor bad, it can be used oped certification eligibility criteria for nurse case to produce either good or bad results. managers, and an examination is available. At this Power is always a two-way street. By its very time, case managers can be physicians, social work- definition, when power is exerted by one person, ers, RNs, LPNs, and even well-intentioned laypersons another person is affected; that is, the use of power with little health-care education. by one person requires that another person give up some of his or her power. Individuals are always in a state of change, either increasing their power or EMPOWERMENT IN NURSING losing some; the balance of power rarely remains static. One concern that has plagued nursing, almost from Nurses who are empowered have a strong, posi- its development as a separate health-care specialty, is tive attitude; are highly motivated; and use that moti- the relatively large amount of personal responsibility vation to motive others on their team. They share

12 U n i t   1 The Growth of Nursing their sources of power and raise the satisfaction levels demanding activities that they would likely prefer to and the quality of care on their unit. avoid because the nurse has good relationships with Powerlessness in nurses is almost never a positive them. Likewise, nurses who have good collegial rela- attribute. Nurses who lack power are likely to be inef- tionships with other nurses, departments, and health- fective in their care and practice. They may lack the care providers are often able to obtain what they ability to respond in crisis situations, may be viewed want from these individuals or groups in providing as lazy, and may create feelings of irritation and care to clients. frustration in the rest of the team. Internally, they may feel they are failures at their jobs. They are more Expert Power likely to be unhappy with their profession, to burn The expert source of power derives from the out quickly, to feel isolated, and to contribute to poor amount of knowledge, skill, or expertise that an patient outcomes. To survive, they may use coping individual or group has. This power source is exer- mechanisms such as passive-aggressive behavior, cised by the individual or group when knowledge, negativism, and hostility that can create a toxic work skills, or expertise is either used or withheld in environment for all of the team.16 order to influence the behavior of others. Nurses should have at least a minimal amount of this type of power because of their education and experi- Origins of Power ence. It follows logically that increasing the level If power is such an important part of nursing and of nurses’ education will, or should, increase this the practice of nurses, where does it come from? Although there are many expert power. As nurses attain and remain in sources, some of them “ By demonstrating their knowledge of positions of power would be inappropri- the client’s condition, recent laboratory longer, the increased ate or unacceptable for tests, and other elements that are vital to experience will also aid those in a helping and the client’s recovery, nurses demonstrate the use of expert power. caring profession. The Nurses in advanced following list includes their expert power. is knowledge may practice roles are good some of the more acces- sible and acceptable ”increase the amount of respect they are examples of those who sources of power that have expert power. Their nurses should consider given by health care providers.  additional education and using in their practice:16 experience provide these • Referent nurses with the ability to • Expert practice skills at a higher level than nurses prepared • Reward at the basic education level. • Coercive By demonstrating their knowledge of the client’s • Legitimate condition, recent laboratory tests, and other ele- • Collective ments that are vital to the client’s recovery, nurses demonstrate their expert power. This knowledge may increase the amount of respect they are given Referent Power by health-care providers. Nurses access this expert The referent source of power depends on establishing source of power when they use their knowledge to and maintaining a close personal relationship with teach, counsel, or motivate clients to follow a plan of someone. In any close personal relationship, one indi- care. Nurses can also use expert power when dealing vidual often will do something he or she would really with other health-care providers. rather not do because of the relationship. This ability to change the actions of another is an exercise of power. Power of Rewards Nurses often obtain power from this source when The reward source of power depends on the ability they establish and maintain good therapeutic rela- of one person to grant another some type of reward tionships with their clients. Clients take medications, for specific behaviors or changes in behavior. The tolerate uncomfortable treatments, and participate in rewards can take on many different forms, including

personal favors, promotions, money, expanded C h a p t e r 1 The Development of a Profession 13 privileges, and eradication of punishments. Nurses, in their daily provision of care, can use this source organization a right to make decisions that they of power to influence client behavior. For example, might not otherwise have the authority to make. a nurse can give a client extra praise for completing Most obviously, political figures and legislators have the prescribed range-of-motion exercises. There are this source of power. This power can also be dissemi- many aspects of the daily care of clients over which nated and delegated to others through legislative acts. nurses have a substantial amount of reward power. In nursing, the state board of nursing has access to This reward source of power is also the underlying the legitimate source of power because of its estab- principle in the process of behavior modification. lishment under the nurse practice act of that state. Coercive Power Similarly, nurses have access to the legitimate source The coercive source of power is the flip side of the of power when they are licensed by the state under reward source. The ability to reprimand, withhold the provisions in the nurse practice act or when rewards, and threaten punishment is the key element they are appointed to positions within a health-care underlying the coercive source of power. Although agency. Nursing decisions made about client care can nurses do have access to this source of power, it is come only from individuals who have a legitimate probably one that they use minimally, if at all. Not source of power to make those decisions—that is, only does the use of coercive power destroy thera- licensed nurses. peutic and personal relationships, but it can also be considered unethical and even illegal in certain situa- Collective Power tions. Threatening clients with an injection if they do The collective source of power is often used in a not take their oral medications may motivate them to broader context than individual client care and is the take those medications, but it is generally not consid- underlying source for many other sources of power. ered to be a good example of a therapeutic commu- When a large group of individuals who have similar nication technique. beliefs, desires, or needs become organized, a col- lective source of power exists.17 For individuals who “Take the pill or I'll give you a shot!” belong to professions, the professional organization is the focal point for this source of power. The main Legitimate Power goal of any organization is to influence policies that The legitimate source of power depends on a leg- affect the members of the organization. This influ- islative or legal act that gives the individual or ence is usually in the form of political activities car- ried out by politicians and lobbyists. Professional organizations that can deliver large numbers of votes have a powerful means of influenc- ing politicians. The use of the collective source of power contains elements of reward, coercive, expert, and even referent sources. Each source may come into play at one time or another. How Do Nurses Become Empowered? Despite some feelings of powerlessness as a group, nurses really do have access to some important and rather substantial sources of power. Nurses can be empowered from several sources. Empowerment can originate from the social structure of the work setting when nurses work to increase their control over the workplace and feel more satisfied with the care they provide. Relationships are also a very strong source of empowerment by sharing power with others, par- ticularly those who are often viewed as having more power than nurses. Empowerment can be either a group effort or an effect of environmental change or

14 U n i t   1 The Growth of Nursing Issues in Practice Kasey is an RN who has worked on the busy surgical unit of a large city hospital for the past 6 years. As one of three RNs on the unit’s day shift, she often serves as the charge nurse when the assigned charge nurse has a day off. She is hardworking, caring, and well orga- nized and provides high-quality care for the often very unstable postoperative clients the unit receives on a daily basis. About 2 weeks ago, Kasey’s mother was admitted for a high-risk surgical removal of a brain tumor that was not responding to chemotherapy or radiation therapy. The surgery did not go well, and Kasey’s mother was admitted to the surgical unit after the procedure. Dur- ing the past 2 weeks, she has shown a gradual but steady decline in condition and is no longer able to recognize her family, speak, or do any self-care. It is believed she will prob- ably not live more than another week. Per hospital policy, Kasey is not assigned to care for her mother; however, during her shifts, Kasey is spending more and more time with her mother, sometimes to the detriment of her assigned clients. She is also beginning to make more demands on the unit nursing staff, often overseeing their care and requesting that only certain nurses care for her mother. One of the other nurses on the unit suggested that Kasey’s mother be moved to a less spe- cialized unit. When Kasey heard about the suggestion, she became livid and, in the middle of the nurses’ station, loudly scolded the nurse for her insensitivity. Questions for Thought 1. Is the practice of not allowing nurses to provide care for their relatives evidence based or accustomed practice? How would you find out? 2. Identify the steps in making this policy evidence based. 3. Do you think nurses should be allowed to care for relatives? Why? Why not? the individual nurse’s own efforts at self-growth and to influence legislators and legislation if all of those actualization. Most commonly, it is a combination of nurses were members of the organization rather than all three factors. the approximately 300,000 who actually do belong. What can nurses, either as individuals or as a Political Activity group, do to increase their power? A second way in which nurses can gain power is by becoming involved in political action. Although this Professional Unity produces discomfort in many, nurses must realize Probably the first, and certainly the most important, that they are affected by politics and political deci- way in which nurses can gain power in all areas is sions in every phase of their daily nursing activities. through professional unity. The most powerful groups are those that are best organized and most united. The The simple truth is that if nurses do not become power that a professional organization has is directly involved in politics and participate in important leg- related to the size of its membership. According to islation that influences their practice, someone other the ANA, there are approximately 3.6 million actively than nurses will be making those decisions for them. practicing nurses in the United States. It is not dif- The average legislator knows little about issues such ficult to imagine the power that the ANA could have as clients’ rights, national health insurance, quality of

C h a p t e r 1 The Development of a Profession 15 nursing care, third-party reimbursement for nurses, the “old boy” system remains alive and well in many and expanded practice roles for nurses, yet they make segments of 21st-century society. The old boy system, decisions about these issues almost daily. It would which is found in most large organizations, ranging seem logical that more informed and better decisions from universities to businesses and governmental could be made if nurses took an active part in the agencies, provides individuals, usually white men, legislative process. with the encouragement, support, and nurturing that allow them to move up quickly through the ranks in Accountability and Professionalism the organization to achieve high administrative posi- A third method of increasing power is by demon- tions. An important element in making this system strating the characteristics of accountability and work involves never criticizing another “old boy” in professionalism. Nursing has made great strides in public, even though there may be major differences these two areas in recent years. Nurses, through pro- of opinion in private. Presentation of a united front fessional organizations, have been working hard to is extremely important in maintaining power within establish standards for high-quality client care. More this system. Nursing and nursing organizations have important, nurses are now concerned with dem- never had this type of system for the advancement of onstrating competence and delivering high-quality nurses. client care through Part of the difficulty processes such as peer in establishing a nurse- review and evaluation. important, way in which nurses can gain support network is that By accepting responsibil- ity for the care that they “ power in all areas is through professional provide and by setting unity. e most powerful groups are the standards to guide those that are best organized and most that care, nurses are tak- united.  ing the power to govern Probably the rst, and certainly the most nurses have not been in nursing away from non- high-level positions for nursing groups. very long. The frame- Networking work for a support sys- tem for nurses is now in place; with some com- mitment to the concept ” developed network to allow the brightest, best, and and some activity, it can grow into a well- Finally, nurses can gain power through establishing a most ambitious people in the profession to achieve nurse-support network. It is common knowledge that high-level positions.16 Conclusion Nursing has taken great strides forward in achiev- ing professional status in the health-care system. Cur- Ongoing changes in the health-care system are hav- rently, many nurses accept that nursing is a profession ing a major impact on how and where nursing is and therefore are not very concerned about further- practiced and even on who practices it. If nurses ing the process. Even as nursing has matured and utilize their tremendous potential power by banding evolved into a field of study with an identifiable body together as a profession, they will be able to influ- of knowledge, some of the questions and problems ence decisions about the direction in which health that have plagued this profession persist. In addition, care is going. Subsequently, nurses, in addition to advances in technology, management, and society politicians, health-care providers, hospital admin- have raised new questions about the nature and role istrators, and insurance companies, will be shaping of nursing in the health-care system. Only by under- the future of the nursing profession and health care standing and exploring the issues of professionalism itself. Nurses were at the table for the formation of will nurses be prepared to practice effectively in the the Affordable Care Act. It is essential that they be present and meet the complex challenges of the future. involved in any modifications or revisions that are made to it in the future.

16 U n i t   1 The Growth of Nursing Critical-Thinking Exercises • Distinguish between an occupation and a profession. • Is nursing a profession? Defend your position. • Discuss four ways in which nursing can improve its professional status. • Name the three sources of power to which nurses have the most access. Discuss how nurses can best use these sources of power to improve nursing, nursing care, and the health-care system. NCLEX-STYLE QUESTIONS 5. Whose scope of practice is NOT regulated by the state board of nursing? 1. Which qualities are characteristic of a profession? 1. Registered nurse Select all that apply. 2. Licensed practical nurse 1. Specialized body of knowledge 3. Case manager 2. High level of individual responsibility and 4. Physician assistant accountability 3. Potential for high pay 6. Reggie is doing online research for his nursing fun- 4. Relatively high degree of autonomy damentals class. In the article he’s reading, several 5. A code of ethics links that he has clicked on have shown the message “Page not found.” What should Reggie do next? 2. An APRN discusses the possible causes of a cli- 1. Stop clicking the links and keep reading. ent’s abnormal laboratory work with the client’s 2. Find a more up-to-date source for his physician. What source of power is the APRN information. demonstrating? 3. Write an angry email to the site’s administrator. 1. Referent 4. Click more links to see if they work. 2. Expert 3. Rewards 7. Some states require that APRNs practice under the 4. Coercive license of a physician. What area of the nursing profession is being limited by these regulations? 3. Yolanda is doing research for a nursing paper on 1. Specialized body of knowledge lung cancer, and she wonders if the website she’s 2. Public service and altruistic activities looking at is credible. What finding should make 3. A code of ethics that guides members in their her suspicious of the content on the site? practice 1. There are no credentials listed after the authors’ 4. Autonomy and independence of practice names. 2. The domain name of the site’s Web address 8. Place the steps of developing an evidence-based ends in .edu. practice in the order they should occur. 3. The articles are from a current peer-reviewed 1. Evaluate effectiveness of current practices. journal. 2. Identify the goal of the intervention. 4. The study she’s reading about was funded by the 3. Develop a plan to implement new findings. American Cancer Society. 4. Train staff to use the new intervention. 5. Search for practices that are demonstrably more 4. ___________ is the ability or capacity to exert effective. influence over another person or group of persons.

C h a p t e r 1 The Development of a Profession 17 9. For decades, Homans sign was used to assess for 10. To increase their power, what should nurses do? the presence of deep vein thrombosis (DVT) in the Select all that apply. lower leg. However, after many studies called into 1. Network question the risks involved with and the diagnostic 2. Become politically active value of Homans sign, it has fallen out of favor. 3. Demonstrate professionalism What is this an example of? 4. Join professional organizations 1. Accustomed practice 5. March in demonstrations 2. Evidence-based practice 3. Specialized body of knowledge 4. A nursing intervention References 10. Clark S. The BSN entry into practice debate. Nursing Man- agement, 47(11):17–19, 2016. https://doi.org/10.1097/01 1. Williams E. Define professionalism in nursing. Chron, 2018. .NUMA.0000502806.22177.c4 Retrieved from http://work.chron.com/define-professionalism- nursing-15763.html 11. McGhie-Anderson LR. Advanced nursing education: Criti- cal factors that influence diploma and associate degree nurses 2. A nurse’s guide to professional boundaries. National Council to advance. Nursing Education Perspectives, 6(38):2–6, 2017. of State Boards of Nursing, 2018. Retrieved from https://www https://doi.org/10.1097/01.NEP.0000000000000226 .ncsbn.org/ProfessionalBoundaries_Complete.pdf 12. Blair D. Licensed practical nurse (LPN) vs registered nurse 3. Aukett J. What is a profession? British Dental Journal, 223(5): (RN). Practical Nursing.Org. 2017. Retrieved from https:// 323–324, 2017. Retrieved from https://www.nature.com/articles/ www.practicalnursing.org/lpn-vs-rn sj.bdj.2017.754.pdf?origin=ppub 13. Advanced practice nurse fact sheet. Nurse Journal, 2017. 4. MacLellan L., Levett-Jones T, Higgins I. The enemy within: Retrieved from https://nursejournal.org/advanced-practice/ Power and politics in the transition to nurse practitioner. Nursing advanced-practice-nursing-fact-sheet Plus One, 2:1–7, 2016. https://doi.org/10.1016/j.npls.2016.01.003 14. Holly V. Clinical nurse specialists call for greater invest- 5. Krautsheid L. Defining professional nursing accountability. ment in opioid crisis. National Association of Clinical Nurse Literature review. Journal of Professional Nursing, 30(1):43–47. Specialists, 2017. Retrieved from http://nacns.org/2017/10/ https://doi.org/10.1016/j.profnurs.2013.06.008. clinical-nurse-specialists-call-for-greater-investment-in- opioid-crisis 6. Salinis A. Why evidence-based practice matters to students [blog post]. Nurse.com, 2017. Retrieved October 2017 from https:// 15. Green A. Job description of a nurse case manager. Career www.nurse.com/blog/2017/02/22/why-evidence-based-practice- Trend, 2017. Retrieved from https://careertrend.com/about- matters-to-students-alexanders-student-blog 6201175-job-description-nurse-case-manager.html 7. Why become a nurse? Everyday Nursing (2018). Retrieved from 16. Merchant P. 5 sources of power in an organization. Chron, http://everynurse.org/become-nurse 2018. Retrieved from http://smallbusiness.chron.com/ 5-sources-power-organizations-14467.html 8. Abu Salah A, Aljerjawy M, Salama A. Gap between theory and practice in the nursing education: the role of clinical setting, 17. Duygulu S. Don’t underestimate your power to influence 2018. JOJ Nurse Health Care, 7(2): 555707. DOI: 10.19080/ change! Reflections in Nursing Leadership, 2017. Retrieved JOJNHC.2018.07.555707 from https://www.reflectionsonnursingleadership.org/ features/more-features/don-t-underestimate-your-power- 9. American Nurses Association. Code of Ethics for Nurses with to-influence-change. Interpretive Statements. Silver Spring, MD: American Nurses Association, 2015. Retrieved from https://www.nursingworld.org/ practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses

Historical Perspectives 2 Joseph T. Catalano Learning Objectives UNDERSTANDING OUR HISTORY After completing this chapter, the reader will be able to: Knowledge about the profession’s past can help us understand how nursing developed and even suggest solutions to problems • Explain why studying the his- that face the profession today. Several threads run throughout tory of health care and nurs- the history of nursing, including society’s beliefs about the causes of ing is important to the nursing illness, the value placed on individual life, and the role of women in profession society. The wars of modern history have also had a significant impact on nursing, particularly in influencing the development of technology • Name three “historical threads” and guiding the direction of health care. This chapter is not a treatise found in the study of nursing on the history of health care and nursing but rather an introduction to history and discuss why they some key historical milestones and individuals that helped to form the are important foundations of health care and nursing care. • Discuss Christian influences on ORIGINS OF NURSING health care and nursing According to the American Nurses Association (ANA), nursing is the • Discuss the influences of the protection, promotion, and optimization of clients’ health and abilities, Renaissance and Reformation the prevention of disease and illness, and the alleviation of suffering on health care and nursing through the diagnosis and treatment of human response to disease and injury. This comprehensive and modern definition of nursing was only • Describe the major changes derived after centuries of development. However, one of the common in health care and nursing elements seen throughout the history of nursing is the belief that by during and immediately after providing care to the ill and injured, including individuals, families, World War II and communities, optimal health and quality of life could be restored or maintained. • Identify key historical persons who advanced the profession of nursing 18

C h a p t e r 2 Historical Perspectives 19 Before Nursing understanding of the basis of disease. Writings from 1500 . . refer to surgical procedures, the role Nursing, as it is currently practiced with its empha- of the midwife, bandaging, preventive care, and sis on theory and best practices, is a relatively recent development in the historical timeline. The major even birth control. Women enjoyed a higher status concern of most early civilizations was the survival in Egyptian society and even worked in hospitals.1 and propagation of the tribe or group. Because illness Physicians, however, were still men, who served in and injury threatened this survival, many primitive multiple roles as surgeons, priests, architects, and health-care practices grew from processes of trial and politicians. error. In prehistoric times, women were the primary The Babylonian Empire, united in 2100 . ., was care providers for the ill and injured because they were a civilization that focused on astrology and what the ones who were at home while the men were off we now call holistic health practices. Its health-care fighting or hunting. Evil spirits were thought to be the practices included special diets, massage therapy, cause of many illnesses, and the medicine men and and rest to drive evil spirits from a body. People women who practiced witchcraft to ward off or rid the would go to the marketplace to seek advice on how group of spirits were considered religious figures. to treat their ailments. During the height of the empire, strict guidelines governed doctors’ fees and Driving Out Demons responsibilities in medical practice. There is also In ancient Eastern civilizations, starting from about evidence from this period of child care and treat- 3500 . ., health care was intertwined with religion. ment of some diseases in special temples, but most Taoism emphasized care still took place in balance and the driving “ e major concern of most early the home. of demons out of the civilizations was the survival of the group, By 1900 . ., the ailing body. Acupunc- and because illness and injury threatened ture developed over the this survival, many primitive health-care Hebrews had formed a next several thousands practices grew from processes of trial nation along the Medi- of years, and medicinal terranean and adopted many of the health prac- ”herbs were used in pre- tices of the neighbor- ventive health care. and error.  ing civilizations. They In Southeast Asia, integrated elements of Hinduism emphasized the Egyptian sanitary the need for good hygiene, and written records laws to form the Mosaic Code of Laws, which, as in would soon chronicle a number of surgical proce- many other cultures, mixed religion and medicine. dures. This was also the first culture to document Caring for widows, orphans, the poor, and strang- medical treatment outside the home. The rise of ers in need was part of daily life and an essential Buddhism around 530 . . caused a surge in interest element of their religious laws. Hebrews had good in health care, leading to the development of public knowledge of anatomy and physiology, especially hospitals and the requirement of high standards the circulatory system. Physician-priests routinely for doctors and other hospital workers. Buddhists performed operations such as surgical deliveries emphasized good hygiene and prevention of disease. (named cesarean deliveries later by the Romans), The development of medical knowledge was some- amputations, and circumcisions. They also what hindered by the refusal of physicians to come enforced rules of purification, performed sacrifices, in contact with blood and infectious body secre- and conducted rituals related to food preparation. tions and the prohibition against dissection of the They also believed strongly in praying to their one human body. god for help in times of plagues and disaster for healing and cure. Women’s role in their society was Ancient Sciences a mixture of being a step lower than men and being During the same period, the ancient Egyptians’ held in high esteem. The Old Testament is filled belief that all disease was caused by evil spirits with women of great strength and character, yet in and punishing gods was changing. Health-care everyday society, they did not have much stature. providers from that time showed a well-developed There were no specific prohibitions against women

20 U n i t   1 The Growth of Nursing providing care of the sick and injured, and as in from herbs and plants. Roman physicians were even- most early societies, this care was given at home. tually able to distinguish among various conditions and to perform many kinds of surgeries. They also did physical therapy for athletes; diagnosed symp- What Do You Think? toms of infections; identified job-related dangers of lead, mercury, and asbestos; and published medical How might the study of nursing history inform your nurs- textbooks. ing practice? What do you expect to learn? The Romans’ advances in creating an unlimited supply of clean water through aqueducts were criti- The Father of Medicine cal in maintaining the good health of the citizens, Ancient Greek culture focused on appeasing the as were central heating, spas and baths, and more gods, and its medical practice was no exception. The god Apollo was devoted to medicine and good advanced systems for sewage disposal. Because the great Roman armies were so crucial to the health. The Greeks performed sacrifices to appease empire, they developed early hospitals to care for the gods and practiced abortion and infanticide in an attempt to control the population. People took sick and injured soldiers. These were mobile and were staffed by female and male attendants who hot baths at spas to improve health, but the sick performed duties that would today be thought of as and injured were cared for at clinics. Although women were held in high esteem, they were not nursing care. Their skill set included cleaning and bandaging wounds, feeding and washing clients, permitted to provide and providing comfort any health care outside the home. to the wounded and Around 400 . ., the e term nurse is thought to have dying. In many ways, originated in this period from the Latin women enjoyed an writings of Hippocrates word nutrire, meaning “to nourish, equal status in society. Most care, including the “began to change medi- practice of midwifery, ”Hippocrates was called “the father of medicine.” was still provided in the cal practice in Greece. nurture, or suckle a child.”  home. One of a roving group of physician-priests, His beliefs focused on harmony with the natural Early Efforts at Nursing law instead of on appeasing the gods. He empha- sized treating the whole client—mind, body, spirit, Although caring for the ill and injured had become and environment—and diagnosing on the basis of an established element in most early societies, the symptoms rather than on an isolated idea of a dis- concept of a special group to provide this care ease. He was also concerned with ethical standards evolved some time later. The concept of “nurse” grew for physicians, expressed in the now-famous Hip- primarily from the care provided by Christian orders pocratic Oath. of nuns who were solely dedicated to the care of the sick and dying. Health Care in the Roman Empire The Sanctity of Life Ancient Romans clung to superstitions and polythe- The rise of Christianity, starting from . . 30, ism as the foundations for medical and religious brought with it a strong belief in the sanctity practices. The dominant Roman Empire ruled from of all human life. Christians considered prac- around 290 . . and absorbed useful elements of tices such as human sacrifice, infanticide, and whatever culture it conquered—including the Greeks abortion—which had been common in Roman and Hebrews. The Romans developed quite an society—to be murder. Following the teachings advanced system of medicine and a pharmacology of Jesus meant that caring for the sick, poor, and that included more than 600 medications derived disadvantaged was of primary importance, and

groups of believers soon organized to offer care C h a p t e r 2 Historical Perspectives 21 for those in need. Leeches were cutting edge Early writings of the Christian period record medical practice. women’s important role in ministering to the sick and providing food and care for the poor and Early Military Hospitals homeless. Wealthy Roman women who had con- At the end of the Dark Ages, there was a series of verted to Christianity established hospital-like insti- holy wars and invasions, including the Crusades, tutions and residences for these caregivers in their which produced many sick and injured who were homes. The term nurse is thought to have origi- far from home. Military nursing orders developed to nated in this period from the Latin word nutrire, care for the soldiers, but these were made up exclu- meaning “to nourish, nurture, or suckle a child.” sively of men who wore suits of armor to protect The majority of care was still provided by a family themselves against attacks. These orders, with the member in the home. Most early Christian hospitals emblem of a Red Cross, were extremely well orga- were roadside houses for sick travelers, as well as nized and dedicated, and they existed well into the for the poor and destitute, who were cared for by Renaissance. male and female attendants alike. The attendants Development of the Modern Nurse learned from a process of trial and error and from Current society readily accepts technology and scien- observing others. tific breakthroughs; however, earlier religion-based societies had more difficulty moving forward with A Time of Disease these developments, which were sometimes seen as The Dark Ages, from roughly . . 500 to 1000, were works of Satan. The Renaissance developed into a marked by widespread poverty, illness, and death. battle between progressive thinkers and a very con- Plagues and other diseases, such as smallpox, leprosy, servative governance structure that resisted change. and diphtheria, ravaged the known world and killed Health Care in the Renaissance large segments of populations. Health care at this In the intellectual reawakening of the Renaissance in time was almost nonexistent. Europe, starting in about 1350, nursing emerged in a form that would be recognizable today and However, the strong beliefs of the Catholic formed the cornerstone of what we now know as a Church, which was based in Rome, produced mon- profession. Inventions from this time include the asteries and convents that became centers for the microscope and thermometer, but the use of more care of the poor and the sick. By . . 500, there modern diagnoses and treatments was viewed with were several religious nursing orders in what are today England, France, and Italy. Men and women worked there and also traveled to rural areas where they were needed, combining religious rituals and prayers with home remedies and providing treat- ments such as bandaging, cautery, bloodletting, enemas, and leeching. The biggest contribution to health care in this period may have been the insis- tence on cleanliness and hygiene, which lessened the spread of infections. Medieval nurses did not have any formal schooling but learned through apprenticeships with older monks or nuns. Eventu- ally, hospitals came to be built outside of monas- tery grounds. Also established were secular orders, which could provide a wider range of services to the sick because they were not limited by religious restrictions and obligations.

22 U n i t   1 The Growth of Nursing and this led to an early form of community health skepticism. Monastic hospitals still regarded the res- nursing. The Sisters of Charity expanded their care to toration of health as secondary to the salvation of the include home care. Only a few male nursing orders soul. Major political changes initiated by the Prot- survived the Protestant Reformation and Industrial estant Reformation in 1517 had the greatest effect Revolution. Several non-Catholic nursing orders on the health care of the period. In Catholic nation- were founded, including one by the famous Quaker states, including Italy, France, and Spain, health Elizabeth Fry, who established the Society of Protes- care remained generally unchanged from that of the tant Sisters of Charity in London in 1840, which pro- Middle Ages, although the number of male nursing vided training to nurses who cared for the sick and orders gradually decreased. By 1500, the majority of poor, including prisoners and children. health care was provided by female religious orders. What Do You Think? NURSING IN THE UNITED STATES Imagine yourself living in one of the historical periods discussed in this chapter. Given your or your fam- Five hospitals existed in America before the Revolu- ily’s health-care problems, how would your lives be tionary War; they housed the homeless and the poor different? and included rudimentary infirmaries. However, there were no identifiable groups of nurses for these infirmaries.2 Health care in America at this time A Nursing Hierarchy reflected that of the European countries from which In the nation-states that the settlers had come. Catholic Church, such as Infant mortality rates England, Germany, and the Netherlands, health “care soon degenerated to a state even worse than broke away from the were very high, ranging between 50 and 75 per- e Civil War caused more death and cent.2 One of the first injury than any other war in the history schools of nursing was of the United States, and the demand for established in 1640 by nurses increased dramatically.  ”reduced under Protestant leadership, and the male that of the Middle Ages. the Sisters of St. Ursula The role of women was in Quebec, and Spanish and French religious orders would establish hospital- nurse all but disappeared. Secular nursing orders based training schools in the New World over the gradually took over the duties of the many substan- next 100 years. dard hospitals that had been established in metropoli- tan areas. The most famous of these was the Sisters of In Colonial Times Charity, established in 1600. During the Revolutionary War, there were no orga- These orders were the first to establish a nursing nized medical or nursing corps, but small groups of hierarchy. Primary nurses were called sisters, and untrained volunteers cared for the wounded and sick those assisting them were called helpers and watchers. in their homes or in churches or barns. In 1751, Ben- At this time, people began to recognize the benefits jamin Franklin founded Pennsylvania Hospital, the of skilled nursing care. The first nursing textbooks first U.S. hospital dedicated to treating the sick. appeared, and the use of midwives became wide- Between the Revolutionary War and the Civil spread. Although hospitals were gaining importance, War, health care in the United States increased mark- most clients still received health care at home. edly with the influx of religious nursing orders from The Industrial Revolution (1760–1840) caused Europe. More early schools of nursing developed at a flood of people throughout Europe to move from this time. Despite the rapid increase in the number of rural areas into cities. Cramped living situations hospitals, most nursing care was still given at home caused very bad health conditions and the spread of by family members. Hospitals were considered a last disease and plagues. Factory owners supported some resort where people went to die; consequently, the forms of health care to keep their workers on the job, hospitals had very high mortality rates.

When the States Went to War C h a p t e r 2 Historical Perspectives 23 The Civil War caused more death and injury than any other war in the history of the United States, Most of the duties carried out by physicians at and the demand for nurses increased dramatically. that time would fall well within today’s scope of Women volunteers (as many as 6000 for the North practice for nurses. However, in the face of the and 1000 for the South) began to follow the armies large numbers of injured produced in World to the battlefields to provide basic nursing care, War I, nurses’ roles rapidly expanded, and they although many of these volunteers were untrained. began to be recognized for their skills in provid- Army Nurse Corps nurses, who were commissioned, ing care and saving lives. navy nurses, and the American Red Cross all date from this period. Large numbers of women came Untrained Nurses out of their homes to work in the hospitals, and a At the beginning of World War I, there were only number of African American volunteers in the North about 400 nurses in the Army Nurse Corps, but by paved the way for others to enter the health-care field 1917, that number had swelled to 21,000. Because in the future. many hospitals were recruiting uneducated women to provide basic care, a committee on nursing During the Civil War, women was formed to establish standards, and eventu- volunteers followed the armies ally the Red Cross began a training program for and provided basic nursing care. nurse’s aides. This was supported by physicians but opposed by many nursing leaders who were con- After 1914 cerned that such a program relegated nursing to Prior to the beginning of World War I, nurses’ “women’s work,” which would be seen as something primary duties were to carry out the orders of anyone could do with minimal training. Because physicians, clean, cook, and empty bedpans. nurse’s aides were a cheap source of labor, they began to replace more trained nurses in hospitals. Unfortunately, this also resulted in a lower quality of care and started a cost-saving practice that con- tinues to today. Between Wars After the war, a segment of the nursing profes- sion began to focus on improving the educational standards of nursing care. At the time, 90 percent of nursing care was still given at home, but nurses began to practice in industry and in branches of government outside of the military. The standards of nursing care were low, and external quality controls were nonexistent. The Great Depression took its toll on health care and nursing, as funds dried up, jobs became scarce, and many nursing schools closed. At this time, the federal government became one of the larg- est employers of nurses. The newly organized Joint Committee on Nursing recommended that jobs go to more qualified nurses and that the workday be reduced from 12 to 8 hours, although these measures were not widely implemented.1 During this period, hospitals became the primary source of health care, supported by hospital insurance programs. As the size of hospitals increased, more nursing jobs became available.

24 U n i t   1 The Growth of Nursing Establishing Standards A Growing Need World War II produced another nursing shortage, Technical nursing programs, which granted associ- and in response, Congress passed the Bolton Act, ate degrees (associate degree nurse [ADN]) at 2-year which shortened hospital-based diploma programs community colleges, were developed as a quick-fix from 36 to 30 months. The new Cadet Nurse Corps solution to help with the nursing shortage. With the established minimum educational standards for postwar baby boom, the need for nurses continued nursing programs and forbade discrimination on the to grow, and what was supposed to have been a tem- basis of race, creed, or sex.2 Many schools revised porary resolution to a short-term problem became and improved their curricula to meet these new a permanent fixture. By the mid-1960s, ADNs out- standards. numbered nurses with baccalaureate degrees (BSNs) To encourage more nurses to enter the military, and LPNs. Also, ADNs won the right to take the the U.S. government granted women full commis- same licensing examinations as RN graduates from sioned status and gave them the same pay as men diploma and BSN programs. with the same rank. By the end of the war, African After World War II, technology developed during American and male nurses were also admitted to the war began to be transformed for use in civilian the armed services. life, including health care. This made the health-care system increasingly complicated, and some major Modern Times: Emerging Specialties nursing leaders questioned whether 1- or 2-year The single largest transformation of the practice of LPN and ADN programs were adequate to meet the nursing occurred during World War II. Navy and needs of a profession on the brink of an explosion army nurses had such a of knowledge. Slowly, the ing attracted more women volunteers to the armed services than to any other “occupation at the time. Nurses were revered as positive image that nurs- number of BSN programs and graduate-level pro- Medieval nurses did not have any grams began to increase. formal schooling but learned through apprenticeships with older monks Vietnam: Traveling or nuns.  Hospitals ”during the war. Even nurses captured by the Japanese that had been developed during the Korean War selfless heroes under fire in The mobile army surgi- several movies produced cal hospital (MASH) units were allowed to keep practicing because their role were replaced during the Vietnam War with medical was so highly respected. On the battlefields and at unit, self-contained transportable (MUST) hospitals, rear area hospitals, they often worked together with which were staffed by nurses and physicians. Some untrained care providers and physicians, thus initiat- 5000 nurses served in this war, and for the first time, ing the concept of a health-care team. graduates of 2-year ADN programs were commis- sioned into the armed services. (However, the armed A Team of Nurses services now commission only nurses with a BSN.) The advancements in health care made during Several navy nurses were injured in the line of duty, World War II required that nurses receive more and one army nurse was killed. The efforts of these highly specialized education to meet clients’ and other women who served are recognized at the unique needs. After the war, many of the highly Vietnam Women’s Memorial in Washington, dedi- educated and experienced nurses left the profes- cated in 1993. sion to raise families, and their vacancies were filled by graduates of new programs that trained licensed practical nurses (LPNs) and licensed voca- THE EVOLUTION OF SYMBOLS IN NURSING tional nurses (LVNs) in just 1 year. At this time, the concept of team nursing came to be widely All professions have symbols that are easily identi- accepted, although it removed the registered nurses fied and connected with the work and services they (RNs) from direct client care, requiring them to provide. In the past, when most of the popula- serve as team leaders. tion was illiterate, these symbols were helpful in

C h a p t e r 2 Historical Perspectives 25 distinguishing one professional from another. In A Sign of Caring modern society, the symbols connect the professions The lamp was first introduced as a symbol for the to their historical roots and provide the philosophical nursing profession at the time of Florence Nightin- basis for the work they do. gale. In addition to her fame as an early health-care reformer and pioneer, she became well known for The Lamp her role in caring for injured soldiers during the The simple definition of a lamp is a device that pro- Crimean War. She made history when she took her vides a continuous source of light for an extended 38 nurses to Turkey to try to improve the squalid, period of time. The first evidence of lamp use, a filthy conditions she found in the primitive British hollowed-out stone with oil residue in it, can be field hospitals. As Nightingale and her nurses made traced back to 10,000 . . Early variations on the oil their night rounds, caring for the wounded in unlit lamp included seashell lamps and coconut lamps. wards, they carried lamps to light the way. For the Since then, technology has advanced lamps to clay wounded and suffering, these lamps became signs of bowls, pottery, wood, and various types of metals. caring, comfort, and often the difference between life and death. Pushing Back Darkness Nightingale’s lamp was not the often-depicted The significance of the lamp is really the significance “genie” or “Aladdin’s” lamp. Rather, Nightingale of light. Its origins can be traced back to the first would have used one of the many lamps in circula- attempts of human beings to control fire and use it tion around the wards, picking up whichever was as a tool of survival. These early humans soon found closest at hand. The most common type used was that fire extended their the ordinary camp warmth on cold nights,day, was a source of lamp, or a Turkish kept wild animals from candle lantern. She attacking, and was useful Large numbers of women came out of later became immortal- their homes to work in the hospitals, and a ized as the “lady with a “for cooking. number of African American volunteers in lamp” in a poem written Light, first in the form the North paved the way for others to enter by Longfellow (“Santa of torches and candles the health-care eld in the future.  Filomena”). ”used by human beings for thousands of years to For graduate nurses, and later in the form of the lamp, or candle, the oil lamp, has been retains its significance as a symbol of the ideals and push back the darkness of night. It dispelled fear and selfless devotion of Florence Nightingale. It also allowed people to pursue learning long after the sun signifies the knowledge and learning that the gradu- went down. ates have attained during their years in the nursing The lamp has long been used as a religious sym- program. Some nursing graduates physically carry bol. It often represents the eternal flame that dispels a candle during their pinning ceremonies that sym- darkness and evil. Commonly found in Christian bolically represents the brightly burning lamp of symbolism is the Lady of Light, often depicted as their knowledge, skills, care, and devotion as they radiant and glowing brightly and filled with good- go forth to minister to the sick and injured in their ness, purity, and wisdom. The lamp can also rep- nursing practice. resent the flame of life, eventually extinguished by death. The Nursing Pin As schools and universities developed during the Unlikely as it may seem, the modern nursing pin can Middle Ages, many adopted the lamp as a symbol trace its origins to the heavy protective war shields of learning. The burning of the lamp signifies the used by soldiers as far back as the Greek and Roman continual seeking of knowledge and the pushing Empires. The primary purpose of these shields was back of the darkness of illiteracy. It also symbolizes to protect the warriors from the spears, swords, and the enlightenment that accompanies knowledge. The arrows of the opposing army, but they could also be coats of arms or logos used by many universities con- used as weapons to knock down the enemy. Adorned tain the image of a lamp. with the emblems of the soldier’s country and his

26 U n i t   1 The Growth of Nursing graduate nurses by awarding each of them a “badge particular unit in the army, these ancient war shields of excellence.” The badge or pin she designed for also served as a quick way to distinguish friend her school is a deep-blue Maltese cross (Fig. 2.1). from foe. In the center of the cross is a relief image of Night- ingale’s head. As the number of nursing schools During the Crusades, the Knights Hospital- increased, each program designed a unique pin to lers were formed to provide medical care for the represent its own particular values, philosophies, wounded and sick. The Knights wore black tunics beliefs, and goals. over their armor, carried no weapons, and wore a white Maltese cross on chains around their necks. The pinning ceremony is part of a long tradition Those wearing this cross became known for their that acknowledges nursing graduates as belonging skill in treating the injured and healing the wounded. to a unique group and identifies them as new mem- Since that time, the Maltese cross has been recog- bers of the health-care community. The historical nized as a symbol of those who care for the sick. origins of the pin remind nursing professionals Although large by today’s standards, the Maltese of what it symbolizes. Like the badge worn by law cross is often considered the first true nursing pin. enforcement officers, it is also a sign of their legal authority as licensed professionals. Nursing gradu- The shields of some medieval knights were ates wear their pins proudly in the work setting as painted with the coats of arms of the kings they were evidence of their successful completion of the nurs- defending. Only the best knights, recognized for ing program. their skill in battle, strength, honesty, and dedication The Cap to the service of the king, were permitted to use the It is rare to see a nurse wearing the traditional nurs- king’s coat of arms on their shields. The coat of arms ing cap in today’s modern hospitals. However, the displayed to the world the characteristics by which cap has a long, rich history. Throughout much of his- the king wished to be known. A classic example is tory, women were required to keep their heads cov- the symbol of the lion, found on the shields of the ered with some type of garment. This practice was knights who served King Richard the Lionheart, prevalent in the early Hebrew, Greek, and Roman which indicated the king’s fearlessness and power. cultures that served as the roots for modern West- ern society and the current profession of nursing. Similarly, during the Middle Ages when most of the population was illiterate, tradesmen and craft Figure 2.1 Florence Nightingale’s nursing excellence pin. guilds began adopting symbols as pictorial represen- tations of their services, skills, and crafts. Modern companies use trademarks and brand names in the same way today. Medieval schools and universities also began using symbols to represent their values and goals. The modern practice of “branding the university,” or adopting an official symbol or logo for the school, can be traced back to these early prac- tices. These symbols were embossed on clothing, but- tons, badges, and pins that were worn by members of the group. Also traceable to this time in history are the “shields” and badges worn by firefighters and law enforcement officers. Although these shields offer little in the way of protection from arrows and spears, they symbolize official authority and identify the wearer as belonging to a unique, specially trained group. The first modern nursing pin is attributed to Florence Nightingale. After receiving the medal of the Red Cross of St. George from Queen Victoria for her selfless service to the injured and dying in the Crimean War, Nightingale chose to extend the honor she had received to her most outstanding

Few women in Western society wear any type of reg- C h a p t e r 2 Historical Perspectives 27 ular hair cover now. A few groups of religious nuns still wear traditional head coverings as they were Fig u r e 2 .2 Florence Nightingale’s nursing cap. required to do in the past, although most orders have A Cap for Every School gone to a civilian dress code that does not require the In the United States, the first standardized nurs- traditional veil. ing cap is generally attributed to Bellevue Training School in New York City around 1874. The cap’s A Symbol of Service primary purpose was to keep the nurse’s long hair The origins of what we identify as modern nursing from getting in the way, but it also identified nurses can be traced back to an early Christian era group who had graduated from Bellevue. The Bellevue cap of women called deaconesses. Deaconesses were set covered the whole head to just above the ears and apart from other women of the period by their white resembled a modern knitted ski hat except that it head coverings, which indicated that their primary was made of white linen with a rolled fringe at the service was to care for the sick. During the early bottom. centuries of Christianity, groups of deaconesses banded together and formed what later became reli- As the number of nursing schools increased, gious orders that were prevalent in the Holy Roman there was a corresponding increase in the need for Empire. The former deaconesses, now recognized as unique caps. Each nursing school designed its own religious order nuns, remained the primary providers cap. Nursing caps became very frilly, elaborate, and of care for the sick throughout the Middle Ages. The sometimes large and unwieldy. Some caps adopted traditional garb of nuns, the long-robed habit with the upside-down ice cream cone shape, similar to the wimple or veil, can be considered the first official the cloth cone through which ether was given as nurse’s uniform. Each religious order had its own an anesthetic. By looking at the cap, a person could unique style of habit and wimple. The order the nun still determine the school from which the nurse had belonged to could be easily identified from the habit graduated. or veil she was wearing. Traditionally, in the 3-year hospital-based schools Religious orders continued to be the primary of nursing, there were two separate ceremonies— source of care for the sick well into the 19th century. one for capping and one for pinning. The capping However, as the Industrial Revolution progressed ceremony usually took place after the student com- and the concept of the modern hospital developed, pleted the initial 6 months of classroom education, the care of the sick moved away from religious orders to care by laypeople who did not wear the nun’s robe and veil. By the time Florence Nightingale trained at the Institute of Protestant Deaconesses in Germany, the veil had evolved into a white cap that signified “service to others.” However, Florence Nightingale lived and practiced nursing during the Victorian era, which required “proper” women to keep their heads covered. The nursing cap Florence Nightingale wore was similar to the head garb worn by cleaning ladies of the day. It was hood shaped with a ruffle around the face and tied under the chin (Fig. 2.2). This early cap served multiple purposes. It met the requirements of the times for women to keep their heads covered; it kept the nurse’s long hair, which was fashionable during the Victorian era, up and off her face; and it kept the hair from becoming soiled. An unintended benefit was that it kept contaminants from the hair from infecting wounds.

28 U n i t   1 The Growth of Nursing NURSING LEADERS which was considered the probationary period of The nursing profession as it is practiced today owes the program. Capping indicated that the student a great deal to several outstanding nurses who had a was now off probation and that she had earned the vision for the future. The few discussed here are rep- right to wear the cap during clinical rotations in the resentative of the great drive and dedication of the hospital. many individuals who created change and influenced the development of the nursing profession. During nursing school, the cap was also used as a sign of rank and status. In the 3-year hospital-based Florence Nightingale (1820–1910) nursing schools, first-year students wore plain white Universally regarded as the founder of modern nurs- caps. Second-year students had a vertical black band ing, Florence Nightingale dedicated her long life to added to the edge of the cap, and third-year students improving health care and nursing standards. Raised were given a second vertical black band. When the in England, Nightingale was considered highly edu- student graduated, the vertical black bands were cated for her time. Through travels with her family, removed, and a horizontal black band was placed she became aware of the substandard health care in across the front of the cap. many countries in Europe. In 1851, she attended a 3-month nurses’ training program at the church- Unchanging Values run hospital in Kaiserswerth, Germany. She was As shorter hair became an acceptable style for impressed with the program but believed this brief women in the 20th century, the nursing cap lost its training was insufficient. She later ran a private nurs- function of controlling long hair. However, it con- ing home and realized that the only way to improve tinued as a status symbol and a source of pride and health care was to educate women to be reliable, identity for the graduates of nursing schools into high-quality nurses.3 the 1970s. As technology increased in the health- care work environment, the traditional nursing Volunteering Under Fire cap became more of an obstacle for nurses in the Plans to develop a school of nursing in England were practice setting. Also, research demonstrated that interrupted in 1854 by a cholera epidemic. Nightin- the cap, rather than protecting clients from infec- gale volunteered her services and learned a great deal tion by organisms from the nurse’s hair, actually about how to prevent the spread of disease. When helped to colonize organisms. By the 1980s, health- the Crimean War broke out that same year, she care facilities no longer required nurses to wear obtained permission to take a group of 37 volunteer caps as part of the uniform, and nursing schools nurses into the battlefield area. British medical offi- eliminated the cap as a mandatory item of students’ cers initially refused the assistance of Nightingale’s uniforms. nurses. As conditions worsened, the medical officers became overwhelmed with the care of large numbers Most nursing programs have eliminated the cap- of patients and reluctantly allowed the nurses to care ping ceremony as a throwback to an era that was for the wounded in the primitive hospital. repressive to women. However, the nursing cap connects graduates to a rich and long history. It After just 6 months of the nurses cleaning and retains its significance, from the time of Florence bandaging wounds, cooking, and cleaning the wards, Nightingale, as a sign that the primary goal of nurs- the mortality rate dropped from 42 percent to 2 per- ing is “service to those in need.” The nursing cap cent.3 Nightingale expanded her reform to include is a reminder of the unchanging values of wisdom, supplies, a military post office, convalescent camps faith, honesty, trust, and dedication. These values are for long-term recovery, and residences for soldiers’ as important in today’s modern, technology-filled families. She also began to help with the care given at hospitals as they were in the era when washing floors the front lines. At the height of her work in the war, was a required basic nursing skill. Nightingale supervised 125 nurses in several large hospitals, and her accomplishments were recognized What Do You Think? by the Queen of England with an Order of Merit, the highest award given to English civilians. Does your nursing school have a unique nursing cap that was used in the past? What is the symbolism of the cap’s design?

C h a p t e r 2 Historical Perspectives 29 What Do You Think? Isabel Adams Hampton Robb (1860–1910) What would current nursing practice and nursing Isabel Adams Hampton Robb started out as a teacher in her home province of Ontario, Canada, education be like without the influences of Florence but in 1881 she went to New York City to train to Nightingale? be a nurse. After graduation, she moved to Rome and became a superintendent of a hospital there. She had always focused on the academic rather A Health-Care Reformer than the clinical side of nursing. In Italy, her con- The war experience strengthened Nightingale’s viction grew that nurses needed a solid theoretical convictions that nursing education required major reform. Believing that nursing schools should be education—a belief that was not well accepted by the medical community of the time. From run by nurses and be independent of hospitals and that point on, she dedicated her life to raising physicians, she advocated a program of at least 1 year that included basic biological science, tech- the standards of nursing education in the United States, first as director of the Illinois Train- niques to improve nursing care, and supervised ing School for Nurses, a school that was unique practice. She regarded nursing as a lifelong career and felt that nurses should be in direct contact for its time in that it was university based and emphasized academic with clients rather than “ e war experience strengthened learning. Some of her cooking and cleaning. Nightingale’s convictions that nursing unique ideas for the She worked tirelessly education required major reform. time were to develop for the reform of health Believing that nursing schools should and implement a grad- care and nursing and be run by nurses and be independent of ing policy for nursing was appointed to many students that required related committees and nurses to prove their commissions. A prolific hospitals and physicians, she advocated a abilities in order to be writer, she wrote exten- ”sively about improving awarded a diploma. program of at least 1 year that included She also advocated for hospital conditions, basic biological science, techniques to the reduction of the sanitation, nursing edu- improve nursing care, and supervised long hours involved cation, and health care practice.  in training nurses. in general. She later headed the Her famous Florence new Johns Hopkins Nightingale School of Nursing and Midwifery opened in 1860 and Training School for Nurses and implemented her ideas there as well.4 began to train nurses, who were in great demand Hampton Robb brought together leaders from throughout Europe and the United States. At this school, Nightingale advocated health maintenance key nursing schools to form the American Society of Superintendents of Training Schools for Nurses, and the concept that nursing was both an art and and she served as its chairwoman. The group was a science. She taught that each person should be treated as an individual and that nurses should the precursor to the National League for Nursing, which was dedicated to improving the standards for meet the needs of clients, not the demands of nursing education. In 1896, Hampton Robb became physicians. The school flourished, although it faced the first president of a group for staff nurses in active practice called the Nurses Associated Alum- strong opposition from physicians who felt that nae of the United States and Canada, which would nurses were already overeducated. Many early graduates went on to become important nurs- later become the American Nurses Association (ANA), dedicated to the improvement of clinical ing leaders. Nightingale’s ideas were somewhat practice.4 She later helped develop the American diluted during the first half of the 20th century, but they have since resurfaced and are now eval- Journal of Nursing, the first professional journal dedicated to the improvement of nursing, which is uated in the light of a rapidly changing health- still the official journal of the ANA. care system.3

30 U n i t   1 The Growth of Nursing of women.6 She noticed that many of her fellow students struggled to learn about all the medica- Lillian Wald (1867–1940) tions that were becoming available, and she would Lillian Wald was raised in Ohio and graduated later write the first medication textbook for nurses. from the New York Hospital Training School for She worked alongside Lillian Wald at the Henry Nurses in 1901. After working as a hospital nurse, Street Settlement and Isabel Hampton Robb at Johns she entered medical school, but encounters with Hopkins Hospital. New York’s poor and sick caused her to change direction. She instead opened the Henry Street Like Wald, Dock believed that poverty and Settlement, a storefront health clinic in one of the squalor contributed to poor health, and she poorest sections of the city, which organized nurses dedicated herself to social reform to address these to make home visits, focusing on sanitary condi- problems.6 However, she soon learned that her tions and children’s health.5 Wald became a dedi- influence was limited because she was a woman, cated social reformer, an efficient fundraiser, and and she spent most of her career dedicated to the an eloquent speaker. Although women still did not pursuit of equal rights. For 20 years, she lobbied have the right to vote, her political influence was legislators at all levels about women’s right to vote, felt worldwide. believing that this was the only way to influence social reform and health care. An excellent example Under Wald’s auspices, Columbia University of the diverse ways that nurses can help achieve developed courses to prepare nurses for careers in higher-quality health care, Dock is considered one public health. Wald also advocated wellness educa- of the most influential leaders in the early 20th tion, which the medical community did not value at century. the time. However, the Metropolitan Life Insurance Company saw the value in her beliefs and asked her Annie W. Goodrich (1866–1954) to organize its nursing branch. She is also credited Annie Goodrich provided nursing care at Lillian with founding the American Red Cross’s Town and Wald’s Henry Street Settlement in New York after Country Nursing Service and with initiating the receiving her nursing degree. She was known as an concept of school nursing. In 1912, she founded outstanding nursing educator and ran a number and became the first president of the National of nursing schools in New York. In 1910, she was Organization for Public Health Nursing. She was appointed as state inspector of nursing schools, a the first to place nurses in public schools.5 Many position that up to that time had been held only child health and wellness programs in use today are by physicians. After the U.S. Army asked her to based on her efforts. Current proposals for health- survey its hospital nursing departments, Goodrich care reform often include her ideas about public proposed that it organize its own nursing school. health nursing, independent clinics, and health The school opened later that year, with her as its maintenance. dean, and this school would serve as the model for others established at army hospitals during What Do You Think? World War I. Who is your favorite historical nursing leader? What are To respond to the need for nurses in the war, some of that person’s characteristics that appeal to you? Goodrich also established a nursing training pro- Is there a current nurse or nurse educator who is a role gram at Vassar College. After the war, other colleges model for you? What are some of that person’s charac- and universities slowly began to develop their own teristics that appeal to you? nursing programs. Goodrich had demonstrated that teaching theoretical information in a classroom Lavinia Lloyd Dock (1858–1956) was just as important as clinical practice in train- Lavinia Lloyd Dock left her home in Pennsylvania in ing highly skilled nurses. When the war was over, 1885 to attend New York’s Hunter-Bellevue School Goodrich returned to the Henry Street Settlement of Nursing. Her contributions as a reformer focused and then became a nursing educator, eventually serv- on the professionalization of nursing and the equality ing as dean at the Yale School of Nursing. Her many

writings about nursing education and her experi- C h a p t e r 2 Historical Perspectives 31 ences with military nursing have been a great contri- well as give the client feedback on how they are bution to the nursing profession.7 progressing.8 Loretta C. Ford (1920–) At first, the NP program prepared nurses in child Credited with founding nurse practitioner (NP) and family care, educating clients in preventive practice, Loretta C. Ford was born in New York health. The extremely popular program eventually City. She received her diploma in nursing from the became a master’s degree program. It also expanded Robert Wood Johnson University Hospital in New its focus to a broader population as it grew, includ- Brunswick, New Jersey. She held a staff nurse posi- ing caring for adults. Ford’s program educated NPs tion there until she accepted a commission as an to integrate the traditional role of the nurse with officer in the U.S. Army Air Force in 1943. After the advanced medical training and community health, war, she was accepted into the Bachelor of Science thereby providing clients with high-quality care and (BS) program at the University of Colorado Col- education not found in the traditional health-care lege of Nursing. She earned her BS in 1949 and her setting. Master of Science in nursing in 1951. Subsequently, she worked as a public health nurse in Boulder, Ford became the founding dean of the University Colorado, and then for the Boulder County Health of Rochester School of Nursing and director of the Department, where she served as director from Nursing Service at the University Hospital in 1972. 1956 to 1958.8 The school now has nine specialty NP programs, including child psychiatry, which helps fill a need for Ford began her career in education in 1955, when mental health services in rural upstate New York.9 In she was appointed assistant professor at the Univer- 2003, she was awarded the Blackwell Award (named sity of Colorado College of Nursing in Denver. She for the first female doctor in America) from Hobart received her doctorate in education from the Uni- and William Smith Colleges, which is given to a versity of Colorado in 1961 and became a professor woman whose life exemplifies outstanding service in 1965. to humanity. Among many other accolades, she was inducted into the National Women’s Hall of Fame During her time at University of Colorado, in 2011 for being recognized as an internationally she began working with a pediatrician, Dr. Henry renowned nursing leader who has transformed the K. Silver. Together, they noted that there was profession of nursing and made health care more a severe regional shortage of family care physi- accessible to the general public. Ford is now retired cians and pediatricians, particularly in the rural and living in Florida; however, she has remained and underserved areas of Colorado. In response, involved with the University of Rochester School of they came up with an innovative approach to the Nursing. She still consults and lectures on the his- health-care provider shortage. They applied for and torical development of the nurse practitioner along received a small grant from the university in 1965, with issues in advanced nursing practice and health- which led to the creation of a demonstration project care policy. that focused on extending the role of the nurse in the health-care community.9 It was so effective that NPs are found in every corner of the health-care they published their findings, which later became system today. There are over 150,000 NPs work- the blueprint for an educational curriculum for NPs. ing within the United States, and the number grows daily. In many states, NPs can function indepen- Soon after the pilot project was completed, the dently and provide services such as ordering, per- University of Colorado started the first formal NP forming, and interpreting diagnostic tests. They can program in the country. Initially, it was a certificate diagnose and treat acute and chronic conditions program for nurses with a baccalaureate in nursing such as diabetes, high blood pressure, infections, and degree. Ford believed that the nurse practitioner injuries. In some states they are legally permitted to philosophy should be to provide a holistic approach prescribe medications independently. Although still to the client’s health. Nurse practitioners should receiving some resistance from physicians’ groups, focus on health, functionality, and daily living, as NPs have transformed both the health-care system and the profession of nursing.8