Sample Nursing Now- Today's Issues, Tomorrows Trends 7th Edition

Joseph T. Catalano • • TodayJs ssuesJTomorrowJs Trends

Nursing Now!



Nursing Now! Today’s Issues, Tomorrow’s Trends Seventh edition Joseph T. Catalano, PhD, RN Program Consultant, Author President, Oklahoma Nurses Association Ada, Oklahoma

F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2015 by F. A. Davis Company Copyright © 1996, 2000, 2003, 2006, 2009 by F. A. Davis Company. All rights reserved. This 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, record- ing, 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: Megan Keim Publisher: Joanne P. DaCunha, RN, MSN Director of Content Development: Darlene D. Pedersen, MSN, APRN, BC Content Project Manager: Christina L. Snyder Illustration and Design Manager: Carolyn O’Brien As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The 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. The 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. The 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. Proudly sourced and uploaded by [StormRG] Kickass Torrents | TPB | ET | h33t Library of Congress Cataloging-in-Publication Data Catalano, Joseph T., author. Nursing now! : today’s issues, tomorrow’s trends / Joseph T. Catalano. — Seventh edition. p. ; cm. Includes bibliographical references and index. ISBN 978-0-8036-3972-0 I. Title. [DNLM: 1. Nursing—trends. 2. Nursing Care—trends. WY 16.1] RT82 610.7306’9—dc23 2014027951 Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting 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. The fee code for users of the Transactional Reporting Service is: 8036-2763-7/12 0 + $.25.

Dedication To all the present and future leaders of the nursing profession who have and will dedicate their time, efforts, and talents to empower nurses across all specialties and practice settings to promote the profession of nursing and improve health care.



Preface Major revisions was the name of the game for the the Aging Population on Health-Care Delivery,” seventh edition of Nursing Now: Today’s Issues, was added and discusses how the large influx of the Tomorrow’s Trends, with tons of new information elderly have added additional stress to an already and topics! We believe you will be very pleased with stressed system of care. how it turned out. It remains truly unique among is- sues and trends books. The seventh edition retains the It is also impossible to deny that there has eye-appealing and user-friendly format that made been an increase in natural and man-made disasters previous editions so popular. over the past few years. Disaster preparedness is something all nurses need to be familiar with, and The changes keep coming in health care new Chapter 26, “Preparing for Functioning Effec- since the last publication of this text. Major demo- tively in a Disaster,” discusses both the role of the graphic shifts are occurring as baby boomers reach public in preparing for disasters and the special retirement age and the population of new immigrants preparation nurses need to have to function after a rapidly expands. As the health-care reform bill con- disaster in providing care for the victims. tinues to be implemented, large groups of individuals now have health-care insurance who didn’t in the The chapter on the NCLEX exam was up- recent past. Nurses, as always, are at the forefront of dated to reflect the recent changes by the National these changes, providing care for the elderly and Council of State Boards of Nursing, including samples those who speak English as a second language. They of the new alternative-format questions. All other have to implement reforms that look more to quality chapters were revised with the addition of new con- of care rather than the number of services provided. tent and resources. There is new material on bioethics and leadership and management; expanded discussion Thanks to our readers’ suggestions, we have of SBAR, QSEN, and Six Sigma; discussion of the added several new chapters. Chapter 13, “Under- LACE model and future plans for advanced practice standing and Dealing Successfully With Difficult nurses; expanded information on writing and submit- Behavior,” is an outgrowth of Chapter 12 on com- ting online résumés; and many other new develop- munication. It organizes difficult behavior around ments in health care. the five elements of the grieving process. It also pro- vides examples of both what clients might say or do Graduates from today’s nursing programs when being difficult and the appropriate responses have opportunities for professional practice and ad- by the nurse. Because of the emphasis placed on vancement that could only be dreamed of a few years quality of care and outcomes of care in the health- ago. Yes, the demands are many, but the rewards are care reform bill, Chapter 15, “Ensuring Quality great. Today’s nursing students must learn more, do Care,” was added to clearly define what quality is more, and be more. Students entering nursing and means and the efforts to achieve it. Chapter 19, schools today come from diverse cultural, personal, “The Politically Active Nurse,” discusses the pros and educational backgrounds. They must master a and cons of health-care reform in a balanced man- tremendous amount of information and learn a wide ner. It is very timely, as the health-care reform bill variety of skills so that they can pass the licensure will be fully implemented over the next few years. exam and become highly skilled registered nurses. Every nurse has noticed the increase of the elderly in the health-care system, so Chapter 23, “Impact of The seventh edition of Nursing Now! Today’s Issues, Tomorrow’s Trends offers students a starting point to influence the future of health care in the vii

viii Preface Another dichotomy that nurses face on a daily basis is the ability to hold on to key unchanging United States. We are very excited about the revised principles while working in a constantly changing text and believe its quality and content meet the high environment. Simply stated, a nurse’s ability to adapt standards demanded by our readers. to changes in the health-care system while remaining focused on providing high-quality care is the basis for As in past editions, we have retained the a successful professional practice. The only way that interactive format of the text, in addition to the nurses will be able to effectively practice their profes- journal layout, current issues boxes, and integrated sion in a demanding health-care system is to remain questions throughout. There are many new graphic firmly rooted in those values and beliefs that have illustrations and case studies. We also added a num- always served as their source of strength. Even more ber of new illustrations to increase the visual appeal so than in the past, nurses need to look to each other of the book. The available website with interactive for the inspiration and the strength that allow them learning activities for students has been updated to succeed. Professional organizations still serve as and expanded. the single most powerful force for nurses, and mem- bership in professional organizations is becoming The book’s primary purpose remains the increasingly important. same as in past editions. It presents an overview and synthesis of the important issues and trends that are It is our belief that this book will help future basic to the development of professional nursing and nurses become familiar with the important issues and that affect nursing both today and into the future. trends that affect the profession and health care. The Our readers tell us that the book can be used both at nursing profession needs highly skilled nurses who the beginning of the student’s educational process as can be civil, teach, do research, solve complicated an “Introduction to Nursing” course, and also toward client problems, provide highly skilled care, obtain the end of the process as an “Issues and Trends” advanced degrees, and influence the political realm course. Some instructors even use it throughout that so affects all aspects of health care. The leaders their programs, incorporating chapters as the content of the profession will come from those students who is reflected in their course presentations. Nursing have a clear understanding of what it means to be a students remain the primary intended audience for professional nurse and are willing to invest effort in Nursing Now! However, practicing nurses have re- attaining their goals. ported there is a sufficiently wide range of current issues and topics covered in enough depth to be Joseph T. Catalano, PhD, RN useful for their practice.

Acknowledgments I would like to express my sincere thanks to my stu- their tolerance and encouragement as I ignore them dents and colleagues who have given their time, while I’m on the computer. And a special thank you knowledge, creativity, and understanding of what is to Sharon Bator, whose tireless work and outstanding required to promote the profession of nursing both in organizational skills contributed to the editing and the present and for the future. I would also like to revision of several chapters. thank Pam, Sarah, Amanda, Dandy, and Pepper for ix



Contributors Mary Abadie, RN, MSN, CPNP Joseph T. Catalano, PhD, RN Assistant Professor Program Consultant, Author Southern University and A&M College Ada, Oklahoma School of Nursing Baton Rouge, Louisiana Sarah T. Catalano Public Relations Coordinator Tonia Aiken, RN, BSN, JD Cothran Development Strategies President and CEO Ada, Oklahoma Aiken Development Group New Orleans, Louisiana Captain Dr. Leah S. Cullins, MSN, APRN, FNP-BC NIH-NINR SGI Fellow Sharon M. Bator, RN, MSN, CPE Louisiana Commission on HIV, AIDS, Assistant Professor and Hepatitis C Southern University and A&M College Assistant Professor School of Nursing Southern University School of Nursing Baton Rouge, Louisiana Undergraduate & Graduate Programs Southern University and A&M College Barbara Bellfield, MS, RNP-C, RN Baton Rouge, Louisiana Family Nurse Practitioner Ventura County Public Health Lydia DeSantis, RN, PhD, FAAN Loma Vista Road University of Miami Ventura, California School of Nursing Miami, Florida Cynthia Bienemy, RN, PhD Director, Louisiana Center for Nursing Joan Anny Ellis, RN, PhD Louisiana State Board of Nursing Director, Educational Services Baton Rouge, Louisiana Woman’s Hospital Baton Rouge, Louisiana Doris Brown, Med, MS, RN, CNS Associate Professor Public Health Executive Director Southern University and A&M College Robert Wood Johnson Nurse Fellow 2006–2009 School of Nursing Baton Rouge, Louisiana Baton Rouge, Louisiana Sandra Brown, RN, DNS, APRN, FNP-BC Mary Evans, JD, RN Professor 316 N. Tejon Southern University and A&M College Colorado Springs, Colorado School of Nursing Baton Rouge, Louisiana xi

xii Contributors Karen Mills, MSN, RN Nurse Family Partnership State Nurse Consultant Betty L. Fomby-White, RN, PhD Louisiana Office of Public Health Southern University and A&M College Baton Rouge, Louisiana School of Nursing Baton Rouge, Louisiana Roberta Mowdy, MS, RN Associate Faculty Instructor University of Phoenix Online Department of Nursing East Central University Donna Gentile O’Donnell, RN, MSN Ada, Oklahoma Deputy Health Commissioner (Retired) Philadelphia, Pennsylvania Joseph Mulinari, PhD, RN College of Mt. St. Vincent Anita H. Hansberry, RN, MS Department of Nursing Assistant Professor Riverdale, New York Southern University and A&M College School of Nursing Linda Newcomer, RN, MSN Baton Rouge, Louisiana Instructor Department of Nursing Nicole Harder, RN, BN, MPA East Central University Coordinator, Learning Laboratories Ada, Oklahoma Helen Glass Centre for Nursing Faculty of Nursing Robert Newcomer, PhD University of Manitoba Assistant Professor Winnipeg, Manitoba, Canada East Central University Ada, Oklahoma Jacqueline J. Hill, RN, PhD Associate Professor & Chair Anyadie Onu, RN, MS Undergraduate Nursing Program Assistant Professor Southern University A&M College Southern University and A&M College Baton Rouge, Louisiana School of Nursing Baton Rouge, Louisiana Edna Hull, PhD, RN, CNE Associate Professor & Program Director Janet S. Rami, RN, PhD Our Lady of the Lake College Southern University and A&M College Metropolitan New Orleans Center School of Nursing New Orleans, Louisiana Baton Rouge, Louisiana Sharon W. Hutchinson, PhD, MN, RN, CNE Mary Ann Remshardt, EdD, RN Associate Professor and Chair Assistant Professor Graduate Nursing Programs Department of Nursing Southern University School of Nursing East Central University Southern University and A&M College Ada, Oklahoma Baton Rouge, Louisiana Joyce Miller, BSN, CPE, CCM Clarity Hospice of Baton Rouge Baton Rouge, Louisiana

Viki Saidleman, MS, RN Contributors xiii Instructor Department of Nursing Cheryl Taylor, PhD, RN East Central University Associate Professor of Nursing Ada, Oklahoma Director Office of Nursing Research NLN Consultant to National Student Nurses Nancy C. Sharts-Hopko, RN, PhD, FAAN Association Professor Southern University and A&M College Villanova University School of Nursing Villanova, Pennsylvania Baton Rouge, Louisiana Enrica K. Singleton, RN, PhD Karen Tomajan, MS, RN, NEA-BC Professor Clinical/Regulatory Consultant Southern University and A&M College INTEGRIS Baptist Medical Center School of Nursing Oklahoma City, Oklahoma Baton Rouge, Louisiana Esperanza Villanueva-Joyce, EdD, CNS, RN Wanda Raby Spurlock, DNS, RN, BC, CNS, National Dean for Academics FNGNA Education Affiliates Associate Professor Southern University and A&M College Kathleen Mary Young, RN, C, MA School of Nursing Instructor Baton Rouge, Louisiana Western Michigan University Kalamazoo, Michigan Melissa Stewart DNS, RN, CPE Assistant Professor Our Lady of the Lake College School of Nursing Baton Rouge, Louisiana



Contents U n i t 1 The Growth of Nursing 1 1 The Development of a Profession 3 2 Historical Perspectives 20 3 Theories and Models of Nursing 38 4 The Process of Educating Nurses 72 5 The Evolution of Licensure, Certification, and Nursing Organizations 99 U n i t 2 Making the Transition to Professional 119 6 Ethics in Nursing 121 7 Bioethical Issues 145 8 Nursing Law and Liability 178 9 NCLEX: What You Need to Know 205 10 Reality Shock in the Workplace 226 U n i t 3 Leading and Managing 255 11 Leadership, Followership and Management 257 12 Communication, Negotiation, and Conflict Resoloution 285 13 Understanding and Dealing Successfully With Difficult Behavior 310 14 Health-Care Delivery Systems 353 15 Ensuring Quality Care 376 16 Delegation in Nursing 396 17 Incivility: The Antithesis of Caring 411 18 Nursing Informatics 429 19 The Politically Active Nurse 452 U n i t 4 Issues in Delivering Care 483 20 The Healt-Care Debate: Best Allocation of Resources for the Best Outcomes 485 21 Spirituality and Health Care 519 22 Cultural Diversity 540 23 Impact of the Aging Population on Health-Care Delivery 565 xv

xvi Contents 24 Nursing Research and Evidence-Based Practice 581 25 Integrative Health Practices 611 26 Preparing for Functioning Effectively in a Disaster 646 27 Developments in Current Nursing Practice 674 Glossary 688 Index 705

1 The Growth of Nursing 1



The Development 1 of a Profession Joseph T. Catalano Learning Objectives SWHAT IS A PROFESSION? ince the time of Florence Nightingale, each generation of nurses, in After completing this chapter, its own way, has fostered the movement to professionalize the image of the reader will be able to: nurses and nursing. The struggle to change the status of nurses—from that of female domestic servants to one of high-level health-care • Define the terms position, job, providers who base their protocols on scientific principles—has been a occupation, and profession primary goal of nursing’s leaders for many years. Yet some people, both inside and outside the profession of nursing, question whether the • Compare the three approaches search for and attainment of professional status is worth the effort and to defining a profession price that must ultimately be paid. At some levels in nursing, the question of professionalism • Analyze those traits defining a takes on immense significance. However, to the busy staff nurse—who profession that nursing has at- is trying to allocate client assignments for a shift, distribute the medica- tained tions at 9 a.m. to 24 clients, and supervise two aides, a licensed practical nurse (LPN) or licensed vocational nurse (LVN) and a nursing student— • Evaluate why nursing has failed the issue may not seem very significant at all. to attain some of the traits that Indeed, when nurses were first developing their identity sepa- define a profession rately from that of physicians, there was no thought about their being part of a profession. Over the years, as the scope of practice and respon- • Correlate the concept of power sibilities have expanded, nurses have increasingly begun to consider with its important characteristics what they do to be professional activities. This chapter presents some of the current thoughts concerning professions and where nursing stands in relation to these viewpoints. 3

4 U n i t 1 The Growth of Nursing APPROACHES TO DEFINING A PROFESSION but where they are located along the continuum. Oc- cupations such as medicine, law, and the ministry are In common use, terms such as position, job, occupa- widely accepted by the public as being closest to the tion, profession, professional, and professionalism professional end of the continuum.3 Other occupa- often are used interchangeably and incorrectly. The tions may be less clearly defined. following definitions will clarify what is meant by ?What Do You Think? these terms within this text: Do you really care if nursing is a profession? How will it Position: A group of tasks assigned to one individual affect the way you practice nursing? Job: A group of positions similar in nature and level of skill that can be carried out by one or more individuals Occupation: A group of jobs similar in type of work The major difficulty with this approach is that that are usually found throughout an industry or it lacks criteria on which to base judgments. Final de- work environment termination of the status of an occupation or profes- sion depends almost completely on public perception Profession: A type of occupation that requires pro- of the activities of that occupation. Nursing has always longed preparation and formal qualifications and had a rather negative public image when it comes to meets certain higher level criteria (discussed later being viewed as a profession. in this chapter) that raise it to a level above that of an occupation1 Professional: A person who belongs to and practices Power Approach The power approach uses a profession (The term two criteria to define a profession: professional is probably “Over the years, as the scope of practice the most misused of all and responsibilities have expanded, 1. How much independ- these terms when de- nurses have increasingly begun to con- scribing people who are clearly involved in jobs sider what they do to be professional ence of practice does this occupation or occupations, such as have? a “professional truck 2. How much power ”football player,” or even “professional thief.”)activities. does this occupation driver,” “professional Professionalism: The demonstration of high-level control? personal, ethical, and skill characteristics of a The concept of power is discussed later in member of a profession2 this chapter, but in this context, it refers to political For almost 100 years, experts in social sci- power and the amount of money that the person in ence have been attempting to develop a “foolproof” that occupation earns.4 approach to determining what constitutes a profession Using this determinant, occupations such as but with only minimal success. Three common mod- medicine, law, and politics clearly would be consid- els are the process approach, the power approach, and, ered professions. The members of these occupations most widely accepted, the trait approach. earn high incomes, practice their skills with a great deal of independence; and exercise significant power Process Approach over individuals, the public, and the political commu- The process approach views all occupations as points nity, both individually and in organized groups. The of development into a profession situated along a ministry is generally perceived as having power and continuum ranging from position to profession: influence. However, most people in this group, except for a few individuals such as television evangelists, Continuum of Professional Development: have relatively low income levels. Nursing, of course, Position Profession with its comparatively lower salaries, low member- ship in professional organizations, and perceived lack Using this approach, the question becomes of political power, would clearly not meet the power not whether nursing and truck driving are professions criteria for a profession.

The question that comes to mind is whether C h a p t e r 1 The Development of a Profession 5 power, independence of practice, and high income are the only elements that determine professional status. However, by today’s standards, most of the tasks per- Although those three factors confer status in our cul- formed by these early nurses are generally considered ture, other elements can be considered significant in to be menial and routine. how a profession is viewed. For example, to many people, members of the clergy have a great deal of On the other hand, as health care has ad- power when they act as counselors, speakers of the vanced and made great strides in technology, phar- truth, and community leaders. macology, and all branches of the physical sciences, a high level of intellectual functioning is required Trait Approach for even relatively simple nursing tasks, such as tak- Of the many researchers and theorists who have at- ing a client’s temperature or blood pressure using tempted to identify the traits that define a profession, automated equipment. On a daily basis, nurses use Abraham Flexner, Elizabeth Bixler, and Eliza Pavalko assessment skills and knowledge, have the ability to are most widely accepted as the leaders in the field. reason, and make routine judgments based on clients’ These three social scientists have determined that the conditions. Without a doubt, professional nurses following common characteristics are important: must function at a high intellectual level. • High intellectual level High Level of Individual Responsibility • High level of individual responsibility and account- and Accountability Not too long ago, a nurse was rarely, if ever, named as ability a defendant in a malpractice suit. In general, the pub- • Specialized body of knowledge lic did not view nurses as having enough knowledge to • Knowledge that can be learned in institutions of be held accountable for errors that were made in client care. This is not the case in the health-care system higher education today. Nurses are often the primary, and frequently the • Public service and altruistic activities only, defendants named when errors are made that re- • Public service valued over financial gain sult in injury to the client. Nurses must be accountable • Relatively high degree of autonomy and independ- and demonstrate a high level of individual responsibil- ity for the care and services they provide.5 ence of practice • Need for a well-organized and strong organization The concept of accountability has legal, ethi- cal, and professional implications that include accept- representing the members of the profession and ing responsibility for actions taken to provide client controlling the quality of practice care and for the consequences of actions that are • A code of ethics that guides the members of the not performed. Nurses can no longer state that “the profession in their practice • 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 Nightingale raised the bar for education, and gradu- ates of her school were considered to be highly edu- cated compared with other women of that time.

6 U n i t 1 The Growth of Nursing physician told me to do it” as a method of avoiding wide range of the best and most current information responsibility for their actions. through electronic sources. Of course, one of the key limiting factors of evidence-based practice is the Specialized Body of Knowledge quality of the information on which the practice is Most early nursing skills were based either on tradi- based. Evaluating the quality of information on the tional ways of doing things or on the intuitive Web can be difficult at times. knowledge of the individual nurse. As nursing de- The first step in developing an evidence- veloped into an identifiable, separate discipline, a based practice is to identify exactly what the inter- specialized body of knowledge called nursing science vention is supposed to accomplish. Once the goal was compiled through the research efforts of nurses or client outcome is identified, the nurse needs to with advanced educational degrees.6 As the body of evaluate current practices to determine whether specialized nursing knowledge continues to grow, it they are delivering the desired client outcomes. forms a theoretical basis for the best practices move- If the current practices are unsuccessful or if the ment in nursing today. As more nurses obtain ad- nurse feels they can be more efficient with fewer vanced degrees, conduct research, and develop complications, research sources need to be col- philosophies and theories about nursing, this body lected. These can be from published journal of knowledge will increase in scope and quantity. articles (either electronic or hard copy) and from presentations at research or practice conferences, Evidence-Based Practice which often present the most current information. In professional nursing today, there is an increasing Then a plan should be developed to implement the emphasis on evidence-based practice. Almost all of new findings. This process can be applied to chang- the currently used nursing ing policy and proce- theories address this issue “Evidence-based practice is the practice dures or developing in some way. Simply of nursing in which interventions are training programs for fa- stated, evidence-based based on data from research that cility staff. Research data practice is the practice of should always be used nursing in which interven- demonstrates that they are appropriate when initiating new ”tions are based on data practices or modifying old ones. from research that demon- and successful. Public Service and Altruistic Activities strates that they are appro- priate and successful. It involves a systematic process of uncovering, evaluating, and using information When defining nursing, almost all major nursing from research as the basis for making decisions about theorists include a statement that refers to a goal of and providing client care.7 Many nursing practices helping clients adapt to illness and achieve their high- and interventions of the past were performed merely est level of functioning. The public (variously referred because they had always been done that way (accus- to as consumers, patients, clients, individuals, or hu- tomed practice) or because of deductions from physi- mans) is the focal point of all nursing models and ological or pathophysiological information. Clients nursing practice. The public service function of nurs- are now more sophisticated and knowledgeable about ing has always been recognized and acknowledged health-care issues and demand a higher level of by society’s willingness to continue to educate nurses knowledge and skill from their health-care providers. in public, tax-supported institutions and in private The development of information technol- schools. In addition, nursing has been viewed univer- ogy has made evidence-based practice in nursing a sally as an altruistic profession composed of selfless reality. In the past, nurses relied primarily on units individuals who place the lives and well-being of their within their own facilities for information about the clients above their personal safety. In the earliest days, success of treatments, decisions about health care, dedicated nurses provided care for victims of deadly and outcomes for clients. Nursing education now plagues with little regard for their own welfare. Today, requires nursing students to perform Web-based nurses are found in remote and often hostile areas, research for papers and projects so that by the time providing care for the sick and dying, working 12-hour of graduation, they feel comfortable accessing a shifts, being on call, and working rotating shifts.

C h a p t e r 1 The Development of a Profession 7 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 infor- mation 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 any- thing 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 sup- posed to know what is good 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 information you seek. Marker 1: Peer Review All major professional journals have a peer-review process that requires any man- uscripts submitted to be reviewed by two or three professionals who are consid- ered 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 a Web source, look for a clear statement of the source of the information and how that information 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 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 per- son’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, personal website pages are less likely to contain authoritative information. You can also look at the last three letters in the website address. The ones that end 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 no one else could use it as their original information. Marker 3: Prejudice and Bias Although there is almost always a small degree of prejudice and bias in all written material, 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 (continued)

8 U n i t 1 The Growth of Nursing I s s u e s N o w continued 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 the R. J. Reynolds Company would proba- bly have a decidedly different viewpoint than an article written by a scientist who was employed by the National Health Information Center. See if contact informa- tion is provided by the author and who the sponsor 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 forms of the Web have been around since Tim Berners-Lee invented the World Wide Web in 1989, so some of the material 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., Web, journals, books) to compare the material for currentness. Many websites have links where you can access other related infor- mation. 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 tell a book by its cover,” experienced Web surfers 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 information 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 decorative, 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 presented in any website. Sources: Carlson EA. What to look for when evaluating Web sites. Orthopaedic Nursing, 28(4): 199–202, 2009; Golterman L, Banasiak NC. Primary care approaches. Evaluating web sites. Reliable child health resources for parents. Pediatric Nursing, 37(2):81–83, 2011; Spector ND, Matz PS, Levine LJ, Gargiulo KA, McDonald MB 3rd, McGregor RS. e-Professionalism: Challenges in the age of information. Journal of Pediatrics, 156(3):345–346, 2010.

Few individuals enter nursing to become C h a p t e r 1 The Development of a Profession 9 rich and famous. It is likely that those who do so for these reasons quickly become disappointed and move This code of ethics is recognized by other professions on to other career fields. Although the pay scale has as a standard with which others are compared. The increased tremendously since the 1990s, nursing is, at nurses’ code of ethics and its implications are dis- best, a middle-income occupation. Surveys among cussed in greater detail in Chapter 6. students entering nursing programs continue to indi- cate that the primary reason for wishing to become a Competency and Professional License nurse is to “help others” or “make a difference” in Nurses must pass a national licensure examination to someone’s life and to have “job security.” Rarely do demonstrate that they are qualified to practice nurs- these beginning students include “to make a lot of ing. Nurses are allowed to practice only after passing money” as their motivation.7 this examination. The granting of a nursing license is a legal activity conducted by the individual state Well-Organized and Strong Representation under the regulations contained in that state’s nurse Professional organizations represent the members of practice act. the profession and control the quality of professional practice. The National League for Nursing (NLN) and WHEN NURSING FALLS SHORT OF THE CRITERIA the American Nurses Association (ANA) are the two major national organizations that represent nursing Before Florence Nightingale practiced nursing, peo- in today’s health-care system. The NLN is primarily ple considered it to be unnecessary, if not outright responsible for regulating the quality of the educa- dangerous, to educate nurses through independent tional programs that prepare nurses for the practice nursing programs in publicly supported educational of nursing, whereas the ANA is more concerned with institutions. As nursing has developed, particularly in the quality of nursing practice in the daily health-care the United States, the recognition of the intellectual setting. These and other organizations are discussed nature of the practice, as well as the vast amount of in more detail in Chapter 5. knowledge required for the job, has led to a belief by some nursing leaders that college education for Both these groups are well organized, but nurses is now a necessity.8–10 neither can be considered powerful when compared with other professional organizations, such as the Autonomy and Independence of Practice American Hospital Association, the American Med- Historically, the handmaiden or servant relationship ical Association (AMA), or the American Bar Associ- of the nurse to the physician was widely accepted.11 It ation (ABA). One reason for their lack of strength is was based on several factors, including social norms. that fewer than 10 percent of all nurses in the United For example, women became nurses, whereas men States are members of any professional organization became physicians; women were subservient to men, at the national level.3 Many nurses do belong to spe- the nature of the work being such that nurses cleaned cialty organizations that represent a specific area of and physicians cured. In terms of the relative levels of practice, but these lack sufficient political power to education of the two groups, the average nursing pro- produce changes in health-care laws and policies at gram lasted for 1 year, whereas physician education the national level. lasted for 6 to 8 years. Nurses’ Code of Ethics Unfortunately, despite efforts to expand Nursing has several codes of ethics that are used to nursing practice into more independent areas guide nursing practice. The ANA Code of Ethics for through updated nurse practice legislation, nursing Nurses, the most widely used in the United States, retains much of its subservient image. In reality, was first published in 1971 and updated in 1985 and nursing is both an independent and interdependent 2001. In 2013, the ANA began surveying its members discipline. Nurses in all health-care settings must for input into possible changes in the Code. The cur- work closely with physicians, hospital administrators, rent 2014 ANA Code of Ethics, while maintaining the pharmacists, and other groups in the provision of integrity found in earlier versions, is now more rele- care. In some cases, nurses in advanced practice vant to current health-care and nursing practices. roles, such as nurse practitioners, can and do estab- lish their own independent practices. Most state

10 U n i t 1 The Growth of Nursing specialists. Each of these requires a different type of educational background, clinical expertise, and, some- nurse practice acts allow nurses more independence times, professional credentialing. In general, all nurses in their practice than they realize. To be considered a make valuable contributions within the health-care true profession, nursing will need to be recognized by delivery system. There has been an increased demand other disciplines as having practitioners who practice for nurses who are educated to deliver care in the nursing independently. community setting and in long-term health-care set- tings rather than in the hospital. There has also been a Professional Identity and Development need for nurse case managers who are prepared to co- The issue of job versus career is in question here. ordinate care for vulnerable populations requiring A job is a group of positions, similar in nature and costly services over extended periods. Nursing educa- level of skill, that can be carried out by one or more tion programs are attempting to meet these needs by individuals. There is relatively little commitment to preparing individuals who can practice independently a job, and many individuals move from one job to and autonomously, network, collaborate, and coordi- another with little regard to the long-term out- nate services. These programs also offer more clinical comes. A career, in contrast, is usually viewed as a experiences in rehabilitation, nursing home, and com- person’s major lifework, which progresses and de- munity settings. velops as the person grows older. Careers and pro- fessions have many of the same characteristics, ?What Do You Think? including a formal education, full-time employ- ment, requirement for lifelong learning, and a dedi- List and rate several of your recent experiences with the cation to what is being achieved. Although an health-care system. In what roles did you observe regis- increasing number of nurses view nursing as their tered nurses functioning? life’s work, many still treat nursing more as a job. Registered Nurses, Licensed Practical Nurses, The problem becomes circular. The reason and Unlicensed Assistive Personnel nurses lack a strong professional identity and do not Registered nurses (RNs) who have been educated at consider nursing as a lifelong career is that nursing the associate, diploma, or baccalaureate level have does not have full status as a profession.11 Until traditionally been considered the cornerstone of the nurses are fully committed to the profession of nurs- current health-care delivery system. In the past, most ing, identify with it as a profession, and are dedicated RNs worked within hospital settings and provided to its future development, nursing will probably not direct client care and nursing administration func- achieve professional status. tions within these facilities. Owing to past trends in health-care funding, there were fewer hospital ad- MEMBERS OF THE HEALTH-CARE TEAM missions, which temporarily decreased the demand for RNs in acute care facilities and increased the The health-care delivery system employs large need for well-prepared nurses who could function numbers of diagnosticians, technicians, direct autonomously within the community. However, care providers, administrators, and support staff current trends in population and health care have (Table 1.1). It is estimated that more than 300 job demonstrated a need for RNs in both acute care and titles are used to describe health-care workers. community settings. The need still remains within Among these are nurses, physicians, physician institutional settings for licensed practical nurses assistants, social workers, physical therapists, occu- (LPNs) and unlicensed assistive personnel (UAPs) pational therapists, respiratory therapists, clinical who work under the supervision of an RN. This pat- psychologists, and pharmacists. All these individu- tern of care is particularly evident in nursing homes als provide services that are essential to daily and other long-term care facilities.12 operation of the health-care delivery system in this country. Advanced Practice Nurses For individuals who are unfamiliar with the health- Of particular importance among this array of care delivery system, it is sometimes difficult to health-care workers are various types of nurses: Regis- tered nurses, licensed practical (vocational) nurses, nurse practitioners, case managers, and clinical nurse

C h a p t e r 1 The Development of a Profession 11 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 Social worker Limited—focus on spinal column and nervous system. Certification—no Unable to prescribe medications. individual license Limited—foot problems. Can prescribe medications, License perform foot surgery. Physical therapist License Practices on physician’s license. Practice limited by medical practice act and wishes of supervising physician. Respiratory therapist License Increasingly important as health care becomes more Clinical psychologist License complex. Resolves financial, housing, psychosocial, and employment problems; does discharge planning Pharmacist License 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 pulmonary functioning as possible 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. understand the similarities and differences between illness prevention, early diagnosis, and treatment of nursing titles and roles. This confusion is particu- common health problems. Their educational prepara- larly evident in the case of clinical nurse specialists tion varies, but in most cases individuals successfully (CNSs) and nurse practitioners (NPs), who are complete a graduate nurse practitioner program and sometimes collectively referred to as advanced are certified by the American Nurses Credentialing practice registered nurses (APRNs).13 Center (ANCC) or an appropriate professional nursing organization. Depending on the individual state nurse The Nurse Practitioner practice act, NPs have a range of responsibilities for di- In general, NPs are prepared to provide direct client care agnosing diseases and prescribing both treatments and in primary care settings, focusing on health promotion, medications. A growing number of states now grant

12 U n i t 1 The Growth of Nursing NPs direct third-party reimbursement for their serv- agencies, funding sources, locations, and time. Titling, ices without a physician. educational preparation, and certification of nurse case managers are now available. The ANCC has de- The Clinical Nurse Specialist veloped certification eligibility criteria for nurse case managers, and an examination is available. At this Clinical nurse specialists usually practice in second- time, case managers can be physicians, social workers, ary- or tertiary-care settings and focus on care of in- RNs, and even well-intentioned laypersons with little dividuals who are experiencing an acute illness or an health-care education. exacerbation of a chronic condition. In general, they are prepared at the graduate level and are ANCC cer- tified.14 These highly skilled practitioners are com- EMPOWERMENT IN NURSING fortable working in high-tech environments with seriously ill individuals and their families. Because of the nature of their work, they are excellent health- One concern that has plagued nursing, almost from care educators and physician collaborators. its development as a separate health-care specialty, Attempts have been made to combine the is the relatively large amount of personal responsi- roles of the CNS and NP so that the best qualities of bility shouldered by nurses combined with a rela- both roles are preserved. The goal of this combina- tively small amount of control over their practice. tion is to provide high-quality care to individuals in Even in the more enlightened atmosphere of today’s a wide array of health-care settings who have a wide society, with its concerns about equal opportunity, range of health problems. Advocates of this move- equal pay, and collegial relationships, many nurses ment include the NLN, still seem uncomfortable with the concepts of power the American Association “Depending on the individual state and control in their prac- of Colleges of Nursing nurse practice act, NPs have a range of tice. Their discomfort (AACN), and the ANA. responsibilities for diagnosing diseases may arise from the belief Titling for this new and prescribing both treatments and that nursing is a helping blended role is uncon- and caring profession firmed, and state legisla- whose goals are separate ”tures may make the final medications. from issues of power. Historically, decisions through their li- nurses have been mostly powerless, and previous censing laws.14 As such, titling, educational prepa- ration, and practice privileges will probably vary attempts at gaining power and control over their from one state to another. practice have been met with much resistance from groups who benefit from making sure that nurses Case Managers remain without authority. Nevertheless, all nurses One argument for the blended NP–CNS role is the use an authoritative voice in their daily practice, need for case managers who possess the expertise even if they do not realize it. Until nurses under- of both levels of preparation. Case managers coordi- stand the sources of their influence, how to increase nate services for clients with high-risk or long-term it, and how to use it in providing client care, they health problems who have access to the full contin- will be relegated to a subservient position in the uum of health-care services. Case managers provide health-care system. services in various settings, such as acute care facili- ties, rehabilitation centers, and community agencies. The Nature of Power They also work for managed care companies, insur- The term power has many meanings. From the stand- ance companies, and private case management agen- point of nursing, power is probably best defined as cies. Their roles vary according to the circumstances the ability or capacity to exert influence over another of their employment; however, their overall goal is to person or group of persons.16 In other words, power coordinate the use of health-care services in the most is the ability to get other people to do things even efficient and cost-effective manner possible.15 when they do not want to do them. Although power Case management is the glue that holds in itself is neither good nor bad, it can be used to pro- health-care services together across practitioners, duce either good or bad results.

C h a p t e r 1 The Development of a Profession 13 Power is always a two-way street. By its with someone. In any close personal relationship, very definition, when power is exerted by one per- one individual often will do something he or she son, another person is affected; that is, the use of would really rather not do because of the relation- power by one person requires that another person ship. This ability to change the actions of another is give up some of his or her power. Individuals are an exercise of power. always in a state of change, either increasing their power or losing some; the balance of power rarely re- Nurses often obtain power from this source mains static. Empowerment refers to the increased when they establish and maintain good therapeutic amount of power that an individual or group is ei- relationships with their clients. Clients take medica- ther given or gains. tions, tolerate uncomfortable treatments, and partici- pate in demanding activities that they would likely prefer to avoid because the nurse has good relation- ships with them. Likewise, nurses who have good collegial relationships with other nurses, departments, and physicians are often able to obtain what they want from these individuals or groups in providing care to clients. Origins of Power Expert Power If power is such an important part of nursing and the practice of nurses, where does it come from? Although The expert source of power derives from the amount there are many sources, some of them would be in- of knowledge, skill, or expertise that an individual or appropriate or unacceptable for those in a helping and group has. This power source is exercised by the indi- caring profession. The following list includes some of vidual or group when knowledge, skills, or expertise the more accessible and acceptable sources of power is either used or withheld in order to influence the that nurses should consider using in their practice:16 behavior of others. Nurses should have at least a min- imal amount of this type of power because of their • Referent education and experience. It follows logically that in- • Expert creasing the level of nurses’ education will, or should, • Reward increase this expert power. As nurses attain and • Coercive remain in positions of power longer, the increased • Legitimate experience will also aid the use of expert power. • Collective Nurses in advanced practice roles are good examples of those who have expert power. Their additional Referent Power education and experience provide these nurses with The referent source of power depends on establish- the ability to practice skills at a higher level than ing and maintaining a close personal relationship nurses prepared at the basic education level. By demonstrating their knowledge of the client’s condition, recent laboratory tests, and other elements that are vital to the client’s recovery, nurses demonstrate their expert power. This knowledge may increase the amount of respect they are given by physicians. Nurses access this expert source of power when they use their knowledge to teach, counsel, or motivate clients to follow a plan of care. Nurses can also use expert power when dealing with physicians. Power of Rewards The reward source of power depends on the ability of one person to grant another some type of reward for specific behaviors or changes in behavior. The rewards can take on many different forms, including

14 U n i t 1 The Growth of Nursing personal favors, promotions, money, expanded privi- leges, and eradication of punishments. Nurses, in their daily provision of care, can use this source of power to influence client behavior. For example, a nurse can give a client extra praise for completing the prescribed range-of-motion exercises. There are many aspects of the daily care of clients over which nurses have a substantial amount of reward power. This reward source of power is also the underlying principle in the process of behavior modification. Coercive Power Collective Power The collective source of power is often used in a The coercive source of power is the flip side of the broader context than individual client care and is the reward source. The ability to reprimand, withhold underlying source for many other sources of power. rewards, and threaten punishment is the key element When a large group of individuals who have similar underlying the coercive source of power. Although beliefs, desires, or needs become organized, a collective nurses do have access to this source of power, it is source of power exists.17 For individuals who belong to probably one that they use minimally, if at all. Not professions, the professional organization is the focal only does the use of coercive power destroy therapeu- point for this source of power. The main goal of any tic and personal relationships, but it can also be organization is to influence policies that affect the considered unethical and even illegal in certain situa- members of the organization. This influence is usually tions. Threatening clients with an injection if they do in the form of political activities carried out by politi- not take their oral medications may motivate them to cians and lobbyists. take those medications, but it is generally not consid- ered to be a good example of a therapeutic communi- Professional organizations that can deliver cation technique. large numbers of votes have a powerful means of in- fluencing politicians. The use of the collective source Legitimate Power of power contains elements of reward, coercive, ex- pert, and even referent sources. Each source may The legitimate source of power depends on a legisla- come into play at one time or another. tive or legal act that gives the individual or organiza- tion a right to make decisions that they might not How to Increase Power in Nursing otherwise have the authority to make. Most obviously, Despite some feelings of powerlessness, nurses re- political figures and legislators have this source of ally do have access to some important, and rather power. This power can also be disseminated and dele- substantial, sources of power. What can nurses, gated to others through legislative acts. In nursing, either as individuals or as a group, do to increase the state board of nursing has access to the legitimate their power? source of power because of its establishment under the nurse practice act of that state. Similarly, nurses have access to the legitimate source of power when they are licensed by the state under the provisions in the nurse practice act or when they are appointed to positions within a health-care agency. Nursing decisions made about client care can come only from individuals who have a legitimate source of power to make those decisions—that is, licensed nurses.

C h a p t e r 1 The Development of a Profession 15 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 hard working, caring, and well organized and provides high-quality care for the often very unstable postoperative clients they receive 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. During the past 2 weeks, she has shown a grad- ual 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 probably not live more than an- other week. Per hospital policy, Kasey is not assigned to care for her mother; how- ever, 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 request- ing 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 specialized unit. When Kasey heard about the suggestion, she became livid and loudly scolded the nurse for her insensitivity in the middle of the nurses’ station. Questions for Thought 1. Is the practice of not allowing nurses to provide care for their relatives evi- dence-based or accustomed practice? 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?

16 U n i t 1 The Growth of Nursing Professional Unity professionalism. Nursing has made great strides in Probably the first, and certainly the most important, these two areas in recent years. Nurses, through way in which nurses can gain power in all areas is professional organizations, have been working hard through professional unity. The most powerful to establish standards for high-quality client groups are those that are best organized and most care. More important, nurses are now concerned united. The power that a professional organization with demonstrating competence and delivering has is directly related to the size of its membership. high-quality client care through processes such According to the ANA, there are approximately as peer review and evaluation. By accepting 2.7 million nurses in the United States. It is not diffi- responsibility for the care that they provide and cult to imagine the power that the ANA could have by setting the standards to guide that care, nurses to influence legislators and legislation if all of those are taking the power to govern nursing away from nurses were members of the organization rather than non-nursing groups. the 250,000 who actually do belong. This point— that nurses need to belong to their national nursing Networking organization—cannot be emphasized enough. Finally, nurses can gain power through establishing a nurse support network. It is common knowledge Political Activity that the “old boy” system remains alive and well in A second way in which many segments of our nurses can gain power is “By demonstrating their knowledge of seemingly enlightened by becoming involved in 21st-century society. The political action. Although this produces discomfort the client’s condition, recent laboratory old boy system, which is tests, and other elements that are vital to found in most large or- in many, nurses must the client’s recovery, nurses demonstrate ganizations, ranging ”realize that they are af- from universities to busi- nesses and governmental fected by politics and agencies, provides indi- political decisions in viduals, usually men, every phase of their daily their expert power. This knowledge may increase the amount of respect they are given by physicians. nursing activities. with the encouragement, The simple truth is that if nurses do not be- support, and nurturing that allow them to move up come involved in politics and participate in important quickly through the ranks in the organization to legislation that influences their practice, someone achieve high administrative positions. An impor- other than nurses will be making those decisions for tant element in making this system work involves them. Nurses need to become involved in political ac- never criticizing another “old boy” in public, even tivities from local to national levels. The average legis- though there may be major differences of opinion lator knows little about issues such as clients’ rights, in private. Presentation of a united front is ex- national health insurance, quality of nursing care, tremely important in maintaining power within this third-party reimbursement for nurses, and expanded system. Nursing and nursing organizations have practice roles for nurses, yet they make decisions about never had this type of system for the advancement these issues almost daily. It would seem logical that of nurses. more informed and better decisions could be made if Part of the difficulty in establishing a nurse nurses took an active part in the legislative process. support network is that nurses have not been in high- level positions for very long. The framework for a sup- Accountability and Professionalism port system for nurses is now in place; with some A third method of increasing power is by demon- commitment to the concept and some activity, it strating the characteristics of accountability and can grow into a well-developed network to allow the

C h a p t e r 1 The Development of a Profession 17 brightest, best, and most ambitious people in the shortages were handled was to use a quick-fix method profession to achieve high-level positions.16 of producing more nurses in a shorter period of time by reducing the educational requirements. The cur- Future Trends in the Nursing Profession rent nursing education system is producing approxi- Clearly, it would be difficult to make an airtight case mately 40,000 graduates from diploma and associate for nursing as a profession. Yet nursing does meet degree programs every year.10 Although this number many of the criteria proposed for a profession. Al- may help alleviate the nursing shortage, the more though it would probably be most accurate to call critical question to ask is whether this level of educa- nursing a developing or tion is going to prepare aspiring profession, for “Probably the first, and certainly the nurses to meet the chal- the purposes of this book, most important, way in which nurses lenges of a rapidly chang- nursing will be referred to can gain power in all areas is through ing and demanding as a profession. Only health-care system. when nurses begin to professional unity. The most powerful As the national think of nursing as a pro- employment picture groups are those that are best organized continues to evolve for fession, work toward rais- ”ing the educational and most united. registered nurses, from bedside caregivers to standards for entry level, coordinators of care, and as financial resources be- and begin practicing independently as professionals will the status of profession become a reality for nurs- come stressed, perhaps more nurses will begin to ing. The movement of any discipline from the status look on what they do as a lifelong commitment. of occupation to one of profession is a dynamic and Professional commitment is a complicated issue, ongoing process with many considerations. but little doubt exists that nurses will not have in- Experts now predict a severe shortage of creased independence of practice until they begin to professional nurses, ranging from 200,000 to 800,000, demonstrate that they are professionals committed by the year 2025. In the past, the way that nursing to the field of nursing. Conclusion system. Currently, many nurses accept the premise that nursing is a profession and therefore are not Ongoing changes in the health-care system will have a very concerned about furthering the process. Even major impact on how and where nursing is practiced, as nursing has matured and evolved into a field and even on who practices it. If nurses utilize their of study with an identifiable body of knowledge, tremendous potential power by banding together as the questions and problems that have plagued this a profession, they will be able to influence decisions profession persist. In addition, advances in technol- about the direction in which health-care is going. Sub- ogy, management, and society have raised new sequently, nurses, rather than politicians, physicians, questions about the nature and role of nursing in hospital administrators, and insurance companies, will the health-care system. Only by understanding be shaping the future of the nursing profession. The and exploring the issues of professionalism will move toward mandated staffing ratios is one way that nurses be prepared to practice effectively in the nurses are demonstrating their power to achieve a goal present and meet the complex challenges of the when they band together and exert power as a group. future. Nursing has taken great strides forward in achieving professional status in the health-care

18 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.

References C h a p t e r 1 The Development of a Profession 19 1. Gokenbach V. Professionalism in nursing: What does it really 10. Smith TG. A policy perspective on the entry into practice issue. mean? Nurse Together, 2012. Retrieved March 2013 from Online Journal of Issues in Nursing, 15(1):2, 2010. http://www.nursetogether.com/Career/ Career-Article/itemid/ 2245.aspx 11. Cabaniss R. Educating nurses to impact change in nursing’s image. Teaching and Learning in Nursing, 6(3):112–118, 2011. 2. Russell KA, Beaver LK. Professionalism extends beyond the workplace. Journal of Nursing Regulation, 3(4):15–18, 2013. 12. Martin K, Wilson CB. Newly registered nurses’ experience in the first year of practice: A phenomenological study. Interna- 3. Stagen M. The five C’s of professionalism. Healthcare Traveler tional Journal for Human Caring, 5(2):21–27, 2011. 17(12):16, 2010. 13. Hartigan C. APRN regulation: The licensure-certification in- 4. Hahn J. Integrating professionalism and political awareness into terface. Advanced Critical Care, 22(1):50–67, 2011. the curriculum. Nurse Educator 35(3):110–113, 2010. 14. Cahill M, Hysong A. Moving forward with role recognition for 5. Cox C. Legal responsibility and accountability. Nursing Manage- clinical nurse specialists. Journal of Nursing Regulation, 3(3): ment (UK), 17(3):18–20, 2010. 47–50, 2012. 6. Nairn S. A critical realist approach to knowledge: implications 15. Stachowiak ME, Bugel MJ. The clinical nurse leader and the for evidence-based practice in and beyond nursing. Nursing In- case manager: Are both roles needed? American Journal of quiry, 19(1):6–17, 2012. Nursing, 113(1):59–63, 2013. 7. Eley D, Eley R, Bertello M, Rogers-Clark C. Why did I become a 16. Rudge T, Holmes D, Perron AE. The rise of practice develop- nurse? Personality traits and reasons for entering nursing. Jour- ment within reformed bureaucracy: Discourse, power and the nal of Advanced Nursing, 68(7):1546–1555, 2012. government of nursing. Journal of Nursing Management, 19(7):837–844, 2011. 8. Elcock K. What is nursing? Exploring theory and practice. Nurs- ing Standard, 24(25):30, 2010. 17. Bogue RJ, Joseph ML, Sieloff CL. Shared governance as verti- cal alignment of nursing group power and nurse practice 9. Lane SH, Kohlenberg E. The future of baccalaureate degrees for council effectiveness. Journal of Nursing Management, nurses. Nursing Forum, 45(4):218–227, 2010. 17(1):4–14, 2009.

2 Historical Perspectives Joseph T. Catalano Learning Objectives KUNDERSTANDING OUR HISTORY After completing this chapter, nowledge about the profession’s past can help us understand how the reader will be able to: nursing developed and even suggest solutions to problems that face the profession today. Several threads run throughout the history of nursing, • Explain why studying the history of health care and nursing is im- portant to the nursing profession including society’s beliefs about the causes of illness, the value placed • Name three “historical threads” on individual life, and the role of women in society. The wars of mod- found in the study of nursing ern history have also had a significant impact on nursing, particularly history and discuss why they in influencing the development of technology and guiding the direction are important of health care. This chapter is not a treatise on the history of health care • Discuss Christian influences on and nursing but presents some key historical milestones and individu- health care and nursing als that helped to form the foundations of health and nursing care. • Discuss the influences of the Renaissance and Reformation on health care and nursing ORIGINS OF NURSING • Describe the major changes in health care and nursing that occurred during and immediately According to the American Nurses Association (ANA), the modern after World War II definition of nursing is the protection, promotion, and optimization of • Identify key historical persons clients’ health and abilities, the prevention of disease and illness, and who advanced the profession of the alleviation of suffering through the diagnosis and treatment of nursing human response to disease and injury. This comprehensive and modern definition of nursing was only arrived at after centuries of development. However, one of the common elements seen throughout the history of nursing is the belief that by providing care to the ill and injured, includ- ing individuals, families, and communities, optimal health and quality of life could be restored or maintained. 20

C h a p t e r 2 Historical Perspectives 21 Before Nursing and even birth control. Women enjoyed a higher Current nursing practice is a relatively recent devel- status in Egyptian society and even worked in opment. The major concern of most early civiliza- hospitals.1 Physicians, however, were still men, tions was the survival of the group, and because who served in multiple roles as surgeons, priests, illness and injury threatened this survival, many architects, and politicians. primitive health-care practices grew from processes The Babylonian Empire, united in 2100 BC, of trial and error. In prehistoric times, women tended was a civilization that focused on astrology. Its to care for the ill and injured. Evil spirits were health-care practices included special diets, massage thought to be the cause of illness, and the medicine therapy, and rest to drive evil spirits from a body. men and women who practiced witchcraft were People would go to the marketplace to seek advice considered religious figures. on how to treat their ailments. During the height of the empire, strict guidelines governed doctors’ fees Driving Out Demons and responsibilities in medical practice. There is also In ancient Eastern civilizations, starting from about evidence from this period of child care and treat- 3500 BC, health care was intertwined with religion. ment of some diseases, but most care still took place Taoism emphasized balance and the driving of in the home. demons out of the ailing body. Acupuncture devel- By 1900 BC, the Hebrews had formed a oped over the next several thousands of years, and nation along the Mediterranean and adopted many medicinal herbs were used in preventive health care. of the health practices of their neighbors. They inte- In Southeast Asia, Hinduism emphasized grated elements of the Egyptian sanitary laws to form the need for good hy- the Mosaic Code of Laws “giene, and written records The major concern of most early civi- which, as in many other lizations was the survival of the group, cultures, mixed religion would soon chronicle a and because illness and injury threat- and medicine. Caring for number of surgical proce- widows, orphans, and dures. This was also the first culture to document ened this survival, many primitive other strangers in need medical treatment outside health-care practices grew from was part of daily life. the home, although Hebrews had good knowl- women were prohibited edge of anatomy and ”of Buddhism around 530 BC caused a surge in inter- circulatory system. Physician-priests routinely processes of trial and error. from working. The rise physiology, especially the est in health care, with the development of public performed operations such as cesarean deliveries hospitals, the requirement of high standards for (named later by the Romans), amputations, and cir- doctors and other hospital workers, and an empha- cumcisions. They also enforced rules of purification, sis on hygiene and prevention of disease. The performed sacrifices, and conducted rituals related to development of medical knowledge was somewhat food preparation. hindered by the refusal of physicians to come in ?What Do You Think? contact with blood and infectious body secretions and the prohibition against dissection of the Is the study of history really necessary for nursing students? human body. Why or why not? Ancient Sciences During the same period, the ancient Egyptians’ The Father of Medicine belief that all disease was caused by evil spirits and punishing gods was changing. Health-care Ancient Greek culture focused on appeasing the gods, providers from that time showed a well-developed and its medical practice was no exception. The god understanding of the basis of disease. Writings Apollo was devoted to medicine and good health. The from 1500 BC refer to surgical procedures, the Greeks performed sacrifices to appease the gods and role of the midwife, bandaging, preventive care, practiced abortion and infanticide in an attempt to

22 U n i t 1 The Growth of Nursing control the population. People took hot baths at spas Early Efforts at Nursing to improve health, but the sick and injured were Although caring for the ill and injured had become cared for at clinics. Although women were held in an established element in most early societies, the high esteem, they were not permitted to provide any concept of a special group to provide this care health care outside the home. evolved some time later. The concept of “nurse” grew primarily from the care provided by Christian orders Around 400 BC, the writings of Hippocrates of nuns who were solely dedicated to the care of the began to change medical practice in Greece. One of a sick and dying. Even today, these early roots are re- roving group of physician-priests, Hippocrates was flected in Great Britain, where nurses are still referred called “the father of medicine.” His beliefs focused on to as “sisters.” harmony with the natural law instead of on appeasing the gods. He emphasized treating the whole client— The Sanctity of Life mind, body, spirit, and environment—and making diagnoses on the basis of symptoms rather than on The rise of Christianity, starting from AD 30, brought an isolated idea of a disease. He was also concerned with it a strong belief in the sanctity of all human life. with ethical standards for physicians, expressed in Christians considered practices such as human sacri- the now-famous Hippocratic Oath. (See http://www fice, infanticide, and abortion—which had been com- .medterms.com/script/main/art.asp?articlekey=20909 mon in Roman society—to be murder. Following the for a copy of the oath.) teachings of Jesus meant that caring for the sick, poor, and disadvantaged was of primary importance, Health Care in the Roman Empire and groups of believers soon organized to offer care for those in need. Ancient Romans clung to superstitions and poly- theism as the foundations for medical and religious Early writings of the Christian period record practices. The dominant Roman Empire ruled from women’s important role in ministering to the sick around 290 BC and absorbed useful elements of and providing food and care for the poor and home- whatever culture it conquered—including the less. Wealthy Roman women who had converted to Greeks and Hebrews. The Romans developed quite Christianity established hospital-like institutions and an advanced system of medicine and a pharmacol- residences for these caregivers in their homes. The ogy that included more than 600 medications de- term nurse is thought to have originated in this rived from herbs and plants. Roman physicians period, from the Latin word nutrire, meaning to were eventually able to distinguish among various nourish, nurture, or suckle a child. The majority of conditions and performed many surgeries. They care was still provided by a family member in the also did physical therapy for athletes; diagnosed home. Most early Christian hospitals were roadside symptoms of infections; identified job-related dan- houses for the sick, poor, or destitute who were cared gers of lead, mercury, and asbestos; and published for by male and female attendants alike. The atten- medical textbooks. dants learned from a process of trial and error and from observing others. The Romans’ advances in creating an unlimited supply of clean water through aqueducts were critical in maintaining the good health of the citizens, as were central heating, spas and baths, and more advanced systems for sewage disposal. Because the great Roman armies were so crucial to the empire, they developed early hospitals to care for sick and injured soldiers. These were mobile and were staffed by female and male attendants who performed duties that would today be thought of as nursing care: Cleaning and bandaging wounds, feeding and clean- ing clients, and providing comfort to the wounded and dying. In many ways, women enjoyed an equal place in society, and they provided home health care and midwifery.

C h a p t e r 2 Historical Perspectives 23 A Time of Disease highly resourceful in dealing with issues related The Dark Ages, from roughly AD 500 to 1000, were to technology. Current society readily accepts tech- marked by widespread poverty, illness, and death. nology and scientific breakthroughs; however, Plagues and other diseases such as smallpox, leprosy, earlier religion-based societies had more difficulty and diphtheria ravaged the known world and killed moving forward with these developments, which large segments of populations. Health care at this were sometimes seen as works of Satan. The Renais- time was almost nonexistent. sance developed into a battle between progressive However, the strong beliefs of the Catholic thinkers and a very conservative governance struc- Church, which was based in Rome, produced monas- ture that resisted change. teries and convents that became centers for the care of the poor and the sick. By AD 500, there were Health Care in the Renaissance several religious nursing orders in what is today In the intellectual reawakening of the Renaissance in England, France, and Italy. Men and women worked Europe, starting in about 1350, nursing emerged in a there and also traveled to rural areas where they were recognizable form, although it did not grow steadily needed, combining religious rituals with home reme- as a profession during this period. Inventions from dies and providing treatments such as bandaging, this time include the microscope and thermometer, cautery, bloodletting, enemas, and leeching. The but the use of more modern diagnoses and treat- biggest contribution to health care in this period may ments was viewed with skepticism. Monastic hospi- have been the insistence on cleanliness and hygiene, tals still regarded the restoration of health as which lessened the spread of infections. Medieval secondary to the salvation of the soul. Major political nurses did not have any formal schooling but learned changes initiated by the Protestant Reformation in through apprenticeships 1517 had the greatest effect with older monks or nuns. “The term nurse is thought to have origi- on the health care of the Eventually hospitals came nated in this period, from the Latin period. In Catholic nation- to be built outside of word nutrire, meaning to nourish, states, including Italy, monastery grounds. France, and Spain, health ”Secular orders were also care remained generally unchanged from that of established, which could nurture, or suckle a child. provide a wider range of the Middle Ages, although the number of male nurs- services to the sick because they were not limited by ing orders gradually decreased. By 1500, the majority religious restrictions and obligations. of health care was provided by female religious orders. Early Military Hospitals ?What Do You Think? At the end of the Dark Ages, there was a series of Imagine yourself living in one of the historical periods dis- holy wars and invasions, including the Crusades, cussed in this chapter. Given your or your family’s health- which produced many sick and injured who were far care problems, how would your lives be different? from home. Military nursing orders developed to care for the soldiers, but these were made up exclusively of men who wore suits of armor to protect themselves and their hospitals against attacks. These orders, with A Nursing Hierarchy the emblem of the Red Cross, were extremely well In the nation-states that broke away from the organized and dedicated, and they existed well into Catholic Church, such as England, Germany, and the the Renaissance. Netherlands, health care soon degenerated to a con- dition even worse than that of the Middle Ages. The Development of the Modern Nurse role of women was reduced under Protestant leader- It is hard to argue with the fact that technology ship, and the male nurse all but disappeared. Secular and scientific advancements have changed the nursing orders gradually took over the duties of the way nurses practice in today’s society. However, many substandard hospitals that had been established technological advancements both solve and create in metropolitan areas. The most famous of these was problems. Nurses have proven themselves to be the Sisters of Charity, established in 1600.

24 U n i t 1 The Growth of Nursing These orders were the first to establish a with the influx of religious nursing orders from Europe. nursing hierarchy. Primary nurses were called sisters, More early schools of nursing developed at this time. and those assisting them were called helpers and Despite the rapid increase in the number of hospitals, watchers. At this time, people began to recognize the most nursing care was still given at home by family benefit of skilled nursing care. The first nursing text- members. Hospitals were considered a last resort and books appeared, and the use of midwives became still had very high mortality rates. widespread. Although hospitals were gaining impor- tance, most clients still received health care at home. When the States Went to War The Civil War caused more death and injury than any The Industrial Revolution (1760–1840) caused war in the history of the United States, and the demand a flood of people throughout Europe to move from for nurses increased dramatically. Women volunteers rural areas into cities, and cramped living situations (as many as 6000 for the North and 1000 for the South) caused very bad health conditions and the spread of began to follow the armies to the battlefields to provide disease and plagues. Factory owners supported some basic nursing care, although many of them were un- forms of health care to keep their workers on the job, trained. Navy Nurses, the American Red Cross, and the and this led to an early form of community health nurs- Army Nurse Corps all date from this period. Large ing. The Sisters of Charity expanded their care to in- numbers of women came out of their homes to work clude home care. Only a few male nursing orders in the hospitals, and a number of African American survived the Protestant Reformation and Industrial volunteers in the North paved the way for others to Revolution. Several non-Catholic nursing orders were enter the health-care field in the future. founded, including the one by the famous Quaker, Elizabeth Fry, who established the Society of Protestant Sisters of Charity in London in 1840, which provided training to nurses who cared for the sick and poor, including prisoners and children. NURSING IN THE UNITED STATES Five hospitals existed in America before the Revolu- tionary War that housed the homeless and the poor and included rudimentary infirmaries. However, there were no identifiable groups of nurses for these infirmaries.2 Health care in America at this time reflected that of the European countries from which the settlers had come. Infant mortality rates were very high, ranging between 50 and 75 percent. One of the first schools of nursing was established in 1640 by the Sisters of St. Ursula in Quebec, and Spanish and French religious orders would establish hospital-based training schools in the New World over the next 100 years. In Colonial Times Technological developments in the 19th century included medications such as morphine and During the Revolutionary War, there was no organ- codeine for pain and quinine to treat malaria. The ar- ized medical or nursing corps, but small groups of rival of 30 million immigrants in this century meant untrained volunteers cared for the wounded and that the need for health care increased accordingly. sick in their homes or in churches or barns. In 1751, Benjamin Franklin founded Pennsylvania Hospital, the first U.S. hospital dedicated to treating the sick. Between the Revolutionary and Civil Wars, health care in the United States increased markedly

C h a p t e r 2 Historical Perspectives 25 Hospitals sprang up, and many instituted their own 8 hours, although these measures were not widely schools of nursing. Still, home care was the preferred implemented. During this period, hospitals became the type of nursing. primary source of health care, supported by hospital insurance programs. As the size of hospitals increased, After 1914 more nursing jobs became available. Nursing and nurses still had a very negative image prior to the beginning of World War I. Their primary duties Establishing Standards were to carry out the orders of physicians, clean, cook, World War II produced another nursing shortage, and empty bedpans. Most of the duties carried out by and in response, Congress passed the Bolton Act, physicians would fall well within the current-day scope which shortened hospital-based training programs of practice for nurses. However, in the face of the large from 36 to 30 months. The new Cadet Nurse Corps numbers of injured produced in World War I, nurses’ established minimum educational standards for nurs- roles rapidly expanded and they began to be recognized ing programs and forbade discrimination on the basis for their skills in providing care and saving lives. of race, creed, or sex.2 Many schools revised and im- proved their curricula to meet these new standards. Untrained Nurses To encourage more nurses to enter the At the beginning of World War I, there were only military, the U.S. government granted women full about 400 nurses in the Army Nurse Corps, but by commissioned status and gave them the same pay as 1917, that number had swelled to 21,000. Because men with the same rank. By the end of the war, many hospitals were recruiting untrained women to African American and male nurses were also admit- provide basic care, a committee on nursing was ted to the armed services. formed to establish standards, and eventually the Red Cross began a training Modern Times: program for nurse’s aides. Emerging Specialties This was supported by The single largest transfor- physicians but opposed by “many nursing leaders who Medieval nurses did not have any formal schooling but learned through apprentice- mation of the practice of ”be seen as something anyone could do with minimal more volunteers than any other occupation at the time. ships with older monks or nuns. nursing occurred during were concerned that it World War II. Navy and relegated nursing to “women’s work,” which would army nurses had such a positive image that it attracted training. Because nurse’s aides were a cheap source of Nurses were revered as selfless heroes under fire in sev- labor, they began to replace more trained nurses in eral movies produced during the war. Even nurses cap- hospitals. Unfortunately, this also resulted in a lower tured by the Japanese were allowed to keep practicing quality of care. because their role was so highly respected. On the bat- Between Wars tlefields and at rear area hospitals, they often worked together with untrained care providers and physicians, After the war, a segment of the nursing profession thus initiating the concept of a health-care team. began to focus on improving the educational standards of nursing care. At the time, 90 percent of nursing care A Team of Nurses was still given at home, but nurses began to practice in The advancements in health care made during World industry and in branches of government outside of the War II required that nurses receive more highly military. The standards of nursing care were low, and specialized education to meet clients’ unique needs. external quality controls were nonexistent. After the war, many nurses left the profession to raise The Great Depression took its toll on health families, and the spaces were filled by graduates of care and nursing, as jobs became scarce and many new programs that trained licensed practical nurses nursing schools closed. At this time, the federal gov- (LPNs) and licensed vocational nurses (LVNs) in just ernment became one of the largest employers of 1 year. At this time, the concept of team nursing nurses. The newly organized Joint Committee on came to be widely accepted, although it removed Nursing recommended that jobs go to more qualified the registered nurses (RNs) from direct client care, nurses and that the workday be reduced from 12 to requiring them to serve as team leaders.

26 U n i t 1 The Growth of Nursing A Growing Need The Lamp Technical nursing programs, which granted associate The simple definition of a lamp is a device that pro- degrees (associate degree nurse [ADN]) at 2-year vides a continuous source of light for an extended community colleges, were developed to help with the period of time. The first evidence of lamp use can be nursing shortage. With the baby boom, the need for traced back to 10,000 BC, when a hollowed out stone nurses continued to grow, and what had been a with oil residue was found in a cave. Early variations quick-fix solution began to take a stronger hold. By on the oil lamp included seashell lamps and coconut the mid-1960s, ADNs outnumbered the nurses with lamps. Since then, technology has advanced lamps to baccalaureate degrees (BSN) and the technical LPNs. clay bowls, pottery, and various types of metals. Also, ADNs won the right to take the same licensing Pushing Back Darkness examinations as RN graduates from diploma and BSN programs. The significance of the lamp is really the significance Still, as the health-care system became in- of light. Its origins can be traced back to the first at- creasingly complicated, some nursing leaders ques- tempts of human beings to control fire and use it as a tioned whether 1- or 2-year LPN and ADN programs tool of survival. These early humans soon found that were adequate to meet the needs of the profession. fire was a source of warmth on cold nights, kept wild Slowly, the number of BSN programs and graduate- animals from attacking, and was useful for cooking. level programs began to increase. Light, first in the form of torches and can- dles and later in the form of the oil lamp, has been Vietnam: Traveling Hospitals used by human beings for thousands of years to push The mobile army surgical hospital (MASH) units back the darkness of night. It dispelled fear and that had been developed “Large numbers of women came out of allowed people to pursue during the Korean War their homes to work in the hospitals, learning long after the sun were replaced during the and a number of African American went down. Vietnam War with med- volunteers in the North paved the way ical unit, self-contained for others to enter the health-care field The lamp has long transportable (MUST) been used as a religious hospitals, which were symbol. It often represents the eternal flame that dis- ”graduates of 2-year ADN programs were commis- staffed by nurses and in the future. pels darkness and evil. Commonly found in Chris- physicians. Some 5000 tian symbolism is the “Lady of Light,” often depicted as radiant and glowing brightly and filled with goodness, nurses served in this war, and for the first time, sioned into the armed services. Several navy nurses purity, and wisdom. The lamp can also represent the were injured in the line of duty, and one army flame of life, eventually extinguished by death. nurse was killed. The efforts of these and other As schools and universities developed dur- women who served are recognized at the Vietnam ing the Middle Ages, many adopted the lamp as a Women’s Memorial in Washington, dedicated symbol of learning. The burning of the lamp signified in 1993. the continual seeking of knowledge. It also symbol- izes the enlightenment that accompanies knowledge. THE EVOLUTION OF SYMBOLS IN NURSING The coats of arms or logos used by many universities contain the image of a lamp. All professions have symbols that are easily identi- A Sign of Caring fied and connected with the work and services they provide. In the past, when most of the population The lamp was first introduced as a symbol for the nurs- was illiterate, these were helpful in distinguishing ing profession at the time of Florence Nightingale. In one professional from another. In modern society, addition to her fame as an early health-care reformer the symbols connect the professions to their histori- and pioneer, she became well known for her role in cal roots and provide the philosophical basis for the caring for injured soldiers during the Crimean War. work they do. She made history when she took her 38 nurses to Turkey to try to improve the squalid, filthy conditions

C h a p t e r 2 Historical Perspectives 27 she found in the primitive British field hospitals. As symbol of those who care for the sick. Although large Nightingale and her nurses made their night rounds, by today’s standards, the Maltese cross is often consid- caring for the wounded in unlit wards, they carried oil ered the first true nursing pin. lamps to light the way. For the wounded and suffering, The shields of some medieval knights were these lamps became signs of caring, comfort, and often painted with the coats of arms of the kings they were the difference between life and death. defending. Only the best knights, recognized for their Nightingale’s lamp was not the often-depicted skills in battle, strength, honesty, and dedication to “genie” or “Aladdin’s” lamp. Rather, Nightingale the service of the king, were permitted to use the would have used one of the many lamps in circulation king’s coat of arms on their shields. The coat of arms around the wards, picking up whichever was closest at displayed to the world the characteristics by which hand—an ordinary camp lamp or a Turkish candle the king wished to be known. A classic example is the lantern. She later became immortalized as the “lady symbol of the lion, found on the shields of the knights with a lamp” in a poem written by Longfellow (“Santa who served King Richard the Lionheart, which indi- Filomena”). In our modern society, oil lamps are cated the king’s fearlessness and power. sometimes used for atmosphere or nostalgic re- Similarly, during the Middle Ages when minders of the past, although when the power goes most of the population was illiterate, tradesmen out, they can be very handy. However, for graduate and craft guilds began adopting symbols as pictorial nurses, the lamp, or its close cousin the candle, re- representations of their services, skills, and crafts. tains its significance as a symbol of the ideals and Modern companies use trademarks and brand selfless devotion of Florence Nightingale. It also names in the same way today. Medieval schools and signifies the knowledge and learning that the gradu- universities also began using symbols to represent ates have attained during their years in the nursing their values and goals. The modern practice of program. Even though the “branding the university,” “nursing graduates may The Civil War caused more death and or adopting an official not physically carry an oil injury than any war in the history of symbol or logo for the lamp during pinning cere- the United States, and the demand school, can be traced back monies, they symbolically to these early practices. ”votion as they minister to the sick and injured in their tons, badges, and pins that were worn by members carry the brightly burning for nurses increased dramatically. These symbols were em- lamp of their care and de- bossed on clothing, but- nursing practice. of the group. Also traceable to this time in history are the “shields” and badges worn by firefighters The Nursing Pin and law enforcement officers. Although these Unlikely as it may seem, the modern nursing pin can shields offer little in the way of protection from ar- trace its origins to the heavy protective war shields rows and spears, they symbolize official authority used by soldiers as far back as the Greek and Roman and identify the wearer as belonging to a unique, Empires. The primary purpose of these shields was to specially trained group. protect the warriors from the spears, swords, and ar- The first modern nursing pin is attributed rows of the opposing army. Adorned with the em- to Florence Nightingale. After receiving the medal blems of the soldier’s country and his particular unit of the Red Cross of St. George from Queen Victoria in the army, these ancient war shields also served as a for her selfless service to the injured and dying in the quick way to distinguish friend from foe. Crimean War, Nightingale chose to extend the honor During the Crusades, the Knights Hospi- she had received to her most outstanding graduate tallers were formed to provide medical care for the nurses by awarding each of them a “badge of excel- wounded and sick. The Knights wore black tunics over lence.” The badge or pin she designed for her school their armor, carried no weapons, and wore a white is a deep-blue Maltese cross (Fig. 2.1). In the center Maltese cross on chains around their necks. Those of the cross is a relief image of Nightingale’s head. wearing this cross became known for their skills in As the number of nursing schools increased, each treating the injured and healing the wounded. Since program designed a unique pin to represent its own that time, the Maltese cross has been recognized as a particular values, philosophies, beliefs, and goals.

28 U n i t 1 The Growth of Nursing of women called deaconesses. Deaconesses were set apart from other women of the period by their F i g u r e 2 . 1 Florence Nightingale’s nursing excellence pin white head coverings, which indicated that their primary service was to care for the sick. Originally The pinning ceremony is part of a long tradi- this head covering was more like a veil that nuns tion that acknowledges nursing graduates as belonging wear, but after the Victorian era, it evolved into a to a unique group and identifies them as new members cap. During the early centuries of Christianity, of the health-care community. The historical origins groups of deaconesses banded together and formed of the pin remind nursing professionals of what it what later became the religious orders that were so symbolizes. Like the badge worn by law enforcement prevalent in the Holy Roman Empire. The former officers, it is also a sign of their legal authority as deaconesses, now recognized as religious order licensed professionals. Nursing graduates wear their nuns, remained the primary providers of care for pins proudly in the work setting as evidence of their the sick throughout the Middle Ages. The tradi- successful completion of the nursing program. tional garb of nuns, the long-robed habit with the wimple or veil, can be considered the first official Question for Thought nurse’s uniform. Each religious order had its own unique style of habit and wimple. The order the Obtain a picture of your nursing school’s pin. nun belonged to could be easily identified from the What do the various symbols on the pin signify? habit or veil she was wearing. The Cap Religious orders continued to be the primary It is rare to see a nurse wearing the traditional “nurs- source of care for the sick well into the 19th century. ing cap” in today’s modern hospitals. However, the However, as the Industrial Revolution progressed and cap has a long, rich history. Although it may seem the concept of the modern hospital developed, the sexist by today’s standards, throughout much of his- care of the sick moved away from religious orders to tory, women were required to keep their heads cov- care by laypeople who did not wear the nun’s robe ered with some type of garment. This practice was and veil. prevalent in the early Hebrew, Greek, and Roman cultures that served as the roots for modern Western By the time Florence Nightingale trained at society and the current profession of nursing. the Institute of Protestant Deaconesses in Germany, A Symbol of Service the veil had evolved into a white cap that signified The origins of what we identify as modern nursing “service to others.” However, Florence Nightingale can be traced back to an early Christian era group lived and practiced nursing during the Victorian era, which required “proper” women to keep their heads covered. The nursing cap Florence Nightin- gale 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. A Cap for Every School In the United States, the first standardized nursing cap is generally attributed to Bellevue Training School in New York City around 1874. The cap’s primary purpose was to keep the nurse’s long hair from getting in the way, but it also identified nurses who had graduated from Bellevue. The Bellevue cap

C h a p t e r 2 Historical Perspectives 29 band added to the edge of the cap, and third-year stu- dents were given a second vertical black band. When the student graduated, the vertical black bands were removed, and a horizontal black band was placed across the front of the cap. F i g u r e 2 . 2 Florence Nightingale’s nursing cap Unchanging Values As shorter hair became an acceptable style for women covered the whole head to just above the ears and re- in the 20th century, the nursing cap lost its function sembled a modern knitted ski hat, except for being of controlling long hair. However, it continued as a white linen with a rolled fringe at the bottom. status symbol and a source of pride and identity for the graduates of nursing schools into the 1970s. As As the number of nursing schools increased, technology increased in the health-care work envi- there was a corresponding increase in the need for ronment, the traditional nursing cap became more unique caps. Each nursing school designed its own of an obstacle for nurses in the practice setting. Also, cap. Nursing caps became very frilly, elaborate, and research demonstrated that the cap, rather than pro- sometimes large and unwieldy. Some caps adopted tecting clients from infection by organisms from the the upside-down ice cream cone shape, similar to nurse’s hair, actually helped to colonize organisms. the cloth cone through which ether was given as By the 1980s, health-care facilities no longer required an anesthetic. By looking at the cap, a person could nurses to wear caps as part of the uniform, and nurs- still determine the school from which the nurse ing schools eliminated the cap as a mandatory item had graduated. of students’ uniforms. Traditionally, in the 3-year hospital- Most nursing programs have eliminated based schools of nursing, there were two separate the capping ceremony as a throwback to an era that ceremonies—one for capping and one for pinning. was repressive to women. However, the nursing The capping ceremony usually took place after the cap connects graduates to a rich and long history. student completed the initial 6 months of classroom It retains its significance, from the time of Florence education, which was considered the probationary Nightingale, as a sign that the primary goal of nurs- period of the program. Capping indicated that the ing is “service to those in need.” The nursing cap is student was now off probation and that she had a reminder of the unchanging values of wisdom, earned the right to wear the cap during clinical rota- faith, honesty, trust, and dedication. These values tions in the hospital. are as important in today’s modern, technology- filled hospitals as they were in the era when wash- During nursing school, the cap was also used ing floors was a required basic nursing skill. as a sign of rank and status. In the 3-year hospital- based nursing schools, first-year students wore plain ?What Do You Think? white caps. Second-year students had a vertical black Does your nursing school have a unique nursing cap that was used in the past? What is the symbolism of the cap’s design? NURSING LEADERS The nursing profession as it is practiced today owes a great deal to several outstanding nurses who had a vision for the future. The few discussed here are rep- resentative of the great drive and dedication of the many individuals who created change and influenced the development of the nursing profession.

30 U n i t 1 The Growth of Nursing camps for long-term recovery, and residences for sol- diers’ families. She also began to help with the care given at the front lines. At the height of her work in the war, Nightingale supervised 125 nurses in several large hospitals, and her accomplishments were recog- nized by the Queen of England with an Order of Merit, the highest award given to English civilians. ?What Do You Think? What would current nursing practice and nursing education be like without the influences of Florence Nightingale? A Health-Care Reformer Florence Nightingale (1820–1910) Universally regarded as the founder of modern nurs- The war experience strengthened Nightingale’s con- ing, Florence Nightingale dedicated her long life to victions that nursing education required major improving health care and nursing standards. Raised reform. Believing that nursing schools should be run in England, Nightingale was considered highly edu- by nurses and be independent of hospitals and physi- cated for her time. Through travels with her family, cians, she advocated a program of at least 1 year that she became aware of the substandard health care in included basic biological science, techniques to im- many countries in Europe. In 1851, she attended a prove nursing care, and supervised practice. She 3-month nurses’ training program at the church-run regarded nursing as a lifelong endeavor and felt that hospital in Kaiserswerth, Germany. She was im- nurses should be in direct contact with clients rather pressed with the program but believed this brief than doing menial jobs such as cooking and cleaning. training was insufficient. She later ran a private nurs- She worked tirelessly for the reform of health care ing home and realized that the only way to improve and nursing and was appointed to many related com- health care was to educate women to be reliable, mittees and commissions. A prolific writer, she wrote high-quality nurses.3 extensively about improving hospital conditions, san- itation, nursing education, and health care in general. Volunteering Under Fire Her famous Florence Nightingale School of Plans to develop a school of nursing in England were Nursing and Midwifery opened in 1860 and began to interrupted in 1854 by a cholera epidemic. Nightin- train nurses, who were in great demand throughout gale volunteered her services and learned a great deal Europe and the United States. At this school, about how to prevent the spread of disease. When the Nightingale advocated health maintenance and the Crimean War broke out that same year, she obtained concept that nursing was both an art and a science. permission to take a group of 37 volunteer nurses She taught that each person should be treated as an into the battlefield area. British medical officers ini- individual and that nurses should meet the needs of tially refused their assistance, but as conditions wors- clients, not the demands of physicians. ened, the nurses were admitted to the hospital. The school flourished, although it faced After just 6 months of the nurses cleaning strong opposition from physicians who felt that and bandaging wounds, cooking, and cleaning the nurses were already overtrained. Many early gradu- wards, the mortality rate dropped from 42 percent to ates went on to become important nursing leaders. 2 percent.3 Nightingale expanded her reform to in- Nightingale’s ideas were somewhat diluted during the clude supplies, a military post office, convalescent first half of the 20th century, but they have since resurfaced and are now evaluated in the light of a rapidly changing health-care system.3

C h a p t e r 2 Historical Perspectives 31 Issues Now Travel Nursing as a Career As a nursing student, you may have heard of travel nursing or traveling nurses but not really know what they are or if it might be something you would be interested in as a career. Much like the recruitment posters for the armed services, “See the World” seems to be an attractive slogan for those looking for new experiences and adventure. However, there may be some drawbacks to travel nursing. In general, travel nurse staffing companies require a BSN or higher de- gree. This standard allows the nurses to meet any staffing requirements of individ- ual facilities, and research has demonstrated good client outcomes. Travel nurses differ from agency nurses in several ways. Travel nurses are usually committed to working for a facility for a predetermined length of time, usually about 3 months. To allow preparation for travel to the facility, they are scheduled for their time about 2 months before their start date. Agency nurses generally work on a per diem (by the day) basis and live near the facility. They work a few days at a time to meet a short-term staffing need. Travel nurses provide more continuity of care and fill in for long-term needs, such as extended illness, maternity leave, or even sab- batical leave. Travel nurses can select where they want to work and the time period of the work schedule. They usually follow the schedule required by the facility but have scheduled days off like other nurses. Their salaries tend to be higher, and, depending on the company, the benefits may range from “bare bones” to what regular staffers would receive at a large health-care facility. The staffing agency also pays for the nurse’s license and housing costs. Staffing agencies have a group of employees who support the nurse and act as liaisons with the facilities to resolve any problems that may arise. A nurse must be careful when selecting a travel nurse staffing company. The nurse should investigate the company carefully, talk to other nurses it employs, and examine the benefits closely. Generally, the larger the firm, the more locations it serves and the better the benefits and support services. Some nurses use travel nurse employment to research locations in which they may be interned and then permanently relocate when they find the ideal location. So, if you want to be a travel nurse, the opportunities are out there. Travel nursing certainly provides a high degree of autonomy and control of your schedule and career. One of the key elements reported by nurses for career satis- faction is quality of life. The freedom of choice provided by travel nursing would certainly fulfill that need. Sources: Nurses RX. AMN Health Care Company. Retrieved April 2013 from http://www.nursesrx. com/; Travel Nursing: The Authority in Travel Nursing. Retrieved April 2013 from http://www. travelnursing.com/

32 U n i t 1 The Growth of Nursing Robb became the first president of a group for staff nurses in active practice called the Nurses Associ- ated Alumnae of the United States and Canada, which would later become the American Nurses Association (ANA), dedicated to the improvement of clinical practice.4 She later helped develop the American Journal of Nursing, the first professional journal dedicated to the improvement of nursing, which is still the official journal of the ANA. Isabel Adams Hampton Robb (1860–1910) Lillian Wald (1867–1940) Lillian Wald was raised in Ohio and graduated from Isabel Adams Hampton Robb started out as a the New York Hospital Training School for Nurses in teacher in her home province of Ontario, Canada, 1901. After working as a hospital nurse, she entered but in 1881 she went to New York City to train to be medical school, but encounters with New York’s poor a nurse. After graduation, she moved to Rome and and sick caused her to change direction. She instead became a superintendent of a hospital there. She had opened the Henry Street Settlement, a storefront health always focused on the academic rather than the clin- clinic in one of the poorest sections of the city, which ical side of nursing, but in Italy, her conviction grew organized nurses to make home visits, focusing on san- that nurses needed a solid theoretical education—a itary conditions and children’s health.5 Wald became a belief that was not well accepted by the medical dedicated social reformer, an efficient fundraiser, and community of the time. From that point on, she an eloquent speaker. Although women still did not dedicated her life to raising the standards of nursing have the right to vote, her political influence was felt education in the United States, first as director of worldwide. the Illinois Training School for Nurses, a school that was unique for its time in that it was university Under Wald’s auspices, Columbia Univer- based and emphasized academic learning. Some of sity developed courses to prepare nurses for careers her unique ideas for the time were to develop and in public health. Wald also advocated wellness educa- implement a grading policy for nursing students tion, which the medical community did not value at that required nurses to prove their abilities in order the time. However, the Metropolitan Life Insurance to be awarded a diploma. She also advocated for the Company saw the value in her beliefs and asked her reduction of the long hours involved in training to organize its nursing branch. She is also credited nurses. She later headed the new Johns Hopkins with founding the American Red Cross’s Town and Training School for Nurses and would implement Country Nursing Service and with initiating the con- her ideas there as well.4 cept of school nursing. In 1912, she founded and be- came the first president of the National Organization Hampton Robb brought together leaders for Public Health Nursing. She was the first to place from key nursing schools to form the American nurses in public schools.5 Many child health and Society of Superintendents of Training Schools for wellness programs in use today are based on her Nurses, and she served as its chairwoman. The efforts. Current proposals for health-care reform group was the precursor to the National League often include her ideas about public health nursing, for Nursing, which was dedicated to improving the independent clinics, and health maintenance. standards for nursing education. In 1896, Hampton What Do You Think? Who is your favorite historical nursing leader? What are ?some of that person’s characteristics that appeal to you? Is there a current nurse or nurse educator who is a role model for you? What are some of that person’s characteristics that appeal to you?

C h a p t e r 2 Historical Perspectives 33 Lavinia Lloyd Dock (1858–1956) own nursing programs. Goodrich had demonstrated Lavinia Lloyd Dock left her home in Pennsylvania in that teaching theoretical information in a classroom 1885 to attend New York’s Hunter-Bellevue School of was just as important in training highly skilled nurses Nursing. Her contributions as a reformer focused on as clinical practice. When the war was over, Goodrich the professionalization of nursing and the equality of returned to the Henry Street Settlement and then be- women.6 She noticed that many of her fellow students came a nursing educator, eventually serving as dean struggled to learn about all the medications that were at the Yale School of Nursing. Her many writings becoming available, and she would later write the first about nursing education and her experiences with medication textbook for nurses. She worked along- military nursing have been a great contribution to the side Lillian Wald at the Henry Street Settlement and nursing profession.7 Isabel Hampton Robb at Johns Hopkins Hospital. Like Wald, Dock believed that poverty and Loretta C. Ford (1920– ) squalor contributed to poor health, and she dedicated Credited with founding nurse practitioner (NP) prac- herself to social reform to address these problems.6 tice, Loretta C. Ford was born in New York City. She However, she soon learned that she was limited in her received her diploma in nursing from the Robert influence because she was a woman, and she spent Wood Johnson University Hospital in New Brunswick, most of her career dedicated to the pursuit of equal New Jersey. She held a staff nurse position there until rights. For 20 years, she lobbied legislators at all levels she accepted a commission as an officer in the U.S. about women’s right to Army Air Force in 1943. vote, believing that this “The war experience strengthened After the war, she was was the only way to influ- Nightingale’s convictions that nursing accepted into the Bachelor ence social reform and education required major reform. of Science (BS) program health care. An excellent Believing that nursing schools should be at the University of Col- example of the diverse run by nurses and be independent of orado College of Nursing. ways that nurses can help hospitals and physicians, she advocated She earned her BS in 1949 achieve higher-quality a program of at least 1 year that in- and her Master of Science health care, she is consid- in nursing in 1951. Subse- ered one of the most influ- quently, she worked as a ential leaders in the early cluded basic biological science, tech- public health nurse in 20th century. niques to improve nursing care, and Boulder, Colorado, and ”Annie W. Goodrich then for the Boulder supervised practice. County Health Depart- (1866–1954) ment, where she served as Annie Goodrich provided nursing care at Lillian director from 1956 to 1958.8 Wald’s Henry Street Settlement in New York after Ford began her career in education in 1955, receiving her nursing degree. She was known as an when she was appointed assistant professor at the outstanding nursing educator and ran a number of University of Colorado College of Nursing in Denver. nursing schools in New York. In 1910, she was She received her doctorate in education from the appointed as state inspector of nursing schools, a University of Colorado in 1961 and became a position that up to that time had been held only by professor in 1965. physicians. After the U.S. Army asked her to survey During her time at University of Colorado, its hospital nursing departments, Goodrich proposed she began working with a pediatrician, Dr. Henry K. that it organize its own nursing school. The school Silver. Together, they noted that there was a severe opened later that year, with her as its dean, and this regional shortage of family care physicians and pedia- school would serve as the model for others estab- tricians, particularly in the rural and underserved lished at army hospitals during World War I. areas of Colorado. In response, they came up with an To respond to the need for nurses in the innovative approach to the health-care provider war, Goodrich also established a nursing training shortage. They applied for and received a small grant program at Vassar College. After the war, other col- from the university in 1965, which led to the creation leges and universities slowly began to develop their of a demonstration project that focused on extending