6 U N I T 1 ● Exploring Contemporary Nursing
graduates in registered nursing. Each educational track provides the knowledge and skills for a particular entry level of practice. The following factors influence the choice of a nursing program:
• Career goals
• Geographic location of schools
• Costs involved
• Length of programs
• Reputation and success of graduates
• Flexibility in course scheduling
• Opportunity for part-time versus full-time enrollment
• Ease of movement into the next level of education
Practical/Vocational Nursing
During World War II, many registered nurses enlisted in the military. As a result, civilian hospitals, clinics, schools, and other health care agencies faced an acute shortage of trained nurses. To fill the void expeditiously, abbreviated programs in practical nursing were developed NURSING THEORIES AND APPLICATIONS
TABLE 1-2
THEORIST THEORY EXPLANATION
Florence Nightingale 1820–1910
Virginia Henderson 1897–1996
Dorothea Orem 1914–
Sister Callista Roy 1939–
Environmental Theory Man
Health Environment Nursing
Synopsis of Theory
Application to Nursing Practice Basic Needs Theory Man
Health Environment Nursing
Synopsis of Theory
Application to Nursing Practice Self-Care Theory
Man Health Environment Nursing
Synopsis of Theory
Application to Nursing Practice Adaptation Theory Man
Health Environment Nursing
Synopsis of Theory
Application to Nursing Practice
An individual whose natural defenses are influenced by a healthy or unhealthy environment
A state in which the environment is optimal for the natural body processes to achieve reparative outcomes
All the external conditions capable of preventing, suppressing, or contribut- ing to disease or death
Putting the client in the best condition for nature to act
External conditions such as ventilation, light, odor, and cleanliness can prevent, suppress, or contribute to disease or death.
Nurses modify unhealthy aspects of the environment to put the client in the best condition for nature to act.
An individual with human needs that have unique meaning and value The ability to independently satisfy human needs composed of 14 basic
physical, psychological, and social elements
The setting in which a person learns unique patterns for living
Temporarily assisting a person who lacks the necessary strength, will, and knowledge to satisfy one or more of 14 basic needs
People have basic needs that are components of health. The significance and value of these needs are unique to each person.
Nurses assist in performing those activities that the client would perform if he or she had strength, will, and knowledge.
An individual who uses self-care to sustain life and health, recover from disease or injury, or cope with its effects
The result of practices that people have learned to carry out on their own behalf to maintain life and well-being
External elements with which man interacts in the struggle to maintain self-care
A human service that assists people to progressively maximize their self-care potential
People learn behaviors that they perform on their own behalf to maintain life, health, and well-being.
Nurses assist clients with self-care to improve or to maintain health.
A social, mental, spiritual, and physical being affected by stimuli in the internal and external environments
A person’s ability to adapt to changes in the environment Internal and external forces in a continuous state of change
A humanitarian art and expanding science that manipulates and modifies stimuli to promote and to facilitate humans’ ability to adapt
Humans are biopsychosocial beings. A change in one component results in adaptive changes in the others.
Nurses assess biologic, psychological, and social factors interfering with health; alter the stimuli causing the maladaptation; and evaluate the effectiveness of the action taken.
C H A P T E R 1 ● Nursing Foundations 7
8 U N I T 1 ● Exploring Contemporary Nursing
across the country to teach essential nursing skills. The goal was to prepare graduates to care for the health needs of infants, children, and adults who were mildly or chronically ill or convalescing so that registered nurses could be used effectively to care for acutely ill clients.
After the war, many registered nurses opted for part- time employment or resigned to become full-time house- wives. Thus, the need for practical nurses persisted. It became obvious that the role of practical nurses would not be temporary. Consequently, leaders in practical nursing programs organized to form the National Association for Practical Nurse Education and Service, Inc. This group worked to standardize practical nurse education and to facilitate the licensure of graduates. By 1945, eight states had approved practical nurse programs (Mitchell
& Grippando, 1993). In 1995, enrollments in licensed practical nurse (LPN)/licensed vocation nurse (LVN) programs peaked at 47,684, declining to 34,650 in 2001.
In 2002, a slight and continuing increase began (Fig. 1-4).
The Bureau of Labor Statistics (2005) predicts that job opportunities in practical nursing will increase by up to 17% by 2014.
Career centers, vocational schools, hospitals, indepen- dent agencies, and community colleges generally offer practical nursing programs, arranging clinical experiences at local community hospitals, clinics, and nursing homes.
The length of a practical nursing program averages from 12 to 18 months, after which graduates are qualified to take their licensing examination. Because this nursing
preparatory program is the shortest, many consider it the most economical.
Licensed graduates are a vital link between the regis- tered nurse and unlicensed assistive personnel (UAP).
They work under the supervision of a registered nurse, physician, or dentist. LPNs or LVNs provide nursing care to clients with common health needs that have a predictable outcome. Their scope of practice is described in the nurse practice act in the state in which the nurse is licensed. Each state interprets the limits of practice dif- ferently. For example, in one state, an LPN may monitor and hang intravenous solutions, discontinue the infu- sion, and dress the site. The same may not be true in another state. An LPN also may delegate tasks to UAPs, who may or may not have acquired state certification.
The LPN, therefore, must know the extent to which nursing assistants can function and the outcomes of their actions (see guidelines for delegation under “Registered Nursing”). Because of the geographic disparities in LPN practice, educational programs, and state regulations, the National Council of State Boards of Nursing is researching and pursuing strategies to promote more consistency (Practical Nurse Scope of Practice White Paper [2005]; http://www.ncsbn.org/pdfs/Final_11_05_
Practical_Nurse_Scope_Practice_White_Paper.pdf). Addi- tional information on nursing practice standards for the licensed practical/vocational nurse can be obtained from the National Federation of Licensed Practical Nurses Web site: http://www.nflpn.org. To provide career mobility,
125,000
100,000
75,000
50,000
25,000
0
1995 1996 1997 1998 1999 2000 2001 2002 2003
47,684 96,610
44,942 94,321
43,351 89,619
40,195 83,239
37,372 76,523
35,572 71,392
34,650 68,759
38,297 70,692
44,075 76,688
RN LPN/ LVN
FIGURE 1-4
•
Trends in LPN/LVN and RN enrollments, 1995–2003. Numbers are based on U.S. candi- dates taking the NCLEX for the first time in respective years, as reported by the National Council of State Boards of Nursing.many schools of practical nursing have developed “artic- ulation agreements” to help graduates enroll in another school that offers a path to registered nursing through associate or baccalaureate degrees.
Registered Nursing
Registered nurses work under the direction of a physi- cian or dentist in various health care settings ranging from preventive to acute care. They manage or provide direct care to clients who are stable but may have com- plex health needs, or who are unstable with unpredict- able outcomes. In addition to managing client care, RNs educate clients and the public about various medical conditions and provide emotional support to clients and their family members (U.S. Department of Labor, 2006).
RNs delegate client care to LPNs and UAPs when appro- priate. Delegation requires adhering to the following guidelines:
• Right task. . . matching the client’s needs with the caregiver’s skills
• Right circumstance. . . ensuring that the situation is appropriate
• Right person. . . knowing the unique competencies of the caregiver
• Right direction (communication). . . providing suf- ficient information
• Right supervision. . . being available for assistance (Aucoin, 2004)
Students can choose one of three paths to become a reg- istered nurse: a hospital-based diploma program, a pro- gram that awards an associate degree in nursing, or a baccalaureate nursing program. All three meet the re- quirements for taking the national licensing examination (NCLEX-RN). A person licensed as a registered nurse may work directly at the bedside or supervise others in managing the care of groups of clients.
Table 1-3 describes how educational programs pre- pare graduates to assume separate but coordinated re- sponsibilities. When hiring new graduates, however, many employers do not differentiate between these educational programs, arguing that “a nurse is a nurse.”
Hospital-Based Diploma Programs
Diploma programs were the traditional route for nurses through the middle of the 20th century. Their decline became obvious in the 1970s, and the number of diploma
LEVELS OF RESPONSIBILITIES FOR THE NURSING PROCESS*
TABLE 1-3
PRACTICAL/VOCATIONAL NURSE ASSOCIATE DEGREE NURSE BACCALAUREATE NURSE Assessing
Diagnosing
Planning
Implementing
Evaluating
Gathers data by interviewing, observing, and performing a basic physical examination of people with common health problems with predictable outcomes Contributes to the development of
nursing diagnoses by reporting abnormal assessment data
Assists in setting realistic and measurable goals
Suggests nursing actions that can prevent, reduce, or eliminate health problems with predictable outcomes
Assists in developing a written plan of care
Performs basic nursing care under the direction of a registered nurse
Shares observations on the progress of the client in reaching estab- lished goals
Contributes to the revision of the plan of care
Collects data from people with com- plex health problems with unpre- dictable outcomes, their family, medical records, and other health team members
Uses a classification list to write a nursing diagnostic statement, including the problem, its etiol- ogy, and signs and symptoms Identifies problems that require col-
laboration with the physician Sets realistic, measurable goals Develops a written individualized
plan of care with specific nursing orders that reflects the standards for nursing practice
Identifies priorities
Directs others to carry out nursing orders
Evaluates the outcomes of nursing care routinely
Revises the plan of care
Identifies the information needed from individuals or groups to provide an appropriate nursing database
Conducts clinical testing of approved nursing diagnoses Proposes new diagnostic cate-
gories for consideration and approval
Develops written standards for nursing practice
Plans care for healthy or sick indi- viduals or groups in structured health care agencies or the community
Applies nursing theory to the approaches used for resolving actual and potential health prob- lems of individuals or groups Conducts research on nursing
activities that may be improved with further study
*Note that each more advanced practitioner can perform the responsibilities of those identified previously.
C H A P T E R 1 ● Nursing Foundations 9
among all registered nurse programs. Despite the con- densed curriculum, graduates of associate degree programs have demonstrated a high level of competence in passing the NCLEX-RN.
Baccalaureate Programs
Although collegiate nursing programs were established at the beginning of the 20th century, until recently they did not attract many students. Their popularity has been increasing, perhaps because of proposals by the ANA and the National League for Nursing to establish bac- calaureate education as the entry level into nursing prac- tice. The deadline for implementation of this goal, once set for 1985, has been postponed for three reasons:
• The date coincided with a national shortage of nurses.
• There was tremendous opposition from nurses with- out degrees, who believed that their titles and positions would be jeopardized.
• Employers feared that paying higher salaries to per- sonnel with degrees would escalate budgets beyond their financial limits.
Consequently, the adoption of a unified entry level into practice remains in limbo.
Although this preparatory program is the longest and most expensive, baccalaureate-prepared nurses have the greatest flexibility in qualifying for nursing positions, both staff and managerial. Nurses with a baccalaureate degree usually are preferred in areas requiring substan- tial independent decision making, such as public health and home health nursing.
Currently, many nurses are returning to school to earn baccalaureate degrees. Articulation has been difficult for some because of problems transferring credits for courses they took during their diploma or associate degree pro- grams. To increase enrollment, some collegiate programs are offering nurses an opportunity to obtain credit by pass- ing “challenge examinations.” In addition, many colleges and universities provide satellite or outreach programs to accommodate nurses who cannot go to school full-time or travel long distances. Despite a renewed interest in acquir- ing a nursing education, approximately 125,000 qualified applicants for admission were rejected in 2004 because too few nursing faculty were available to teach the requi- site courses (National League for Nursing, 2004).
Graduate Nursing Programs
Graduate nursing programs are available at both the mas- ter’s and doctoral levels. Master’s-prepared nurses fill roles as clinical specialists, nurse practitioners, administrators, and educators. Nurses with doctoral degrees conduct re- search and advise, administer, and instruct nurses pur- suing undergraduate and graduate degrees. Although a graduate degree in nursing is preferred, some nurses pur-
10 U N I T 1 ● Exploring Contemporary Nursing
programs continues to be lowest in relation to other basic nursing educational programs (Fig. 1-5). The reasons for their decline are twofold. First, there has been a movement to increase professionalism in nursing by encouraging education in colleges and universities. Second, hospitals can no longer financially subsidize schools of nursing.
Diploma nurses were, and are, well trained. Because of their vast clinical experience (compared with students from other types of programs), they often are character- ized as more self-confident and easily socialized into the role requirements of a graduate nurse.
A hospital-based diploma program generally lasts 3 years. Many hospital schools of nursing collaborate with nearby colleges to provide basic science and human- ities courses; graduates can transfer these credits if they choose to pursue associate or baccalaureate degrees later.
Associate Degree Programs
During World War II, when qualified nurses were being used for the military effort, hospital-based schools accel- erated the education of some registered nursing students through the Cadet Nurse Corps. After the war ended, Mildred Montag, a doctoral nursing student, began to question whether it was necessary for students in regis- tered nursing programs to spend 3 years acquiring a basic education. She believed that nursing education could be shortened to 2 years and relocated to vocational schools or junior or community colleges. The graduate from this type of program would acquire an associate degree in nursing, would be referred to as a technical nurse, and would not be expected to work in a management position.
This type of nursing preparation has proved extremely popular and now commands the highest enrollment
1 Associate Degree 2 Diploma 3 Baccalaureate Baccalaureate
37%
Diploma 4%
Associate Degree 59%
FIGURE 1-5
•
Distribution of basic RN programs. Numbers are based on educational programs of U.S. candidates taking the NCLEX-RN examination in 2003, as reported by the National Council of State Boards of Nursing.• Negative stereotypes for traditionally female occupa- tions like nursing (Donley et al., 2002; National Council of State Boards of Nursing, 2003).
Governmental Responses
The federal government attempted to address the shortage of nurses by proposing and approving the Nurse Reinvest- ment Act. This legislation authorizes the following:
1. Loan repayment programs and scholarships for nurs- ing students
2. Funding for public service announcements to en- courage more people to enter nursing
3. Career ladder programs to facilitate advancement to higher levels of nursing practice
4. Establishment of nurse retention and client safety enhancement grants
5. Grants to incorporate gerontology into nursing curricula
6. Loan repayment programs for nursing students who agree to teach after graduation (American Asso- ciation of Colleges of Nursing, 2005; U.S. Depart- ment of Health and Human Services, 2002)
Proactive Strategies
Rather than taking a “wait-and-see” position about the nursing shortage and the ramifications of the Nurse Re- investment Act, many nurses are proactively responding to the trends affecting their role in health care (Table 1-4).
Nurses are dealing with the unique challenges of the 21st century by
• Pursuing post-licensure education.
• Training for advanced practiceroles (nurse practitioner, nurse midwifery) to provide cost-effective health care in areas in which numbers of primary care physicians are inadequate.
• Becoming cross-trained (able to assume non-nursing jobs, depending on the census or levels of client acuity on any given day). For example, nurses may be trained to provide respiratory treatments and to obtain elec- trocardiograms, duties that non-nursing health care workers previously performed.
• Learning more about multicultural diversity(unique char- acteristics of ethnic groups) as it affects health beliefs and values, food preferences, language, communication, roles, and relationships.
• Supporting legislative efforts toward national health insurance that involves nurses in primary care (the first health care worker to assess a person with a health need).
• Promoting wellness through home health and community-based programs.
• Helping clients with chronic diseases learn techniques for living healthier and, consequently, longer lives.
sue advanced education in fields outside nursing, such as business, leadership, and education, to enhance their nursing career.
Continuing Education
Continuing education in nursing is defined as any planned learning experience beyond the basic nursing program (ANA, 1974, 2003). Nightingale is credited with having said, “to stand still is to move backwards.” The principle that learning is a lifelong process still applies. Box 1-2 lists reasons why nurses, in particular, pursue continuing edu- cation. Many states now require nurses to show proof of continuing education to renew their nursing license.
Two major issues dominate nursing today. The first con- cerns methods of eliminating the shortage of nurses. The second involves strategies for responding to a growing aging population with chronic health problems.
Health care officials hope that enrollment in all nursing programs and continuing education will improve to reduce the current and projected critical shortage of nurses. In 2002, a shortage of 110,000 registered nurses represented a 6% deficit. The future looks even more alarming. The nursing shortage is projected to double to 12% by 2010, triple to 20% by 2015, and reach 29% by 2020 (U.S. Depart- ment of Health and Human Services, 2002). Some factors contributing to the nursing shortage include the following:
• Retirement rate of nurses that exceeds their replacement
• Attrition of aging faculty, which restricts numbers of student applicants
• Increased aging population requiring health care
• Disappointing salaries for nurses with longevity employment
• Job dissatisfaction as a result of stress and the un- relenting rigor of working in health care
• Heavier workloads and sicker clients
• Publicity about mandatory overtime
• Downsizing nursing staff from dwindling revenues and managed care policies