Part One: History of Nursing

Part Two: Nursing as a Profession

Part Three: Critical Thinking & Values Clarification

Part Four: Education for Nurses

Part Five: Theories & Models of Nursing

Supplementary reading:Catalano, Nursing Now, unpublished chapter, "Historical Perspectives".

This chapter may be viewed online at http:www.fadavis.com/sample_chapter/1526_1.pdf

Please note: In the above URL, type an underscore " _ " between the words "sample" and "chapter" and between "1526" and "1.pdf".  The underscore  _ doesn't show in the URL above because of the hyperlink underline.  email me at sdroske@tc.cc.tx.us if you have any problems accessing that web site.  -Mrs D

Want to learn MORE about the history of nursing?                                                                       Then point your browser to http://www.aahn.org
Here the American Association for the History of Nursing offers biographies of nursing pioneers, a nursing history calendar, important dates from the past, resources for more extensive research, a virtual gift shop, and MORE!!

• Issues in today’s health care system have their roots in the historical process that has developed over the centuries
• Knowledge of these roots assists in understanding the profession and may point toward solutions.

Some of these common threads include:

• The beliefs of a society regarding the causes of illness
• The value a society placed on individual’s life
• The role of women in a society
• Wars and their consequences, particularly their effect on health care

Early civilization’s major concern was survival of the human species. Fundamental needs essential for survival included nourishment, shelter and procreation. Illness and injury threatened survival, and therefore were a concern of everyone in the society.

1350-1600

The Renaissance was a time of intellectual reawakening in Europe. In Italy in the 14^th century, curtains of ignorance and superstition of the medieval period were rolled back as new discoveries, inventions, and philosophies came into being.

Legendary names of the period included:

GALILEO
COPERNICUS
DESCARTES
NEWTON

Inventions of the period included:

Microscope
Thermometers
Pendulum clock
Telescope

Seeds of discontent regarding philosophy, religion, and politics were sown and would come to bloom 100 years later.

Most health care in the Renaissance was provided by religious orders. After 500 years of tradition these hospitals viewed the primary goal of care to be the salvation of the sick individual’s soul. Restoration of health and cure of illness was seen as only a secondary goal.

At that time the use of modern methods of diagnosis and treatment were viewed as disrespectful, improper or even the work of the devil.

Influence of the Reformation (1517)

Reformation originated with Martin Luther, a Catholic monk.

Health care in France, Italy, and Spain was unchanged from that of the middle ages.

Monks and nuns provided primitive health care. During this period the number of male nurses decreased. New technologies were shunned and nursing education was an apprenticeship form. Doctors had little education beyond knowledge gathered in libraries and hospitals.

Major health care changes occurred in nations that broke away from the Catholic Church (England, Germany and the Netherlands).

Monastery and convent hospitals, once rich and powerful, were now seen as a threat to the Protestant leadership. Monks and nuns were expelled from these countries and the hospitals were confiscated and used for other purposes.

No other health care structures were in place in these Protestant countries. Health care degenerated to an even lower level than during the Middle Ages.

Under Protestant political and religious leadership:

• Status of women was reduced from one of importance in care to subordination and dependence
• Women were forbidden to work outside the home
• Primary role of women was care of the home, bearing children, and fulfilling husbands’ needs

• Women of upper classes were forbidden to work outside the home, so women from lower socioeconomic groups, including prostitutes, alcoholics, opium addicts, and prisoners, staffed hospitals. Work hours were long and hard and salary poor.
• Nurses often stole from patients
• Hospitals were filthy
• Care was substandard
• Nursing in these countries was viewed as the lowest and most menial work a woman could do.
• No male caregivers
• Nuns again began to take over care of the sick. (Sisters of Charity). In 1600 care was minimal but general sanitation and ethical standards improved.
• Nursing hierarchy developed: Primary nurse—Sisters; Helpers; Watchers
• Benefit of competent skilled nursing care was beginning to be recognized

• Writing of the first nursing textbook
• Organization and use of midwives
• William Harvey was born (1578-1757) "Father of Modern Medicine"
• Understanding of microbial origin of disease
• Joseph Lister began to understand how disease was spread (developed aseptic practices)
• Louis Pasteur discovered that organisms could be killed by heat (pasteurization)
• Most health care still provided at home

Health Care in North American Colonies before Revolutionary War

Mortality rate was high from diseases, infections, and complications of pregnancy.

Only 5 hospitals existed in North America

• Considered houses for the poor
• No nurses
• Care was provided by other homeless, with no training
• Nursing care consisted of prayer and folk remedies

• The best of early hospitals..& it was terrible!
• Came to be known as "House of Horrors"
• Mortality rate 50-75%
• Anyone with a strong back and willing to work long, hard hours was hired as a nurse
• Men with minimal (equivalent of high school) education were pressed into service as doctors

• Hotel Dieu Hospital in France
• 1640 – School of Nursing established by Sisters of St. Ursula in Quebec

Health Care in Early America

Life of a colonial soldier was dangerous due to widespread virulent illnesses (dysentery, smallpox, scarlet fever), which were made more serious due to poor sanitation, lack of army doctors & nurses, and the untrained volunteers who gave care.

Pennsylvania Hospital - 1751

• Established by Benjamin Franklin before Revolutionary War
• Had divisions for the sick, the insane, and those with "moral defects"

• Established by Society of Friends (Quakers)
• Provided free outpatient care for poor
• Provided surgical, medical, and OB care for the poor

• Offered classes in basic health and biologic sciences, child care and delivery

Health Care after the Revolutionary War

Religious orders began to build hospitals (Dominicans, Sisters of Mercy, Lutheran Deaconesses and Sisters of Charity). As a result, standards of health care improved between Revolutionary War and the Civil War. (1783-1861).

Early schools of nursing were established under religious nursing orders.

Most care was still given at home. Hospitals were a last resort. Only those at "death’s door" went to hospitals… mortality rates were very high.

Health Care during & after Civil War

The Civil War was the most costly war in history for the U.S. in dead & wounded.

The existing health care services were overwhelmed. Neither side had organized first aid, medical or nursing corps. Medical supplies were inadequate or nonexistent.

Surgery and bullet removal performed under filthy conditions, without anesthetic was the norm.
Infection killed as many as wounds.
Demand for nurses increased (not enough nuns)
Female volunteers followed armies.
Nursing knowledge by trial and error
Nurses’ services were unappreciated by doctors.
Major advances in medical & nursing care during Civil War:

• Origin of US Navy nurses. Transport ship "Red Rover" was converted into a hospital ship staffed by Sisters of Mercy.
• American Red Cross was started
• Army Nurse Corps was started
• Public image of nursing improved because of efforts of volunteers

30 million immigrants 1800-1900
Rail system completed, immigrants went west

Industrial Revolution

• Factories, terrible working conditions, overcrowding caused diseases to spread
• Low wages
• Child labor a fact of life (age 7-8 worked 18 hours/day)
• Unventilated sweat shops
• Rampant alcoholism, drug addiction and crime
• Factory owners implemented health care to keep workers on the job
• A form of community health nursing developed (trying to keep workers well)
• Living, working conditions were identified as cause of disease
• Sisters of Charity expanded their services to include home care and care in orphanages
• Brothers of St. John of God (all male) provided similar services. One of the few male nursing orders to survive Reformation & Industrial Revolution
• Quaker Society of Protestant Sisters of Charity provided care primarily of prisoners and children
• Population increased. The need for health care increased. Hospitals sprang up in cities. No standards or external control so there was a wide range in quality care.
• Many of the new hospitals instituted schools of nursing, in response to the increased need for nurses
• Community health programs were developed with visiting nurses
• "In home care" was still preferred
• Quality of care in Catholic countries remained low because they were resistant to newly developing medical knowledge and technology
• Although this period is called "Dark Ages of Nursing", many important contributions were made, including those of Florence Nightingale.

Florence Nightingale (1820-1910)

(English, but born in Italy) known as founder of modern nursing

• "Woman with the Lamp"… today may be better regarded as "Woman with a Brain"!
• Well educated, contrary to prevailing Victorian beliefs
• Through her travels, became aware of substandard hospital care and need for health care
• 1851 attended 3 month nurse training at Kaiserwerth, Germany (she thought was insufficient)
• 1854 Crimean War. She was recognized as an authority and was asked to help troops. She took 37 volunteer nurses to battlefield. Dr’s rejected them until mortality rate increased (4 out of every 10 patients died)
• After 6 months of Nightingale’s improved sanitary conditions, the mortality rate fell from 42.7% to 2.2%
• Nightingale extended reform of British military health care to other areas.
• On front lines, prevented dehydration, hemorrhage, and infection
• Nightingale contracted Crimean Fever (typhoid??). She never fully recovered.
• Her greatest contribution to care of the sick in the Crimean War was decreasing the spread of disease
• Awarded the highest English award given to civilians – The Order of Merit
• Accomplishments were recognized by Queen Victoria of England

• Believed nursing schools should be run by nurses, independent of control of hospitals and physicians
• Included basic biologic sciences in nurses’ education
• Thought status of nurses should be elevated above house maids and servants
• Educated nurses should not spend their time wit menial jobs (cooking, cleaning), but in direct patient care
• Opened Nightingale Training School in 1860. Dr’s thought her nurses were over trained. Goal of her school was to provide nurses to educate other nurses
• Established a Registry of Nurses certified as having achieved minimal level of education
• Advocated nursing as a science and art.
• Taught that each client should be treated as an individual
• Only unmarried women of good character were admitted to her hospital
• Believed that emphasis should be on health maintenance and promotion, not just on the sick. (Even though she never really completely accepted the theory that pathogens cause disease)
• Believed that nurses should meet the needs of clients – not doctors.
• Was responsible for developing the concept that viruses should be educated in all sciences in formal schools of nursing. Formal, systematic education in both theory and practice.

• Head of first university-based nursing school. Primary focus was academic learning. Simple to complex concepts. Arranged for clinical experience.

• 1893 was Director of Johns Hopkins Training School for nurses. Limited student working days to 12 hours (this included 2 hours for recreation). Eliminated private duty services provided by nursing students.

• 1896 was chairman of American Society of Superintendents of Training Schools for Nurses, which eventually became the National League for Nurses dedicated to improving standards of nursing education.

• She married Dr. Hunter Robb and continued active pursuit of nursing despite public opinion. (Nursing was not considered a suitable career for a married woman).

• Organized a separate group for staff nurses in active practice called Nurses Associated Alumnae of the United States and Canada. She was the first president. This group later became American Nurses Association. A few years later she helped develop American Journal of Nursing, the first periodical dedicated to improvement of nursing. (Official journal of ANA).

• Died at age 50. Her belief that education for nurses and doctors should be separate was not well accepted in her time.

• Through her efforts, nursing made major strides in its attempt to emerge as a separate health care profession.

• Middle class, comfortable

• Worked as a hospital nurse

• Enrolled in medical school, but quite after an experience on NY docks (became aware of plight of sick poor)

• Taught home nursing and bed making

• Developed into a dedicated social reformer and an effective fundraiser from her experience with the poor. Eloquent speaker and politically active

• NY’s Columbia University under her supervision developed courses for careers in Public Health

• Strong advocate of wellness education. Organized nursing service branch of The Metropolitan Life Insurance Co. who agreed with her ideas on wellness.

• Started Town & Country Nursing Service of the American Red Cross

• Founded and was first president of National Organization of Public Health Nursing (1912)

• Many current proposals for health care revision especially under a capitation system (HMO etc) come from Wald’s work.

• Upper middle class family, valued education

• Bellevue Training School in NYC

• Wrote first medication text for nurses, "Materia Medica for Nurses" (because her classmates had difficulty learning medications)

• Quickly associated terrible social conditions with generally poor health

• Became a dedicated social reformer because she knew that poverty and squalor must improve before health could

• Worked for short period in Henry Street Clinic with Lillian Wald and at Johns Hopkins with Isabel Robb, but spent most of her career in pursuit of equal rights and social standing for women.

• Provides excellent example of what nurses are capable of doing in achieving higher quality care, even if they are not at the bedside.

• Educated at NY Hospital Training School for Nurses. Outstanding educator

• 1920 was appointed State Inspector of Nurse Training Schools (1st nurse! –had always been a doctor before)

• 1918 – U.S. Army asked her to survey their hospitals and nursing departments. She proposed that Army organize its own school and she was Dean. She helped establish the U.S. Army Nurse Corps.

• WW I increased demand for nurses

• She established Vassar Training Program at Vassar College to meet shortage. (Highly trained—12 weeks of science and 2 years of clinical practice in a hospital)

• After WW I she returned to Home Health, then moved on to education. She was Dean of Yale University School of Nursing

• Wrote many papers regarding nursing education and her experiences as an Army Nurse

• Physicians still thought nurses were over trained and questioned need for university-based education

• She demonstrated the importance of classroom in correlation with clinical practice

Health Care and Nursing After WWI (1914 – 1918)

Effects of WW I on health care are still being felt today.

• Beginning of WW I there were 400 Army nurses. By 1917 there were 21,000.  American Red Cross provided 10,000 nurses.

• Leaders tried to provide quality education but many hospitals recruited untrained women. So the Red Cross began a training program for nurse aides (universally opposed by nursing leaders, but strongly supported by doctors).

• WW I had a negative effect on health care in general and on professional nursing in particular. (Diluted by nurse aide programs)

• Nurse aides began replacing trained nurses because they were cheap labor.

• Only 10% of nurse worked in hospitals (considered last resort health care)
• Private & Public Health Nursing flourished
• U.S. Public Health Service, Veterans Bureau, and Indian Health Service were developed
• Nursing practice expanded to industry

• Many nurses left because of poor image nursing developed because of under-trained aides
• Nursing shortage was created (met by training more aides)
• Nurses seemed uninterested in developing their power base by vote (1920)
• Standards of nursing education were low
• Licensure and accreditation was nonexistent. Anyone could work as a nurse as long as they did not use title "RN".
• Stock market crash (1929) and Great Depression affected health care and nursing. Private duty nurses lost their jobs. They went to hospitals and found them using students as free labor and aides as cheap labor. Some nurse worked for room and board.
• No men admitted in nursing schools. Female occupation!!!
• Many school closed – no funds.
• Federal government became largest employer of nurses
• Franklin D Roosevelt’s Federal Emergency Relief Adm. (FERA) employed 10,000 nurses.
• After WW I, the Joint Commission on the Distribution of Nursing Services was organized. Recommended staffing hospitals with R.N.s instead of students. Suggested decreasing work hours from 12 to 8 per day.
• After WW I, trend was toward using hospitals as the central point of health care (instead of the home)

• Another nursing shortage developed

• Congress passed the Bolton Nurse Training Act, establishing the Cadet Nurse Corps. It included free schooling and obligated nurse for 2-4 years to the Army after graduation from nursing school. Minimal educational standards were established which forbade discrimination (race, creed, sex), shortened hospital training programs from 36 to 30 months.

• Inactive nurses were recruited back into active nursing during WW II. The door was opened for married nurses. Nurses with families were hired part time. Scholarships were available.

• Full commissioned status was granted for nurses who joined the military, making them officers.

• Nurses (military) received same pay as men with same rank.

• With the GI Bill, many nurses went back to school for research and further degrees after WW II. 1952 Journal of Nursing Research published – Virginia Henderson

• Toward end of WW II all discrimination was forbidden, admitting male nurses and African Americans.

• Rapid increases in medical knowledge (antibiotics, tranquilizers, new surgical techniques, dialysis and use of specialty units such as ICU, OB, OR, and recovery rooms)
• Radiographs, lab test, transfusions, ER Dept care greatly expanded health care services
• Hospitals became the focus of health care
• Dr’s became dependent on services that hospitals provided (expensive equipment)
• Traditional belief that all nurses were interchangeable was challenged
• Nurses in specialty areas needed highly advanced and progressive education
• Philosophy long revered by hospital administrators and doctors that "a nurse is a nurse" was less true during and after WW II
• After WWII the need for nurses increased
• Shortage was met with another "quick fix" which was intended to be temporary

KOREA:  MASH – Mobile Army Surgical Hospital; use of helicopters
VIETNAM:  MUST – Medical Unit, Self-Contained, Transportable hospitals replaced MASH

5000 nurses in Vietnam by 1962

To encourage nurses to serve in Vietnam, AND graduates were commissioned as Warrant Officers (before, only a B.S. could do this)

Vietnam nurses

Showed:

• High degree of professionalism
• Independence of practice
• Great courage

Were:

• Essential part of health team
• Good morale booster for troops
• Actively participating in development of new techniques in care of the wounded

___________________________________________________________________________
 
 

Required reading: Catalano J.T., Nursing Now, 2^nd ed.: Chapter 1

The following notes summarize this chapter.

For many years, a primary goal of nursing leaders has been to change the image of nurses from that of domestic servants to one of high level health care providers who base their protocols on scientific principles.

Significance of professionalism varies.

E.g.: The harried staff nurse with too many responsibilities doesn’t have time to focus on others’ perceptions of her status as a "professional" during a busy shift.

In early years nurses gave no thought to being part of a profession.

As the scope of practice expanded and responsibilities increased nurses began to consider what they do as professional activities.

DEFINITIONS:

Position: a group of tasks assigned to one individual

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 that are usually found throughout an industry or work environment

Profession: a type of occupation that meets certain criteria that raise it to a level above an occupation

Professional: one who belongs to & practices a profession. Misuse: e.g. "professional truck driver", "professional thief"

Professionalism: demonstration of high-level personal, ethical and skill characteristics of a member of a profession.
 
 

What constitutes a profession?

For over 100 years experts have attempted to develop an approach to determine what constitutes a profession.

We will examine three approaches often used to determine what constitutes a profession:

1. Process

2. Power

3. Trait

1. Process Approach:

Views all occupations as points of development into a profession along a continuum. (From "occupation" to "profession")

Question then is not whether nursing and truck driving are professions, but where they are located on the continuum.

A major difficulty with the Process Approach is that it lacks criteria for judgments. Final determination of status depends on public perception. Nursing has always had a poor public image when it comes to being viewed as a profession.

2. Power Approach:

Uses 2 criteria to define a profession

• How much independence of practice does this occupation have?
• How much power (political) does this occupation control?

How much money can a person in that occupation earn? (political power goes hand in hand with high-income levels and monetary resources).

Using this criteria, Politics would be considered a profession due to high income, independence of practice, and exercise of significant power.

Ministry: low income, but have power & influence

Nurses: low income, low membership in professional organizations, perceived lack of power

So – are these the ONLY criteria for a profession? ?? (high income, power, independence of practice)

3. Trait Approach:

Social scientists Flexner, Bixler, and Pavalko identified these common traits of a profession:

• High intellectual level
• High level of individual responsibility and accountability
• Specialized body of knowledge
• Knowledge that can be learned in institutions of higher learning
• Public service and altruistic activities
• Public service valued over financial gain
• Relatively high degree of autonomy and independence of practice
• Need for a well organized and strong organization to represent members and control quality of practice
• A code of ethics to guide practice
• Strong professional identity and commitment to development of the organization
• Demonstrations of professional competency and legally licensed

Florence Nightingale increased educational standards for her nurses. Nurse today use assessment skills and knowledge, reason, and make judgments based on clients’ conditions. They must and do function at a high intellectual level.

Nurses must be accountable and demonstrate a high level of individual responsibility. Years ago nurses were never named as a defendant. Accountability has legal, ethical and professional implications. Nurses can no longer use the statement "the doctor told me to do it" as a defense for their actions.

Nursing draws a large portion of its knowledge from many areas of science.

As nursing has developed into an identifiable, separate discipline, a specialized body of knowledge called "Nursing Science" was compiled through the research efforts of nurses who hold advanced educational degrees. This body is small but forms a theoretical basis for the practice of nursing today.

This will increase in scope as more nurses develop philosophies and theories about nursing, get advanced degrees and conduct research.

Public service and altruistic activities: All major nursing theorists include a statement referring to helping clients adapt and achieve highest level of functioning.

Public (consumers, patients, clients, humans, and individuals) is the focal point of all nursing models and nursing practice.

The public has acknowledged nurses’ public service function.

1. Education of nurses in public, tax supported institutions and private schools
2. has always been viewed as being an altruistic profession
3. Perception is that nurses are selfless individuals who place the lives and well being of their clients above their own
4. Survey of students indicates primary reason for entering nursing is "to help others", "to make a difference", or "to have job security".

American Nurses Association is concerned with quality of nursing practice.

Both organizations are well organized but are not considered powerful due to low membership (less than 15% of US nurses belong to any professional organization at the national level)

Many nurses belong to specialty organizations that lack sufficient political power to produce changes in health care.

Code of Ethics: This code, written by the American Nurses Association (ANA), is the most widely used in U.S.

It was first published in 1971.

Updated in 1985 and is currently being revised.

Other professions recognize this code as a standard to which others are compared.
 
 

LICENSE

Nurses must have a legally recognized license to practice.

Nurses must pass NCLEX.

Granting of a license is a legal activity conducted by the individual state under regulations contained in that state’s nurse practice act.

WHEN NURSING FALLS SHORT OF A PROFESSION

Before Nightingale, people considered it unnecessary, even dangerous, to educate nurses.

As nursing has developed, it has come to be a belief that college education for nurses is a necessity.

Since 1950, attempts to require all nurses to be educated in institutions of higher learning have been resisted and rejected.

Nursing is the only major discipline that does not require its members to hold at least a B.S. degree.

At issue today is whether a B.S. degree should be the minimum requirement for entry level into practice.

PROFESSIONAL IDENTITY AND DEVELOPMENT

Job vs. career

A "job" requires little commitment. People move from job to job.

A "career" is viewed as one’s life work and will progress and develop as the person grows.

Careers and professions share characteristics of:

Formal education

Full time employment

Requirement for lifelong learning

Dedication to what is being achieved

Many nurses view nursing as their life’s work, but treat it like a job.

One reason nurses lack a strong professional identity and do not consider nursing a lifelong career is because nursing does not have full status as a profession.

Until nurses are fully committed to the profession of nursing, identify with it as a profession, and are dedicated to its future development, nursing will probably not achieve professional status.

EMPOWERMENT IN NURSING

A concern of nurses, from the beginning of the development of nursing as a health-care specialty, is the large amount of personal responsibility shouldered by nurses combined with a relatively small amount of control over their practice.

Most nurses seem uncomfortable with the concepts of power and control in their practice.

Discomfort may arise from belief that nursing is a helping and caring profession whose goals are separate from issues of power.

Historically, nurses have never had much power, and previous attempts at gaining power and control over their practice have been met with resistance from groups who benefit from keeping nurses powerless.

Whether they recognize it or not, all nurses use power in their daily practice.

Until nurses understand the sources of their power, how to increase it, and how to use it in providing client care, they will be relegated to a subservient position in the health care system.

THE NATURE OF POWER

Power means:

• Ability or capacity to exert influence over another person or group
• Ability to get other people to do things even when they don’t want to
• Being a two-way street
• When power is exerted by one person, another person is affected
• Use of power by one person requires that another person give up some of his power

EMPOWERMENT

Where does power come from??? There are six sources.

1. Referent power: Source depends on establishing and maintaining a close personal relationship with someone. One will often do something he would really rather not do because of the relationship. The ability to change the actions of another is an exercise of power. E.g. Therapeutic relationship with client. Service from other departments for nurse with good relationship with them.
2. Expert power: Source derives from the amount of knowledge, skill or expertise a person or group has. Person or group exercises this power when knowledge, skills or expertise is used or withheld in order to influence behavior of others.
3. Power of rewards: Source depends on the ability of one person to grant another some type of required for specific behaviors or changes in behavior. Rewards may be favors, money, praise, promotions, expanded privileges, and eradication of punishments.
4. Coercive power: Source is the flip side of reward source. The ability to punish, with hold rewards, and threaten punishment is the key element underlying coercive power. Nurses should not rely on use of this type of power. DO NOT threaten clients! Use of coercive power destroys therapeutic and personal relationships. Can also be considered unethical and illegal in certain situations.
5. Legitimate power: Source depends on a legislative or legal act that gives the individual or organization a right to make decisions that they might not otherwise have the authority to make. Political figures and legislators have this power. This source can be disseminated and delegated to others through legislative acts. In nursing, the State Board of Nursing has access to the legitimate source of power because of its establishment under the nurse practice act (NPA) of that state. Nurses have access to legitimate source of power where they are licensed by the state under the provisions in the NPA or when they are appointed to positions within a health care agency.
6. Collective power: This is the underlying source for many other sources of power. When a large group of individuals who have similar beliefs, desires of needs becomes organized, a collective source of power exists. For individuals who belong to professions, the professional organization is the focal point for this source of power. The main goal of any organization is to influence those policies that affect its members. This influence is usually in the form of political activities carried out by politicians and lobbyists. Professional organizations that can deliver large numbers of votes have a powerful means of influencing politicians. Use of collective source of power contains elements of reward source, coercive source, expert source, and referent source.

1. Professional unity: Power is directly related to size of its membership. Three million nurses in U.S. – only 250,000 are members of ANA!
2. Political Activities: Nurses should become involved in political action. If nurses do not become involved in politics and participate in important legislation that influences their practice, someone other than nurses will be making those decisions for them. Nurses need to become involved in political activities from local to national levels.
3. Accountability and Professionalism: Nurses must demonstrate characteristics of accountability and professionalism. Nurses are now concerned with demonstrating competence and delivering high quality client care through processes such as peer review and evaluations. By accepting responsibility for the care that they provide and by setting the standards to guide that care, nurse are taking the poser to govern nursing away from non-nursing groups.
4. Networking: Nurses can gain power by nurse networks. The "old boy" system found in most large organizations and businesses, provide individuals, usually men, with the encouragement, support, and nurturing that allows them to move up quickly through the ranks to achieve high administrative positions. Nursing and nursing organizations have never had this type of system for advancement of nurses. Presentation of a united front is important in maintaining power within the system. Never criticize another "old boy" in public. Part of the difficulty in establishing a nurse support network arises from the fact that nurses really have not been in high-level positions for very long.

Only when nurses begin to think of nursing as a profession, work toward raising the educational standards for the entry level into practice, and begin practicing independently as professionals, will the profession become a reality for nursing.

Nursing shortage is predicted into the 21^st century. In the pas this was corrected with a "quick fix" method, reducing educational requirements.

Currently Diploma and ADN programs produce 40,000 graduates per year. BUT is this level of education going to prepare nurses to meet the challenges of a rapidly changing and demanding health care system?

National employment picture of RN’s is changing from bedside caregivers to coordinators of care.

Nurses will not have increased independence of practice until they demonstrate that they are professionals committed to the field of nursing.

Standards that guide a profession are derived from societal needs and expectations.

In the early days when health care was primitive and society’s expectation of nurses was low, there was little demand for regulations. As society’s needs change, so will regulations and standards.

Today nurses accept licensure and certification exams as a given.
 

Development of Nurse Practice Acts
A Nurse Practice Act (NPA) is a state legislation that regulates the practice of nurses to protect the public and make nurses accountable for their actions.

NPA’s establish State Boards of Nursing and define specific powers regarding the practice of nursing within the state

Rules and regulations written by State Boards of Nursing become statutory laws under the powers delegated by the state legislature.

NPA’s differ from state to state. State Boards of Nursing have in common:

• Power to grant nursing licenses
• Accredit nursing programs
• Establish standards for nursing schools
• Write specific regulations for nurses and nursing
• Have power to deny or revoke nurse license
• Define nursing
• Define scope of practice
• Rule on who can use title "RN" or "LPN"
• Set up application procedure for licensure
• Determine fees for licensure
• Establish requirements for renewal
• Determine responsibility for any regulations governing expanded practice for nurses in their state.

The purpose of licensure is to insure quality of health care. The first efforts at credentialing were met with resistance from physicians and hospital administrators and practicing nurses.

What if anyone "off the streets" were hired as a nurse???

Early Attempts at Licensure

Florence Nightingale was the first to establish a register for the graduates of her schools. The need for credentialing was identified in 1800s. The first organized attempt was in 1896 by the Nurses Associated Alumnae of U.S. & Canada (later known as ANA). It met with resistance and failed.

In 1901 the International Council of Nurses passed a resolution that required each state to establish licensure and exam procedures for nurses. It took 3 years before New York, through the N.Y. Nurses Association, developed a licensure bill that passed the legislature. North Carolina, New Jersey, and Virginia followed with bills weaker than New York’s.

Women did not have the right to vote, so passage of any bill was considered major.

During this period, even AMA had few rules and regulations for licensure.
 
 

Importance of Licensure Examinations

Licensure exams provide an objective method to prove an individual is qualified to practice nursing safely to protect the public.

All states had some form of licensure exam by 1923. They varied in length and format. Some required written and practical exams. Others included orals.

In 1945 the ANA Council of State Boards of Nursing was organized to oversee development of a uniform exam that could be used by all states.

NLN developed such a test and it was implemented in 1950. Originally the exam was called "State Board Exam". It was renamed NCLEX (National Council Licensure Exam) in 1987.

In 1994 a computerized version began and the name changed to "National Council Licensure Exam, Computerized Adaptive Testing for Registered Nurses".

States are currently in the process of implementing the "Mutual Recognition Model for Nursing Licensure" or "Multi-State Licensure" which will allow nurses licensed in one state to practice nursing in other states that belong to their regional agreement.

Eventual goal is have a "universal" nursing license so nurses don’t have to be licensed each time they cross a state line.

Registration vs. Certification

Terms are not synonymous though they are sometimes used interchangeably.

Registration

Registration is listing or registering of names of individuals on an official roster who have met certain pre-established criteria.

Earlier employers would call applicant’s school to determine if he/she was registered

Now they call the State Board of Nursing.

Licensure

Licensure is an activity conducted by the state through the enforcement powers of its regulatory boards to protect the public’s health, safety and welfare by establishing professional standards.

Licensure was established to se a minimum level of competency to protect the public.

Licensure is necessary to ensure that everyone who claims to be a nurse can function at a minimal level of competency and safety.

Three types of licensure are:

1. Permissive

2. Mandatory

3. Institutional

1. Permissive Licensure

Allows individuals to practice nursing as long as they do not use the letters "RN"

Protects "RN" designation but the not practice nursing

Hospital administrators liked this. It was cheaper to hire unlicensed people than RN’s

However, hospital administrators soon recognized that quality of care decreased when educational level is decreased.

2. Mandatory Licensure

All states now have this type of licensure.

Requires anyone who wishes to practice nursing to pass licensure exam and become registered by the State Board of Nursing.

Mandatory nurse practice act requires nurses to be licensed in the state of practice.

This forced the State Boards of Nursing to distinguish between activities that nurses at different levels can perform.

The scope of practice defines boundaries for each level (LPN, RN, Advanced Practice)

Addition of associate degree programs blurred lines of distinction.

Confusing element in today’s health care system are CNA’s (certified nurse aid) and UAPs (unlicensed assistive personnel). Although permissive licensure is no longer legal, CNA’s and UAP’s appear to fall under unofficial permissive licensure.
 
 

3. Institutional Licensure

Rejected universally for nurses but covers respiratory therapists and physical therapists.

In some states bills have been introduced to allow foreign nurses who are licensed in their country to work in specific situations without taking an American licensing exam.

To date, these bills have been stopped by state nursing organizations.

Idea is that the individual health care institution will be permitted to determine which individual are qualified to practice within general guideline established by an outside board.

The most critical problem is the lack of any external control to determine a minimal level of competency

Designations of RN, LPN/LVN would be meaningless with this type of licensure.

These nurses would not be under the control of a State Licensing Board and so would not be held to the same standards of practice.

A second problem: mobility would be limited.

Nurses would have to go through the same licensure procedure with each move.

Currently, nurses who move from state to state obtain licensure by endorsement or reciprocity (or multistate licensure.)

Certification

Certification is a type of credentialing indicating a high level of expertise.

There are several types of certification:

Individual Certification

This is the most common type of certification.

When a nurse demonstrates she has attained a certain level of ability above and beyond the basic level required for licensure in a defined area of practice, she can become certified by taking a written or practical exam.

All nurses certified are required to maintain their skills and competencies through continuing education or retaking of the certification exam.

Organizational Certification

Organizational certification is the certification of a group or a health-care instituion by some external agency.

This type of certification is usually referred to as accreditation and it indicates that an institution has met standards established by a government or non-government agency.

The ability of the institution to collect money from insurance companies ir the federal government depends on whether or not it is accredited.

Most hospitals are accredited by JCAHO (Join Commission on Accreditation of Health Care Organizations) as a minimum level.

Advanced Practice

Some states recognize certification in advanced practice. (e.g. midwife)

Advanced practice nurses are allowed to practice those skills allowed under the nurse practice act of that state.

There is no uniformity among states in recognition of certification of advanced practice nurses.

Some states have very little recognition of certification levels.

Without uniform definition of advanced practice, these nurses will not be utilized to their full potential.

Licensure and certification are both methods of granting credentials to demonstrate that an individual is qualified to provide safe care to the public.

It is important for nurses to keep a watchful eye on pending legislation and practices that health care institutions are initiating. Many proposals are covert ways of reintroducing permissive licensure.

Nursing Organizations and their Importance

Most defining characteristics of a profession is establishment of a professional organization.

An individual nurse does not have much power, but as a group, the potential for power is increased.

National nursing organizations need participation and membership of all nurses to speak with one voice regarding health care issues known to politicians, physicians’ groups, and the public.

The National League for Nursing (NLN)

http://www.nln.org/

The primary purpose of the NLN is to maintain and improve standards of nursing education.

The NLN by-laws state the purpose of the organization: to foster development and improvement of hospital, public health, industrial and other organized nursing services and of nursing education through the coordinated action of nurses, allied professional groups, citizens, agencies, and schools.

Membership is open to nurses, agencies, and lay people.

The primary membership is schools of nursing.

National League for Nursing Accrediting Commission (NNLAC): Schools are given essentials for accreditation and then their programs are evaluated against this criteria.

An evaluation report is written and sent to NLNAC. Then an on-site visit is made. If the school meets the criteria, accreditation is granted for up to eight years.

Accreditation indicates the school meets national standards.

Many Masters programs require that the nurse is a graduate of NLNAC accredited school.

Other services of NLN includes testing, evaluating new graduates, supplying career information, continuing education workshops, conferences, publishing wide range of literature, video tape production of current issues, compiling statistics about nursing, nurses and nursing education.

American Association of Colleges of Nursing (AACN)

http://www.aacn.nche.edu/

Purposes:

• to help colleges with schools of nursing to improve standards for higher education for professional nursing
• through CCNE (Commission on Collegiate Nursing Education), develops standards for accreditation of B.S. schools of nursing.

American Nurses Association

http://www.ana.org/

http://www.nursingworld.org/

Contact: mail to: webfeedback@ana.org

Purposes:

• to improve standards of health and access to health care services
• to improve and maintain high standards for nursing practice and promotion of the growth and development of all nurses.

An individual joins a state organization and through the state organization indirectly is member of ANA.

An individual joins and belongs to district, state, and national organization for $18.63 per month.

New graduates receive a discount the first year.

Other services of ANA:

• testing and certification for advanced levels
• entry level education requirements
• establishment and continual updating of standards of nursing practice (yeardstick against which nurses are measured and held accountable by courts of law)
• established Code of Ethics
• ANA-PAC (one of most powerful in Washington)
• Official bargaining agent for nurses in negotiating contracts and collective bargaining.

Purposes:

• Represent needs of nursing students
• To help maintain high standards of education in schools of nursing

Membership is composed of all nursing students in R.N. programs

One of the benefits of NSNA is that students are able to experience first hand the operation, activities and professional manner of a national nursing organization.

Other services:

• Develop and provide workshops, seminars and conferences
• Develop professional attitudes and behaviors
• Provide scholarships
• Official publication IMPRINT
• Political representation
• Assist students from minority groups (BREAKTHROUGH PROJECT)

International Council of Nurses (ICN)

Serves as an international organization for professional nursing organizations.

ANA is one member of 104 around the world.

The goal of ICN is to improve health and nursing care throughout the world.

Sigma Theta Tau

http://www.nursingsociety.org/

An honorary organization established by colleges and universities to recognize leadership. Candidates are selected from among senior nursing students.

Sigma Theta Tau collects and distributes funds to nurses who are doing nursing research.

Grassroots Organizations

Large organizations tend to lose sight of the fundamental issues.

Grassroots organizations have small memberships and may be created as a completely new and separate organization, or they may break away from a larger, established group.

Two examples of successful grassroots efforts are in California and Pennsylvania.

California broke away from ANA because it was not addressing some key state issues such as:

Length of hospital stay, reduction in professional nursing staff, and preoccupation with profit of managed care.

Pennsylvania formed a completely new organization, "The Nurses of Pennsylvania" (NPA). This new organization focused on the trend to replace licensed RN’s with unlicensed assistive personnel (UAP’s).

One method for nurses to gain significant power in the U.S. is to join professional organizations in large numbers.
 
 

As nursing strives to develop full status as a profession, the issue of collective bargaining is becoming increasingly controversial. Collective bargaining is a highly charged issue. The concept seems in direct opposition to the perceived altruistic nature of nursing. Joining a union seems to contradict nursing’s image of dedication and selflessness.

Since the 1960s the number of nurses who have joined unions has increased steadily.

The question is frequently asked: "Is professionalism compatible with membership in a union?"

Nursing practice has often been controlled by other groups (doctors and hospital administrators).

As nurses accept increasing independence, authority, and responsibility of the profession, they need to consider whether or not joining a union will help them reach their goal.

More and more often, in today’s "real world", nurses are beginning to realize that professionals should have a say in matters that affect their practice, including working conditions, staffing patterns, benefits, and income.

Collective bargaining

Definition: Uniting of employees for the purpose of increasing their ability to influence their employer and to improve working conditions.

Unions were initially formed to protect workers from exploitation, which is good.

Unfortunately, as unions became more successful, they became powerful and in some instances, corrupt.

A recent image of unions is rather negative due to destructive and illegal practices as they struggled for more power. Union membership has decreased somewhat in recent years.

Important points:

Collective bargaining involves negotiations for wages, hours, benefits, and working conditions for a group of employees.

Collective bargaining is a conflict-based power strategy working on the principle that there is greater strength in large numbers.

The primary collective bargaining unit is the union.

The primary goal of collective bargaining is to equalize power between management and labor.
 
 

Legislative development of collective bargaining

1935 – National Labor Relations Act (NLRA)

Granted employees the right to self organize and to form and help in the organization of labor unions

Originally included nonprofit hospitals and other health care providers

1947 – Taft Hartley Act (Labor Management Relations Act, LMRA) excluded nurses in nonprofit hospitals from coverage under NLRA, legally preventing nurses from organizing collective bargaining units or going on strike.

1974 Taft Hartley Act was amended to cover nurses in nonprofit hospitals thus allowing formation of collective bargaining units. This act defined a "supervisor" as "any individual with authority to hire, transfer, suspend, lay off, promote, assign, reward, or discipline another employee." Legally, "supervisors" are classified as management. Management (including nursing supervisors) cannot be involved in collective bargaining.

1991 – US Supreme Court ruled that NLRB had authority to define bargaining units for health care providers in all settings, including acute care hospitals. Eight separate bargaining units were defined, including, but not limited to, nurses and physicians.

This permitted "all RN bargaining units".

The current major representative for nurses is the Service Employees International Union (50,000 nurses).

American Nurses Association (ANA) has always been supportive of collective bargaining.

ANA is not a bargaining agent, but supports State Nurses Associations to function as bargaining agents.

Nurses’ best representation is through the state nurses association. Union groups don’t understand quality and standards of care, ethical dilemmas or even different levels of nursing education.
 
 

• Equalize power between management and employees
• Address economic issues
• Maintain and promote professional practice

Nurses express many concerns about collective bargaining. A few of these concerns are:

• Collective bargaining is unprofessional
• Collective bargaining is unethical
• Collective bargaining is divisive
• Collective bargaining may present a threat to job security

• Questions about representation (ANA? Professional organizations? Who?)
• What about nurses working as supervisors? Are they employees or management?

1. Is collective bargaining unprofessional?

For many it seems unprofessional. Many nurses feel there are other ways to achieve their goals. Union proponents contend that it is even less professional to accept low pay and poor working conditions. They feel that collective bargaining will give nurses control over their practice –which is a key element of professionalism.
2. Is collective bargaining unethical?

A core belief of nurses is priority of clients’ health and well -being over nurses’ personal needs and profit.

Methods commonly used by collective bargaining units such as strikes or work slow downs conflict with this core belief. Some feel that such tactics imply abandonment and violate the code of ethics. Supporters of collective bargaining stress that poor work conditions are as much a threat to clients’ health as work actions taken to correct conditions.
The law requires that striking nurses give hospitals a 10-day notice before going on strike, in order to give the hospital time to find personnel to care for the patients.
 

3. Is collective bargaining divisive?

Collective bargaining sets management and employees against each other. Administrators will listen to collective bargaining units when they will not respond to individuals or groups of nurses.

Different collective bargaining units have different requirements for membership.

Closed shop: requires all employees to pay dues whether they join the union or not. The union believes ALL workers will benefit from the union’s efforts, so ALL should pay.

Closed shop is illegal in states with "right to work" laws.

Open shop: Only those employees who desire to join the union are required to pay union dues. (This type of "shop" is in effect in states without "right to work" laws).

4. Does collective bargaining pose a threat to nurses’ job security?

Indeed, this is one of the most controversial issues in nursing today.

The Contract

Once a collective bargaining unit is chosen, a contract must be negotiated between the nurses and the hospital. A contract is a legal document that is binding for management and union. It may be very specific or quite broad. It may contain such points as requirements and cost of dues for union membership.

Your text, Catalano, nicely describes the process of contract mediation (pages 273-277). As you read these pages, answer the following questions:

What are the steps in the contract negotiation process?

What is "good faith bargaining" and why is it important during negotiation?

What is the difference between a "mediator" and an "arbitrator"?

What is a "strike"? What is a "lockout"?

What are the elements of a good contract?

Governance

Governance is the arrangement of the hierarchy of power within an organization and how that power flows through that organization.

Governance establishes and maintains social, political and economic arrangements by which nurses maintain control of their practice.

Nurses traditionally have had little say in governance. Instead, authority has been in the hands of the hospital board of directors, the medical staff, and the hospital administrator. Nurses traditionally were oriented toward loyalty and respect and had little control – even of their own practice.

Today, however, the goal is increasing autonomy of nursing practice and independent decision making about the quality of nursing care.

Very recently, however, nurses have begun to attain more power in some hospitals, where a nurse is titled "Vice President for Nursing", rather than the traditional "Director of Nurses".

In an attempt to redistribute power and authority within health-care institutions, several alternative forms of governance have been developed:
 
 

1. Board of Nursing Model
2. Contracting for nursing services model
3. Shared governance – a decentralized system

Nursing staff structure in this model is similar to medical staff structure (e.g. board of trustees; then individual boards for nursing; MD’s, etc)

This model puts nursing on an equal footing administratively with MD’s and others, but can result in a top-heavy bureaucracy.

2. Contracting for nursing services model (fee for services model)

Client is billed for nursing care as a separate item on their hospital bill. Rates differ for more complex health care needs.

3. Shared governance model – a decentralized system

Power and authority are transferred to the nursing staff rather than being seated primarily with nursing administration.

This model places the source of power in the clinical area rather than in the administrative area.

Unit based shared governance – a smaller scale

Groups of nurses on each unit form councils for professional practice.
 
 

Governance and collective bargaining

Most nurses are concerned about economics, but nurses are also increasingly concerned about issues of autonomy, accountability, and control of practice.

The form of governance directly affects which issues are most likely to be involved in collective bargaining negotiations.
 
 
 

Required reading: Catalano J.T., Nursing Now, 2^nd ed.: Chapter 5

The following notes summarize this chapter.
 
 

One of the most important nursing responsibilities is to make correct and safe decisions. These decisions affect the client’s health status, recovery time, even life or death. The process of making decisions involves the use of critical thinking (the art of thinking about thinking).

Critical thinking is based on reason, knowledge, reflection, and instinct from experience.

In 1992 NLN designated critical thinking as one of its mandatory outcome objectives. Schools must demonstrate in syllabi where and how they teach critical thinking.
 
 

Characteristics of Critical Thinking

• Creative: Creative thinkers are able to bring together bits of knowledge or information that may seem unrelated and formulate them into a plan.
• Logical, rational, reflective: Must be based on rationales and facts, not emotions or egocentric impulses.

 

 
 
 
 
 
 
 
 
 
 
 
 
 

Deductive reasoning: proceeds from general to the particular. Conclusions are certain and true

Inductive reasoning: proceeds from particular to the general. Conclusions reached are probable or contingent. (used most often in health care due to wide range of variables)

See Catalano, pp 97-100 for discussion and examples of deductive and inductive reasoning.

Both deductive and inductive reasoning is open to fallacy (error in reasoning that leads to a conclusion that does not follow from its premises.

• Independent: Nurses who think critically demonstrate autonomy and are not easily influenced by others.
• Challenges rituals and assumptions about patient care: The nurse must understand the rationale behind a practice, then accept or reject it.
• Free of bias or prejudice: Bias is an unjustified personal opinion. If bias or stereotype is taken as fact, it becomes a prejudice.
• Action oriented: The goal is resolution of the problem.

• Identify the problem. You can’t develop a plan if you don’t know the problem. Try to restate the issue as a declarative statement.
• Gather pertinent data. Sort through data, use only what relates to the problem and reject extraneous data.
• Identify and challenge assumptions, beliefs, ideas and issues. Beliefs are personal or cultural and may influence decisions. Nurses must examine their own philosophies, beliefs, and value systems. Compare your values with agency’s. Also consult Standards of Care, Nurse Practice Act, protocols, and Code of Ethics.
• Imagine and explore alternatives creatively. After a problem is identified, and rituals and assumptions have been explored, consider the alternatives. Usually this step is not completed alone. Look at reports, research. Talk to clients, other professionals. Evaluate critically for accuracy, consistency, cause and effect, and biases.

Required reading: Catalano J.T., Nursing Now, 2nd ed.: Chapter 4

The following notes summarize this chapter.

Unlike many other professions, nursing has several different educational pathways that lead to licensure and professional status. The current system of nursing education creates confusion among the public, and sometimes even among nurses themselves.
Although different nursing programs vary in length, orientation, and content, the graduates all take the same licensing examination. The licensure examination measures knowledge at the minimum level of safe practice. Unfortunately, most workplaces do not recognize the differences in nurses' educational preparation with a pay difference.
 

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Types of nursing education programs

Three types of nursing education programs:
1. Diploma
2. Associate degree
3. Baccalaureate degree

At least 2 other groups of caregivers are identified with nursing: The nursing assistant (CNA), who is certified, and the practical or vocational (LVN, LPN) nurse, who is licensed through a separate and different examination than that taken by the registered nurse.

1.  Hospital-based diploma programs
Graduates receive a diploma – not a degree
This is the earliest type of nursing education in the US.

Originally, students provided free or inexpensive labor for the hospital where they trained.

1870 - First diploma school in US, New England Hospital for Women. Within 10 years every hospital had its own program

In the early days of diploma education, there was no uniformity in the curriculum, length or requirements. To guarantee adequate enrollment, candidates were recruited from lowest levels of society.

Learning was hands-on, 12-14 hours/day, 7 days/week. Dorms were on the hospital grounds, with a housemother. Head nurse of the hospital was supervisor of the school.

Graduates were proficient in basic nursing skills and could assume positions in the hospital where they trained without orientation.

Graduates could work in hospital or home health setting.

Graduates were submissive to medical authority; tried to please

Before licensure and standardization of practice, diploma grads were limited to employment in their own training institutions.

In 1949 the National Nursing Accrediting Service under NLN became the licensing body for all schools which sought accreditation. In 1952, NLN took over.

By the late 1940s & early 1950s, many hospital-based diploma schools had affiliated with nearby colleges; Nursing programs gained a stronger educational foundation because they were required by the NLN to align themselves more closely with other types of post-secondary education.

First formal accreditation was in 1950.

Accreditation required schools to teach specific content and to meet certain criteria such as:

    3-year programs
    Faculty with B.S. or higher degree
    Philosophy statement and implementation
    Learning objectives, outcome criteria
    Pass NCLEX

A concern of all state Boards was that the school should be able to demonstrate that students were not being used as free labor while in school.

Hospitals at this time found the programs expensive because they paid for the students’ room and board and had to hire B.S. faculty. Tuition increased to that of ADN/BSN programs. Many schools closed.

Diploma schools today have sound educational programs that meet the criteria for accreditation. They employ qualified faculty who have developed clinical learning experiences that meet the student's learning needs rather than the hospital's service needs. The programs vary in length from 27 to 36 months. Many diploma programs today are affiliated with a college, so that postsecondary credit can be awarded formally. There is a strong emphasis in diploma programs on client experiences. Also included are experience in nursing management. Graduates work in acute, long-term, and ambulatory health care facilities as RNs.

In 1960s-1970s there was increased popular belief that entry level into practice needed to be B.S. level (so nursing could be considered a profession).  There was a significant decline in the numbers of diploma progams in the 1960s. Many diploma programs converted to degree-granting programs, either A D N or B.S. Finances played a role in this change. Hospitals found nursing programs too expensive to support. Many diploma programs today have strong endowments and private funding support.
 

2.  Associate Degree
Two-year nursing programs, located in community colleges

Associate degree nurisng progrmas prepare more graduates for licensure as RNs than do any of the   other types of programs. The movement toward associate degree nursing education began in 1952.

Several events influenced the beginning of associate degree programs: increased number of community colleges in the US; creation of the cadet nurse program after WW II; studies conducted at that time on nursing education in the US; and  a critical national nursing shortage in the US in the 1950s.
2-year community college-based, associate degree nursing programs were developed by Mildred Montag as a short-term solution.

Originally designed to be technical and to develop skills necessary for bedside nursing. (less time than a B.S.)

The first associate degree program (Columbia University, 1952) proved that they could attract large numbers of students, they were cost effective, and they could produce skillful technical nurses in ½ the time required to prepare B.S. graduates.

After many heated debates it was decided associate degree grads should take the R.N. exam for licensure.

1960s and 1970s – associate degree programs met health care needs.

1980s there were over 800 assoc. degree programs in U.S. (today: 874) with over 64,000 students. Graduates soon exceeded numbers from BS and LPN.

As health care needs have become more complex, the original intention of the associate degree programs to emphasize technical skills has changed. Gradually associate degree programs have incorporated more general education courses of BSN. As curriculum content has increased so has the length of the programs, from 2 to 3 years. Approximately half of the credits needed for the associate degree are from general education courses (eg English, anatomy, speech, psychology, etc.); the other half from nursing courses. Clinical learning experiences are carefully selected to correspond with the content deliverd in classroom lectures. Clinical pre- and post-conferences help to reinforce the relationship between the two.

Associate degree graduates:
 Generally are well accepted in health care
Coming under increased scrutiny due to increasing complexity of health care needs
Can provide safe bedside care
Function well as team members

Some nursing leaders today question whether nurses prepared in a technical course (ADN) have enough knowledge to be providers of professional nursing in today’s complex system of health care. Opposition to associate degree nursing preparation resurfaces from time to time, even though ADN education is now firmly established as a credible preparation for a nursing career. The controversy over "entry into practice" and the preparation needed for "professional" nursing is argued intermittently.
 

3.  Baccalaureate
Baccalaureate programs are located in 4-year colleges and universities. A university nursing program is termed a "basic" or "generic" baccalaureate program when the program of studies includes an upper division (junior & senior years) nursing major that is built onto 2 years of liberal arts and science courses taken during the freshman & sophomore years.
HISTORY: Baccalaureate programs gradually developed – there were few BSN programs while associate degree programs were in vogue

1909: First BS program was at University of Minnesota
1923: Yale started a BS program
Beginning of WW II there were 76 BSN programs
Number of BSN programs increased after WW II (GI bill). Rapid growth, but no uniformity. It was difficult to find qualified faculty. (few PhD nurses)

B.S. program includes:
Public Health Nursing
Teaching & management
Administration
Supervision
Emphasis is on theory, not practice

Students learn basic nursing skills, concepts of health maintenance & promotion, disease prevention; supervisory and leadership techniques and practices, and introduction to research. Clinical course work includes experience in hospital nursing, community health nursing, and leadership responsibility in all clinical settings.

Emphasis is placed in developing skills in critical thinking,making independent nurisng judgments, and working in complex nursing situations.

In recent years some schools have included courses that permit a degree of specialization at the BSN level (coronary care or critical care nursing)

NLN developed criteria for accreditation of BS programs

1965: ANA Position Paper published, which recommended BS as minimum level for entry into practice. This created controversy and resentment. Today this controversy is still unresolved.

Three avenues to attain BS:
BSN: 124 credit hours. 65 in nursing (not enough for BS)
BS – N: major in nursing
Career ladder: RN to BSN
Ladder programs:
Designed for the RN (diploma or ADN) who wishes to return to school to complete a baccalaureate degree in nursing.
Articulation or educational mobility
Upward mobility
Career mobility

Recently there has been an increase in the number of RN baccalaureate (RNB) programs.

There are also master's degree programs that admit RNs with associate degrees who will graduatge in 3 years with a master's degree in nursing, and will receive a baccalaureate degree part-way through the program.

Allow nurses to upgrade their education and move from one education level to another with relative ease and without loss of credits.

The nursing profession is aiming to increase the number of nurses prepared with baccalaureate and higher degrees.

The External Degree:
Students awarded an external degree are not required to attend classes or follow any prescribed methods of learning. Learning is assessed through highly standardized and validated examinations. The New York Regents External Degree (REX) Program of the Unviersity of the State of New York has become part of this movement.

The external degree nursing program is based on principles of adult learning. It advocates flexible & learner oriented education.

Some states do not accept New York Regents degrees for initial licensure.

4. Master’s Programs
B.S. is considered a generalist degree

Master is considered a specialist degree

Master’s in Nursing programs have been around as long as B.S., just not as plentiful.

Early Master’s programs were designed for people with a BS in other fields. It required another 36-42 credit hours of nursing

Today Master’s degree in nursing programs are restricted to RNs with a BS and require one year of clinical practice after BS. (36-46 hours)

Master’s areas include:
Nursing administration
Community health
Psychiatric Mental Health
Adult health
Maternal Child health
Gerontology
Rehabilitation Care
Nursing Education
Anesthesiology
Pediatric Nurse Practitioner (PNP)
Family Nurse Practitioner (FNP)
OB-GYN Practitioner

Written and oral exams are required before graduation

Two basic Master’s Programs:
Master's of Science in Nursing (MSN) is the professional degree
MS-N Master of Science with a major in Nursing (MS Nursing) is the formal academic degree

In practice there is little difference between the two.

Requirements for admission to Master’s Program:

• GPA
• Satisfactory score on GRE (Graduate Record Exam)
• Satisfactory score on MAT (Miller Analogy Test)

5.  Doctoral Level Education
60 more credits

PhD: Doctor of Philosophy – designed to prepare people for research
EdD: Doctor of Education – the professional level degree
DN or ND: Doctor of Nursing – Person has a GS or MS in field other than nursing (generalist degree)
Requirements:

Master’s degree
Satisfactory score on GRE
Admission interview
Statistics
Research
Residency
 

6.  Advanced Practice Nurse

Opportunities are vast
Practitioners diagnose illnesses, prescribe medications, conduct physical exams and refer patients to specialists

Practitioners practice under their own license and work closely with a physician. They do whatever their State Nurse Practice Act allows.

Programs are offered in major universities which require a Master’s degree before allowing them to sit for the certification exam.

Clinical nurse specialist
This comes under Advanced Practice
Self classified usually after completing Master’s in a clinical area

Hired by hospitals

Function as inservice educators or advanced practice clinical practitioners
 
 

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Paradigm Shifting in Nursing Education
Current changes in the market-driven health care economy are producing sweeping changes in health care delivery. Nurses need to be prepared with new skills and knowledge that differ from the traditional methods taught in the past. According to the Department of Health and Human Services, Division of Nursing, in 1996 only 60% of registered nurses worked in hospitals. The remainder was employed in a variety of settings, including home health agencies, ambulatory care settings, insurance companies, education, and research.

Nursing education is beginning to realize that graduates need knowledge and skills different from hospital based, physician directed health care. The Pew Health Professions Commission Report reinforces this need for change in nursing education.

(See Catalano, p 72, for further explanation of the Pew Report.) Its recommendations for nursing schools include issues such as expanding the scientific basis of the programs, promoting interdisciplinary education, developing cultural sensitivity, establishing alliances with managed care agencies and government, and increasing the use of computer technology. It also recommends simplifying nursing titles so there is just one title for each level.

Nursing has several related educational pathways that lead to licensure. All registered nurses must pass the same licensing examination, but they may receive their educational preparation in one of several different types of educational programs that vary in length, philosophy, and content. This variety of educational programs causes confusion not only among the public, but even among nurses themselves. The licensure examination (NCLEX) measures knowledge at the minimum safe level of safe nursing practice. So far, hospitals and other employers of nurses have not provided pay difference to distinguish levels of education despite studies showing performance differences.

The Nurse of the Future

The nurse of the future:

will need to practice with self-reliance, independence and flexibility.
will be required to have well developed decision making skills based on critical thinking ability
will need a working knowledge of community resources and computer competencies
must have ability deliver high quality client education

ANA Position Paper on Education for Nurses
The purpose of the ANA is to ensure high-quality nursing care to the public by fostering high standards of nursing practice and by furthering professional and educational advancement of nurses. ANA took responsibility for establishing the scope of practice for nurses and for guaranteeing competence of practicing nurses. After evaluating the changes that had occurred in the health care system since the 1950s and studying the projected educational needs for nurses, the American Nurses Association (ANA) published a paper in 1965 that was, and still is, highly controversial. (See Catalano, pp 77-78 for further discussion of the ANA Position Paper) The ANA re-evaluated the nature and scope of nursing practice and presented its conclusions in its position paper. The ANA recognized that nurses were required to master a very large and extremely complex body of knowledge and that nurses should be able to make critical and independent decisions regarding patient care. The ANA position paper stated that baccalaureate education should be the basic level of preparation for professional nurses.

Effects of ANA Position Paper on Education:
Hospitals recognized they would no longer retain their role in preparation of nurses.

Colleges and universities were hard pressed to develop undergraduate and graduate programs quickly.

Existing BS programs were called on to expand.

It became evident that a clear distinction between technical and professional programs needed to be made.

ANA is still committed to the Position Paper. Thirty-five years later the profession of nursing is still trying to reach a consensus on educational level required for entry into practice.

Only after the issue of basic entry level education for professional nursing is resolved, and when nurses, like all other professionals, obtain their knowledge from recognized schools of higher education, will nursing becomes a profession.
 
 

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Required reading: Catalano J.T., Nursing Now, 2nd ed.: Chapter 3

The following notes summarize this chapter.

As the nursing profession continues to grow, one of the areas receiving more emphasis is that of nursing theory and research. Nursing theory is receiving increasing emphasis in nursing programs. All nursing programs must have an organizing or conceptual framework around which the program of learning is developed.

Understanding and using nursing theories and models will help you to be a better nurse and to provide better care.

DIFFERENCES BETWEEN THEORY AND MODEL

Although the terms are not synonymous, in nursing practice they are often used interchangeably.

THEORY:

A theory is a "scientifically acceptable general principle which governs practice or is proposed to explain observed facts." (Riehl & Roy, 1974)

A "theory" refers to a speculative statement involving some element of reality that has not been proved. E.g. theory of relativity.

Nursing profession uses the term "theory" when attempting to explain apparent relationships between observed behaviors and their effects on a client’s health.

In this nursing context, the goal of a theory is to describe and explain a particular nursing action in order to make a hypothesis or predict its effect on a client’s outcome.
E.g. turning a client every 2 hours should help prevent skin and respiratory complications.

MODEL:

Refers to a hypothetical representation of something that exists in reality.

Purpose is to attempt to explain a complex reality in a systematic and organized manner.
E.g. Hospital organizational chart demonstrates relationships of various levels of hospital administration.

A model is more concrete than a theory. (Both help explain and direct nursing actions.)

Although a model tends to be more concrete than a theory, they both help explain and direct nursing actions. With the use of a "conceptual model", nurses can provide intelligent answers to the question "What do nurses DO?"

WHAT DO NURSES DO?

Two nurse researchers, McCloskey & Bulechek, conducted a research project in 1990 to develop taxonomy of interventions in nursing practice.

The final results were published in 1994. It categorized and ranked 336 interventions.

A follow up study in 1996 listed 422 interventions. 40 specialty groups responded. (See Catalano, pp 45-47 for results of this study).

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Today, there are many published nursing theories. In an attempt to structure and organize those theories, various authors have categorized and classified them. Categories include growth & development theories, systems theories, stress adaptation theories, and rhythm theories.

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Nursing theories usually are classified according to the structure or approach around which they are developed.
Theories that speak to the art and science of nursing were among the earliest pure nursing theories developed. Included in this group are Florence Nightingale, Virginia Henderson ("Definition of Nursing"); Faye Abdellah ("Twenty-one Nursing Problems") and Madeleine Leninger ("Transcultural Nursing").

Interpersonal process theories deal with interactions between and among people. Many of these theories were developed during the 1960s. Included in this group are Hildegard Peplau ("Psychodynamic Nursing"), Imogene King ("Dynamic Interacting Systems")

Systems theories are so named because they are concerned with the interactions between and among all the factors in a situation. A system usually is viewed as complex and in a state of constant change. A system is a whole with interrelated parts and may be a subsystem of a larger system as well as a suprasystem. For example, a person my be viewed as a system composed of cells, tissue, and organs. The person is a subsystem of a family, which in turn is a subsystem of a community. In a systems approach, the person ususally is considered as a "total" being, or from a "whole" being viewpoint. Systems theories also provide for "input" into the system and "feedback" within the system. The systems approach became popular during the 1970s. Included in this group of theorists are Dorothy Johnson, Sister Calista Roy, and Betty Neuman. (a brief discussion of "general systems theory" is included below)

Stress adaptation models are based on concepts that view the person as adjusting or changing (adapting) to avoid situations (stressors) that would result in the disturbance of balance or equilibrium. The adaptation theory helps to explain how balance is maintained and therefore directs nursing actions. Included in this group one often finds Sister Calista Roy's adaptation model and Betty Neuman. work, but both also may be considered systems models, as well.

Fifteen published nursing models have been used to direct nursing education and nursing care.

These six nursing models are the most widely accepted and are good examples of how the concepts of client, health, environment, and nursing are used to explain and guide nursing.
 

• Roy Adaptation Model
• Orem Self Care Model
• King Model of Goal Attainment
• Watson Model of Human Caring
• Johnson Behavioral System Model
• Neuman Health-Care Systems Model

Your text, Catalano, provides a clear and well-organized discussion of these six nursing models. Read about each model in your text, paying special attention to the underlying philosophy of each theory and each theory’s unique interpretation of client, health, environment, and nursing. The models are nicely summarized in Table 3.3 on page 56.

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KEY CONCEPTS COMMON TO ALL NURSING MODELS

• Client/patient: An approach to the human person
• Health: An approach to health & illness
• Environment: An approach to the environment
• Nursing: An approach to nursing

• Client

Clients are seen as complex entities (biopsychosocial: mind, body, environment)

A client in many nursing models does not have an illness. This explains preference of use of the term "client", instead of "patient".

This is the clearest difference between medical and nursing models:

Medical: curing diseases

Nursing: holistic (cure, restore, prevent)
 

• Health

Originally thought of as merely absence of disease

Currently viewed as health on a continuum (from completely health to death)

Varies widely from one individual to another

Perception of health varies from culture to culture at different historical periods within the same culture.
 

• Environment

Includes living conditions, public sanitation, air & water quality

Also includes interpersonal relationships and social interactions

Internal environmental factors that affect health include: personal psychological processes, religious beliefs, sexual orientation, personality (Esp. type A), emotional responses.
 

• Nursing

Historically included hygiene, activity, nourishment, psychological support and relief of discomfort

Modern nursing still includes the above basic elements and has expanded to include: clients as partners in curing setting of goals and evaluations; manipulation of environmental elements.

The role and function of the nurse depend on which element is given greater emphasis

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GENERAL SYSTEMS THEORY
An organized unit with a set of components that interact

When part of the system fails, it interrupts the function of the whole system, not just the part that failed.

Rarely used as a nursing model, but its process and terminology underlie many nursing models.

Also called "systems theory". It is widely applicable because it reflects reality that underlies basic human thought processes (deductive reasoning).

Open system

Relatively free movement of information, matter, and energy into and out of the system

Closed system

Movement into and out of the system is prevented. This type of system is static and unchanging.

4 Key Parts of a System:

Input: any type of information, energy or material that enters the system from the environment
Output: any information, energy or material that leaves the system and enters the environment
Throughput: process that allows the input to be changed so that it is useful to the system (e.g.: gas for a car does not work if it’s poured on the hood. It must be put in the gas tank.)
Feedback loop: allows the system to monitor its internal functioning so it can either restrict or increase its input and output and maintain highest level of functioning.

Positive feedback:
Leads to change within system with goal of improving system

Negative feedback:
Indicates that no changes in practice patterns are required.
 

1.  Describe health care during the Renaissance and the Reformation.  What group provided most of the health care?  What were some of the problems with health care during these time periods?

2.  Discuss Christian influences on health care and nursing.

3.  Explain the importance of religious nursing orders in the development of the profession of nursing.

4.  Discuss Florence Nightingale's major contributions to the profession of nursing.  Describe her accomplishments during the Crimean War.  What were her views on nursing education?

5.  Know  the major accomplishments of each of these nursing leaders:
Florence Nightingale
Isabel Hampton Robb
Lillian Wald
Clara Barton
Annie Goodrich
Lavinia Lloyd Dock

6.  Describe and differentiate between the following levels of nursing education. (length of program, location on what type of campus, differences in philosophy & focus, specific problems with each type, which are specialized & which are generalized):
Diploma
Associate degree
Baccalaureate degree
Master's degree

7.  What is the main position on nursing education advocated by the ANA Position Paper?

8.  What is an advanced practice nurse?  Give examples of types of advanced practice nurse roles.

9.  Describe nursing education in the United States during the 1800s and early 1900s.

10. What is a career ladder in nursing education?

11.  List several common objections nurses have against joining unions.

12.  Name one legal requirement that may help alleviate the concern of nurses who feel that going on strike may adversely affect patient care.

13.  What is the primary purpose of a professional organization?

14.  Be familiar with the following organizations. (membership, purpose, services, benefits of membership, etc.)
ANA
NLN
Sigma Theta Tau
AACN
NSNA

15.  What is the purpose of licensure?  What is the difference between registration and licensure?
Describe  permissive licensure, mandatory licensure, and institutional licensure.

16.  What is certification?

17.  Discuss ways nurses may use to increase power.

18.  Describe these types of power:
coercive
legitimate
referent
expert
collective

19.  Understand the following approaches to defining a profession:
process
power
trait

20.  When does nursing meet the criteria of a profession?  When does it fall short of meeting the criteria of a profession?

21.  List the steps of critical thinking.

22.Define: bias, stereotype

23 Define: closed system, open system.

24.  How is health defined in the following models:
Orem
Roy
Watson
King
Johnson
Newman

25. What four concepts are common in most nursing theories?

26.  Define collective bargaining

27.  What law passed in 1935 allowed employees the right to self-organization and formation of unions?

28.  What is a common goal of collective bargaining which is important to nursing?

29. Give examples of unfair labor practices in nursing.

30.  Discuss the advantages and disadvantages that a union has over a State Nurses Association as a bargaining unit for nurses.