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ESSENTIALS OF

Nursing Leadership & Management

SEVENTH EDITION

Sally A. Weiss , EdD, APRN, FNP-C, CNE, ANEF

Professor, Lead Faculty Graduate Program Herzing University

Menominee Falls, Wisconsin

Ruth M. Tappen , EdD, RN, FAAN Christine E. Lynn Eminent Scholar and Professor

Florida Atlantic University College of Nursing Boca Raton, Florida

Karen A. Grimley , PhD, MBA, RN, NEA-BC, FACHE

Chief Nursing Executive, UCLA Health Vice Dean, UCLA School of Nursing

Los Angeles, California

F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com

Copyright © 2019 by F. A. Davis Company

Copyright © 2019 , 2015, 2010, 2007, 2004, 2001, 1998 by F. A. Davis Company . All rights reserved. Th is book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmit- ted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher.

Printed in the United States of America

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Acquisitions Editor: Jacalyn Sharp Content Project Manager: Sean West Design and Illustration Manager: Carolyn O’Brien

As new scientifi c information becomes available through basic and clinical research, recommended treat- ments and drug therapies undergo changes. Th e author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. Th e author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. Th e reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs.

Library of Congress Cataloging-in-Publication Data

Names: Weiss, Sally A., 1950- author. | Tappen, Ruth M., author. | Grimley, Karen A., author. Title: Essentials of nursing leadership & management / Sally A. Weiss, Ruth M. Tappen, Karen A.

Grimley. Description: Seventh edition. | Philadelphia : F. A. Davis Company, [2019] | Includes bibliographical

references and index. Identifi ers: LCCN 2019000397 (print) | LCCN 2019001079 (ebook) | ISBN 9780803699045 | ISBN

9780803669536 (pbk. : alk. paper) Subjects: | MESH: Leadership | Nursing, Supervisory | Nursing Services—organization & administra-

tion | United States Classifi cation: LCC RT89 (ebook) | LCC RT89 (print) | NLM WY 105 | DDC 362.17/3068—dc23 LC record available at https://lccn.loc.gov/2019000397

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v

To my granddaughter, Sydni, and my grandsons, Logan and Ian. Th eir curiosity and hunger for learning remind me how nurturing our novice nurses helps them in their quest to seek

new knowledge and continue their professional growth. —S ALLY A. W EISS

To students, colleagues, family, and friends, who have taught me so much about leadership.

—R UTH M. T APPEN

To my kids, Kristina, Kathleen, Meagan, and Ian, for their love and understanding during this lifelong pursuit of learning.

To my dad for teaching me that the only limits we face are the ones we create and to my mom for instilling the value of a good

education. —K AREN A. G RIMLEY

Dedication

vii

We are pleased to bring our readers this seventh edition of Essentials of Nursing Leadership & Management. Th is new edition has been updated to refl ect the dynamic health-care environment, new safety and quality initiatives, and changes in the nursing practice environment. As in our previ- ous editions, the content, examples, and diagrams were designed with the goal of assisting the new graduate to make the transition to professional nursing practice.

Our readers may have noticed that we have added a new author to our team: Dr. Karen A. Grimley, Chief Nurse Executive at UCLA Health Center and Vice Dean of the School of Nursing at UCLA. We are delighted to have her join us, bringing a fresh perspective to this new edition.

Th e seventh edition of Essentials of Nursing Leadership & Management focuses on essential lead- ership and management skills and the knowledge needed by the staff nurse as a key member of the interprofessional health-care team and manager of patient care. Issues related to setting priorities, delegation, quality improvement, legal parameters of nursing practice, and ethical issues were also updated for this edition.

Th is edition discusses current quality and safety issues and the high demands placed on nurses in the current health-care environment. In addition, we continue to bring you comprehensive, practical information on developing a nursing career and addressing the many workplace issues that may arise in practice.

Th is new edition of Essentials of Nursing Leadership & Management will provide a strong foun- dation for the beginning nurse leader. We want to thank all of the people at F. A. Davis for their continued support and assistance in bringing this edition to fruition. We also want to thank our contributors, reviewers, colleagues, and students for their enthusiastic support. Th ank you all.

—S ALLY A. W EISS

R UTH M. T APPEN

K AREN A. G RIMLEY

Preface

ix

CANDACE JONES, BSN, MSN, RN Professor of Nursing

Greenville Technical College Greenville, South Carolina

SUSAN MUDD, MSN, RN, CNE Coordinator, Associate Degree Nursing Program

Elizabethtown Community & Technical College

Elizabethtown, Kentucky

DONNA WADE, RN, MSN Professor of Nursing

Mott Community College Flint, Michigan

JENNA L. BOOTHE, DNP, APRN, FNP-C Assistant Professor

Hazard Community and Technical College Hazard, Kentucky

LYNETTE DEBELLIS, MS, RN Chairperson and Assistant Professor of Nursing

Westchester Community College Valhalla, New York

SONYA C. FRANKLIN, RN, EdD/CI, MHA, MSN, BSN, AS, ADN

Associate Professor of Nursing

Cleveland State Community College Cleveland, Tennessee

Reviewers

xi

unit 1 Professionalism 1 chapter 1 Characteristics of a Profession 3 chapter 2 Professional Ethics and Values 13 chapter 3 Nursing Practice and the Law 35

unit 2 Leading and Managing 55 chapter 4 Leadership and Followership 57 chapter 5 Th e Nurse as Manager of Care 71 chapter 6 Delegation and Prioritization of Client Care Staffi ng 81 chapter 7 Communicating With Others and Working

With the Interprofessional Team 99 chapter 8 Resolving Problems and Confl icts 117

unit 3 Health-Care Organizations 131 chapter 9 Organizations, Power, and Professional

Empowerment 133 chapter 10 Organizations, People, and Change 149

chapter 11 Quality and Safety 163 chapter 12 Maintaining a Safe Work Environment 181 chapter 13 Promoting a Healthy Work Environment 197

unit 4 Your Nursing Career 213 chapter 14 Launching Your Career 215 chapter 15 Advancing Your Career 235

Table of Contents

xii Table of Contents

unit 5 Looking to the Future 249 chapter 16 What the Future Holds 251

Bibliography 263

Appendices appendix 1 Standards Published by the American Nurses Association 285 appendix 2 Guidelines for the Registered Nurse in Giving, Accepting,

or Rejecting a Work Assignment 287 appendix 3 National Council of State Boards of Nursing Guidelines

for Using Social Media Appropriately 293 appendix 4 Answers to NCLEX® Review Questions 295 Index 321

chapter 1 Characteristics of a Profession

chapter 2 Professional Ethics and Values

chapter 3 Nursing Practice and the Law

unit 1 Professionalism

3

OUTLINE Introduction

Professionalism Defi nition of a Profession Professional Behaviors

Evolution of Nursing as a Profession Nursing Defi ned

The National Council Licensure Examination Licensure Licensure by Endorsement Qualifi cations for Licensure Licensure by Examination

NCLEX-RN ®

Political Infl uences and the Advance of Nursing Professionals

Nursing and Health-Care Reform

Nursing Today

The Future of Professional Nursing

Conclusion

OBJECTIVES After reading this chapter, the student should be able to: ■ Explain the qualities associated with a profession

■ Diff erentiate between a job, a vocation, and a profession

■ Discuss professional behaviors

■ Determine the characteristics associated with nursing as a profession

■ Explain licensure and certifi cation

■ Summarize the relationship between social change and the advancement of nursing as a profession

■ Discuss some of the issues faced by the nursing profession

■ Explain current changes impacting nursing ’ s future

chapter 1 Characteristics of a Profession

4 unit 1 ■ Professionalism

Introduction

It is often said that you do not know where you are going until you know where you have been. More than 40 years ago, Beletz ( 1974 ) wrote that most people thought of nurses in gender- linked, task-oriented terms: “a female who per- forms unpleasant technical jobs and functions as an assistant to the physician” (p. 432). Interest- ingly, physicians in the 1800s viewed nursing as a complement to medicine. According to War- rington ( 1839 ), “. . . the prescriptions of the best physician are useless unless they be timely and properly administered and attended to by the nurse” (p. iv).

In its earliest years, most nursing care occurred at home. Even in 1791 when the fi rst hospital opened in Philadelphia, nurses continued to care for patients in their own home settings. It took almost another century before nursing moved into hospitals. Th ese institutions, mostly dominated by male physicians, promoted the idea that nurses acted as the “handmaidens” to the better-educated, more capable men in the medical fi eld.

Th e level of care diff ered greatly in these early health-care institutions. Th ose operated by the religious nursing orders gave high-quality care to patients. In others, care varied greatly from good to almost none at all. Although the image of nurses and nursing has advanced considerably since then, some still think of nurses as helpers who carry out the physician ’ s orders.

It comes as no surprise that nursing and health care have converged and reached a crossing point. Nurses face a new age for human experience; the very foundations of health practices and thera- peutic interventions continue to be dramatically altered by signifi cantly transformed scientifi c, technological, cultural, political, and social realities ( Porter-O’Grady , 2003 ). Th e global environment needs nurses more than ever to meet the health- care needs of all.

Nursing sees itself as a profession rather than a job or vocation and continues with this quest for its place among the health-care disciplines. However, what defi nes a profession? What behaviors are expected from the members of the profession? Chapter 1 discusses nursing as a profession with its own identity and place within this new and ever-changing health-care system.

Professionalism

Defi nition of a Profession A vocation or calling defi nes “meaningful work” depending on an individual ’ s point of view ( Dik & Duff y, 2009 ). Nursing started as a vocation or “calling.” Until Nightingale, most nursing occurred through religious orders. To care for the ill and infi rmed was a duty ( Kalisch & Kalisch, 2004 ). In early years, despite the education required, nursing was considered a job or vocation ( Cardillo, 2013 ).

Providing a defi nition for a “profession” or “pro- fessional” is not as easy as it appears. Th e term is used all the time; however, what characteristics defi ne a professional? According to Saks ( 2012 ), several theoretical approaches have been applied to creating a defi nition of a profession, the older of these looking only at knowledge and expertise, whereas later ones include a code of ethics, prac- tice standards, licensure, and certifi cation, as well as expected behaviors ( Post, 2014 ).

Nurses engage in specialized education and training confi rmed by successfully passing the National Council Licensure Examination (NCLEX®) and receiving a license to practice in each state. Nurses follow a code of ethics and recognized practice standards and a body of con- tinuous research that forms and directs our practice. Nurses function autonomously within the desig- nated scope of practice, formulating and delivering a plan of care for clients, applying judgments, and utilizing critical thinking skills in decision making ( Cardillo, 2013 ).

Professional Behaviors According to Post ( 2014 ), professional characteris- tics or behaviors include:

■ Consideration ■ Empathy ■ Respect ■ Ethical and moral values ■ Accountability ■ Commitment to lifelong learning ■ Honesty

Professionalism denotes a commitment to carry out specialized responsibilities and observe ethical principles while remaining responsive to diverse recipients ( Al-Rubaish, 2010 ). Communicating

chapter 1 ■ Characteristics of a Profession 5

eff ectively and courteously within the work envi- ronment is expected professional behavior. State boards of nursing through the nurse practice acts elaborate expected behaviors in a registered nurse ’ s professional practice and personal life (National Council of State Boards of Nursing [ NCSBN], 2012, 2016 ). Nurses may lose their licenses for a variety of actions deemed unprofessional or illegal. For example, inappropriate use of social media, posting emotionally charged statements in blogs or forums, driving without a license, and committing felonies outside of professional practice may be cause for suspending or revoking a nursing license.

Commitment to others remains central to a profession. In nursing, this entails commitment to colleagues, lifelong learning, and accountability for one ’ s actions. Professionalism in the workplace means coming to work when scheduled and on time. Coming to work late shows disrespect to your peers and colleagues. It also indicates to your super- visor that this position is not important to you.

Always portray a positive attitude. Although everyone experiences a bad day, projecting personal feelings and issues onto others aff ects the work environment. Many agencies and institutions have dress codes. Dress appropriately per the employ- er ’ s expectations. Wearing heavy makeup, colognes, or inappropriate hairstyles demonstrates a lack of professionalism. Finally, always speak profession- ally to everyone in the work environment. A good rule to follow should be, “If you wouldn ’ t say it in front of your grandmother, do not say it in the workplace” ( McKay, 2017 ).

Work politics often create an unfavorable envi- ronment. Stay away from gossip or engaging in negative comments about others in the workplace. Change the topic or indicate a lack of interest in this type of verbal exchange. Negativity is conta- gious and aff ects workplace morale. Professionals maintain a positive attitude in the work environ- ment. If the environment aff ects this attitude, it is time to look for another position ( McKay, 2017 ).

Lastly, professional behavior entails honesty and accountability. If a day off is needed, take a personal or vacation day; save sick days for illness. Own up to errors. In nursing, an error may result in injury or death. Th e health-care environment should promote a culture of safety, not one of pun- ishment for errors. Th is is discussed more in later chapters.

Evolution of Nursing as a Profession

Nursing Defi ned Th e changes that have occurred in nursing are refl ected in the defi nitions of nursing that have developed through time. In 1859, Florence Night- ingale defi ned the goal of nursing as putting the client “in the best possible condition for nature to act upon him” ( Nightingale, 1992/1859 , p. 79). In 1966, Virginia Henderson focused her defi nition on the uniqueness of nursing:

Th e unique function of the nurse is to assist the individual, sick or well, in the performance of those

activities contributing to health or its recovery (or

to peaceful death) that he would perform unaided

if he had the necessary strength, will or knowledge.

And to do this in such a way as to help him gain

independence as rapidly as possible. ( Henderson, 1966 , p. 21)

Martha Rogers defi ned nursing practice as “the process by which this body of knowledge, nursing science, is used for the purpose of assisting human beings to achieve maximum health within the potential of each person” ( Rogers, 1988 , p. 100). Rogers emphasized that nursing is concerned with all people, only some of whom are ill.

In the modern nursing era, nurses are viewed as collaborative members of the health-care team. Nursing has emerged as a strong fi eld of its own in which nurses have a wide range of obligations, responsibilities, and accountability. Recent polls show that nurses are considered the most trusted group of professionals because of their knowl- edge, expertise, and ability to care for diverse populations.

Nightingale ’ s concepts of nursing care became the basis of modern theory development, and in today ’ s language, she used evidence-based prac- tice to promote nursing. Her 1859 book Notes on Nursing: What It Is and What It Is Not laid the foun- dation for modern nursing education and practice. Many nursing theorists have used Nightingale ’ s thoughts as a basis for constructing their view of nursing.

Nightingale believed that schools of nursing must be independent institutions and that women who were selected to attend the schools should be

6 unit 1 ■ Professionalism

from the higher levels of society. Many of Night- ingale ’ s beliefs about nursing education are still applicable, particularly those involved with the progress of students, the use of diaries kept by students, and the need for integrating theory into clinical practice ( Roberts, 1937 ).

Th e Nightingale school served as a model for nursing education. Its graduates were sought worldwide. Many of them established schools and became matrons (superintendents) in hospitals in other parts of England, the British Common- wealth, and the United States. However, very few schools were able to remain fi nancially indepen- dent of the hospitals and thus lost much of their autonomy. Th is was in contradiction to Nightin- gale ’ s philosophy that the training schools were educational institutions, not part of any service agency.

The National Council Licensure Examination

Professions require advanced education and an advanced area of knowledge and training. Many are regulated in some way and have a licensure or certifi cation requirement to enter practice. Th is holds true for teachers, attorneys, physicians, and pilots, just to name a few. Th e purpose of a profes- sional license is to ensure public safety, by setting a level of standard that indicates an individual has acquired the necessary knowledge and skills to enter into the profession.

Licensure Licensure for nurses is defi ned by the NCSBN as the process by which boards of nursing grant permission to an individual to engage in nursing practice after determining that the applicant has attained the competency necessary to perform a unique scope of practice. Licensure is necessary when the regulated activities are complex, require specialized knowledge and skill, and involve independent decision making ( NCSBN, 2012 ). Government agencies grant licenses allowing an individual to engage in a professional practice and use a specifi c title. State boards of nursing issue nursing licenses. Th is limits practice to a specifi c jurisdiction. However, as the NCLEX® is a nation- ally recognized examination, many states have joined together to form a “compact” where the

license in one state is recognized in another. States belonging to the compact passed legislation adopt- ing the terms of the agreement. Th e state in which the nurse resides is considered the home state, and license renewal occurs in the home state ( NCSBN , 2018a ).

Licensure may be mandatory or permissive. Permissive licensure is a voluntary arrangement whereby an individual chooses to become licensed to demonstrate competence. However, the license is not required to practice. In this situation a manda- tory license is not required to practice. Mandatory licensure requires a nurse to be licensed in order to practice. In the United States and Canada, licen- sure is mandatory.

Licensure by Endorsement If a state is not a member of the compact, nurses licensed in one state may obtain a license in another state through the process of endorsement. Each application is considered independently and is granted a license based on the rules and regula- tions of the state.

States diff er in the number of continuing edu- cation credits required, mandatory courses, and other educational requirements. Some states may require that nurses meet the current criteria for licensure at the time of application, whereas others may grant the license based on the criteria in eff ect at the time of the original license. When applying for a license through endorsement, a nurse should always contact the board of nursing for the state and ask about the exact requirements for licensure in that state. Th is information is usually found on the state board of nursing Web site.

NURSYS is a national database that houses information on licensed nurses. Nurses apply- ing for licensure by endorsement may verify their licenses through this database. Th e nurse ’ s license verifi cation is available immediately to the endors- ing board of nursing ( NCSBN , 2016 ). Not all states belong to NURSYS.

Qualifi cations for Licensure Th e basic qualifi cation for licensure requires graduation from an approved nursing program. In the United States, each state may add additional requirements, such as disclosures regarding health or medications that could aff ect practice. Most states require disclosure of criminal conviction.

chapter 1 ■ Characteristics of a Profession 7

Licensure by Examination A major accomplishment in the history of nursing licensure was the creation of the Bureau of State Boards of Nurse Examiners. Th e formation of this agency led to the development of an identical examination in all states. Th e original examination, called the State Board Test Pool Examination, was created by the testing department of the National League for Nursing (NLN). Th is was completed through a collaborative contract with the state boards. Initially, each state determined its own passing score; however, the states did eventually adopt a common passing score. Th e examination is called the NCLEX-RN ® and is used in all states and territories of the United States. Th is test is prepared and administered through a professional testing company.

NCLEX-RN ®

Th e NCLEX-RN ® is administered through com- puterized adaptive testing (CAT). Candidates need to register to take the examination at an approved testing center in the state in which they intend to practice. Because of a large test bank, CAT permits a variety of questions to be adminis- tered to a group of candidates. Candidates taking the examination at the same time may not neces- sarily receive the same questions. Once a candidate answers a question, the computer analyzes the response and then chooses an appropriate question to ask next. If the candidate answers the question correctly, the following question may be more dif- fi cult; if the candidate answers incorrectly, the next question may be easier.

In April 2016, the NCSBN released the updated test plan. Th e new test plan redistributed the percentages for each content area and updated the question format with increased use of technol- ogy that better simulated patient care situations. More updated information on the NCLEX® test plans may be found on the NCSBN Web site ( www.ncsbn.org ).

Political Infl uences and the Advance of Nursing Professionals

Nursing made many advances during the time of social upheaval and change. Th e passing of the Social Security Act in 1935 strengthened public

health services. Public health nursing found itself in an ideal position to step up and assume respon- sibility for providing care to dependent mothers and children, the blind, and disabled children ( Black, 2014 ). In 1965, under President Lyndon B. Johnson, amendments to the Social Security Act designed to ensure access to health care for the elder adult, the poor, and the disabled resulted in the creation of Medicare and Medicaid (Centers for Medicare and Medicaid Services [ CMS ], 2017 ). Health insurance companies emerged and increased in number during this time as well. Hos- pitals started to rely on Medicare, Medicaid, and insurance reimbursement for services. Care for the sick and new opportunities and roles emerged for nurses within this environment.

Historically, as a profession, nursing has made most of its advances during times of social change. Th e 1960s through the 1980s brought many changes for both women and nursing. In 1964, President Johnson signed the Civil Rights Act, which guaranteed equal treatment for all individ- uals and prohibited gender discrimination in the workplace. However, the law lacked enforcement. During this time, the feminist movement gained momentum, and the National Organization for Women was founded to help women achieve equality and give women a voice. Nursing moved forward as well. Specialty care disciplines devel- oped. Advances in technology gave way to the more complex medical–surgical treatments such as cardiothoracic surgery, complex neurosurgical techniques, and the emergence of intensive care environments to care for these patients. Th ese changes fostered the development of specializa- tion for nurses and physicians, creating a shortage of primary care physicians. Th e public demanded increased access to health care, and nursing again stepped forward by developing an advanced prac- tice role for nurses to meet the primary health-care needs of the public.

Th roughout the years, wars created situations that facilitated changes in nursing and its role within society. Wars increased the nation ’ s need for nurses and the public ’ s awareness of nursing ’ s role in society ( Kalisch & Kalisch, 2004 ). Nurses served in the military during both world wars and the Korean confl ict and changed nursing practice during the time of war. For the fi rst time, nurses were close to the front and worked in mobile hos- pital units. Often they lacked necessary supplies

8 unit 1 ■ Professionalism

and equipment ( Kalisch & Kalisch, 2004 ). Th ey found themselves in situations where they needed to function independently and make immediate decisions, often assuming roles normally associated with the physicians and surgeons.

Th e Vietnam War aff orded nurses opportunities to push beyond the boundaries as they functioned in mobile hospital units in the war theater, often without direct supervision of physicians. Th ese nurses performed emergency procedures such as tracheostomies and chest tube insertions in order to preserve the lives of the wounded soldiers ( Texas Tech University, 2017 ). After functioning inde- pendently in the fi eld, many nurses felt restricted by the practice limits placed on them when they returned home.

Challenges for society and nurses continued from the 1980s through 2000. Th e 1980s were marked by the emergence of the HIV virus and AIDS. Although we know more about HIV and AIDs today than we knew more than 30 years ago, society ’ s fear of the disease stigmatized groups of individuals and created fear among global popu- lations and health-care providers. Nurses became instrumental in educating the public and working directly with infected individuals.

Th e increase in available technology allowed for the widespread use of life-support systems. Nurses working in critical care areas often faced ethical dilemmas involving the use of these tech- nologies. During this time period, nurses voiced their opinions and concerns and helped in formu- lating policies addressing these issues within their communities and institutions. Th e fi eld of hospice nursing received a renewed interest and support (National Hospice and Palliative Care Organi- zation [ NHPCO ], 2012 ); therefore, the number of hospice care providers grew and opened new opportunities for nurses.

Th e fi rst part of the 21st century introduced nurses to situations beyond anyone ’ s imagina- tion. Nursing ’ s response to the terrorist attack on the World Trade Center and during the onset and aftermath of Hurricane Katrina raised mul- tiple questions regarding nurses’ abilities to react to major disasters. Nurses, physicians, and other health-care providers attempted to care for and protect patients under horrifi c conditions. Nurses found themselves trying to function “during unfa- miliar and unusual conditions with the health care environment that may necessitate adaptations

to recognized standards of nursing practice” (American Nurses Association [ ANA ], 2006 ).

Nursing has recognized the need for the profession to understand and function during human-caused and natural disasters such as 9/11 and hurricanes. Th e profession has answered the call by increasing disaster preparedness training for nurses.

Nursing and Health-Care Reform

For more than 40 years, Florence Nightingale played an infl uential part in most of the important health-care reforms of her time. Her accomplish- ments went beyond the scope of nursing and nursing education, aff ecting all aspects of health care and social reform.

Nightingale contributed to health-care reform through her work during the Crimean War, where she greatly improved the health and well-being of the British soldiers. She kept accurate records and accountings of her interventions and outcomes, and on her return to England she continued this work and reformed the conditions in hospitals and health care.

Th e 21st century brings both challenges and opportunities for nursing. It is estimated that more than 434,000 nurses will be needed by the year 2024 (Bureau of Labor Statistics [ BLS ], 2017 ). Th e severe nursing shortage has increased the demand for more nurses, whereas the passing of the Aff ordable Care Act (ACA) off ers oppor- tunities for nurses to take the lead in providing primary health care to those who need it. More advanced practice nurses will be needed to address the needs of the diverse population in this country. Health-care reform is discussed in more detail in Chapter 16 .

Nursing Today

Issues specifi c to nursing refl ect the problems and concerns of the health-care system as a whole. Th e average age of nurses in the United States is 46.8 years, and approximately 50% of the nursing workforce is older than 50 ( NCSBN, 2015 ). Because of changes in the economy, many nurses who planned to retire have instead found it nec- essary to remain in the workforce. However, the recent data collected also noted an increase in men

chapter 1 ■ Characteristics of a Profession 9

entering the fi eld as well as an increase in younger and more diverse populations seeking nursing careers.

Concerns about the supply of registered nurses (RNs) and staffi ng shortages persist in both the United States and abroad. For the fi rst time, multi- ple generations of nurses fi nd themselves working together within the health-care environment. Th e oldest of the generations, the early baby boomers, planned to retire during the last several years; however, economics have forced many to remain in the workplace. Th ey presently work alongside Generation X (born between 1965 and 1979) and the generation known as the millennials (born in 1980 and later). Nurses from the baby boomer generation and Generation X provide the major- ity of bedside care. Where the millennials fi nd themselves comfortable with technology, the baby boomers feel the “old ways” worked well.

Generational issues in the nursing workforce present potential confl icts in the work environ- ment as these generations come with diff ering viewpoints as they attempt to work together within the health-care community ( Bragg, 2014 ; Moore, Everly, & Bauer, 2016 ). Each generation brings its own set of core values to the workplace. In order to be successful and work together as cohesive teams, each generation needs to value the others’ skills and perspectives. Th is requires active and assertive communication, recognizing the individual skill sets of the generations, and placing individuals in positions that fi t their specifi c characteristics.

Th e related issues of excessive workload, man- datory overtime, scheduling, abuse, workplace violence, and lack of professional autonomy con- tribute to the concerns regarding the nursing shortage ( Clarke, 2015 ; Wheatley, 2017 ). Th ese issues impact the workplace environment and often place patients at risk. Professional behavior requires respect and integrity, as well as safe practice.