Leddy and pepper's professional nursing pdf

Evidence

Select a challenging nursing care issue (examples include falls, medication errors, pressure ulcers, and other clinical issues that can be improved by evidence in nursing). Do not select a medical issue (disease, medical treatment). Do not select a workforce issue (staffing, call-offs, nurse to patient ratios). Explain the following for the selected clinical issue.

State the issue.
Explain the process you would use to search CINAHL for evidence. Include your search terms.

PROFESSIONAL NURSING

NINTH EDITION

Lucy Jane Hood, RN, PhD Professor and Department Chair, Pre-Licensure Nursing Education MidAmerica Nazarene University Olathe, Kansas

Professor Emeritus Saint Luke’s College of Health Sciences Kansas City, Missouri

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9th edition

Copyright © 2018 Wolters Kluwer

Copyright © 2014, 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins. Copyright © 2003 Lippincott Williams & Wilkins. Copyright © 1998 Lippincott-Raven Publishers. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com, or via our website at lww.com (products and services).

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Library of Congress Cataloging-in-Publication Data

Names: Hood, Lucy J., author. Title: Leddy & Pepper’s professional nursing / Lucy Jane Hood. Other titles: Leddy & Pepper’s conceptual bases of professional nursing |

Leddy and Pepper’s professional nursing | Professional nursing Description: Ninth edition. | Philadelphia : Wolters Kluwer, [2018] |

Preceded by Leddy & Pepper’s conceptual bases of professional nursing / Lucy Jane Hood. Edition 8. 2014. | Includes bibliographical references and index.

Identifiers: LCCN 2017020451 | ISBN 9781496351364 Subjects: | MESH: Nursing Theory | Nursing–trends Classification: LCC RT41 | NLM WY 86 | DDC 610.73–dc23 LC record available at https://lccn.loc.gov/2017020451

This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work.

This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments.

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DEDICATION

To all professional nurses who have a passion for nursing that enables them to share their values, beliefs, and skills to make differences in the lives of others and to shape the nursing profession. To Dr. Susan Leddy and Dr. Mae Pepper, who saw the need for a textbook to meet the needs of registered nurses who were continuing their education. To all the readers of this text who have the courage to take the risk of returning to school or pursuing a professional nursing career. To the following persons whose actions, values, and beliefs enabled me to live out my dream of being a professional nurse: my parents, Bob and Helen Chamberlin; Mary Belle Hickey, RN, my first nurse manager, who always challenged me to be the best possible nurse and gave me the confidence to pursue higher education; my dear mentor, Dr. Susan Leddy, professor of nursing who showed me the essence of nursing scholarship; and my loving husband, Michael, who selflessly gives me the time, support, and humor to live out my dreams.

L.J.H.

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In Memory

J. Mae Pepper January 18, 1936–March 19, 1997 For 20 years, Mae was Susan Leddy’s colleague, coauthor, mentor, and friend. In 1977, Mae joined the faculty at Mercy College in Dobbs Ferry, New York. Mae’s previous teaching experience at the University of North Carolina-Chapel Hill, New York University, and Bronx Community College, as well as her vision, wisdom, and dedication, was crucial to the development and accreditation of the new baccalaureate program for registered nurses and to the subsequent development of the first master’s program at the college.

Mae held the position of Chairperson of the Nursing program from 1981 until her sudden death in March 1997 from a ruptured aortic aneurysm. Although she talked for years about leaving administration in order to do more scholarly work, she continued to serve as Chair out of a sense of duty and responsibility. She was devoted to the students and faculty, and very conscientious in her service to the College and many civic and professional organizations.

Mae found time to read voraciously, listen to music, care for animals, and to enjoy outdoor white-water rafting, camping, and bird watching. She loved her garden, was a careful craftsperson in her furniture refinishing, and liked to go to garage sales and flea markets looking for collectibles. Mae had a good sense of humor and loved a good time. Devoted to her friends and family, she willingly gave time and attention to anyone who asked. She was a great listener, and her counsel was always wise and kind. Mae lived her belief in mutuality, genuineness, and respect for others.

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Susan Kun Leddy February 23, 1939–February 23, 2007 For 14 years, Susan was my mentor and friend. We met in 1993 when I became a doctoral student at Widener University. Susan had a long distinguished career in nursing education. She set high academic standards for herself and also expected her students to attain them. Her favorite question posed to us was “So what?” thereby forcing us to verify the significance of what we said or wrote.

Susan earned a Bachelor of Science nursing degree from Skidmore College in New York in 1960. In 1965, she completed a master of science in nursing degree from Boston University. She completed a doctor of philosophy degree in 1973 at New York University. Never wanting to stop learning, she did postdoctoral work at Harvard University in 1985 and the University of Pennsylvania from 1996 to 1998.

During her first 4 years as a nurse educator, Susan taught in diploma schools and taught in the baccalaureate program at Columbia University before completing her doctoral studies. She and three other faculties founded the RN-BSN program at Pace University. In 1976, she was asked to do a feasibility study and generate a proposal to the state of New York to develop a new RN-to-BSN nursing program at Mercy College. As program chair, Susan and Mae Pepper both opened the program in 1977. The two of them realized the need for a textbook to meet the needs of registered nurses returning to school for baccalaureate education and co-wrote Conceptual Bases for Nursing Practice that was first published in 1981. After a trip to Wyoming, Susan became enthralled with the mountains. She moved to the state and became the first dean of the School of Nursing at the University of Wyoming in 1981. In 1984, she was appointed as the Dean of the reconstituted College of Health Sciences at the University of Wyoming. In 1988, she returned to the East Coast as the Dean of the School of Nursing at Widener University in Chester, Pennsylvania until 1993 when she gave up her administrative position to assume teaching responsibilities mainly in the doctoral program.

Susan was a prolific scholar and has many journal publications. After her retirement and while battling breast cancer, Susan continued to write. In addition to previous editions of this text, she authored Integrative Health Promotion: Conceptual Bases for Nursing Practice and Health Promotion: Mobilizing Strengths to Enhance Health, Wellness & Well-Being. Both of these books received Book of the Year Awards from the American Journal of Nursing.

Susan made time to travel and visited nearly every place in the world. She found her trips exhilarating and stimulating. She incorporated many of the ideas from her travels into her Human Energy Model. Susan also enjoyed quilting, weaving, and dabbling in watercolors. She was very energetic and always had a project to accomplish.

Susan deeply loved her daughters, Deborah and Erin, and made certain that they had what they needed to pursue successful lives. She adored her granddaughter, Katie, who always got her to laugh and smile even through some very rough times.

Susan exemplified the life of a true scholar, superb teacher, and devoted mother. It is my hope to live up to the standards of my beloved mentor and friend. I miss her great words of wisdom and support.

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Contributor

Karen D. Wiegman, PhD, MSN, RN Dean, School of Nursing and Health Science, Professor MidAmerica Nazarene University

Olathe, Kansas

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Reviewers

Elizabeth W. Black, MSN, RN Assistant Professor Gwynedd Mercy University Gwynedd Valley, Pennsylvania

Billie Blake, RN, MSN, BSN, EdD, CNE (Retired) Associate Dean of Nursing St. Johns River State College Orange Park, Florida

Laura Blank, RN, MSN Associate Clinical Professor Northern Arizona University Flagstaff, Arizona

Annie Boucher, RN, MScN Professor Cambrian College Sudbury, Canada

Mary Boylston, EdD, MSN, BSN, AHN-BC Assistant Professor Eastern University St. Davids, Pennsylvania

Beryl K. Broughton, MSN, CRNP, CS, CNE Nursing Faculty ARIA Health School of Nursing Trevose, Pennsylvania

Jennifer Bryer, PhD Acting Assistant Dean, Chairperson, Associate Professor Farmingdale State College Farmingdale, New York

Kathy Burlingame, EdD, MSN, RN Dean of Nursing Galen College of Nursing Louisville, Kentucky

Paula Byrne, DNP, RN Assistant Professor and Chair The College of St. Scholastica Duluth, Minnesota

Ruth Chaplen, DNP, MSN, BSN Associate Professor Rochester College Rochester Hills, Michigan

Betty Daniels, PhD, RN Assistant Professor Brenau University Gainesville, Georgia

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Karen Davis, DNP, RN, CNE Clinical Assistant Professor University of Arkansas for Medical Sciences Little Rock, Arkansas

Lori A. Edwards, DrPH, MPH, RN, PHCNS-BC Assistant Professor, Associate Director for Global Occupational Health University of Maryland Baltimore, Maryland

Marcus M. Gaut, DNP, RN Assistant Professor The University of Southern Mississippi Hattiesburg, Mississippi

Evalyn J. Gossett, MSN, RN Lecturer Indiana University Northwest Gary, Indiana

Debra Kantor, PhD, RN Associate Professor Molloy College Rockville Centre, New York

Coleen Kumar, PhD, RN Dean of Nursing SUNY Downtown Medical Centre College of Nursing Brooklyn, New York

Kathleen M. Lamaute, EdD, MS, FNP-BC, NEA-BC, CNE Associate Professor Molloy College Rockville Centre, New York

Debra Lee, PhD, BSN, RN Assistant Professor, Dean of School of Nursing and Health Sciences Malone University Canton, Ohio

Rosemary Macy, PhD, RN, CNE, CHSE Associate Professor Boise State University Boise, Idaho

Kari Mardian, MEd, BN, RN Instructor Medicine Hat College Medicine Hat, Canada

Tammie McCoy, BA, BSN, MSN, PhD Professor/Chair Mississippi University for Women Columbus, Mississippi

Valerie O’Dell, DNP, RN, CNE Associate Professor/MSN Program Director Youngstown University Youngstown, Ohio

Teresa O’Neill, PhD, APRN, RNC

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Distance Education Coordinator, Professor Emerita University of Holy Cross New Orleans, Louisiana

Cheryl Passel, PhD Assistant Professor Marian University Fond du Lac, Wisconsin

JoAnne Pearce, MS RNC, APRN-BC Assistant Professor Idaho State University Pocatello, Idaho

Theresa T. Quell, PhD, RN Assistant Dean for Academic Programs Fairfield University Norwalk, Connecticut

Janet Reagor, RN, PhD Interim Dean, Assistant Professor Avila University Kansas City, Missouri

Debra Simons, PhD, RN, CNE, CHSE, CCM Associate Dean College of New Rochelle New Rochelle, New York

Diane Spoljoric, PhD, RNC, FNP Associate Professor Purdue Northwest Westville, Indiana

Nancy Steffen, MSN Instructor Century College White Bear Lake, Minnesota

Alicia Stone, PhD, MS, RN, FNP Professor Molloy College Rockville Centre, New York

Wendy Wheeler, RN, BScN, MN Continuous Nursing Faculty Red Deer College Red Deer, Canada

Sylvia K. Wood, DNP, APRN, ANP-BC Assistant Professor St. Joseph’s College Brooklyn, New York

Ronda Yoder, PhD, ARNP Faculty Pensacola Christina College Pensacola, Florida

Karen Zapko, PhD, CNS, MSN, RN Assistant Professor

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Kent State University at Salem Salem, Ohio

Tamara Zurakowski, PhD Clinical Associate Professor Virginia Commonwealth University Richmond, Virginia

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About the Author

Lucy Hood, PhD, RN is the daughter of an American auto worker. She graduated from St. Luke’s Hospital of Kansas City Diploma Nursing School. She returned to school and earned a BSN from Webster College (now Webster University), an MSN from UMKC, and a PhD in Nursing from Widener University, Chester, Pennsylvania. With 14 years of experience in the areas of medical-surgical and neuroscience nursing, she embarked on a career in nursing education. Dr. Hood currently serves as the Department Chair, Pre- Licensure Nursing Education in the School of Nursing and Health Sciences at MidAmerica Nazarene University in Olathe, Kansas. Prior to her current position, she has more than 25 years of teaching experience in traditional undergraduate, RN to BSN, and graduate nursing programs at Saint Luke’s College of Health Sciences in Kansas City, Missouri and MidAmerica Nazarene University. She also has taught in the Clinical Pastoral Education Program at St. Luke’s Hospital of Kansas City. Professional nursing activities include membership in the ANA, MONA, ONS, NLN, and AANN. She has been a member of the MONA Advocacy Committee which involves political activism. She is a volunteer musician for St. Margaret of Scotland Catholic Church. Currently, she and her husband enjoy antiquing, gardening, and caring for their dachshund, Yoda.

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Preface

In the early 1980s, Susan Leddy and Mae Pepper realized the need for a professional development textbook for registered nurses who were returning to school to earn baccalaureate degrees in nursing. This edition builds on the previous contributions that Leddy and Pepper made in earlier editions of Professional Nursing. So that the memory of Susan Leddy and May Pepper will continue, their names have appeared as part of the book title since 2003.

I express my sincere appreciation to the following persons for their creativity and attention to detail during the revision process: Christina Burns, Senior Acquisitions Editor; Dan Reilly, Associate Development Editor; Amberly Hyden, Editorial Coordinator; Jennifer Clements, Art Director; Holly McLaughlin, Design Coordinator; and Karan Singh Rana and the Production Team staff. A special note of thanks to Dr. Cheryl Stetler for permission to reproduce the Stetler Model of Evidence-Based Practice.

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Organization

The ninth edition is organized into the following sections.

Section 1, Exploring Professional Nursing Section 2, The Changing Health Care Context Section 3, Professional Nursing Roles Section 4, Envisioning and Creating the Future of Professional Nursing

Content revisions to the ninth edition include the following.

Chapter 1: The Professional Nurse Presentation of key core competencies essential for effective professional practice including the Massachusetts Department of Higher Education’s The Nurse of the Future Nursing Core Competencies© along with updates related to the Institute of Medicine’s recommendations for improving nursing practice and education has been updated.

Chapter 2: The History Behind the Development of Professional Nursing Presentation of changes from the early 21st century that continue to impact today’s professional practice.

Chapter 4: Establishing Helping and Healing Relationships Updates from The Agency for Healthcare Research and Quality program TeamSTEPPS® 2.0 has been added to this chapter.

Chapter 9: Health Care Delivery Systems Updated content on the changes made to health care delivery as the revisions to health care delivery in the United States that have occurred during the implementation of the Affordable Care Act.

Chapter 13: Environmental and Global Health Updated information on the state of the global environment has been added and the nurse’s role in disaster planning, mitigation, and recovery for natural and human disasters has been placed here.

Chapter 14: Informatics and Technology in Nursing Practice New and updated content presents more specific information about informatics in health care encountered by nurses in daily practice, improvements in technology for patient safety and other recent technologic advances that affect consumer health, professional practice, and health care delivery. Recognizing that all baccalaureate nursing programs contain a course in community health nursing, the chapter on Community Health Nursing was omitted.

Chapter 15: Nursing Approaches to Client Systems Expanded content on the concept as community as clients appears in this chapter along with career opportunities for nurses in community health settings.

Chapter 16: The Professional Nurse’s Role in Teaching and Learning Updated statistics related to health literacy of Americans is contained within this chapter with implications for nurses to consider when planning and implementing health education.

Chapter 18: Quality Improvement: Enhancing Patient Safety and Health Care Quality This chapter has been co-authored with Karen Wiegman, PhD, RN, CS and provides updated information on Accountable Care Organizations and value-based purchasing.

Chapter 19: The Professional Nurse’s Role in Public Policy This chapter contains updated information about current legislative issues, policies, and professional nursing organization initiatives to improve health care safety and advance the nursing profession. In addition, the chapter highlights specific nurses who have contributed and are currently representing professional nursing in the public policy arena.

Chapter 22: Shaping the Future of Nursing Revised information on the future of nursing practice and education based on predictions from the United States Health Resources and Services Administration and from current futurists who analyze current trends to predict the future.

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Learning Tools

Continued efforts have been made to make this book more “user-friendly” and to engage students in the learning process and in the application of this material to practice. The book received an updated look to facilitate reading and mastery of concepts essential for effective professional nursing practice. Features from the previous editions have been renamed and revised and new features added. In addition to such textbook standards as Key Terms and Concepts, Learning Outcomes, and References, each chapter also includes the following.

Real-Life Reflections (formerly Vignettes): Case studies are presented at the beginning of each chapter and revisited at chapter’s end, highlighting for students the application of the chapter’s content to practice and providing questions for thought as they read the chapter.

Questions for Reflection (formerly Think Time): Questions posed throughout the text help students think about their own life experiences in the context of their learning.

Focus on Research: Current journal articles are synopsized to relate research to learning and practice. Concepts in Practice: Hypothetical clinical situations teach professional nurses how they can best incorporate text concepts into real-life practice.

From Theory to Practice: End-of-chapter questions ask students to think about each chapter’s content in the context of their own lives.

Nurse as Author: Short writing exercises designed to strengthen critical thinking and writing skills. The nature of the written exercise in each chapter relates to and depends upon the nature of chapter content.

Your Digital Classroom: At the end of each chapter, online resources are brought together to provide students with opportunities for further study and reflection. These include Online Exploration (compilation of websites appropriate to each chapter’s content); Expanding Your Understanding (Internet-based exercises); and Beyond the Book (a link to and instructions for accessing the numerous online resources now available with this text).

Text boxes have been categorized to help students identify the purpose of their content.

Professional Building Blocks: Highlight clinical and professional implications. Learning, Knowing, and Growing: Provides students with information to help them grow both personally and professionally.

Professional Prototypes: Provide examples of documents, concepts, philosophies, and more with suggestions for personal and professional growth.

Students who follow the Beyond the Book link to the www.thePoint.lww.com can access

Fully searchable eBook Learning Objectives Literature Assessment Tool (includes current journal articles and questions for students at different experience levels)

Video interviews with RNs relating chapter concepts to practice Spanish–English Audio Glossary Web link exercises Time Management Strategies Nursing Professional Roles and Responsibilities supplemental reading

To facilitate reading, this edition is being printed in full color and photographs have been added to break up large chunks of printed material.

As Mae Pepper and Susan Leddy noted in the preface to the third edition,

During these changing times, we have been pleased with the utilization of our book in many educational settings, particularly in baccalaureate and graduate programs. Although the first edition of the book was targeted for upper division RN baccalaureate programs, we have become aware of its utilization in generic baccalaureate programs, masters programs, and practice settings.

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http://www.thePoint.lww.com
It is my hope that this ninth edition of Professional Nursing will carry on the tradition of previous editions and continue to make a meaningful contribution to the profession.

L.J.H.

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Contents

Section 1 Exploring Professional Nursing

Chapter 1 The Professional Nurse Characteristics of Professional Nursing Practice: The Hood Professional Nurse Contributions Model Core Competencies for Professional Nurses The Multiple Roles of the Professional Nurse Challenges of the Professional Nursing Student Skills for Educational Success Image and Physical Appearance Socialization and Resocialization Into the Nursing Profession Developing a Professional Self-Concept Characteristics of a Profession

Chapter 2 The History Behind the Development of Professional Nursing Nursing in Ancient Civilizations (Before 1 CE) Nursing in the Early Christian Era (1–500 CE) Nursing in the Middle Ages (500–1500) The Establishment of Nursing in Europe, England, and the New World (1500–1819) The Movement of Nursing to a Respectable Profession (1820–1917) The Birth of Formal Nursing Education The American Public Health Movement Nursing During the Early 20th Century, the World Wars, and the Post–World War II Era (1890–1960) Nursing in the Modern Era (1960–1999) Media Portrayals of Professional Nurses Nursing in the Early Postmodern Era (2000–2010) Nursing in the Second Decade of the Postmodern Era and Beyond (2010–20 …)

Chapter 3 Contextual, Philosophical, and Ethical Elements of Professional Nursing Contextual Basis of Nursing Practice Nursing Philosophy Morality and Ethics in Nursing Practice Ethical Decision Making Major Contextual Elements Affecting Nursing Practice

Chapter 4 Establishing Helping and Healing Relationships Communication as Interaction Helping Relationships: The Nurse as Helper Healing Relationships: The Nurse’s Role in Healing Helping and Healing Relationships With Colleagues and Other Health Care Team Members

Chapter 5 Patterns of Knowing and Nursing Science The Evolution of Scientific Thought Philosophy of Knowledge Patterns of Nursing Knowledge The Development of Nursing Science

Chapter 6 Nursing Models and Theories Nursing Models

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The Stability Model of Change The Growth Model of Change Complexity Theory as a Framework Nursing Models in Research and Practice

Chapter 7 Professional Nursing Processes Critical Thinking Cognitive Nursing Processes Interpersonal Processes Psychomotor Processes Patterning Nursing Processes

Chapter 8 The Health Process and Self-Care of the Nurse Worldviews of Health Health Protection and Promotion Health Patterning Implications of the Nurse’s View of Health for Role Performance Self-Care of the Nurse

Section 2 The Changing Health Care Context

Chapter 9 Health Care Delivery Systems Challenges of Health Care Delivery in the 21st Century Selected Current Health Care Delivery Systems Health Care Delivery Settings The Interdisciplinary/Interprofessional Health Care Team Nursing Care Delivery Models Nursing Challenges Related to Health Care Delivery Systems

Chapter 10 Developing and Using Nursing Knowledge Through Research The Research Process in Nursing Nursing Research Utilization and Evidence-Based Practice Creating a Public Image of the Nurse as Scholar

Chapter 11 Multicultural Issues in Professional Practice Diversity and Assimilation in a Shrinking World Establishing Cultural Competence Strategies and Challenges for Multicultural Nursing Practice Creating a Multicultural Nursing Profession

Chapter 12 Professional Nurse Accountability Definition of Accountability and Related Concepts Professional Accountability The Groundwork for Accountability Accountability in an Era of Cost Containment Accountability in the Future Checklist for Accountability

Chapter 13 Environmental and Global Health The Global Environment The Community Environment The Work Environment The Home Environment Comprehensive Environmental Health Assessment The Nurse’s Role in Disaster Planning, Mitigation and Recovery

Chapter 14 Informatics and Technology in Nursing Practice

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Informatics and Health Care The Informatics Nurse Specialist Consumer Health Informatics in Practice Educational Informatics Technology in the Acute Care Clinical Setting Technologic Changes Affecting Nursing Practice and Health Care Challenges in Managing Health-Related Informatics and Technology

Section 3 Professional Nursing Roles

Chapter 15 Nursing Approaches to Client Systems The Individual as Client The Family as Client The Community as Client Hallmarks of a Healthy Community Community-Level Nursing Interventions Career Opportunities in Community Health Nursing

Chapter 16 The Professional Nurse’s Role in Teaching and Learning Health Literacy Philosophical Assumptions About Teaching and Learning Teaching–Learning Process Approaches Teaching–Learning as a Responsibility of the Advocate Learning Theories Implications of Change Theory on Teaching–Learning Strategies for Effective Teaching and Learning Specific Client Education Activities Client Education as an Interdisciplinary Process

Chapter 17 Leadership and Management in Professional Nursing Conceptual and Theoretical Approaches to Nursing Leadership and Management Leadership Development Key Leadership and Management Skills for Nurses Leadership Effectiveness Evaluating Leadership Effectiveness

Chapter 18 Quality Improvement: Enhancing Patient Safety and Health Care Quality History of Quality Improvement in Health Care The Need for Improved Patient Safety and Care Quality Quality Improvement Approaches Implementing Continuous Quality Improvement and Total Quality Management Efforts to Improve the Quality of Health Care Professional Nursing Roles in Quality Improvement An Integrated Approach to Quality Improvement and Safety in Health Care

Chapter 19 The Professional Nurse’s Role in Public Policy The Kingdon Model for Political Processes The Nurse’s Role in Influencing Public Policy Current Political and Legislative Issues Affecting Professional Nursing Practice and Health Care Examples of Nurses Influencing Public Policy Opportunities to Learn the Art of Influencing Public Policy

Section 4 Envisioning and Creating the Future of Professional Nursing

Chapter 20 Career Options for Professional Nurses

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Universal Job Skills Levels of Nursing Practice General Nursing Career Opportunities Advanced Nursing Practice Career Options Opportunities for APRNs Indirect Client Care Advanced Nursing Career Options

Chapter 21 Development of a Professional Nursing Career Values and Career Goals Discovering Your Passion in Nursing Envisioning Your Nursing Career Networking Mentoring Career Development Strategies Making a Nursing Career Change

Chapter 22 Shaping the Future of Nursing A Conceptual Approach to the Future Future Scenarios for Society and Health Care Future Scenarios for Health Care Delivery Evolving Health Care Needs and Health Care Delivery The Future of Professional Nursing Practice The Future of Nursing Education The Future of Nursing Scholarship

Appendix Index

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Section 1 EXPLORING PROFESSIONAL NURSING

To people outside the nursing profession, being a nurse means taking care of those who are ill or injured, in a variety of complex and sometimes chaotic situations. Nurses make key contributions in the delivery of health care services by providing safe, high-quality care to individuals, families, and groups. Since its beginning, however, nursing has struggled to attain professional status. The therapeutic relationships nurses establish with clients play a significant role in making differences in the lives of the people they serve. Learning the art and science of nursing requires time and perseverance. When nurses provide solid evidence of their impact on client outcomes, the unique contributions they make become apparent to the other members of the health care team and to the public. Professional nurses engage in lifelong learning to remain competent in the areas of clinical practice.

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Chapter 1

The Professional Nurse

KEY TERMS AND CONCEPTS Professional nurses Professional nurse contributions model Core competency Nurse of the Future Nursing Core Competencies© Caregiver Client advocate Teacher Change agent Coordinator Counselor Colleague Socialization Resocialization Role theory Role Role conflict Returning-to-school syndrome Transitions Professional self-concept Novice-to-expert model Characteristics of a profession Associate’s Degree in Nursing (ADN) Diploma nursing program Bachelor of Science in Nursing (BSN) Differentiated competencies Graduate nursing education Postgraduate nursing education Critical thinking Creative thinking Reflective thinking Autonomy State boards of nursing Licensure Professional organizations General-purpose nursing organizations Specialized nursing organizations National League for Nursing (NLN) American Association of Colleges of Nursing (AACN) National Council of State Boards of Nursing (NCSBN) American Nurses Association (ANA) International Council of Nurses (ICN) Sigma Theta Tau International (STTI) National Student Nurses’ Association (NSNA) Ethical codes

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LEARNING OUTCOMES By the end of this chapter, the learner will be able to:

1. Outline key elements for professional nursing contributions to health care.

2. Identify strategies for thriving in the nursing education environment. 3. Specify a process for socialization into the profession. 4. Discuss methods to facilitate socialization and resocialization into the nursing profession. 5. Outline a process for developing a professional self-concept. 6. Identify the characteristics of a profession. 7. Explain how nursing meets the characteristics of a profession. 8. Discuss additional work that needs to be done to fulfill all characteristics of a profession and attain professional status on a par with that of

other professions.

REAL-LIFE REFLECTIONS Sue graduated from an Associate’s Degree in Nursing (ADN) program and has been working as a night charge nurse on a medical-surgical unit. Her nurse manager recently hired a new nurse with a Bachelor of Science in Nursing (BSN) degree. Sue thinks that perhaps she should go back to school and earn a BSN in order to feel secure about her current position. While speaking with a friend, Sue says, “I am a good nurse even though I don’t have a BSN. I don’t see how more education will make me more professional or improve my patient care, but I see where it may make my charge nurse position secure.”

What assumptions has Sue made relative to the importance of education in nursing practice? How would you respond to her? What are your thoughts about the BSN and higher education for nurses?

Professional nurses comprise the largest group of health care workers in the United States. More than 3 million registered nurses (RNs) are living in the United States, about 2.8 million of whom are employed as professional nurses (Kaiser Family Foundation, 2016; U.S. Bureau of Labor Statistics [BLS], 2015a [U.S. Department of Health & Human Services, 2014]). Professional nurses are RNs with a broad scope of practice that is determined by each state.

Some people consider all caregivers as “nurses.” This logical confusion stems from the fact that people who tend to the sick, injured, disabled, or elderly commonly have the word “nurse” in their job title, such as nursing assistants or licensed practical/vocational nurses (LPN/LVNs). However, professional nurses offer a specialized service to society. They assume ultimate accountability for client outcomes, and they supervise and educate LPN/LVNs and unlicensed assistive personnel (UAP) as they assist in nursing care delivery. Although they frequently perform tasks that could be done by other health team members, professional nurses bring an ability to improvise while individualizing client care in a variety of settings. Professional nurses use science and theories as a basis for professional practice along with art when modifying care approaches. Thus nursing is often considered both an art and a science (see Box 1.1, Professional Prototypes, “Essential Features of Professional Nursing”).

1.1 Professional Prototypes Essential Features of Professional Nursing

Professional nurses assume responsibility to the public for using the best evidence to provide safe, high- quality health-related services for all whom they serve. In Nursing’s Social Policy Statement, the American Nurses Association (2010) identified the following “key essential features of professional nursing” (p. 9). 1. Provide “a caring relationship” that facilitates health and healing. 2. Attend “to the range of human experiences and responses to health and illness within the physical and

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social environments.”

3. Integrate “assessment data with knowledge gained from an appreciation of the patient or the group.” 4. Apply “scientific knowledge to the process of diagnosis and treatment” by using “judgment and critical

thinking.” 5. Advance “professional nursing knowledge through scholarly inquiry.” 6. Influence “social and public policy to promote social justice.” 7. Assure “safe, quality, and evidence-based practice.”

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CHARACTERISTICS OF PROFESSIONAL NURSING PRACTICE: THE HOOD PROFESSIONAL NURSE CONTRIBUTIONS MODEL

As interdisciplinary health team members, nurses make many unique contributions to health care delivery in clinical settings. The Professional Nurse Contributions Model (Fig. 1.1) synthesizes the affective, cognitive, behavioral, and psychomotor domains of professional practice. The model’s circular form designates how the interprofessional health care team surrounds health care consumers. A solid outer circle emphasizes the importance of all team members working cohesively for the benefit of care recipients. Each of the concepts in this model is integrally connected to the others to result in a unified whole.

In an ideal world, all health care team members share an altruistic attitude toward the individuals they serve. Many people enter the nursing profession because they genuinely care (caring) about other people and have a desire to help others in time of need (compassion). Caring, compassion, and commitment are the key affective domains for optimal professional nursing that are intricately linked and comprise the outer circle of the model. The attitudes of caring, compassion, and commitment are key for nurses to view nursing as a profession rather than just a job. Two additional attributes of nurses that are closely linked are competence and confidence. Clients expect competence from health care providers. Likewise, health care providers expect competence from each other. To provide safe, effective patient care, nurses must have competence with clinical skills and decision making. Many nursing education programs use simulations with high- or low- fidelity manikins to provide students with the opportunities to learn essential clinical skills and clinical decision making in a safe learning environment (Wilson & Rockstraw, 2012). Current literature emphasize that students gain and retain knowledge, learn clinical skills, and develop confidence in nursing abilities from simulated learning experiences (Alexander et al., 2015; Aqel & Ahmad, 2014; Engum & Jeffries, 2012; Weaver, 2011).

Before competence can be achieved, however, professional nurses must have confidence in their ability to execute the clinical, communication, and cognitive skills needed for effective practice. Simulated clinical experiences in nursing education also build confidence in nursing students (Weaver, 2011). As the nurse’s confidence improves, he or she becomes willing to question orders and actions by others that may not appear to be logical or safe. Patients and families feel more at ease when receiving care from a confident nurse. For example, the nurse who knows how to start an IV line and has confidence in his or her ability will attempt to start IVs. As the nurse gains experience in starting IVs, he or she refines his or her technique and eventually possess the ability to start IVs in any patient. The nurse’s colleagues identify him or her as the IV starting expert on the unit (confidence booster). The nurse gains more experience starting IVs even when colleagues cannot (increasing competence). Thus, there appears to be a symbiotic relationship between confidence and competence in nursing practice.

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FIGURE 1.1 Hood’s professional nurse contributions model.

The innermost circle in the model depicts the overlapping skills and circumstances with which nurses must work and cope. The roles assumed by nurses require that they have a repertoire of clinical, cognitive, and communication skills. The nurse must always have sound reasons behind clinical decisions and actions and be able to communicate the reasons well. A broad knowledge base related to all information and strategies available enable the nurse to decide the best course of action to take in any given clinical situation. Highly refined clinical, cognitive, and communication skills delineate professional nurses from all other members of the health care team.

Nurses deliver health care in complex systems, so it is important that they understand the nature of these systems and are able to manipulate them. Wiggins (2008) described health care systems as complex adaptive systems in which interdependency exists among individuals and groups. Each individual’s actions within complex adaptive systems are based on current knowledge and past experiences. Just like the human body is composed of interacting systems, the client is part of a community, communities form states, states form nations and nations are part of the global community. The earth is part of a solar system which is part of a galaxy which is part of the universe.

Nurses frequently encounter complicated client situations and must adapt to change as new scientific evidence emerges, reforms occur in legal aspects of health care delivery, and, most importantly, patient conditions fluctuate. Finally, professional nursing practice has an element of unpredictability and disorder that is conceptualized as chaos. Nurses continuously make complex and multiple decisions and may bring order in today’s clinical environments. Once order is achieved, something occurs that results in disorder. The pattern of ever-emerging chaos creates constant challenges for nurses. Upon acknowledgment of the deeper underlying, uniform pattern of chaos, nurses understand that they cannot control all clinical practice events. Even though a clinical setting may have a well-defined organization, nurses must adapt to and work in an ever-changing, highly complex, and chaotic environment.

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CORE COMPETENCIES FOR PROFESSIONAL NURSES

The concept of core competency arose in the 1990s. A core competency can be defined as “a defined level of expertise that is essential or fundamental to a particular job; the primary area of expertise; specialty; the expertise that allows an organization or individual to beat its competitors” (Dictionary.com, n.d.). In professional nursing, core competencies are fundamental knowledge, abilities, and skills that enable nurses to provide safe, effective care to other persons in health care settings. In many health care settings, professional nurses are expected to display competence in a particular area of practice on an annual basis. Frequently, nursing staff development departments design and deploy activities to verify that nurses possess a certain level of competence with the knowledge and skills appropriate to their clinical practice areas.

In 1973, the American Nurses Association (ANA) published the first Standards of Nursing Profession. The goal was to develop a generic list of standards for professional nurses that would apply across practice settings. The standards primarily focused upon nursing process (assessment, diagnosis, planning, implementation, and evaluation) which at the time articulated a thinking model for all nurses to use in clinical practice. As time passed, the original standards of nursing practice have evolved into the Scope and Standards of Nursing that outline all key elements of professional nursing practice including nursing process and key competencies (knowledge and skills) for meeting each standard of professional practice. Although the competencies are designated, the execution of each competency may be context dependent. For example, Standard 3 Outcome Identification and Standard 4 Planning specify that the patient, significant others, and other health team members should be involved in determining the desired outcomes and how to achieve them (ANA, 2015c). If the patient is unconscious or has been legally declared mentally incompetent, then the patient is unable to be an active participant in the determination of care goals and planned actions to attain them.

By the 1990s, the ANA recognized the need to develop standards of practice for nursing specialty areas and collaborated with the nursing specialty organization to develop context-based scope and standards or practice including those for school faith community, psychiatric–mental health, transplant, holistic, pediatric, forensic, hospice and palliative care nursing, and nursing administration. The ANA’s (2015c) third edition of the Nursing: Scope and Standards of Practice, contains 6 standards addressing nursing process (assessment, diagnosis, outcome identification, planning, implementation, and evaluation) and 11 standards related to professional performance (ethics, culturally congruent practice, communication, collaboration, leadership, education, evidence-based practice and research, practice quality, professional practice evaluation, resource utilization, and environmental health) (ANA, 2015a). Disposing used needles and sharp implements (e.g., needles, disposable scissors) into hard, impermeable boxes labeled “biohazard” is an example of a competency related to environmental health. In 1990s, the Institute of Medicine (IOM) published a series of reports outlining safety and quality concerns within the American health care system. The Robert Wood Johnson Foundation provided funding to Linda Cronenwett, PhD as principal investigator and the American Association of Colleges of Nursing (AACN) for the Quality Safety Education for Nursing Initiative to develop strategies for nursing practice and education for continuously improving and enhancing safety in health care delivery. During the first phase of the project, the following six core competencies were identified for professional nursing: “patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, informatics, and safety” (QSEN Institute, 2014, para 4). Along with identifying the competencies, the initiative developed sets of knowledge, skills, and attitudes for each of them. The project initially addressed pre-licensure nursing education, but eventually was expanded to address graduate nursing education (QSEN Institute, 2014).

In March 2006, the Massachusetts (MA) Department of Higher Education and the MA Organization of Nurse Executives held a workshop Creativity and Connections: Building the Framework for the Future of Nursing Education and Practice that was attended by 32 key stakeholders in nursing education and practice. An outcome of the workshop was the formation of a subcommittee to develop a set of core professional nursing competencies to facilitate a seamless continuum for progression in nursing education. Between 2006 and 2009, the committee reviewed the best practices, standards and initiatives education progression to create a list of nursing competencies for each level of nursing education. Results of the review were compiled into a set of 10 core competencies that were then compared to outcomes required for associate degree and baccalaureate degree program accrediting agencies. Funded by the MA Department of Higher Education and the Johnson and Johnson Promise of Nursing for the MA Nursing School Grant Program, the Nurse of the Future Competency Committee identified 10 core competencies that are essential for professional nursing practice known as The Nurse of the Future Nursing Core Competencies© (Fig. 1.2). The identified competencies are patient-centered care, professionalism, leadership, systems-based practice, information and technology,

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http://Dictionary.com
communication, teamwork and collaboration, safety, quality improvement, and evidence-based practice (Massachusetts Action Coalition, 2014; Massachusetts Dept. of Higher Education, 2010). Similar to QSEN competencies, each one of The Nurse of the Future Nursing Core Competencies© contain specific knowledge, skills, and attitudes for nurses to display. The identified competencies include the hallmarks of baccalaureate education: systems-based thinking, evidence-based practice, and nursing leadership (AACN, 2008). Table 1.1 links the Hood Professional Contributions Model with The Nurse of the Future Nursing Core Competencies©. Caring, compassion, commitment, and confidence are the key attitudes that provide the affective domain of professional nursing practice. Caring and compassion denote the nurse’s genuine concern for others and a desire to help them. When a nurse displays confidence in what is being done as a professional, recipients of nursing care, other health care team members, and the public perceive that the nurse possesses the knowledge, skill, and attitude for effective role performance. Competence ascertains that nurses are capable of performing skills (cognitive, clinical, and communication) effectively to provide safe, optimal care. Complex systems, chaos, and change describe the clinical practice environments of professional nurses.

FIGURE 1.2 Massachusetts Nurse of the Future Nursing Core Competencies Graphic.

TABLE 1.1 Hood’s Professional Nursing Contributions Model and the Nurse of the Future Nursing Core Competencies© Linkages

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THE MULTIPLE ROLES OF THE PROFESSIONAL NURSE

Nurses assume multiple roles while meeting the health care needs of clients. They serve as caregivers when providing direct client care. Their client advocate role emerges when they intervene on behalf of clients to ensure that adequate information and decision-making resources are provided and that client wishes are respected at all times. They assume the role of teacher when providing education to UAP, clients, family members, students, each other, and interprofessional colleagues. When working to reform public policy, modify work processes, or transform workplace environments, nurses become change agents. They accept the role of coordinator when assuming supervisory and managerial responsibilities. Nurses also act as counselors, providing emotional and spiritual support to clients. Finally, they assume the role of colleague among all health team members. To execute these multiple roles effectively and with genuine compassion, nurses must commit themselves to lifelong learning.

Take Note! To execute multiple roles effectively and with genuine compassion, nurses must commit themselves to lifelong learning if they are to effectively and compassionately execute their multiple

roles.

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CHALLENGES OF THE PROFESSIONAL NURSING STUDENT

Anyone who assumes the role of professional nursing student will need to make lifestyle changes to be successful. The added responsibilities of nursing school means that life as previously known will be greatly altered. Previous routines will be disrupted and personal sacrifices will be needed. Money once used for recreation is spent on tuition, student fees, books, and other school supplies. Less time is available to spend with family and friends. Families and friends have different reactions as the nursing student role is assumed. The reactions vary from feeling neglected (which may result in actions to derail the educational process) to intense pride (as they watch their significant other grow). Ongoing communication between the new student, family, and friends enables all involved parties to understand how roles will be altered and what lifestyle changes will need to occur (Dunham, 2008; Quan, 2006).

Meeting job and school responsibilities may be challenging for employed students. Employers may not support educational endeavors. Some coworkers may add to the difficulties by complaining about or refusing work schedule changes; others may express pride in their colleague and help to accommodate the student’s schedule.

Part of the toll of returning to school is entering into unfamiliar learning situations. The once-confident honor student or professional nurse may question his or her ability to survive in an intense academic program. The educational process is designed to change people. During times of change, people frequently encounter feelings of discomfort.

REAL-LIFE REFLECTIONS Remember Sue, from the beginning of the chapter. What obstacles might she encounter at home and in the workplace if she decides to return to school? Can you suggest strategies Sue can use to defray the potential chaos that returning to school might bring?

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SKILLS FOR EDUCATIONAL SUCCESS

In ideal educational situations, students and faculty interact with each other as colleagues. Faculty design educational experiences and students bear the responsibility for active engagement in learning activities. In traditional education, faculty members serve as authoritarian experts who impart knowledge to students and may create oppressive climates. In educative-caring education, students and faculty members hold equal status and faculty members strive to create effective learning climates based on active and participative learning (Bevis & Watson, 2000; Billings & Halstead, 2005; Young & Paterson, 2007). Such egalitarian interactions with faculty members provide students with experience in collegiality.

When students assume responsibility for learning, they reap maximum benefits from the educational process. To make professional transitions, nurses focus their educational efforts on refining previously learned skills while establishing theoretical foundations for professional practice. Theory-based practice enables professional nurses to understand complex situations and anticipate potential complications in clinical settings. Learners need a variety of skills to be successful in the educational process.

Take Note! To make the most of the educational process, students must assume responsibility for learning and utilize a variety of skills.

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Reading, Listening, and Speaking

Reading constitutes a major component of a successful education experience, but finding time to read remains a challenge for today’s busy students—especially as they juggle multiple roles. Effective reading skills streamline the study process. Trying to read and digest each word printed on a page (or screen) is inefficient. When students master the skill of reading for major ideas within a passage, reading becomes more efficient (Dunham, 2008; Osuna, 2014). Strategies to develop reading effectiveness and efficiency include reading for general understanding of ideas, using learning outcomes to identify key concepts, taking notes while reading, highlighting key points, and taking brief reading breaks between major headings within a chapter. During reading breaks, some students find it beneficial to paraphrase what has been read.

In educational settings, effective speaking and listening skills are essential to success. Students listen to faculty members as they share their nursing expertise. Taking time to think before responding to faculty- posed questions enables better organization of thoughts and selection of the best words to convey an answer. Most nursing programs require that students give oral classroom presentations to facilitate refinement of public speaking skills.

Asking questions is essential to avoid making errors in both education and health care settings. Most people (especially clinical nursing faculty and nurses) welcome questions from students. However, fear prevents some students from asking questions. Sometimes, the most difficult task to master is learning what questions need to be asked and having the courage to ask them.

Because nursing relies on teamwork, faculty frequently assign group project. Some students dread group projects because of the difficulty finding time to connect with group members. Osuna (2014) offers the following suggestions to survive group projects: 1. Provide all members of the group with contact information to facilitate the sharing of project information. 2. Appoint a group leader who organizes the project timeline, requests member project sections, pulls the

entire project together for a finished product (edits writing for consistent style and finalizes required formatting), serves as a resource person and tackles issues when they arise.

3. Develop a project timeline with the equal input of all group members. 4. Define specific tasks (including the format for each member to submit the section to the leader) required

for the project and make group assignments. 5. Hold all members accountable for sections of the project. 6. Communicate openly, timely, and respectfully.

Hopefully, by following the aforementioned suggestions, the project gets completed following instructions outlined in the course syllabus. When problems arise, the group should be able to manage them. However, sometimes faculty involvement may be needed should an irreconcilable issue arise.

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Writing

Writing is another critical skill for educational and career success. Professional nurses use writing skills to document client care, develop clinical practice policies, compose email messages and letters, publish articles, develop budgets, and submit change proposals (Fig. 1.3). Writing requires nurses to use critical and reflective thinking (Broussard & Oberleitner, 1997).

FIGURE 1.3 Writing by hand in the clinical setting enables the professional nurse to have key information readily available for change of shift reports, report key patient information to physicians, and record patient assessments in the event of computer failure.

Written course assignments provide opportunities to polish writing and thinking skills. Success requires understanding the purpose of the writing assignment, setting a timeline for completion by the designated deadline, allowing time for multiple drafts, and having a trusted friend or family member proofread the work before submission.

Perhaps the most difficult aspect of preparing an assignment is narrowing the topic appropriately to fit assignment criteria and enabling a realistic approach for gathering relevant and reputable resources among the vast sources of information. Librarians and faculty welcome the opportunity to help students secure reliable resources such as books, peer-reviewed journal articles (online, in print, or on microfilm), nursing experts, government documents, and online information from academic, nonprofit organizational nurse specialty group and government websites (Dunham, 2008; Stebbins, 2006).

Students should be cautious when considering information from for-profit sources and some special interest organizations. If an assignment requires detailed information about a particular medication, then perhaps the drug manufacturer’s website might contain appropriate information. However, some websites serve as a “virtual soapbox” for any person, organization, or company. Health professionals and students must carefully evaluate the validity of information from websites used for personal, professional, and client education (Table 1.2).

Hyperlinks appearing within a website may send viewers to websites of lesser quality. Some website information can disappear without warning, and unless the website has security mechanisms, the information may be susceptible to unauthorized and accidental changes (Alexander & Tate, 1998; Stebbins, 2006; University of Southern Maine, 2012). For example, any person who accesses the online encyclopedia, Wikipedia, has the capability to change posted information. Therefore, this particular site should not be considered a reliable resource.

Writing style for student work varies according to assignment criteria. Nonfiction prose can be developed using description, narration, exposition, and argumentation. Description is used to create a dominant impression. When storytelling is the goal, narration serves as an effective tool. Exposition, which is used to show the how and why of something, can employ one or more of the following tools: (1) exemplification (providing illustrations or examples for a concept); (2) process analysis (giving step-by-step instructions for how to do something); (3) compare and contrast (outlining similarities and differences); (4) analogy (comparing something unknown to something familiar); (5) classification (placing into groups based on common features); (6) definition (explaining the meaning of something); and (7) causal analysis (outlining cause-and-effect relationships). Finally, argumentation can be used to present an objective rationale to support a position (Fondiller, 2007). A casual or informal debate among friends or colleagues involves a presentation

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of diverse viewpoints based on personal opinions. However, a scholarly debate consists of having some form of evidence (scientific, statistical, research, or ideally information from a peer-reviewed reference) to substantiate the various views being discussed.

TABLE 1.2 Guidelines for Evaluating Online Information

Effective writing requires that authors select words to convey messages clearly. Reading serves as a vehicle to expand vocabulary that can be used in writing (Fondiller, 2007; Martinez, 2000). Dictionaries and thesauri provide a rich source of words for use in writing. Many dictionaries also provide grammatical rules for written language, and word-processing programs offer spelling and grammar check features. Some writers find it useful to read aloud written passages (Dunham, 2008).

Most educational programs have a standard format for written assignments. Students enrolled in these programs should purchase the publication manual for the selected format. Students also may find internet sites that provide assistance with questions about frequently encountered formats such as the American Psychological Association guidelines for manuscript preparation. However, nothing supersedes proofreading by another person to verify that what is written clearly communicates the intended ideas and follows the proper writing guidelines.

In recent years, much attention has been paid to plagiarism. Use of computers and the internet can entice students to cut and paste large pieces of text into assignments and then pass it off as their own work. Plagiarism is best avoided by citing all sources used, avoiding the use of too many citations, paraphrasing and summarizing information carefully, limiting the use of direct quotations, and never purchasing a paper from a friend or paper mill (Stebbins, 2006).

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Organizational Skills

Scholastic success requires good organizational skills. Previously learned organizational skills transfer readily in helping to balance personal and professional responsibilities. Work–life–school balance means simply to have a feeling of control, achievement, and enjoyment in daily life (Malloy, 2005; Young & Koopsen, 2011). Key organizational skills for success include managing information, refining test-taking skills, and managing personal time.

Managing Information

The enormous amount of information that one must review, evaluate, and study to remain current in today’s professional practice environment challenges all nurses, not just students. Scientific discoveries and changes in health care delivery systems surface quickly. Students and professional nurses spend much time sorting through large volumes of correspondence, publications, advertisements, and professional information. Going through information immediately as it arrives eliminates clutter. Setting priorities for action facilitates meeting professional, personal, and school deadlines. Time spent organizing personal libraries and files saves time by making available resources easier to find (Dunham, 2008; Osuna, 2014; Quan, 2006). To stay abreast of the latest information, some nurses subscribe to online newsletters and service lists (LISTSERV) that offer summaries of new developments in the health care arena.

Refining Test-Taking Skills

Testing serves as a means for assessing learning, yet many students find test taking stressful. Optimal test preparation, which increases the chance of a favorable performance, includes reading all required class assignments, attending class, asking questions during class, taking notes, reviewing learning objectives for each class, reviewing class materials frequently, attending test reviews (if available), and talking with faculty members to clarify content when needed. Some students find they are better prepared if they participate in a peer study group, establish a study schedule, make audiotapes of class sessions (if permitted), outline readings, recopy notes, or create study cards (Dunham, 2008; Osuna, 2014).

Some students become overly anxious during examinations, which may result in poor performance. For some students, a bit of stress may be helpful. Each student perceives stress in a different manner. However, when stress produces anxiety, the following tips might be helpful: arriving 15 minutes early to the test site, practicing relaxation techniques (deep breathing exercises, visualizing success, and guided imagery), skimming notes and textbooks, and talking with classmates. Quan (2006) and Osuna (2014) suggest that study groups offer the opportunity to talk with others about the content covered in courses while also helping to establish new friendships. Complementary health practices such as aromatherapy (e.g., smelling the essential oil of mandarin [citrus reticulate], which evokes feelings of calmness, thereby allaying anxiety) may be also useful (Leddy, 2003).

Managing Personal Time

Time takes on paramount importance for all students enrolled in a nursing program because of role conflicts. Balancing work, professional, student, and family responsibilities is an art. Family members may feel neglected. Scheduling time to tend to the needs of family and friends may provide a welcome study break and facilitate the maintenance of optimal mental and spiritual health (Dunham, 2008; Malloy, 2005; Osuna, 2014).

Success in education requires a team effort. Learning to say no and asking for help without feeling guilty are essential time management techniques. Delegation of household tasks (such as cooking, cleaning, and laundry) to other family members frees time for study while providing other family members with an opportunity to learn or refine life survival skills (Dunham, 2008; Malloy, 2005; Quan, 2006). Finally, networking with one’s colleagues can result in time saving ideas, such as sharing quick, easy recipes.

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IMAGE AND PHYSICAL APPEARANCE

Physical appearance plays a role in projecting a professional image. Nursing caps became obsolete in the 1970s, and nurses quickly abandoned their white uniforms for colorful scrub suits and dresses. Clean, pressed scrubs and dresses present a professional appearance. However, when nurses wear printed scrubs with cartoon characters, they may fail to project the desired professional image unless they are working with children.

Cleanliness and safety should be priorities when preparing for professional practice. Clean clothing, well- manicured natural nails, and clean shoes decrease the spread of infection. Dangling earrings and necklaces serve as hazards for nurses if they encounter confused or combative clients. Tongue piercing impairs the clarity of a nurse’s speech. Visible body piercing and extensive tattooing might create distress for some clients. Clients have more confidence in nurses who display a professional appearance.

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SOCIALIZATION AND RESOCIALIZATION INTO THE NURSING PROFESSION

Nurses who assume a different role undergo the processes of socialization and resocialization. In simple terms, socialization is the process of preparing someone for a particular societal role. The definition of professional socialization is expanded to include the “formation and internalization of a professional identity congruent with the professional role” (Lynn, McCain, & Boss, 1989, p. 232). Resocialization occurs when someone adapts his or her role to a new setting. As they pursue new jobs or educational endeavors throughout their careers, professional nurses have many socialization and resocialization experiences.

Traditionally, the study of socialization emphasizes how external factors, such as family, peers, school, and other institutions, affect a person’s development. Professional socialization addresses the processes by which a person develops a professional identity along with how a profession accepts an individual into its ranks.

Significant environmental changes (e.g., changing a job, moving to a different practice setting, returning to school) stimulate the resocialization process. Thus, resocialization is also a lifelong occurrence. Nurses can reduce the discomfort of resocialization by understanding all aspects of the change processes required for successful professional transitions.

For example, some nursing students select a path of educational mobility as their route to enter the nursing profession. These students start health careers as UAP, then become LPN/LVNs or associate degree nurses before pursuing a baccalaureate or higher nursing degree. Resocialization is needed at each level of education to help the nurse synthesize a changed theoretical foundation for practice, adapt to new professional role expectations, and form a new professional identity. The IOM (2011) advocates this model to advance the nursing profession, and proposed that by 2020, 80% of all nurses should hold a baccalaureate degree and that the number of nurses with a doctorate should be doubled.

Nurses returning to school provide a rich source of information to educational programs. Because of previous client care experiences, they possess a sense of self as a nurse; know how to use current health care technologies; understand governmental and accrediting agency regulations; know how to interact with other health care team members; have encountered human suffering and death; have coped with personal fears, anxiety, concerns, and shortcomings; have worked within complex organizations; have seen others who model lifelong learning; and acknowledge the inevitability of change (Diekelmann & Rather, 1993).

Despite their knowledge and expertise, nurses returning to school still face the process of resocialization. Nurses typically undergo a transformation in the way they practice after earning a new degree. In some cases, however, resocialization may be ineffective and students may finish programs with more knowledge but without changes in their internalized professional self-image.

Take Note! Throughout their education and careers, nurses will face numerous circumstances in which adaptability—their ability to socialize and resocialize—will be a key to their success.

REAL-LIFE REFLECTIONS Describe the resocialization process that Sue might experience if she decides to return to school. How might she make the process easier? What advice would you give to a student just beginning her nursing education to help him or her navigate the

socialization process?

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Role Theory

Role theory serves as the basis for socialization. As a concept, roles link persons and society. Linton (1945) proposed that a role contains three key pieces: values, attitudes, and behaviors. Professional socialization focuses on preparation for a particular role that offers service to society rather than life in general. Because roles are viewed as separate and discontinuous, it is assumed that stress occurs when a person takes on a new role or new expectations within an existing role (Bradby, 1990). When getting married, for example, a person adopts the new role of spouse, and new expectations might be assumed as part of that role (e.g., homemaker, breadwinner, and child caregiver). Adult nursing students often hold multiple roles that sometimes compete for attention, such as employee, spouse/significant other, and parent. When a new role is assumed (becoming a “student” again), students must adjust how they meet all current life roles. Role conflict arises when roles assumed by a person compete with each other for time and attention (Bradby, 1990). The newly acquired student role competes with other roles because of school demands.

Most students enter nursing because they want to help others. In contrast, the professional educational image of the nurse differs somewhat from societal views. These differences include “an increased emphasis on health maintenance and promotion, establishment of analytic and therapeutic nurse–client relationships, strong technical skills along with a broad scientific knowledge base to guide professional interventions, use of critical inquiry processes to creatively individualize nursing care to address client concerns and needs, and the assumption of responsibility and accountability for patient care decisions” (Hinshaw, 1976, p. 5). Clearly, the socialization process involves changes in knowledge, skills, attitudes, and values that may trigger strong negative emotional reactions.

Take Note! The changes in knowledge, skills, attitudes, and values required by the socialization process may trigger strong negative emotional reactions.

QUESTIONS FOR REFLECTION 1. What potentially competing roles may surface in your life as you begin your nursing education or return to

school? 2. Why is it important to identify potentially competing roles? 3. List your roles in order of priority. Why did you list them in this order?

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Shane’s Returning-to-School Syndrome

Shane (1980) described a returning-to-school syndrome encountered by RNs seeking to earn higher nursing degrees. Although the syndrome was described decades ago, it remains relevant today.

The first phase, the honeymoon, is positive. Nurses identify similarities between their previous educational experience and the present experience that reinforce their original role identity as a nurse. The nurse feels energetic about learning new things.

The next stage, conflict, is characterized by turbulent negative emotions. Conflict arises during the first nursing theory or clinical nursing course when faculty challenge nurses to change their ways of thinking and/or practicing. Feelings of professional inadequacy may emerge during this stage and may be expressed by angry outbursts, feelings of helplessness, or depression.

Successful resolution of conflict results in the next stage, the beginning of reintegration. Here, nurses struggle to hold on to cherished beliefs about practice and frequently wonder why they decided to pursue a higher degree. Hostile feelings toward the nursing program and faculty are common during this phase.

Once the nurse works through the first three stages, the final stage of integration emerges. This stage is characterized by the ability to blend the original culture of work with the new culture of school. The integration of the old with the new results in a positive resolution of the returning-to-school syndrome. Nurses recognize that a transformation has occurred. They notice that their clinical practice has forever changed, and they incorporate their newly acquired theoretical knowledge into practice. Using in practice what they have learned in school stimulates these nurses and fosters a new curiosity to learn more.

Moving into a new practice arena or position may mean that despite years of clinical experience and specialized education, an expert nurse becomes a novice again. By recognizing the various stages of socialization and resocialization processes, nurses can identify sources of actual and potential feelings of discomfort and work effectively by steering rather than reacting to the processes of change.

REAL-LIFE REFLECTIONS Thinking back to Sue, what assumptions can you identify that she has made about the benefit of seeking a

baccalaureate degree in nursing? What personal transitions will be required of Sue to successfully work through resocialization using Shane’s

returning-to-school syndrome? Why are these transitions important?

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Bridges’ Managing Transitions

Bridges (2003) offered an explanation for understanding the psychological impact of returning to school. He proposed that persons undergo transitions (psychological adaptations to changes) whenever they are exposed to changes, and developed a three-step process to facilitate transitions that “starts with an ending and finishes with a beginning” (p. 5). People do not move sequentially through the phases; instead, they experience the phases, at times, simultaneously.

The first phase is “letting go” of previous ways and identities. Professional nursing students frequently experience stress as they embark on a new educational program because they realize that what they have done in past practice may not have always been the best practice.

The second phase Bridges called “the neutral zone,” which is when the old identity has vanished but the new one is not fully developed. People going through this phase experience an unsettled feeling because they may not know how to act or what questions to ask. They try new ways of looking at and doing things without discarding old ways. When starting a new course or educational program, students sometimes do not know how to begin. In a beginning nursing program (ADN or BSN), students assume a new role of nurse. Nurses returning to college for a bachelor’s or advanced nursing degree must assume the role of a student and reconcile with the new role of a professional or an advanced practice nurse (APRN). Feelings of fearful uneasiness surface as the person tries to reconcile the new with the old. If a person leaves the neutral zone before repatterning is solidified, the change will most likely not be successful. Because “the neutral zone is a lonely place” (Bridges, 2003, p. 47), communication is critical. Creative use of the neutral zone involves setting short-term goals, spending time in personal reflection to examine the meaning of change, discovering new ways of doing things, experimenting with the new role, taking time to embrace setbacks and losses, and networking with others in similar transitions. Students enrolled in the same program frequently and effectively support each other while experiencing the neutral zone. After working through the uncertainty and obscurity of the neutral zone, they make an emotional commitment to start anew.

Bridges (2003) called the final phase the new beginning, which is a mental image or experience hallmarked by “a release of new energy in a new direction” (p. 57). A new beginning means a new commitment and identity. Bridges specified that new beginnings require four P’s: “the purpose, a picture, the plan, and a part to play” (p. 60). Quick successes such as the accomplishment of small goals facilitate the process of internalizing a new identity. For example,

Professional nursing students who actually use theories derived from best evidence to guide clinical practice may see the positive effects of a theoretically based practice. Take the situation of a nurse caring for a patient who is having difficulty sleeping. A theoretical approach to the problem analyzes and addresses the environmental, psychological, and spiritual factors that may be interfering with the patient’s ability to sleep. Instead of immediately administering a sedative, the nurse rubs the patient’s back and spends time talking with the patient who expresses concern about the impact of the current illness on his or her family. After sharing the concerns with the nurse and with the muscle relaxation that occurs from the massage, the patient is able to sleep.

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DEVELOPING A PROFESSIONAL SELF-CONCEPT

As a person develops patterns of behavior, the self-system becomes organized and strives to actualize itself, although it is continually being repatterned. The self-system interacts symbiotically with the environment, providing the conditions from which a personal view of the self emerges—the self-concept. The self-concept encompasses all beliefs about oneself and personal interpretations about the past, present, and future (Jones, 2004). Because humans develop personal selves first, those personally organized sets of behaviors form the basis of the selves brought into the profession. Thus, the personal self strongly influences the emerging professional self.

The development of the professional self-concept (how a person perceives oneself as a nurse) follows the same path as that of development of the personal self. In every profession, the professional has significant others. During various stages of professional growth and development, nurses have different significant others who help them during times of transitions. For example, beginning nursing students may view faculty members as significant others, while novice nurses may identify experienced nursing colleagues and/or nurse managers as significant others.

The significant others in professional self-development serve as role models or mentors as nurses adjust to changing situations and try to be the kind of person capable of meeting situational demands. Role models provide nurses with examples of how to be, and mentors provide guidance and emotional support. Professional self-concept development also requires that individual nurses engage in episodic self-appraisal along with a willingness to accept the challenges and criticisms of mentors and role models. The personal self- concept cannot be separated from the professional self-concept, although professional significant others are different from personal significant others.

Successful implementation of professional nursing roles and tasks reinforces one’s perception of the professional self. Repeated successes in practice solidify the concept of being a competent professional nurse, resulting in increased self-confidence. Because the development of a professional self requires interactions with others in the profession, separating the developmental from the socialization processes may be impossible.

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Benner’s Novice-to-Expert Model

Benner (1984) devised a model of stages from novice to expert that has relevance for experienced nurses. Benner’s novice-to-expert model describes stages in the progression of patient care expertise that can result from practicing nursing experience (Table 1.3). This model, based on the work by Dreyfus and Dreyfus (1980), suggests the following three general aspects of skilled performance. 1. Movement from reliance on abstract principles to the use of past concrete experience as paradigms. 2. Change in perception of what is needed in a particular situation from a compilation of equally important

bits of information to a more or less complete whole in which only certain parts are relevant.

TABLE 1.3 Benner’s Stages From Novice to Expert

3. Passage from detached observer to involved performer who is engaged in the situation. Stage I, the novice stage, corresponds to the student experience in nursing school. Because no background

understanding exists, the novice depends on context-free rules to guide actions. Although this approach enhances safety, “rule-governed behavior is extremely limited and inflexible” (Benner, 1984, p. 21). When nursing students encounter situations that do not conform to the rules learned, they become highly critical of what happened and cling steadfastly to what they learned in class.

The new nursing graduate demonstrates marginally acceptable performance as an advanced beginner in stage II. The advanced beginner relies on basic theory and principles and believes that “clinical situations have a discernible order” (Benner, Tanner, & Chesla, 1996, p. 54). The advanced beginner can formulate principles for actions, but because all actions are viewed as equally important, help is needed for priority setting. Advanced beginners typically become very uncomfortable when they encounter chaotic clinical situations.

The competent practitioner, who has reached stage III, typically has worked in the same setting for 2 to 3 years. This person has conscious awareness of long-range goals and can engage in deliberate planning based on abstract and analytical contemplation. As a result of this planning activity, the practitioner has a feeling of mastery and the ability to cope with contingencies and feels efficient and organized. Competent practitioners typically must think about what can be done before acting in novel or chaotic situations.

By stage IV, which requires 3 to 5 years of experience, the nurse is a proficient practitioner. The proficient nurse perceives situations as “wholes” rather than as accumulations of aspects, and performance is guided by maxims. Actions do not need to be thought out, and meanings are perceived in relation to long-term goals. In addition, the proficient practitioner can interpret nuances in situations and recognize which aspects of a situation are most significant. Proficient practitioners automatically use creative adaptive strategies when they encounter complex, unfamiliar, or chaotic clinical situations.

The fifth and final stage—expert practitioner—is achieved only after extensive experience. The expert has an intuitive grasp of situations and thus does not have to think through actions analytically. In fact, experts are so skilled at grasping the situation as a whole that they often are unable to think in terms of steps. Expert nurses instinctively act effectively for the client’s welfare in any clinical situation.

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Professional Nursing Roles

Benner (1984, p. 6) identified that nurses use many competencies as they engage in clinical practice. She organized them into the following seven categories according to the roles and key function that fall within the domain of professional nursing. 1. “The helping role” provides the foundation for the roles of caregiver (provider of direct client care),

colleague (helpful team member), and client advocate (person looking out for the client’s best interests). 2. “The teaching–coaching function” provides the foundation for the roles of teacher (provider of education

and information) and counselor (one who provides emotional support and encouragement). 3. “The diagnostic and patient-monitoring function” provides the foundation for the caregiver and critical

thinker (someone who uses complex thought processes) roles. 4. “Effective management of rapidly changing situations” provides the foundation for the caregiver, change

agent (person who initiates and guides the change process), and coordinator (person who manages, leads, and verifies that things get done) roles.

5. “Administration and monitoring of therapeutic interventions and regimens” provide the foundation for the caregiver and change agent roles.

6. “Monitoring of and ensuring the quality of health care practices” provide the foundation for the roles of coordinator, client advocate, and change agent.

7. “Organizational and work-role competencies” provide the foundation for the client advocate, change agent, and coordinator roles. According to Benner, experience is absolutely necessary for the development of professional expertise.

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CHARACTERISTICS OF A PROFESSION

The characteristics of a profession (what differentiates a professional from a technician) have been debated for many years. The Flexner Report issued by the Carnegie Foundation in 1910 served as the criteria for determining medicine as a profession. Since the 1950s, the nursing profession has been analyzed using sociologic theories that define a “profession.”

Although considered a profession for many years, an assessment of the characteristics of a profession reveals that nursing fails to meet all required criteria and is more accurately classified as an “emerging profession” (Table 1.4). Although nursing does use a specialized knowledge base, has autonomy and control over its work, requires specialized competence, regulates itself, possesses a collegial subculture, and has public acceptance (Freidson, 1994; Miller, Adams & Beck, 1993), nursing fails to have standardized education criteria for entry into the profession.

TABLE 1.4 Professional Status Progress: Nursing Meets All But One Criterion How Nursing Meets Characteristics of a Profession

Take Note! Although considered a profession for many years, an assessment of the characteristics of a profession reveals

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that nursing fails to meet all required criteria and is more accurately classified as an “emerging profession.”

Currently, three levels of education qualify persons to take the licensing examination for professional nurse registration. The Associate’s Degree in Nursing (ADN) consists of 2 years of concentrated study focused on clinical skills in the community college setting. The diploma nursing program offers 3 years of nursing education focused on learning nursing skills in a hospital-based setting. In diploma nursing programs, students typically receive the most clock hours of clinical instruction. The Bachelor of Science in Nursing (BSN), or baccalaureate, degrees consist of 4 years of nursing education in institutions of higher learning (4- year colleges and universities). Along with education focused on the art and science of nursing, BSN programs also emphasize the importance of a liberal education, nursing research, and community health nursing. The AACN (2015b) reported that 55% of all practicing nurses held BSN or higher degrees in nursing.

Trends in the initial preparation of professional nurses have changed over time. Table 1.5 summarizes key changes. Diploma nursing programs prepared the majority of new nurses until 1971, associate degree nursing programs prepared most of the new nurses by the mid-1970s and continue to be the dominant form of educational preparation for newly licensed professional nurses. However, the number of baccalaureate- prepared nurses appears to be continually rising.

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Intellectual Characteristics

Because nurses make decisions that affect clients’ lives, they need the intellectual capability to master scientific concepts, understand the impact of self on others, use this information in clinical practice, and understand potential consequences of alternative actions (AACN, 2008). Professional nurses possess the following three intellectual characteristics.

TABLE 1.5 Percentage of Graduates From Baccalaureate, Associate Degree and Diploma Nursing Programs 1960–2015

1. A body of knowledge on which professional practice is based. 2. A specialized education to transmit this body of knowledge to others. 3. The ability to use their knowledge in critical and creative thinking.

Because of the global nature of professional nursing to meet client care needs, nurses frequently use knowledge that originated in other professional disciplines. However, they use the cognitive skills of critical and creative thinking to adapt this knowledge to the realm of professional nursing practice.

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Specialized Body of Knowledge

Professional practice is based on a body of knowledge derived from experience (leading to expertise) and research (leading to theoretical foundations for knowledge and practice). Most state boards of nursing (SBN) specify that an ADN serves as the minimum educational qualification for practice as an RN. However, according to the IOM (2011) extensive literature review, patients who receive care received from baccalaureate-prepared nurses had better outcomes than those who received care from associate degree– prepared nurses. Areas of improved outcomes included reduced incidences of hospital-acquired pneumonia, urinary catheter–associated infections, and failure to rescue (recognition of early signs of life-threatening complications and taking action before patients experienced a respiratory or cardiac arrest).

Most states require advanced education and professional certification for nurses who assume advanced practice roles. Professional nurses make clinical judgments based on solid, scientific rationales. They modify plans and actions to meet the demands of specific client situations. ADN programs tend to emphasize technical skills over theoretical concepts. New nurses and nurses who have been education with a skills focus seek out a single “right” answer when delivering patient care. However, seasoned nurses who use theory in practice, anticipate complications before they occur, analyze all aspects that affect health care delivery, and adapt institutional policies and procedures when needed to address complex patient care situations.

Liberal arts education serves as a hallmark of professional education. A liberal arts education provides a knowledge base that enhances a person’s ability to practice citizenship, communicate effectively, appreciate advantages of diverse viewpoints, and understand more deeply what it means to be human. Liberal arts courses foster the development of thinking and communication skills, cognizance of historical contributions, understanding of science, exploration of personal values, appreciation of the fine arts, and sensitivity of human diversity (AACN, 2007). Associate degree nursing educational programs require nearly 2 years of liberal education, especially in science and mathematics, and baccalaureate degree programs include courses in the fine arts, statistics, and social sciences that provide baccalaureate degree nurses with a broader perspective of what it means to be human. Knowledge and skills derived from a liberal arts education enhance the nurse’s ability to adapt knowledge and skills to novel situations through the use of global rather than narrow thinking.

Whether nursing has a unique body of knowledge or applies knowledge borrowed from the fields of medical, behavioral, or physical science has long been a matter of debate. In the early days of nursing, nurses derived knowledge through intuition, tradition, and experience or by borrowing it from other disciplines (Kalisch & Kalisch, 2004). Today, the nursing profession uses nursing models and frameworks as a foundation for practice. These models and frameworks provide guidance for nurse researchers to substantiate scientifically the unique contributions that nurses make in health care delivery.

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Specialized Plan of Formal Education

The NCSBN coordinates efforts to license registered and practical nurses. The NCSBN Nursing Licensure Examination for Registered Nurses (NCLEX-RN) provides computer adaptive testing that measures minimal competence for safe professional nursing practice. Examination content includes health promotion, pharmacotherapeutics, nursing assessment, clinical decision making, nursing interventions, and client care outcome evaluation.

Education for other health care professions (pharmacists, social workers, physical therapists, occupational therapists, chaplains, and physicians) requires postbaccalaureate education. Some nursing leaders have proposed requiring a master’s degree (or even a doctorate) as the educational entry level for professional nursing. The IOM (2011) recommends that by 2020, 80% of all RNs hold a bachelor’s degree in nursing. The IOM report also recommends interdisciplinary education of all future health team members, including professional nurses. Some collegiate health science programs offer interdisciplinary learning experiences that provide nursing students an opportunity to collaborate with other future interprofessional health team members.

In 1965, the ANA issued a white paper (a detailed proposal) that specified that the entry level into professional nursing should be the BSN degree. The AACN concurs with this position. Efforts during the mid-1980s resulted in differentiated competencies for ADN- and BSN-prepared nurses. Professional nursing has two accrediting agencies for nursing education programs; the National League for Nursing (NLN) (all levels of nursing education from practical/vocational nursing through doctoral programs) and the AACN for baccalaureate and higher-degree programs (Kumm et al., 2014). Distinguishing program outcomes and competencies for each level of nursing education has been difficult. In the following Focus on Research section, a group of nurse researcher wanted to determine if there were indeed differences in program outcomes and competencies at the end of associate degree and baccalaureate nursing programs.

FOCUS ON RESEARCH Baccalaureate Educational Outcomes Being Met by Associate Degree Nursing Programs

The purpose of the study was to determine which baccalaureate nursing program outcomes were being met by 17 associate degree nursing programs that graduated 92% of AD-prepared nurses in a Midwestern state. The authors designed a 114-item structured questionnaire that asked 5 demographic questions and 109 questions pertaining to the AACN Essentials for BSN education programs. Following Institutional Board approval, data were collected from 30 nurse educators who attended a workshop addressing the differences between associate degree and baccalaureate nursing education. The study reveals that 42 of the BSN essentials that were met by ADN programs were found under the domains of information and application of patient care technology, professionalism and professional values, and generalist nursing practice. ADN programs effectively met outcomes for technology centered on electronic health record use and acquiring information for safe, quality patient care. Generalist nursing practice outcomes were centered on providing bedside care to patients and families. ADN programs covered legal issues surrounding professional practice and what it means to be a member of a profession. Professional outcomes not met by the ADN programs included nursing history, analysis of contemporary nursing issues, lifelong learning, managing ethical dilemmas, comprehensive environmental assessment, genetics and genomics, providing care within a community, supervising other health team members, emergency preparedness, and tolerance for ambiguity. Six areas not included in ADN education are liberal education, organizational and system leadership for patient safety and quality care, evidence-based practice and nursing scholarship, health care policy, financing and regulatory systems, interprofessional communication and collaboration to improve patient outcomes and clinical prevention, and population health. Weaknesses of this study include that data were collected exclusively in one Midwestern state that requires national accreditation of all ADN programs. Information from this study can be used to refine differentiated ADN and BSN competencies/outcomes and be used for nursing faculty to design relevant curricula for RN-to-BSN programs.

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Kumm, S., Godfrey, N., Martin, D., Tucci, M., Muenks, M., & Spaeth, T. (2014). Baccalaureate outcomes met by associate degree nursing programs. Nurse Educator, 39(5), 216–220. doi: 10.1097/NNE0000000000000053.

However, in 2010, the NLN developed a list of differentiated competencies for professional nurses based upon earned degrees. The NLN model of differentiated competencies fall under the domains of human flourishing, nursing judgment, professional identity, and spirit of inquiry (NLN, 2010). Table 1.6 outlines the different expectations of ADN- and BSN-prepared nurses. All nurses advocate for their patients and act as interprofessional colleagues. ADN competencies tend to center around caregiver, counselor, and educator roles with patients and families, while BSN competencies include working with communities. However, in recent years, ADN nurses are educated to provide nursing care following established evidence-based policies and procedures while using critical thinking skills to make decisions when deviations to policies and procedures are needed. BSN-prepared nurses are educated to engage in independent thinking, analyze current evidence-based practices, critique new research findings, and spearhead efforts to change practice standards for improved nursing care. ADN and BSN nurses practice in a variety of settings. Because of the independence required and the complexity of community health nursing, BSN preparation has become the minimal education preparation for this specialized area of professional nursing practice.

However, implementation of the different levels of practice has been very difficult because after gaining years of valuable clinical experience, ADN-prepared nurses have effectively assumed leadership and supervisory roles in many health care organizations. However, many health care organizations require at least BSN and sometimes graduate nursing degrees for nursing management positions. Some health care organizations use clinical ladders for promoting staff nurses and many of these require a BSN degree to reach higher levels. Along with organizational requirements, multiple research studies have demonstrated that patients have improved outcomes when receiving care from BSN-prepared nurses and nurses who hold certification in a specialized area of clinical practice.

TABLE 1.6 Differentiated Core Competencies for ADN- and BSN-Prepared Nurses

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QUESTIONS FOR REFLECTION 1. Which of the BSN outcomes/competencies listed in Table 1.6 do you think will be of utmost interest to

you as you pursue your degree? Why does this one interest you the most? 2. Which of the BSN outcomes/competencies listed in Table 1.6 do you not find particularly interesting to

you? Why do you find this not as interesting? 3. Do you agree with the list of differentiated competencies for ADN- and BSN-prepared nurses found on

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Table 1.6? Why or why not?

Currently, LPNs provide direct resident care in extended facilities and RNs provide supervision. Many times, the RN supervisor in an extended care facility has been prepared at the associate degree level. The PEW Health Professions Commission (1998) emphasized the importance of strengthening career mobility paths within the nursing profession and proposed a seamless educational path from nursing assistant to RN and RN to nursing doctorate (PEW Health Professions Commission, 1998). Aiken, Clarke, Cheung, Sloane, and Silber (2003) published a landmark study that found that surgical patient outcomes differed based on the educational level of RNs caring for them. The study findings suggest that when clients receive care in an acute care unit staffed with 50% BSN-prepared nurses, mortality is reduced by 5% and substantial reductions are found in incidences of failure to rescue, nosocomial pneumonia, and pulmonary failure. In 2007, the Agency for Healthcare Research and Quality examined the findings of 94 studies using meta-analysis techniques and found that lower client mortality rates were apt to occur when nurses had BSN preparation and had more than 7 years of nursing experience. The study also showed that statistically significant reductions occurred in failure to rescue, patient falls, urinary tract infections, nosocomial pneumonia, and pulmonary failure when nurse to patient ratios fell from 1:5 to 1:4. This and other studies also found that the likelihood of a nurse making a medication or treatment error increased threefold when shift lengths exceeded 12.5 hours. This and other consistently support BSN preparation for all nurses as a means to improve the quality of health care in hospitals.

Graduate nursing education programs offer advanced education for nurses interested in pursuing careers in advanced practice nursing (certified nurse midwifery, nurse practitioners, or clinical nurse specialists), or in nursing education, nursing administration, or nursing informatics. Most graduate nursing education programs offer a master’s degree, which can usually be completed within 3 years if a student assumes a full-time plan of study. The majority of programs give students up to 7 years to complete graduate work.

In 2004, the AACN noted several issues with the educational preparation of APRNs at the master’s degree level. First, the amount of time spent by nurses engaged in nursing graduate study surpassed the amount of time spent by members of other health care disciplines earning master’s degrees (60 vs. 45 credit hours, respectively). Second, some APRNs specified a need for more education to meet the demands of advanced practice. The AACN proposed that all future APRNs would earn a Doctor of Nursing Practice (DNP) degree by 2015. Many other members of the interprofessional health care team, including pharmacists and physical therapists, hold doctorates. The AACN proposed that graduate nursing programs prepare the clinical nurse leader, who would provide “care in all health settings at the point of care, and assumes accountability for client care outcomes by coordinating, delegating, and supervising the care provided by the health care team” (AACN, 2004, p. 10). Currently, there is much debate over the implementation of the DNP requirement for APRN certification and practice.

Postgraduate nursing education leads to a doctorate in nursing. Traditional doctoral nursing programs offer a philosophy degree (PhD) to prepare nurse researchers and collegiate faculty. Nurses engaged in PhD programs have the expectation to generate new nursing knowledge through a rigorous, scientific research study. The practice nursing doctorate (DNP) is a clinically focused degree targeted toward an advanced area of nursing practice. Nurses engaged in DNP programs conduct a final, extensive, evidence-based project that is practice and application oriented. Instead of generating new nursing knowledge, DNP students are expected to translate new scientific advancement to practice situation. Nurses with DNP preparation have the credentials to be clinical faculty in nursing education programs (AACN, 2015). Although less common, some institutions of higher learning still offer clinical doctorates such as Doctor of Nursing (DN), or the Doctor of Nursing Science (DNS or DNSc). Grants and scholarships are available for nurses interested in doctoral work.

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Using Knowledge by Critical Thinking

Critical thinking has cognitive and affective characteristics. Critical thinking imposes standards (Paul, 1992) and prevents illogical thinking. Rubenfeld and Scheffer (2015) identify the following habits of the mind associated with critical thinking: “confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection” (p. 7). They also identify the cognitive skills of critical thinking as “analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge” (p. 7).

Creative Thinking

As a key component of critical thinking (Rubenfeld & Scheffer, 2015), creative thinking generates alternative approaches to clinical situations. Creative thinking requires an ability to think outside of what usually is done and results in novel approaches to client care. If not tempered with critical thinking, however, solutions generated with creative thinking may be hazardous. For example, when using therapeutic touch to relive a client’s pain, the nurse notes that the client experiences a substantial fall in blood pressure resulting in hypotension. If the hypotension results in the client fainting when getting out of bed after the therapeutic touch session and sustaining an injury, the nurse is accountable for the adverse outcome. Nurses engage in creative thinking when confronted with clients who have complex integrative health problems that require individually designed plans to attain desired outcomes.

Reflective Thinking

Reflective thinking is engaging in purposeful analysis about what one is currently doing and about what one has done (Schon, 1987). Reflection plays a key role in professional nursing practice (Fig. 1.4). Consider the following clinical situation.

Ms. S has advanced cancer and lives in constant pain. Because the pain is unbearable, Ms. S’s physician orders patient-controlled analgesia (PCA) with morphine. Ms. S is fearful that the morphine will not ease her pain, will result in addiction, and will produce a loss of consciousness. Her fear and anxiety cause increased muscle tension. As the nurse initiates the morphine drip, she remembers the pharmacologic action and potentially adverse effects of the morphine. She educates Ms. S about morphine and how best to use the PCA device for optimal pain control. As the nurse talks with Ms. S, she performs a back massage, knowing the theoretical benefits of human touch and the physiologic response to muscle massage.

FIGURE 1.4 Reflective thinking enables nurses to analyze and improve their professional performance.

When nurses think about theoretical and scientific principles while delivering client care, they engage in reflection in action (Clarke, James, & Kelly, 1996; Kim, 1999; Powell, 1989; Schon, 1983).

Schon (1983, 1987) advocated for reflection on action, another form of professional reflection. Reflection on action occurs when the professional practitioner conducts a retrospective analysis of action taken (Clarke et al., 1996; Schon, 1987). Returning to the example above, the nurse analyzes care given to Ms. S, considering what interventions were implemented and whether they were successful. Reflection on action enables the practitioner to develop a deeper understanding of practice and provides a vehicle to learn from experience (Clarke et al., 1996; Schon, 1987). Journal writing also provides practice with reflection on action.

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Take Note! Cognitive skills such as critical, creative, and reflective thinking help nurses make sound clinical decisions when providing client care.

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Independent Clinical Decision Making

Professional nurses make independent decisions to solve problems in clinical practice. Sometimes, nurses act prematurely because of inadequate information and insufficient time to generate alternative approaches.

Concepts in Practice

Visiting Hours

Which of the following actions would you take with a patient whose visitors insist on staying beyond the visiting hours established by hospital policy? 1. Possible action 1: Tell the patient and the visitors that the visitors must leave. 2. Possible action 2: Allow the visitors to stay for an additional hour. 3. Possible action 3: Explore the reasons why the visitors want to stay and the significance of having the

visitors spend time with the patient. Base your decision on the result of information generated. As a nurse, you would use critical thinking to realize that collecting more information surrounding the situation will result in an optimal decision. Perhaps the visitors have arrived from out of town and have no place to stay. Maybe the client has not seen them in a long time or the client may be afraid to be left alone in the hospital the night before a potentially life-threatening procedure.

When nurses use critical thinking and logical reasoning to support the actions taken, they make effective clinical decisions.

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Nursing Process

Nurses use the nursing process, a systematic thinking method to process information about specific client care situations. This problem-solving process consists of five interacting steps: assessment, diagnosis, planning, implementation, and evaluation (Fig. 1.5). Assessment consists of collecting subjective (what clients say) and objective (measured or verifiable by another) information about clients. Nurses then categorize data into clusters to determine nursing diagnoses (an actual or potential client response) upon which a care plan is developed. After the care plan is implemented (executed), nurses evaluate the effectiveness of the plan and start the process again with assessment. Effective use of the nursing process requires critical, creative, and reflective thinking.

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Service to Society

Ever since nursing began, it has been associated with serving others. However, the intrinsic motivation “to care” is only one way to look at caring. Morse, Bottorff, Neander, and Solberg (1991, p. 122) identified the following five conceptualizations of caring: (1) caring as a human trait; (2) caring as a moral imperative; (3) caring as an affect; (4) caring as an interpersonal interaction; and (5) caring as a therapeutic intervention. Obviously, caring encompasses more than just intuitive concern for others. Several nursing theories use caring as a major concept or central theme.

Professional service to society requires impeccable integrity, individual responsibility for ethical practice, and lifelong commitment. However, some nurses view nursing as a job rather than a profession.

Many nurses leave the profession (permanently or temporarily) to pursue personal interests or to raise a family. Some nurses work to supplement family income, and others work because they are sole or primary income providers for their family. Nurses needing job security avoid confronting less-than-ideal nursing practice situations. Employing agencies sometimes exploit these nurses. Regardless of high client-to-nurse ratios, rotating shifts, and floating, some nurses make do and maintain the status quo. However, other nurses confront poor working conditions and always do what is best for clients.

Service to others involves ethical and legal responsibilities. Nurses must have the integrity to do what is right, especially in situations that cause moral dilemmas. The International Council of Nurses (ICN) has published a Code of Ethics and the ANA (ANA, 2015b) also has published a Code of Ethics and Social Policy Statements for nurses to follow. Fowler (2015b) articulates that the ANA’s Nursing’s Social Policy Statement serves as a reciprocal contract between nurses and society. Society expects nurses to offer caring services with the patient as the primary concern of the nurse when services are offered. Nurses are expected to have the necessary knowledge, skill, and competence to execute their professional duties. Nurses also acknowledge that there are hazards associated with patient care (violent patients, exposure to contagious diseases and placing oneself in peril to negotiate hazardous weather conditions to report for duty). Nurses as individuals and as members of the profession are accountable and responsible for professional practice endeavors. Professional nurses are expected to develop and stay abreast of new scientific knowledge to improve the health for all people. They also must engage in ethical practice as specified by professional nursing codes of ethics. As members of an interprofessional health care team, they are expected to collaborate with other team members and recipients of care to identify care needs, set care outcomes, and plan care. Nurses are also expected to promote the health of the public by addressing health disparities and intervene to protect the public via whistleblowing and advocacy efforts. In return, nurses expect society to authorize practice autonomy, extend self-governance, protect the title of RN and scope of practice, receive respect and fair remuneration for services, be free to practice nursing to the full extent of educational preparation, receive support to sustain the nursing profession, and be protected from hazardous service activities.

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FIGURE 1.5 Nursing process as a continuous cycle.

Service to society requires legal assurances that practitioners are competent. Credentialing systems, such as licensure, provide a means to certify minimal competence for safe practice by a person legally permitted to use the title “registered nurse.” State nurse practice acts also provide legal reinforcement against incompetence. Upon initial state licensure, the nurse receives a copy of his or her state’s nurse practice act. Printed copies of specific nurse practice acts can be obtained from individual SBNs (a fee usually is charged), or copies may be downloaded from SBN websites. When litigation occurs, courts of law hold nurses accountable for what a usual and prudent nurse would do in a particular client care situation.

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Autonomy and Self-Regulation

Autonomy means that professionals have control over their practice. Autonomy involves independence, a willingness to take risks, and accountability for one’s actions, as well as self-determination and self-regulation. In the United States, each state has a nursing board that governs practice that occurs within its borders. State Boards of Nursing (SBNs) regulate professional nursing practice by issuing professional licenses to qualified individuals. Through licensure and the legal system, society protects consumers from unsafe nursing practice by holding nurses responsible for their professional actions. SBNs have legal authority to ensure that all nurses follow the state’s nurse practice act. Thus, the nursing profession regulates itself.

Nurse practice acts define various levels of nursing practice, determine rules that guide each level of nursing practice, and provide specific guidelines for continued licensure. The SBN has legal authority and accountability to implement the nurse practice act. Most SBNs are composed of a group of persons typically appointed by the state’s governor, with nurses holding most of the positions. Requirements for RN licensure appear in each state’s practice act. Most nurse practice acts contain information related to reasons for licensure, nursing definitions, minimum standards for nursing education programs, licensure requirements, licensure exemptions, reasons for license revocation, endorsement provisions for nurses licensed in other states, development of a state board of examiners, nursing board responsibilities, and penalties for practicing nursing without a license or not in accordance with the state nurse practice act (see Box 1.2, Professional Building Blocks, “Licensure Versus Registration”). Each SBN has the responsibility for carrying out activities covered in its nurse practice act.

1.2 Professional Building Blocks Licensure Versus Registration

Licensure refers to “a form of credentialing whereby permission is granted by a legal authority to do an act, without such permission, action would be illegal, trespass, a tort, or otherwise not allowable” (Loquist, 1999, p. 105). A professional nursing license is a legal document that certifies that an individual has met minimum standards for qualified practice. As a state function, licensure protects citizens from unsafe or incompetent health care providers. Upon licensure, nurses become registered in a particular state to practice professional nursing according to the state’s nurse practice act.

Registration denotes “enrolling or recording the name of a qualified individual on an official roster by an agency of government” (Loquist, 1999, p. 15). Although licensure is permanent (unless it is revoked for illegal or immoral behavior), registration must be renewed periodically (usually every 1 to 2 years) by paying a fee to each state in which current registration is desired.

Recognizing the need for a united approach to nursing licensure and education, the 50 SBNs formed the NCSBN in 1978. This national board has developed licensure examinations for professional and practical nursing, a mutual compact for interstate nursing licensure, and educational materials for new and experienced nurses.

As in the United States, Canadian legislation to regulate nursing practice is passed by the provincial and territorial governments. In all provinces (except Ontario, where the College of Nurses of Ontario assumes responsibility), regulation of professional nurse registration lies with the provincial or territorial professional nursing associations. Canadian nursing regulatory bodies determine educational and practice standards and define the scope of nursing practice. They also specify who may use the title RN and outline mechanisms for professional discipline. Finally, the regulatory bodies also approve educational programs to prepare persons for entry into practice and to establish continuing educational and competency requirements for members of the nursing profession (Brunke, 2003; Ross-Kerr, 2011).

Because the profession of nursing defines nursing practice, sets practice standards, and has established mechanisms to discipline members failing to meet practice standards, nursing fulfills the element of autonomy and self-regulation. In some cases, the regulatory bodies also provide a means for professional nurses to engage in the activities resulting in the creation of a collegial subculture, another hallmark of a profession.