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Library of Congress Cataloging-in-Publication Data Names: Masters, Kathleen, editor. Title: Role development in professional nursing practice / [edited by]

Kathleen Masters. Description: Fifth edition. | Burlington, Massachusetts : Jones & Bartlett

Learning, 2018. | Includes bibliographical references and index. Identifiers: LCCN 2018023086 | eISBN 9781284152920 Subjects: | MESH: Nursing--trends | Nursing--standards | Professional

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Dedication

This book is dedicated to my Heavenly Father and to my loving family: my husband, Eddie, and my two daughters, Rebecca and Rachel. Words cannot

express my appreciation for their ongoing encouragement and support throughout my career.

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CONTENTS

Preface Contributors

UNIT I: FOUNDATIONS OF PROFESSIONAL NURSING PRACTICE

A History of Health Care and Nursing Karen Saucier Lundy and Kathleen Masters

Classical Era Middle Ages The Renaissance The Dark Period of Nursing The Industrial Revolution And Then There Was Nightingale . . . Continued Development of Professional Nursing in the United Kingdom The Development of Professional Nursing in Canada The Development of Professional Nursing in Australia Early Nursing Education and Organization in the United States The Evolution of Nursing in the United States: The First Century of Professional Nursing The New Century International Council of Nurses Conclusion References

Frameworks for Professional Nursing Practice Kathleen Masters

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Overview of Selected Nursing Theories Overview of Selected Nonnursing Theories Relationship of Theory to Professional Nursing Practice Conclusion References

Philosophy of Nursing Mary W. Stewart

Philosophy Early Philosophy Paradigms Beliefs Values Developing a Personal Philosophy of Nursing Conclusion References

Competencies for Professional Nursing Practice Jill Rushing and Kathleen Masters

Overview Nurse of the Future: Nursing Core Competencies Critical Thinking, Clinical Judgment, and Clinical Reasoning in Nursing Practice Conclusion References

Education and Socialization to the Professional Nursing Role Kathleen Masters and Melanie Gilmore

Professional Nursing Roles and Values The Socialization (or Formation) Process Facilitating the Transition to Professional Practice Conclusion References

Advancing and Managing Your Professional Nursing Career Mary Louise Coyne and Cynthia Chatham

Nursing: A Job or a Career? Trends That Affect Nursing Career Decisions Showcasing Your Professional Self Mentoring Education and Lifelong Learning Professional Engagement Expectations for Your Performance Taking Care of Self Conclusion References

Social Context and the Future of Professional Nursing Mary W. Stewart, Katherine E. Nugent, and Kathleen Masters

Nursing’s Social Contract with Society

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Public Image of Nursing The Gender Gap Changing Demographics and Cultural Competence Access to Health Care Societal Trends Trends in Nursing Conclusion References

UNIT II PROFESSIONAL NURSING PRACTICE AND THE MANAGEMENT OF PATIENT CARE

Safety and Quality Improvement in Professional Nursing Practice Kathleen Masters

Patient Safety Quality Improvement in Health Care Quality Improvement Measurement and Process The Role of the Nurse in Quality Improvement Conclusion References

Evidence-Based Professional Nursing Practice Kathleen Masters

Evidence-Based Practice: What Is It? Barriers to Evidence-Based Practice Promoting Evidence-Based Practice Searching for Evidence Evaluating the Evidence Implementation Models for Evidence-Based Practice Conclusion References

Patient Education and Patient-Centered Care in Professional Nursing Practice Kathleen Masters

Dimensions of Patient-Centered Care Communication as a Strategy to Support Patient-Centered Care Patient Education as a Strategy to Support Patient-Centered Care Evaluation of Patient-Centered Care Conclusion References

Informatics in Professional Nursing Practice Kathleen Masters and Cathy K. Hughes

Informatics: What Is It? The Effect of Legislation on Health Informatics Nursing Informatics Competencies Basic Computer Competencies

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Information Literacy Information Management Current and Future Trends Conclusion References

Leadership and Systems-Based Professional Nursing Practice Kathleen Masters and Sharon Vincent

Healthcare Delivery System Nursing Leadership in a Complex Healthcare System Nursing Models of Patient Care Roles of the Professional Nurse Conclusion References

Teamwork, Collaboration, and Communication in Professional Nursing Practice Kathleen Masters

Interprofessional Teams and Healthcare Quality and Safety Interprofessional Collaborative Practice Domains Interprofessional Team Performance and Communication Conclusion References

Ethics in Professional Nursing Practice Janie B. Butts and Karen L. Rich

Ethics Ethical Theories and Approaches Professional Ethics and Codes Ethical Analysis and Decision Making in Nursing Relationships in Professional Practice Moral Rights and Autonomy Social Justice Death and End-of-Life Care Conclusion References

Law and Professional Nursing Practice Kathleen Driscoll and Kathleen Masters

The Sources of Law Classification and Enforcement of the Law Nursing Scope and Standards Malpractice and Negligence Nursing Licensure Professional Accountability Conclusion References

Appendix A Provisions of Code of Ethics for Nurses

Appendix B The ICN Code of Ethics for Nurses Glossary Index

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PREFACE

Although the process of professional development is a lifelong journey, it is a journey that begins in earnest during the time of initial academic preparation. The goal of this book is to provide nursing students with a road map to help guide them along their journey as professional nurses.

This book is organized into two units. The chapters in the first unit focus on the foundational concepts that are essential to the development of the individual professional nurse. The chapters in Unit II address issues related to professional nursing practice and the management of patient care, specifically in the context of quality and safety. In the Fifth Edition, the chapter content is conceptualized, when applicable, around nursing competencies, professional standards, and recommendations from national groups, such as Institute of Medicine reports. All chapters have been updated, several chapters have been expanded, and two new chapters have been added in this edition. The chapters included in Unit I provide the student nurse with a basic foundation in such areas as nursing history, theory, philosophy, socialization into the nursing role, professional development, the social context of nursing, and professional nursing competencies. The social context of nursing chapter has been expanded to incorporate not only societal trends but also trends in nursing practice and education that are changing the future landscape of the profession. The chapters in Unit II are more directly related to patient care management and, as stated previously, are presented in the context of quality and safety. Chapter topics include the role of the nurse in patient safety and quality improvement, evidence-based nursing practice, the role of the nurse in patient education and patient- centered care, informatics in nursing practice, the role of the nurse related to teamwork and collaboration, systems-based practice and leadership, ethics in nursing practice, and the law as it relates to patient care and nursing. Unit II chapters have undergone revision, with a refocus of the content on recommended nursing and healthcare competencies as well as recommendations from faculty using the text in the classroom.

The Fifth Edition incorporates the revised Nurse of the Future: Nursing Core

Competencies: Registered Nurse throughout each chapter. The 10 essential competencies that are intended to guide nursing curricula and practice emanate from the central core of the model that represents nursing knowledge (Massachusetts Department of Higher Education, 2016) and are based on the American Association of Colleges of Nursing (AACN) Essentials of Baccalaureate Education for Professional Nursing Practice, National League for Nursing Council of Associate Degree Nursing competencies, Institute of Medicine recommendations, Quality and Safety Education for Nurses (QSEN) competencies, and American Nurses Association standards, as well as other professional organization standards and recommendations. The 10 competencies included in the model are patient-centered care, professionalism, informatics and technology, evidence-based practice, leadership, systems-based practice, safety, communication, teamwork and collaboration, and quality improvement. Essential knowledge, skills, and attitudes (KSAs) reflecting cognitive, psychomotor, and affective learning domains are specified for each competency. The KSAs identified in the model reflect the expectations for initial nursing practice following the completion of a prelicensure professional nursing education program (Massachusetts Department of Higher Education, 2016).

This new edition has competency boxes throughout the chapters that link examples of the KSAs appropriate to the chapter content to Nurse of the Future: Nursing Core Competencies required of entry-level professional nurses. The competency model is explained in detail in Chapter 4 and is available in its entirety online at http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf.

The Fifth Edition also includes applicable AACN essentials incorporated as key outcomes throughout each chapter to assist faculty with the alignment of curricular content with criteria required by accreditors. The key outcomes also demonstrate for students the link between expectations included in the competency model, the expectations embodied in the essentials document, and the chapter content. A discussion of the AACN (2008) Essentials of Baccalaureate Education for Professional Nursing Practice is also included in Chapter 4.

This new edition continues to use case studies, congruent with Benner, Sutphen, Leonard, and Day’s (2010) Carnegie Report recommendations that nursing educators teach for “situated cognition” using narrative strategies to lead to “situated action,” thus increasing the clinical connection in our teaching or that we teach for “clinical salience.” In addition, critical thinking questions are included throughout each chapter to promote student reflection on the chapter concepts. Classroom activities are also provided based on chapter content. Additional resources not connected to this text, but applicable to the content herein, include a toolkit focused on the nursing core competencies available at http://www.mass.edu/nahi/documents/NursingCoreCompetenciesToolkit-March2016.pdf and teaching activities related to nursing competencies available on the QSEN website at http://qsen.org/teaching-strategies/.

Although the topics included in this textbook are not inclusive of all that could be discussed in relationship to the broad theme of role development in professional nursing practice, it is my prayer that the subjects herein make a contribution to the profession of nursing by providing the student with a solid foundation and a desire to grow as a professional nurse throughout the journey that we call a professional nursing career. Let the journey begin.

—Kathleen Masters

References American Association of Colleges of Nursing. (2008). The essentials of baccalaureate

http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf
http://www.mass.edu/nahi/documents/NursingCoreCompetenciesToolkit-March2016.pdf
http://qsen.org/teaching-strategies/
education for professional nursing practice. Retrieved from http://www.aacnnursing.org/Education-Resources/AACN-Essentials

Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.

Massachusetts Department of Higher Education. (2016). Nurse of the future: Nursing core competencies: Registered nurse. Retrieved from http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf

Editor Kathleen Masters, DNS, RN Professor and Dean University of Southern Mississippi College of Nursing Hattiesburg, Mississippi

http://www.aacnnursing.org/Education-Resources/AACN-Essentials
http://www.mass.edu/nahi/documents/NOFRNCompetencies_updated_March2016.pdf
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CONTRIBUTORS

Janie B. Butts, PhD, RN Professor University of Southern Mississippi College of Nursing Hattiesburg, Mississippi

Cynthia Chatham, DSN, RN Associate Professor University of Southern Mississippi College of Nursing Long Beach, Mississippi

Mary Louise Coyne, DNSc, RN Professor University of Southern Mississippi College of Nursing Long Beach, Mississippi

Kathleen Driscoll, JD, MS, RN University of Cincinnati College of Nursing Cincinnati, Ohio

Melanie Gilmore, PhD, RN Associate Professor (Retired) University of Southern Mississippi College of Nursing Hattiesburg, Mississippi

Cathy K. Hughes, DNP, RN Teaching Assistant Professor University of Southern Mississippi

College of Nursing Hattiesburg, Mississippi

Karen Saucier Lundy, PhD, RN, FAAN Professor Emeritus University of Southern Mississippi College of Nursing Hattiesburg, Mississippi

Katherine E. Nugent, PhD, RN Professor and Dean (Retired) University of Southern Mississippi College of Nursing Hattiesburg, Mississippi

Karen L. Rich, PhD, RN Associate Professor University of Southern Mississippi College of Nursing Long Beach, Mississippi

Jill Rushing, MSN, RN Director of BSN Program University of Southern Mississippi College of Nursing Hattiesburg, Mississippi

Mary W. Stewart, PhD, RN Director of PhD Program University of Mississippi Medical Center School of Nursing Jackson, Mississippi

Sharon Vincent, DNP, RN, CNOR University of North Carolina College of Nursing Charlotte, North Carolina

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UNIT I

Foundations of Professional Nursing Practice

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CHAPTER 1

A History of Health Care and Nursing1 Karen Saucier Lundy and Kathleen Masters

Learning Objectives

After completing this chapter, the student should be able to:

1. Identify social, political, and economic influences on the development of professional nursing practice.

2. Identify important leaders and events that have significantly affected the development of professional nursing practice.

Key Terms and Concepts

Greek era Roman era Deaconesses Florence Nightingale Reformation Chadwick Report Shattuck Report William Rathbone Ethel Fenwick Jeanne Mance Mary Agnes Snively Goldmark Report Brown Report Isabel Hampton Robb American Nurses Association (ANA) Lavinia Lloyd Dock American Journal of Nursing (AJN) Margaret Sanger Lillian Wald Jane A. Delano Annie Goodrich Mary Brewster Henry Street Settlement Elizabeth Tyler Jessie Sleet Scales Dorothea Lynde Dix Clara Barton Frontier Nursing Service Mary Breckinridge Mary D. Osborne Frances Payne Bolton International Council of Nurses (ICN)

Although no specialized nurse role per se developed in early civilizations, human cultures recognized the need for nursing care. The truly sick person was weak and helpless and could not fulfill the duties that were normally expected of a member of the

community. In such cases, someone had to watch over the patient, nurse him or her, and provide care. In most societies, this nurse role was filled by a family member, usually female. As in most cultures, the childbearing woman had special needs that often resulted in a specialized role for the caregiver. Every society since the dawn of time had someone to nurse and take care of the mother and infant around the childbearing events. In whatever form the nurse took, the role was associated with compassion, health promotion, and kindness (Bullough & Bullough, 1978).

Classical Era More than 4,000 years ago, Egyptian physicians and nurses used an abundant pharmacologic repertoire to cure the ill and injured. The Ebers Papyrus lists more than 700 remedies for ailments ranging from snakebites to puerperal fever (Kalisch & Kalisch, 1986). Healing appeared in the Egyptian culture as the successful result of a contest between invisible beings of good and evil (Shryock, 1959). Around 1000 B.C., the Egyptians constructed elaborate drainage systems, developed pharmaceutical herbs and preparations, and embalmed the dead. The Hebrews formulated an elaborate hygiene code that dealt with laws governing both personal and community hygiene, such as contagion, disinfection, and sanitation through the preparation of food and water. The Jewish contribution to health is greater in sanitation than in their concept of disease. Garbage and excreta were disposed of outside the city or camp, infectious diseases were quarantined, spitting was outlawed as unhygienic, and bodily cleanliness became a prerequisite for moral purity. Although many of the Hebrew ideas about hygiene were Egyptian in origin, the Hebrews were the first to codify them and link them with spiritual godliness (Bullough & Bullough, 1978).

Disease and disability in the Mesopotamian area were considered a great curse, a divine punishment for grievous acts against the gods. Experiencing illness as punishment for a sin linked the sick person to anything even remotely deviant. Not only was the person suffering from the illness but also he or she also was branded by society as having deserved it. Those who obeyed God’s law lived in health and happiness, and those who transgressed the law were punished with illness and suffering. The sick person then had to make atonement for the sins, enlist a priest or other spiritual healer to lift the curse, or live with the illness to its ultimate outcome (Bullough & Bullough, 1978). Nursing care by a family member or relative would be needed, regardless of the outcome of the sin, curse, disease-atonement-recovery, or death cycle. This logic became the basis for explanation of why some people “get sick and some don’t” for many centuries and still persists to some degree in most cultures today.

The Greeks and Health In Greek mythology, the god of medicine, Asclepias, cured disease. One of his daughters, Hygieia, from whom we derive the word hygiene, was the goddess of preventive health and protected humans from disease. Panacea, Asclepias’ other

daughter, was known as the all-healing “universal remedy,” and today her name is used to describe any ultimate cure-all in medicine. She was known as the “light” of the day, and her name was invoked and shrines built to her during times of epidemics (Brooke, 1997).

During the Greek era, Hippocrates of Cos emphasized the rational treatment of sickness as a natural rather than a god-inflicted phenomenon. Hippocrates (460–370 B.C.) is considered the father of medicine because of his arrangements of the oral and written remedies and diseases, which had long been secrets held by priests and religious healers, into a textbook of medicine that was used for centuries (Bullough & Bullough, 1978).

In Greek society, health was considered to result from a balance between mind and body. Hippocrates wrote a most important book, Air, Water, and Places, which detailed the relationship between humans and the environment. This is considered a milestone in the eventual development of the science of epidemiology as the first such treatise on the connectedness of the web of life. This topic of the relationship between humans and their environment did not recur until the development of bacteriology in the late 1800s (Rosen, 1958).

Perhaps the idea that most damaged the practice and scientific theory of medicine and health for centuries was the doctrine of the four humors, first spoken of by Empedocles of Acragas (493–433 B.C.). Empedocles was a philosopher and a physician, and as a result, he synthesized his cosmologic ideas with his medical theory. He believed that the same four elements that made up the universe were found in humans and in all animate beings (Bullough & Bullough, 1978). Empedocles believed that man [sic] was a microcosm, a small world within the macrocosm, or external environment. The four humors of the body (blood, bile, phlegm, and black bile) corresponded to the four elements of the larger world (fire, air, water, and earth) (Kalisch & Kalisch, 1986). Depending on the prevailing humor, a person was sanguine, choleric, phlegmatic, or melancholic. Because of this strongly held and persistent belief in the connection between the balance of the four humors and health status, treatment was aimed at restoring the appropriate balance of the four humors through the control of their corresponding elements. Through manipulating the two sets of opposite qualities—hot and cold, wet and dry—balance was the goal of the intervention. Fire was hot and dry, air was hot and wet, water was cold and wet, and earth was cold and dry. For example, if a person had a fever, cold compresses would be prescribed; for a chill the person would be warmed. Such doctrine gave rise to faulty and ineffective treatment of disease that influenced medical education for many

years (Taylor, 1922). Plato, in The Republic, details the importance of recreation, a balanced mind and

body, nutrition, and exercise. A distinction was made among gender, class, and health as early as the Greek era; only males of the aristocracy could afford the luxury of maintaining a healthful lifestyle (Rosen, 1958).

In The Iliad, a poem about the attempts to capture Troy and rescue Helen from her lover, Paris, 140 different wounds are described. The mortality rate averaged 77.6%, the highest as a result of sword and spear thrusts and the lowest from superficial arrow wounds. There was considerable need for nursing care, and Achilles, Patroclus, and other princes often acted as nurses to the injured. The early stages of Greek medicine reflected the influences of Egyptian, Babylonian, and Hebrew medicine. Therefore, good medical and nursing techniques were used to treat these war wounds: The arrow was drawn or cut out, the wound washed, soothing herbs applied, and the wound bandaged. However, in sickness in which no wound occurred, an evil spirit was considered the cause. The Greeks applied rational causes and cures to external injuries, whereas internal ailments continued to be linked to spiritual maladies (Bullough & Bullough, 1978).

Roman Era During the rise and the fall of the Roman era (31 B.C.–A.D. 476), Greek culture continued to be a strong influence. The Romans easily adopted Greek culture and expanded the Greeks’ accomplishments, especially in the fields of engineering, law, and government. For Romans, the government had an obligation to protect its citizens not only from outside aggression, such as warring neighbors, but also from inside the civilization, in the form of health laws. According to Bullough and Bullough (1978), Rome was essentially a “Greek cultural colony” (p. 20).

Galen of Pergamum (A.D. 129–199), often known as the greatest Greek physician after Hippocrates, left for Rome after studying medicine in Greece and Egypt and gained great fame as a medical practitioner, lecturer, and experimenter. In his lifetime, medicine evolved into a science; he submitted traditional healing practices to experimentation and was possibly the greatest medical researcher before the 1600s (Bullough & Bullough, 1978). He was considered the last of the great physicians of antiquity (Kalisch & Kalisch, 1986).

The Greek physicians and healers certainly made the most contributions to medicine, but the Romans surpassed the Greeks in promoting the evolution of nursing. Roman armies developed the notion of a mobile war nursing unit because their battles

took them far from home where they could be cared for by wives and family. This portable hospital was a series of tents arranged in corridors; as battles wore on, these tents gave way to buildings that became permanent convalescent camps at the battle sites (Rosen, 1958). Many of these early military hospitals have been excavated by archaeologists along the banks of the Rhine and Danube rivers. They had wards, recreation areas, baths, pharmacies, and even rooms for officers who needed a “rest cure” (Bullough & Bullough, 1978). Coexisting were the Greek dispensary forms of temples, or the iatreia, which started out as a type of physician waiting room. These eventually developed into a primitive type of hospital, places for surgical clients to stay until they could be taken home by their families. Although nurses during the Roman era were usually family members, servants, or slaves, nursing had strengthened its position in medical care and emerged during the Roman era as a separate and distinct specialty.

The Romans developed massive aqueducts, bathhouses, and sewer systems during this era. At the height of the Roman Empire, Rome provided 40 gallons of water per person per day to its 1 million inhabitants, which is comparable to our rates of consumption today (Rosen, 1958).

Middle Ages Many of the advancements of the Greco-Roman era were reversed during the Middle Ages (A.D. 476–1453) after the decline of the Roman Empire. The Middle Ages, or the medieval era, served as a transition between ancient and modern civilizations. Once again, myth, magic, and religion were explanations and cures for illness and health problems. The medieval world was the result of a fusion of three streams of thought, actions, and ways of life—Greco-Roman, Germanic, and Christian (Donahue, 1985). Nursing was most influenced by Christianity with the beginning of deaconesses, or female servants, doing the work of God by ministering to the needs of others. Deacons in the early Christian churches were apparently available only to care for men, whereas deaconesses cared for the needs of women. The role of deaconesses in the church was considered a forward step in the development of nursing and in the 1800s would strongly influence the young Florence Nightingale. During this era, Roman military hospitals were replaced by civilian ones. In early Christianity, the Diakonia, a kind of combination outpatient and welfare office, was managed by deacons and deaconesses and served as the equivalent of a hospital. Jesus served as the example of charity and compassion for the poor and marginal of society.

Communicable diseases were rampant during the Middle Ages, primarily because of the walled cities that emerged in response to the paranoia and isolation of the populations. Infection was next to impossible to control. Physicians had little to offer, deferring to the church for management of disease. Nursing roles were carried out primarily by religious orders. The oldest hospital (other than military hospitals in the Roman era) in Europe was most likely the Hôtel-Dieu in Lyon, France, founded about 542 by Childebert I, king of Paris. The Hôtel-Dieu in Paris was founded around 652 by Saint Landry, bishop of Paris. During the Middle Ages, charitable institutions, hospitals, and medical schools increased in number, with the religious leaders as caregivers. The word hospital, which is derived from the Latin word hospitalis, meaning service of guests, was most likely more of a shelter for travelers and other pilgrims as well as the occasional person who needed extra care (Kalisch & Kalisch, 1986). Early European hospitals were more like hospices or homes for the aged, sick pilgrims, or orphans. Nurses in these early hospitals were religious deaconesses who chose to care for others in a life of servitude and spiritual sacrifice.

Black Death

During the Middle Ages, a series of horrible epidemics, including the Black Death or bubonic plague, ravaged the civilized world (Diamond, 1997). In the 1300s, Europe, Asia, and Africa saw nearly half their populations lost to the bubonic plague. Worldwide, more than 60 million deaths were attributed to this horrible plague. In some parts of Europe, only one-fourth of the population survived, with some places having too few survivors alive to bury the dead. Families abandoned sick children, and the sick were often left to die alone (Cartwright, 1972).

Nurses and physicians were powerless to avert the disease. Black spots and tumors on the skin appeared, and petechiae and hemorrhages gave the skin a darkened appearance. There was also acute inflammation of the lungs, burning sensations, unquenchable thirst, and inflammation of the entire body. Hardly anyone afflicted survived the third day of the attack. So great was the fear of contagion that ships carrying bodies of infected persons were set to sail without a crew to drift from port to port through the North, Black, and Mediterranean seas with their dead passengers (Cohen, 1989).

Medieval people knew that this disease was in some way communicable, but they were unsure of the mode of transmission (Diamond, 1997); hence the avoidance of victims and a reliance on isolation techniques. During this time, the practice of quarantine in city ports was developed as a preventive measure that is still used today (Bullough & Bullough, 1978; Kalisch & Kalisch, 1986).

The Renaissance During the rebirth of Europe, political, social, and economic advances occurred along with a tremendous revival of learning. Donahue (1985) contends that the Renaissance has been “viewed as both a blessing and a curse” (p. 188). There was a renewed interest in the arts and sciences, which helped advance medical science (Boorstin, 1985; Bullough & Bullough, 1978). Columbus and other explorers discovered new worlds, and belief in a sun-centered rather than an Earth-centered universe was promoted by Copernicus (1473–1543). Sir Isaac Newton’s (1642–1727) theory of gravity changed the world forever. Gunpowder was introduced, and social and religious upheavals resulted in the American and French revolutions at the end of the 1700s. In the arts and sciences, Leonardo da Vinci, known as one of the greatest geniuses of all time, made a number of anatomic drawings based on dissection experiences. These drawings have become classics in the progression of knowledge about the human anatomy. Many artists of this time left an indelible mark and continue to exert influence today, including Michelangelo, Raphael, and Titian (Donahue, 1985).