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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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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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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
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
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
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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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.
References American Association of Colleges of Nursing. (2008). The essentials of baccalaureate
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
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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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Foundations of Professional Nursing Practice
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A History of Health Care and Nursing1 Karen Saucier Lundy and Kathleen Masters
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.
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).
The Reformation Religious changes during the Renaissance influenced nursing perhaps more than any other aspect of society. Particularly important was the rise of Protestantism as a result of the reform movements of Martin Luther (1483–1546) in Germany and John Calvin (1509–1564) in France and Switzerland. Although the various sects were numerous in the Protestant movement, the agreement among the leaders was almost unanimous on the abolition of the monastic or cloistered career. The effects on nursing were drastic: Monastic-affiliated institutions, including hospitals and schools, were closed, and orders of nuns, including nurses, were dissolved. Even in countries where Catholicism flourished, royal leaders seized monasteries frequently.
Religious leaders, such as Martin Luther, who led the Reformation in 1517, were well aware of the lack of adequate nursing care as a result of these sweeping changes. Luther advocated that each town establish something akin to a “community chest” to raise funds for hospitals and nurse visitors for the poor (Dietz & Lehozky, 1963). Thus, the closures of the monasteries eventually resulted in the creation of public hospitals where laywomen performed nursing care. It was difficult to find laywomen who were willing to work in these hospitals to care for the sick, so judges began giving prostitutes, publically intoxicated women, and poverty-stricken women
the option of going to jail, going to the poorhouse, or working in the public hospital. Unlike the sick wards in monasteries, which were generally considered to be clean and well managed, the public hospitals were filthy, disorganized buildings where people went to die while being cared for by laywomen who were not trained, motivated, or qualified to care for the sick (Sitzman & Judd, 2014a).
In England, where there had been at least 450 charitable foundations before the Reformation, only a few survived the reign of Henry VIII, who closed most of the monastic hospitals (Donahue, 1985). Eventually, Henry VIII’s son, Edward VI, who reigned from 1547 to 1553, endowed some hospitals, namely, St. Bartholomew’s Hospital and St. Thomas’ Hospital, which would eventually house the Nightingale School of Nursing later in the 1800s (Bullough & Bullough, 1978).
The Dark Period of Nursing The last half of the period between 1500 and 1860 is widely regarded as the “dark period of nursing” because nursing conditions were at their worst (Donahue, 1985). Education for girls, which had been provided by the nuns in religious schools, was lost. Because of the elimination of hospitals and schools, there was no one to pass on knowledge about caring for the sick. As a result, the hospitals were managed and staffed by municipal authorities; women entering nursing service often came from illiterate classes, and even then, there were too few to serve (Dietz & Lehozky, 1963). The lay attendants who filled the nursing role were illiterate, rough, inconsiderate, and often immoral and alcoholic. Intelligent women and men could not be persuaded to accept such a degraded and low-status position in the offensive municipal hospitals of London. Nursing slipped back into a role of servitude as menial, low-status work. According to Donahue (1985), when a woman could no longer make it as a gambler, prostitute, or thief, she might become a nurse. Eventually, women serving jail sentences for such crimes as prostitution and stealing were ordered to care for the sick in the hospitals instead of serving their sentences in the city jail (Dietz & Lehozky, 1963). The nurses of this era took bribes from clients, became inappropriately involved with them, and survived the best way they could, often at the expense of their assigned clients.
Nursing had, during this era, virtually no social standing or organization. Even Catholic sisters of the religious orders throughout Europe “came to a complete standstill” professionally because of the intolerance of society (Donahue, 1985, p. 231). Charles Dickens, in Martin Chuzzlewit (1844), created the enduring characters of Sairey Gamp and Betsy Prig. Sairey Gamp was a visiting nurse based on an actual hired attendant whom Dickens had met in a friend’s home. Sairey Gamp was hired to care for sick family members but was instead cruel to her clients, stole from them, and ate their rations; she was an alcoholic and has been immortalized forever as a reminder of the world in which Florence Nightingale came of age (Donahue, 1985). The first hospital in the Americas, the Hospital de la Purísima Concepción, was founded some time before 1524 by Hernando Cortez, the conqueror of Mexico. The first hospital in the continental United States was erected in Manhattan in 1658 for the care of sick soldiers and slaves. In 1717, a hospital for infectious diseases was built in Boston; the first hospital established by a private gift was the Charity Hospital in New Orleans. A sailor, Jean Louis, donated the endowment for the hospital’s founding
(Bullough & Bullough, 1978). During the 1600s and 1700s, colonial hospitals with little resemblance to modern
hospitals were often used to house the poor and downtrodden. Hospitals called “pesthouses” were created to care for clients with contagious diseases; their primary purpose was to protect the public at large rather than to treat and care for the clients. Contagious diseases were rampant during the early years of the American colonies, often being spread by the large number of immigrants who brought these diseases with them on their long journey to America. Medicine was not as developed as in Europe, and nursing remained in the hands of the uneducated. By 1720, average life expectancy at birth was only around 35 years. Plagues were a constant nightmare, with outbreaks of smallpox and yellow fever. In 1751, the first true hospital in the new colonies, Pennsylvania Hospital, was erected in Philadelphia on the recommendation of Benjamin Franklin (Kalisch & Kalisch, 1986).
By today’s standards, hospitals in the 1800s were disgraceful, dirty, unventilated, and contaminated by infections; to be a client in a hospital actually increased one’s risk of dying. As in England, nursing was considered an inferior occupation. After the sweeping changes of the Reformation, educated religious health workers were replaced with lay people who were “down and outers,” in prison or had no option left but to work with the sick (Kalisch & Kalisch, 1986).
The Industrial Revolution During the mid-1700s in England, capitalism emerged as an economic system based on profit. This emerging system resulted in mass production, as contrasted with the previous system of individual workers and craftsmen. In the simplest terms, the Industrial Revolution was the application of machine power to processes formerly done by hand. Machinery was invented during this era and ultimately standardized quality; individual craftsmen were forced to give up their crafts and lands and become factory laborers for the capitalist owners. All types of industries were affected; this new-found efficiency produced profit for owners of the means of production. Because of this, the era of invention flourished, factories grew, and people moved in record numbers to work in the cities. Urban areas grew, tenement housing projects emerged, and overcrowding in cities seriously threatened individuals’ well-being (Donahue, 1985).
Workers were forced to go to the machines, not the other way around. Such relocations meant giving up not only farming but also a way of life that had existed for centuries. The emphasis on profit over people led to child labor, frequent layoffs, and long workdays filled with stressful, tedious, unfamiliar work. Labor unions did not exist, and neither was there any legal protection against exploitation of workers, including children (Donahue, 1985). All these rapid changes and often threatening conditions created the world of Charles Dickens, where, as in his book Oliver Twist, children worked as adults without question.
According to Donahue (1985), urban life, trade, and industrialization contributed to these overwhelming health hazards, and the situation was confounded by the lack of an adequate means of social control. Reforms were desperately needed, and the social reform movement emerged in response to the unhealthy by-products of the Industrial Revolution. It was in this world of the 1800s that such reformers as John Stuart Mill (1806–1873) emerged. Although the Industrial Revolution began in England, it quickly spread to the rest of Europe and to the United States (Bullough & Bullough, 1978). The reform movement is critical to understanding the emerging health concerns that were later addressed by Florence Nightingale. Mill championed popular education, the emancipation of women, trade unions, and religious toleration. Other reform issues of the era included the abolition of slavery and, most important for nursing, more humane care of the sick, the poor, and the wounded (Bullough & Bullough, 1978). There was a renewed energy in the religious community with the reemergence of new religious orders in the Catholic Church that provided service to
the sick and disenfranchised. Epidemics had ravaged Europe for centuries, but they became even more serious
with urbanization. Industrialization brought people to cities, where they worked in close quarters (as compared with the isolation of the farm) and contributed to the social decay of the second half of the 1800s. Sanitation was poor or nonexistent, sewage disposal from the growing population was lacking, cities were filthy, public laws were weak or nonexistent, and congestion of the cities inevitably brought pests in the form of rats, lice, and bedbugs, which transmitted many pathogens. Communicable diseases continued to plague the population, especially those who lived in these unsanitary environments. For example, during the mid-1700s, typhus and typhoid fever claimed twice as many lives each year as did the Battle of Waterloo (Hanlon & Pickett, 1984). Through foreign trade and immigration, infectious diseases were spread to all of Europe and eventually to the growing United States.
The Chadwick Report Edwin Chadwick became a major figure in the development of the field of public health in Great Britain by drawing attention to the cost of the unsanitary conditions that shortened the life span of the laboring class and threatened the wealth of Britain. Although the first sanitation legislation, which established a National Vaccination Board, was passed in 1837, Chadwick found in his classic study, Report on an Inquiry into the Sanitary Conditions of the Labouring Population of Great Britain, that death rates were high in large industrial cities, such as Liverpool. A more startling finding, from what is often referred to simply as the Chadwick Report, was that more than half the children of labor-class workers died by age 5, indicating poor living conditions that affected the health of the most vulnerable. Laborers lived only half as long as the upper classes.
One consequence of the report was the establishment in 1848 of the first board of health, the General Board of Health for England (Richardson, 1887). More legislation followed that initiated social reform in the areas of child welfare, elder care, the sick, mentally ill persons, factory health, and education. Soon sewers and fireplugs, based on an available water supply, appeared as indicators that the public health linkages from the Chadwick Report had an effect.
The Shattuck Report In the United States during the 1800s, waves of epidemics of yellow fever, smallpox, cholera, typhoid fever, and typhus continued to plague the population as in England
and the rest of the world. As cities continued to grow in the industrialized young nation, poor workers crowded into larger cities and suffered from illnesses caused by the unsanitary living conditions (Hanlon & Pickett, 1984). Similar to Chadwick’s classic study in England, Lemuel Shattuck, a Boston bookseller and publisher who had an interest in public health, organized the American Statistical Society in 1839 and issued a census of Boston in 1845. Shattuck’s census revealed high infant mortality rates and high overall population mortality rates. In 1850, in his Report of the Massachusetts Sanitary Commission, Shattuck not only outlined his findings on the unsanitary conditions but also made recommendations for public health reform that included the bookkeeping of population statistics and development of a monitoring system that would provide information to the public about environmental, food, and drug safety and infectious disease control (Rosen, 1958). He also called for services for well-child care, school-age children’s health, immunizations, mental health, health education for all, and health planning. The Shattuck Report was revolutionary in its scope and vision for public health, but it was virtually ignored during Shattuck’s lifetime. Nineteen years later, in 1869, the first state board of health was formed (Kalisch & Kalisch, 1986).
And Then There Was Nightingale . . . Florence Nightingale (Figure 1-1) was named one of the 100 most influential persons of the last millennium by Life magazine (“The 100 People Who Made the Millennium,” 1997). She was one of only eight women identified as such. Of those eight women, including Joan of Arc, Helen Keller, and Elizabeth I, Nightingale was identified as a true “angel of mercy,” having reformed military health care in the Crimean War and used her political savvy to forever change the way society views the health of the vulnerable, the poor, and the forgotten. She is probably one of the most written about women in history (Bullough & Bullough, 1978). Florence Nightingale has become synonymous with modern nursing.
Figure 1-1 Engraving From 1873 featuring the English reformer and founder of modern nursing, Florence Nightingale.
© traveler1116/E+/Getty Images
Born on May 12, 1820, in her namesake city, Florence, Italy, Florence Nightingale was the second child in the wealthy English family of William and Frances Nightingale. As a young child, Florence displayed incredible curiosity and intellectual abilities not common to female children of the Victorian age. She mastered the fundamentals of Greek and Latin, and she studied history, art, mathematics, and philosophy. To her family’s dismay, she believed that God had called her to be a nurse. Nightingale was keenly aware of the suffering that industrialization created; she became obsessed with the plight of the miserable and suffering people. Conditions of general starvation accompanied the Industrial Revolution, prisons and workhouses overflowed, and persons in all sections of British life were displaced. She wrote in the spring of 1842,
“My mind is absorbed with the sufferings of man; it besets me behind and before. . . . All that the poets sing of the glories of this world seem to me untrue. All the people that I see are eaten up with care or poverty or disease” (Woodham-Smith, 1951, p. 31).
Nightingale’s entire life would be haunted by this conflict between the opulent life of gaiety that she enjoyed and the misery of the world, which she was unable to alleviate. She was, in essence, an “alien spirit in the rich and aristocratic social sphere of Victorian England” (Palmer, 1977, p. 14). Nightingale remained unmarried, and at the age of 25, she expressed a desire to be trained as a nurse in an English hospital. Her parents emphatically denied her request, and for the next 7 years, she made repeated attempts to change their minds and allow her to enter nurse training. She wrote, “I crave for some regular occupation, for something worth doing instead of frittering my time away on useless trifles” (Woodham-Smith, 1951, p. 162). During this time, she continued her education through the study of math and science and spent 5 years collecting data about public health and hospitals (Dietz & Lehozky, 1963). During a tour of Egypt in 1849 with family and friends, Nightingale spent her 30th year in Alexandria with the Sisters of Charity of St. Vincent de Paul, where her conviction to study nursing was only reinforced (Tooley, 1910). While in Egypt, Nightingale studied Egyptian, Platonic, and Hermetic philosophy; Christian scripture; and the works of poets, mystics, and missionaries in her efforts to understand the nature of God and her “calling” as it fit into the divine plan (Calabria, 1996; Dossey, 2000).
The next spring, Nightingale traveled unaccompanied to the Kaiserwerth Institute in Germany and stayed there for 2 weeks, vowing to return to train as a nurse. In June 1851, Nightingale took her future into her own hands and announced to her family that she planned to return to Kaiserwerth and study nursing. According to Dietz and Lehozky (1963, p. 42), her mother had “hysterics” and scene followed scene. Her father “retreated into the shadows,” and her sister, Parthe, expressed that the family name was forever disgraced (Cook, 1913). In 1851, at the age of 31, Nightingale was finally permitted to go to Kaiserwerth, and she studied there for 3 months with Pastor Fliedner. Her family insisted that she tell no one outside the family of her whereabouts, and her mother forbade her to write any letters from Kaiserwerth. While there, Nightingale learned about the care of the sick and the importance of discipline and commitment of oneself to God (Donahue, 1985). She returned to England and cared for her then ailing father, from whom she finally gained some support for her intent to become a nurse—her lifelong dream.
In 1852, Nightingale wrote the essay “Cassandra,” which stands today as a classic feminist treatise against the idleness of Victorian women. Through her voluminous journal writings, Nightingale reveals her inner struggle throughout her adulthood with
what was expected of a woman and what she could accomplish with her life. The life expected of an aristocratic woman in her day was one she grew to loathe, and she expressed this detestation throughout her writings (Nightingale, 1979). In “Cassandra,” Nightingale put her thoughts to paper, and many scholars believe that her eventual intent was to extend the essay to a novel. She wrote in “Cassandra,” “Why have women passion, intellect, moral activity—these three—in a place in society where no one of the three can be exercised?” (Nightingale, 1979, p. 37). Although uncertain about the meaning of the name Cassandra, many scholars believe that it came from the Greek goddess Cassandra, who was cursed by Apollo and doomed to see and speak the truth but never to be believed. Nightingale saw the conventional life of women as a waste of time and abilities. After receiving a generous yearly endowment from her father, Nightingale moved to London and worked briefly as the superintendent of the Establishment for Gentlewomen During Illness hospital, finally realizing her dream of working as a nurse (Cook, 1913).
The Crimean Experience: “I Can Stand Out the War with Any Man” Nightingale’s opportunity for greatness came when she was offered the position of superintendent of the female nursing establishment of the English General Hospitals in Turkey by the secretary of war, Sir Sidney Herbert. Soon after the outbreak of the Crimean War, stories of the inadequate care and lack of medical resources for the soldiers became widely known throughout England (Woodham-Smith, 1951). The country was appalled at the conditions so vividly portrayed in the London Times. Pressure increased on Sir Sidney to react. He knew of one woman who was capable of bringing order out of the chaos and wrote a letter to Nightingale on October 15, 1854, as a plea for her service. Nightingale accepted the challenge and set sail with 38 self-proclaimed nurses with varied training and experiences, of whom 24 were Catholic and Anglican nuns. Their journey to the Crimea took a month, and on November 4, 1854, the brave nurses arrived at Istanbul and were taken to Scutari the same day. Faced with 3,000 to 4,000 wounded men in a hospital designed to accommodate 1,700, the nurses went to work (Kalisch & Kalisch, 1986). They found 4 miles of beds 18 inches apart. Most soldiers were lying naked with no bedding or blanket. There were no kitchen or laundry facilities. The little light present took the form of candles in beer bottles. The hospital was literally floating on an open sewage lagoon filled with rats and other vermin (Donahue, 1985).
By taking the newly arrived medical equipment and setting up kitchens, laundries,
recreation rooms, reading rooms, and a canteen, Nightingale and her team of nurses proceeded to clean the barracks of lice and filth. Nightingale was in her element. She set out not only to provide humane health care for the soldiers but also to essentially overhaul the administrative structure of the military health services (Williams, 1961).
Florence Nightingale and Sanitation Although Nightingale never accepted the germ theory, she demanded clean dressings; clean bedding; well-cooked, edible, and appealing food; proper sanitation; and fresh air. After the other nurses were asleep, Nightingale made her famous solitary rounds with a lamp or lantern to check on the soldiers. Nightingale had a lifelong pattern of sleeping few hours, spending many nights writing, developing elaborate plans, and evaluating implemented changes. She seldom believed in the “hopeless” soldier, only one who needed extra attention. Nightingale was convinced that most of the maladies that the soldiers suffered and died from were preventable (Williams, 1961).
Before Nightingale’s arrival and her radical and well-documented interventions based on sound public health principles, the mortality rate from the Crimean War was estimated to be from 42% to 73%. Nightingale is credited with reducing that rate to 2% within 6 months of her arrival at Scutari. She did this through careful, scientific epidemiologic research (Dietz & Lehozky, 1963). Upon arriving at Scutari, Nightingale’s first act was to order 200 scrubbing brushes. The death rate fell dramatically once Nightingale discovered that the hospital was built literally over an open sewage lagoon (Andrews, 2003).
According to Palmer (1982), Nightingale possessed the qualities of a good researcher: insatiable curiosity, command of her subject, familiarity with methods of inquiry, a good background of statistics, and the ability to discriminate and abstract. She used these skills to maintain detailed and copious notes and to codify observations. Nightingale relied on statistics and attention to detail to back up her conclusions about sanitation, management of care, and disease causation. Her now- famous “cox combs” are a hallmark of military health services management by which she diagrammed deaths in the army from wounds and from other diseases and compared them with deaths that occurred in similar populations in England (Palmer, 1977).
Nightingale was first and foremost an administrator: She believed in a hierarchical administrative structure with ultimate control lodged in one person to whom all subordinates and offices reported. Within a matter of weeks of her arrival in the Crimea, Nightingale was the acknowledged administrator and organizer of a mammoth
humanitarian effort. From her Crimean experience on, Nightingale involved herself primarily in organizational activities and health planning administration. Palmer contends that Nightingale “perceived the Crimean venture, which was set up as an experiment, as a golden opportunity to demonstrate the efficacy of female nursing” (Palmer, 1982, p. 4). Although Nightingale faced initial resistance from the unconvinced and oppositional medical officers and surgeons, she boldly defied convention and remained steadfastly focused on her mission to create a sanitary and highly structured environment for her “children”—the British soldiers who dedicated their lives to the defense of Great Britain. Because of her insistence on absolute authority regarding nursing and the hospital environment, Nightingale was known to send nurses home to England from the Crimea for suspicious alcohol use and character weakness.
It was through this success at Scutari that she began a long career of influence on the public’s health through social activism and reform, health policy, and the reformation of career nursing. Using her well-publicized successful “experiment” and supportive evidence from the Crimea, Nightingale effectively argued the case for the reform and creation of military health care that would serve as the model for people in uniform to the present (D’Antonio, 2002). Nightingale’s ideas about proper hospital architecture and administration influenced a generation of medical doctors and the entire world, in both military and civilian service. Her work in Notes on Hospitals, published in 1860, provided the template for the organization of military health care in the Union Army when the U.S. Civil War erupted in 1861. Her vision for health care of soldiers and the responsibility of the governments that send them to war continues today; her influence can be seen throughout the previous century and into this century as health care for the women and men who serve their country is a vital part of the well-being not only of the soldiers but also of society in general (D’Antonio, 2002).
Returning Home a Heroine: The Political Reformer When Nightingale returned to London, she found that her efforts to provide comfort and health to the British soldier succeeded in making heroes of both herself and the soldiers (Woodham-Smith, 1951). Both had suffered from negative stereotypes: The soldier was often portrayed as a drunken oaf with little ambition or honor, and the nurse as a tipsy, self-serving, illiterate, promiscuous loser. After the Crimean War and the efforts of Nightingale and her nurses, both returned with honor and dignity, never again downtrodden and disrespected.
After her return from the Crimea, Florence Nightingale never made a public
appearance, never attended a public function, and never issued a public statement (Bullough & Bullough, 1978). She single-handedly raised nursing from, as she put it, “the sink it was” into a respected and noble profession (Palmer, 1977). As an avid scholar and student of the Greek writer Plato, Nightingale believed that she had a moral obligation to work primarily for the good of the community. Because she believed that education formed character, she insisted that nursing must go beyond care for the sick; the mission of the trained nurse must include social reform to promote the good. This dual mission of nursing—caregiver and political reformer—has shaped the profession as we know it today. LeVasseur (1998) contends that Nightingale’s insistence on nursing’s involvement in a larger political ideal is the historic foundation of the field and distinguishes us from other scientific disciplines, such as medicine.
How did Nightingale accomplish this? She effected change through her wide command of acquaintances: Queen Victoria was a significant admirer of her intellect and ability to effect change, and Nightingale used her position as national heroine to get the attention of elected officials in Parliament. She was tireless and had an amazing capacity for work. She used people. Her brother-in-law, Sir Harry Verney, was a member of Parliament and often delivered her “messages” in the form of legislation. When she wanted the public incited, she turned to the press, writing letters to the London Times and having others of influence write articles. She was not above threats to “go public” by certain dates if an elected official refused to establish a commission or appoint a committee. And when those commissions were formed, Nightingale was ready with her list of selected people for appointment (Palmer, 1982).
Nightingale and Military Reforms The first real test of Nightingale’s military reforms came in the United States during the Civil War. Nightingale was asked by the Union to advise on the organization of hospitals and care of the sick and wounded. She sent recommendations back to the United States based on her experiences and analysis in the Crimea, and her advisement and influence gained wide publicity. Following her recommendations, the Union set up a sanitary commission and provided for regular inspection of camps. She expressed a desire to help with the Confederate military also but, unfortunately, had no channel of communication with them (Bullough & Bullough, 1978).
The Nightingale School of Nursing at St. Thomas: The Birth of Professional Nursing
The British public honored Nightingale by endowing 50,000 pounds sterling in her name upon her return to England from the Crimea. The money had been raised from the soldiers under her care and donations from the public. This Nightingale Fund eventually was used to create the Nightingale School of Nursing at St. Thomas, which was to be the beginning of professional nursing (Donahue, 1985). Nightingale, at the age of 40, decided that St. Thomas’ Hospital was the place for her training school for nurses. While the negotiations for the school went forward, she spent her time writing Notes on Nursing: What It Is and What It Is Not (Nightingale, 1860). The small book of 77 pages, written for the British mother, was an instant success. An expanded library edition was written for nurses and used as the textbook for the students at St. Thomas. The book has since been translated into many languages, although it is believed that Nightingale refused all royalties earned from the publication of the book (Cook, 1913; Tooley, 1910). The nursing students chosen for the new training school were handpicked; they had to be of good moral character, sober, and honest. Nightingale believed that the strong emphasis on morals was critical to gaining respect for the new “Nightingale nurse,” with no possible ties to the disgraceful association of past nurses. Nursing students were monitored throughout their 1-year program both on and off the hospital grounds; their activities were carefully watched for character weaknesses, and discipline was severe and swift for violators. Accounts from Nightingale’s journals and notes reveal instant dismissal of nursing students for such behaviors as “flirtation, using the eyes unpleasantly, and being in the company of unsavory persons.” Nightingale contended that “the future of nursing depends on how these young women behave themselves” (Smith, 1934, p. 234). She knew that the experiment at St. Thomas to educate nurses and raise nursing to a moral and professional calling was a drastic departure from the past images of nurses and would take extraordinary women of high moral character and intelligence. Nightingale knew every nursing student, or probationer, personally, often having the students at her house for weekend visits. She devised a system of daily journal keeping for the probationers; Nightingale herself read the journals monthly to evaluate their character and work habits. Every nursing student admitted to St. Thomas had to submit an acceptable “letter of good character,” and Nightingale herself placed graduate nurses in approved nursing positions.
One of the most important features of the Nightingale School was its relative autonomy. Both the school and the hospital nursing service were organized under the head matron. This was especially significant because it meant that nursing service began independently of the medical staff in selecting, retaining, and disciplining students and nurses (Bullough & Bullough, 1978). Nightingale was opposed to the use of a standardized government examination and the movement for licensure of trained
nurses. She believed that schools of nursing would lose control of educational standards with the advent of national licensure, most notably those related to moral character. Nightingale led a staunch opposition to the movement by the British Nurses’ Association (BNA) for licensure of trained nurses, one the BNA believed critical to protecting the public’s safety by ensuring the qualification of nurses by licensure exam. Nightingale was convinced that qualifying a nurse by examination tested only the acquisition of technical skills, not the equally important evaluation of character (Nutting & Dock, 1907; Woodham-Smith, 1951).
Taking Health Care to the Community: Nightingale and Wellness Early efforts to distinguish hospital from community health nursing are evidence of Nightingale’s views on “health nursing,” which she distinguished from “sick nursing.” She wrote two influential papers, one in 1893, “Sick-Nursing and Health-Nursing” (Nightingale, 1893), which was read in the United States at the Chicago Exposition, and the second, “Health Teaching in Towns and Villages” in 1894 (Monteiro, 1985). Both papers praised the success of prevention-based nursing practice. Winslow (1946) acknowledged Nightingale’s influence in the United States by being one of the first in the field of public health to recognize the importance of taking responsibility for one’s health. According to Palmer (1982), Nightingale was a leader in the wellness movement long before the concept was identified. Nightingale saw the nurse as the key figure in establishing a healthy society. She saw a logical extension of nursing in acute hospital settings to the community. Clearly, through her Notes on Nursing, she visualized the nurse as “the nation’s first bulwark in health maintenance, the promotion of wellness, and the prevention of disease” (Palmer, 1982, p. 6).
William Rathbone, a wealthy ship owner and philanthropist, is credited with the establishment of the first visiting nurse service, which eventually evolved into district nursing in the community. He was so impressed with the private duty nursing care that his sick wife had received at home that he set out to develop a “district nursing service” in Liverpool, England. At his own expense, in 1859, he developed a corps of nurses trained to care for the sick poor in their homes (Bullough & Bullough, 1978). He divided the community into 16 districts; each was assigned a nurse and a social worker that provided nursing and health education. His experiment in district nursing was so successful that he was unable to find enough nurses to work in the districts. Rathbone contacted Nightingale for assistance. Her recommendation was to train more nurses, and she advised Rathbone to approach the Royal Liverpool Infirmary
with a proposal for opening another training school for nurses (Rathbone, 1890; Tooley, 1910). The infirmary agreed to Rathbone’s proposal, and district nursing soon spread throughout England as successful health nursing in the community for the sick poor through voluntary agencies (Rosen, 1958). Ever the visionary, Nightingale contended that the goal is to care for the sick in their own homes (Attewell, 1996). A similar service, health visiting, began in Manchester, England, in 1862 by the Manchester and Salford Sanitary Association. The purpose of placing health visitors in the home was to provide health information and instruction to families. Eventually, health visitors evolved to provide preventive health education and district nurses to care for the sick at home (Bullough & Bullough, 1978).
Although Nightingale is best known for her reform of hospitals and the military, she was a great believer in the future of health care, which she anticipated should be preventive in nature and would more than likely take place in the home and community. Her accomplishments in the field of “sanitary nursing” extended beyond the walls of the hospital to include workhouse reform and community sanitation reform. In 1864, Nightingale and William Rathbone once again worked together to lead the reform of the Liverpool Workhouse Infirmary, where more than 1,200 sick paupers were crowded into unsanitary and unsafe conditions. Under the British Poor Laws, the most desperately poor of the large cities were gathered into large workhouses. When sick, they were sent to the workhouse infirmary. Trained nursing care was all but nonexistent. Through legislative pressure and a well-designed public campaign describing the horrors of the workhouse infirmary, reform of the workhouse system was accomplished by 1867. Although not as complete as Nightingale had wanted, nurses were in place and being paid a salary (Seymer, 1954).
The Legacy of Nightingale A great deal has been written about Nightingale—an almost mythic figure in history. She truly was a beloved legend throughout Great Britain by the time she left the Crimea in July 1856, 4 months after the war. Longfellow immortalized this “Lady with the Lamp” in his poem “Santa Filomena” (Longfellow, 1857). However, when Nightingale returned to London after the Crimean War, she remained haunted by her experiences related to the soldiers dying of preventable diseases. She was troubled by nightmares and had difficulty sleeping in the years that followed (Woodham-Smith, 1983). Nightingale became a prolific writer and a staunch defender of the causes of the British soldier, sanitation in England and India, and trained nursing.
As a woman, she was not able to hold an official government post, nor could she
vote. Historians have had varied opinions about the exact nature of the disability that kept her homebound for the remainder of her life. Recent scholars have speculated that she experienced posttraumatic stress disorder (PTSD) from her experiences in the Crimea; there is also considerable evidence that she suffered from the painful disease brucellosis (Barker, 1989; Young, 1995). She exerted incredible influence through friends and acquaintances, directing from her sick room sanitation and poor law reform. Her mission to “cleanse” spread from the military to the British Empire; her fight for improved sanitation both at home and in India consumed her energies for the remainder of her life (Vicinus & Nergaard, 1990).
According to Monteiro (1985), two recurrent themes are found throughout Nightingale’s writings about disease prevention and wellness outside the hospital. The most persistent theme is that nurses must be trained differently and instructed specifically in district and instructive nursing. She consistently wrote that the “health nurse” must be trained in the nature of poverty and its influence on health, something she referred to as the “pauperization” of the poor. She also believed that above all, health nurses must be good teachers about hygiene and helping families learn to better care for themselves (Nightingale, 1893). She insisted that untrained, “good intended women” could not substitute for nursing care in the home. Nightingale pushed for an extensive orientation and additional training, including prior hospital experience, before one was hired as a district nurse. She outlined the qualifications in her paper “On Trained Nursing for the Sick Poor,” in which she called for a month’s “trial” in district nursing, a year’s training in hospital nursing, and 3 to 6 months training in district nursing (Monteiro, 1985).
The second theme that emerged from her writings was the focus on the role of the nurse. She clearly distinguished the role of the health nurse in promoting what we today call self-care. In the past, philanthropic visitors in the form of Christian charity would visit the homes of the poor and offer them relief (Monteiro, 1985). Nightingale believed that such activities did little to teach the poor to care for themselves and further “pauperized” them—dependent and vulnerable—keeping them unhealthy, prone to disease, and reliant on others to keep them healthy. The nurse then must help the families at home manage a healthy environment for themselves, and Nightingale saw a trained nurse as being the only person who could pull off such a feat.
By 1901, Nightingale lived in a world without sight or sound, leaving her unable to write. Over the next 5 years, Nightingale lost her ability to communicate and most days existed in a state of unconsciousness. In November 1907, Nightingale was honored with the Order of Merit by King Edward VII, the first time it was ever given to a woman.
After 50 years, in May 1910, the Nightingale Training School of Nursing at St. Thomas celebrated its jubilee. There were now more than a thousand training schools for nurses in the United States alone (Cook, 1913; Tooley, 1910).
Nightingale died in her sleep around noon on August 13, 1910 and was buried quietly and without pomp near the family’s home at Embley, her coffin carried by six sergeants of the British Army. Only a small cross marks her grave at her request: “FN. Born 1820. Died 1910.” (Brown, 1988). The family refused a national funeral and burial at Westminster Abbey out of respect for Nightingale’s last wishes. She had lived for 90 years and 3 months.
Continued Development of Professional Nursing in the United Kingdom Although Florence Nightingale opposed registration, based on the belief that the essential qualities of a nurse could not be taught, examined, or regulated, registration in the United Kingdom began in the 1880s. The Hospitals Association maintained a voluntary registry that was an administrative list. In an effort to protect the public led by Ethel Fenwick, the BNA was formed in 1887 with its charter granted in 1893 to unite British nurses and to provide registration as evidence of systematic training. Finally, in 1919, nurse registration became law. It took 30 years and the tireless efforts of Ethel Fenwick, who was supported by other nursing leaders, such as Isla Stewart, Lucy Osbourne, and Mary Cochrane, to achieve mandated registration (Royal British Nurses’ Association, n.d.).
Another milestone in British nursing history was the founding in 1916 of the College of Nursing as the professional organization for trained nurses. For a century, the organization has focused on professional standards for nurses in their education, practice, and working conditions. Although the principles of a professional organization and those of a trade union have not always fit together easily, the Royal College of Nursing has pursued its role as both the professional organization for nurses and the trade union for nurses (McGann, Crowther, & Dougall, 2009). Today the Royal College of Nursing is recognized as the voice of nursing by the government and the public in the United Kingdom (Royal College of Nursing, n.d.).
The Development of Professional Nursing in Canada Marie Rollet Hebert, the wife of a surgeon–apothecary, is credited by many with being the first person in present-day Canada to provide nursing care to the sick as she assisted her husband after arriving in Quebec in 1617; however, the first trained nurses arrived in Quebec to care for the sick in 1639. These nurses were Augustine nuns who traveled to Canada to establish a medical mission to care for the physical and spiritual needs of their patients, and they established the first hospital in North America, the Hôtel-Dieu de Québec. These nuns also established the first apprenticeship program for nursing in North America. Jeanne Mance came from France to the French colony of Montreal in 1642 and founded the Hôtel Dieu de Montréal in 1645 (Canadian Museum of History, n.d.).
The hospital of the early 19th century did not appeal to the Canadian public. They were primarily homes for the poor and were staffed by those of a similar class rather than by nurses (Mansell, 2004). The decades of the 1830s and 1840s in Canada were characterized by an influx of immigrants and outbreaks of diseases, such as cholera. There is evidence that it was difficult, especially in times of outbreak, to find sufficient people to care for the sick. Little is known of the hospital “nurses” of this era, but the descriptions are unflattering and working in the hospital environment was difficult. Early midwives did have some standing in the community and were employed by individuals, although there is record of charitable organizations also employing midwives (Young, 2010).
During the Crimean War and American Civil War, nurses were extremely effective in providing treatment and comfort not only to battlefield casualties but also to individuals who fell victim to accidents and infectious disease; however, it was in the North-West Rebellion of 1885 that Canadian nurses performed military service for the first time. At first, the nursing needs identified were for such duties as making bandages and preparing supplies. It soon became apparent that more direct participation by nurses was needed if the military was to provide effective medical field treatment. Seven nurses, under the direction of Reverend Mother Hannah Grier Coome, served in Moose Jaw and Saskatoon, Saskatchewan. Although their tour of duty lasted only 4 weeks, these women proved that nursing could, and should in the future, play a vital role in providing treatment to wounded soldiers. In 1899, the Canadian Army Medical Department was formed, followed by the creation of the
Canadian Army Nursing Service. Nurses received the relative rank, pay, and allowances of an army lieutenant. Nursing sisters served thereafter in every military force sent out from Canada, from the South African War to the Korean War (Veterans Affairs Canada, n.d.). In 1896, Lady Ishbel Aberdeen, wife of the governor-general of Canada, visited Vancouver. During this visit, she heard vivid accounts of the hardship and illness affecting women and children in rural areas. Later that same year at the National Council of Women, amid similar stories, a resolution was passed asking Lady Aberdeen to found an order of visiting nurses in Canada. The order was to be a memorial to the 60th anniversary of Queen Victoria’s ascent to the throne of the British Empire; it received a royal charter in 1897. The first Victorian Order of Nurses (VON) sites were organized in the cities of Ottawa, Montreal, Toronto, Halifax, Vancouver, and Kingston. Today the VON delivers over 75 different programs and services, such as prenatal education, mental health services, palliative care services, and visiting nursing, through 52 local sites staffed by 4,500 healthcare workers and over 9,016 volunteers (VON, n.d.).
By the mid- to late 19th century, despite previous negativity, nursing came to be viewed as necessary to progressive medical interventions. To make the work of the nurse acceptable, changes had to be made to the prevailing view of nursing. In the 1870s, the ideas of Florence Nightingale were introduced in Canada. Dr. Theophilus Mack imported nurses who had worked with Nightingale and founded the first training school for nurses in Canada at St. Catharine’s General Hospital in 1873. Many hospitals appeared across Canada from 1890 to 1910, and many of them developed training schools for nurses. By 1909, there were 70 hospital-based training schools in Canada (Mansell, 2004).
In 1908, Mary Agnes Snively, along with 16 representatives from organized nursing bodies, met in Ottawa to form the Canadian National Association of Trained Nurses (CNATN). By 1924, each of the nine provinces had a provincial nursing organization with membership in the CNATN. In 1924, the name of the CNATN was changed to the Canadian Nurses Association (CNA). CNA is currently a federation of 11 provincial and territorial nursing associations and colleges representing nearly 150,000 registered nurses (CNA, n.d.).
In 1944, the CNA approved the principle of collective bargaining. In 1946, the Registered Nurses Association of British Columbia became the first provincial nursing association to be certified as a bargaining agent. By the 1970s, other provincial nursing organizations gained this right. Between 1973 and 1987, nursing unions were created. Today each of the 10 provinces has a nursing union in addition to a professional association (Ontario Nurses’ Association, n.d.). One of the best known of
these professional associations is the Registered Nurses’ Association of Ontario (RNAO). Established in 1925 to advocate for health public policy, promote excellence in nursing practice, increase nursing’s contribution to shaping the healthcare system, and influence decisions that affect nurses and the public they serve, the RNAO is the professional association representing registered nurses, nurse practitioners (NPs), and nursing students in Ontario (RNAO, n.d.). Through the RNAO, nurses in Canada have led the world in systematic implementation of evidence-based practice and have made their best practice guidelines available to all nurses to promote safe and effective care of patients.
As Canadians entered the decade of the 1960s, there was serious concern about the healthcare system. In 1961, all Canadian provinces signed on to the Hospital Insurance and Diagnostic Services Act. This legislation created a national, universal health insurance system. The same year, the Royal Commission on Health Services was established and presented four recommendations. One of the recommendations was to examine nursing education. Prior to this, the CNA had requested a survey of nursing schools across Canada with the goal of assessing how prepared the schools were for a national system of accreditation. The findings of this survey, paired with the commission’s recommendation, led to the establishment of the Canadian Nurses Foundation (CNF) in 1962. The CNF (2014) provides funding for nurses to further their education and for research related to nursing care. The Canadian Association of Schools of Nursing (n.d.) is the organization that promotes national nursing education standards and is the national accrediting agency for university nursing programs in Canada.
Nursing in Canada transformed itself to meet the needs of a changing Canadian society and in doing so was responsible for a shift from nursing as a spiritual vocation to a secular but indispensable profession. Nurses’ willingness to respond in times of need, whether economic crisis, epidemic, or war, contributed to their importance in the healthcare system (Mansell, 2004). Canadian nursing associations agreed that starting in the year 2000, the basic educational preparation for the registered nurse would be the baccalaureate degree, and all provinces and territories launched a campaign known as EP 2000, which later became EP 2005. Currently, the baccalaureate degree earned from a university is the accepted entry level into nursing practice in Canada (Mansell, 2004).
The Development of Professional Nursing in Australia In the earliest days of the colony, the care of the sick was performed by untrained convicts. Male attendants undertook the supervision of male patients and female attendants undertook duties with the female patients. Attention to hygiene standards was almost nonexistent. In 1885, the poor health and living conditions of disadvantaged sick persons in Melbourne prompted a group of concerned citizens to meet and form the Melbourne District Nursing Society. This society was formed to look after sick poor persons at home to prevent unnecessary hospitalization. Home visiting services also have a long history in Australia, with Victoria being the first state to introduce a district nursing service in 1885, followed by South Australia in 1894, Tasmania in 1896, New South Wales in 1900, Queensland in 1904, and Western Australia in 1905 (Australian Bureau of Statistics, 1985).
Australian nurses were involved in military nursing as civilian volunteers as early as the 1880s (University of Melbourne, 2015); however, involvement of Australian women as nurses in war began in 1898 with the formation of the Australian Nursing Service of New South Wales, which was composed of 1 superintendent and 24 nurses. Based on the performance of the nurses, the Australian Army Nursing Service was formed in 1903 under the control of the federal government. The Royal Australian Army Nursing Corps (RAANC) had its beginnings in the Australian Army Nursing Service (RAANC, n.d.). Since that time, Australian nurses have dealt with war, the sick, the wounded, and the dead. They have served in Australia, in war zones around the world, in field hospitals, on hospital ships anchored off shore near battlefields, and on transports (Australian War Memorial, n.d.; Biedermann, Usher, Williams, & Hayes, 2001). Other military opportunities for nurses include the Royal Australian Navy and the Royal Australian Air Force.
Nursing registration in Australia began in 1920 as a state-based system. Prior to 1920, nurses received certificates from the hospitals where they trained, the Australian Trained Nurses Association (ATNA), or the Royal British Nurses’ Association in order to practice. Today nurses and midwives are registered through the Nursing and Midwifery Board of Australia (NMBA), which is made up of member state and territorial boards of nursing and supported by the Australian Health Practitioner Regulation Agency. State and territorial boards are responsible for making registration and notification decisions related to individual nurses or midwives (NMBA, n.d.).
Around the turn of the 20th century, in order to create a formal means of supporting their role and improve nursing standards and education, the nurses of South Australia formed the South Australian branch of ATNA. From this organization the Australian Nursing and Midwifery Federation in South Australia (ANMFSA) evolved (ANMFSA, 2012). The Australian Nursing and Midwifery Accreditation Council (ANMAC) is now the independent accrediting authority for nursing and midwifery under Australia’s National Registration and Accreditation Scheme. The ANMAC is responsible for protecting and promoting the safety of the Australian community by promoting high standards of nursing and midwifery education through the development of accreditation standards, accreditation of programs, and assessment of internationally qualified nurses and midwives for migration (ANMAC, 2016).
In the late 1920s, two nurses, Evelyn Nowland and a Miss Clancy, began working separately on the idea of a union for nurses and were brought together by Jessie Street, who saw the improvement of nurses’ wages and conditions as a feminist cause. What is now the New South Wales Nurses and Midwives’ Association (NSWNMA) was registered as a trade union in 1931 (NSWNMA, 2014). Through the amalgamation of various organizations, there is now one national organization to represent registered nurses, enrolled nurses, midwives, and assistants doing nursing work in every state and territory throughout Australia: the Australian Nursing and Midwifery Federation (ANMF). The organization was established in 1924 and serves as a union for nurses with an ultimate goal of improving patient care. The ANMF is now composed of eight branches: the Australian Nursing and Midwifery Federation (South Australia branch), the NSWNMA, the Australian Nursing and Midwifery Federation Victorian Branch, the Queensland Nurses Union, the Australian Nursing and Midwifery Federation Tasmanian Branch, the Australian Nursing and Midwifery Federation Australian Capital Territory, the Australian Nursing and Midwifery Federation Northern Territory, and the Australian Nursing and Midwifery Federation Western Australia Branch (ANMF, 2015).
Early Nursing Education and Organization in the United States Formal nursing education in the United States did not begin until 1862, when Dr. Marie Zakrzewska opened the New England Hospital for Women and Children, which had its own nurse training program (Sitzman & Judd, 2014b). Many of the first training schools for nursing were modeled after the Nightingale School of Nursing at St. Thomas in London. They included the Bellevue Training School for Nurses in New York City; the Connecticut Training School for Nurses in New Haven, Connecticut; and the Boston Training School for Nurses at Massachusetts General Hospital (Christy, 1975; Nutting & Dock, 1907). Based on the Victorian belief in the natural abilities of women to be sensitive, possess high morals, and be caregivers, early nursing training required that applicants be female. Sensitivity, high moral character, purity of character, subservience, and “ladylike” behavior became the associated traits of a “good nurse,” thus setting the “feminization of nursing” as the ideal standard for a good nurse. These historical roots of gender- and race-based caregiving continued to exclude males and minorities from the nursing profession for many years and still influence career choices for men and women today. These early training schools provided a stable, subservient, white female workforce because student nurses served as the primary nursing staff for these early hospitals. Minority nurses found limited educational opportunities in this climate. The first African American nursing school graduate in the United States was Mary P. Mahoney. She graduated from the New England Hospital for Women and Children in 1879 (Sitzman & Judd, 2014b).
CRITICAL THINKING QUESTIONS
Some nurses believe that Florence Nightingale holds nursing back and represents the negative and backward elements of nursing. This view cites as evidence that Nightingale supported the subordination of nurses to physicians, opposed registration of nurses, and did not see mental health nurses as part of the profession. After reading this chapter, what do you think? Is Nightingale relevant in the 21st century to the nursing profession? Why or why not?
Nursing education in the newly formed schools was based on accepted practices that had not been validated by research. During this time, nurses primarily relied on tradition to guide practice rather than engaging in research to test interventions; however, scientific advances did help to improve nursing practice as nurses altered interventions based on knowledge generated by scientists and physicians. During this
time, a nurse, Clara Maass, gave her life as a volunteer subject in the research of yellow fever (Sitzman & Judd, 2014b).
A significant report, known simply as the Goldmark Report, Nursing and Nursing Education in the United States, was released in 1922 and advocated for the establishment of university schools of nursing to train nursing leaders. The report, initiated by Nutting in 1918, was an exhaustive and comprehensive investigation into the state of nursing education and training resulting in a 500-page document. Josephine Goldmark, social worker and author of the pioneering research of nursing preparation in the United States, stated,
From our field study of the nurse in public health nursing, in private duty, and as instructor and supervisor in hospitals, it is clear that there is need of a basic undergraduate training for all nurses alike, which should lead to a nursing diploma. (Goldmark, 1923, p. 35)
The first university school of nursing was developed at the University of Minnesota in 1909. Although the new nurse training school was under the college of medicine and offered only a 3-year diploma, the Minnesota program was nevertheless a significant leap forward in nursing education. Nursing for the Future, or the Brown Report, authored by Esther Lucille Brown in 1948 and sponsored by the Russell Sage Foundation, was critical of the quality and structure of nursing schools in the United States. The Brown Report became the catalyst for the implementation of educational nursing program accreditation through the National League for Nursing (Brown, 1936, 1948). As a result of the post–World War II nursing shortage, an associate degree in nursing was established by Dr. Mildred Montag in 1952 as a 2-year program for registered nurses (Montag, 1959). In 1950, nursing became the first profession for which the same licensure exam, the State Board Test Pool, was used throughout the nation to license registered nurses. This increased mobility for the registered nurse resulted in a significant advantage for the relatively new profession of nursing (“State Board Test Pool Examination,” 1952).
The Evolution of Nursing in the United States: The First Century of Professional Nursing The Profession of Nursing Is Born in the United States Early nurse leaders of the 20th century included Isabel Hampton Robb, who in 1896 founded the Nurses’ Associated Alumnae, which in 1911 officially became known as the American Nurses Association (ANA); and Lavinia Lloyd Dock, who became a militant suffragist linking women’s roles as nurses to the emerging women’s movement in the United States. Mary Adelaide Nutting, Lavinia L. Dock, Sophia Palmer, and Mary E. Davis were instrumental in developing the first nursing journal, the American Journal of Nursing (AJN) in October 1900. Through the ANA and the AJN, nurses then had a professional organization and a national journal with which to communicate with one another (Kalisch & Kalisch, 1986).
State licensure of trained nurses began in 1903 with the enactment of North Carolina’s licensure law for nursing. Shortly thereafter, New Jersey, New York, and Virginia passed similar licensure laws for nursing. Over the next several years, professional nursing was well on its way to public recognition of practice and educational standards as state after state passed similar legislation.
Margaret Sanger worked as a nurse on the Lower East Side of New York City in 1912 with immigrant families. She was astonished to find widespread ignorance among these families about conception, pregnancy, and childbirth. After a horrifying experience with the death of a woman from a failed self-induced abortion, Sanger devoted her life to teaching women about birth control. A staunch activist in the early family planning movement, Sanger is credited with founding Planned Parenthood of America (Sanger, 1928).
By 1917, the emerging new profession saw two significant events that propelled the need for additional trained nurses in the United States: World War I and the influenza epidemic. Nightingale and the devastation of the Civil War had well established the need for nursing care in wartime. Mary Adelaide Nutting, now professor of nursing and health at Columbia University, chaired the newly established Committee on Nursing in response to the need for nurses as the United States entered the war in Europe. Nurses in the United States realized early that World War I was unlike previous wars. It was a global conflict that involved coalitions of nations against
nations and vast amounts of supplies and demanded the organization of all the nations’ resources for military purposes (Kalisch & Kalisch, 1986). Along with Lillian Wald and Jane A. Delano, director of nursing in the American Red Cross, Nutting initiated a national publicity campaign to recruit young women to enter nurses’ training. The Army School of Nursing, headed by Annie Goodrich as dean, and the Vassar Training Camp for Nurses prepared nurses for the war as well as home nursing and hygiene nursing through the Red Cross (Dock & Stewart, 1931). The committee estimated that there were at most about 200,000 active “nurses” in the United States, both trained and untrained, which was inadequate for the military effort abroad (Kalisch & Kalisch, 1986).
At home, the influenza epidemic of 1917 to 1919 led to increased public awareness of the need for public health nursing and public education about hygiene and disease prevention. The successful campaign to attract nursing students focused heavily on patriotism, which ushered in the new era for nursing as a profession. By 1918, nursing school enrollments were up by 25%. In 1920, Congress passed a bill that provided nurses with military rank (Dock & Stewart, 1931). Following close behind, the passage of the Nineteenth Amendment to the U.S. Constitution granted women the right to vote.
Lillian Wald, Public Health Nursing, and Community Activism The pattern for health visiting and district nursing practice outside the hospital was similar in the United States to that in England (Roberts, 1954). American cities were besieged by overcrowding and epidemics after the Civil War. The need for trained nurses evolved as in England, and schools throughout the United States developed along the Nightingale model. Visiting nurses were first sent to philanthropic organizations in New York City (1877), Boston (1886), Buffalo (1885), and Philadelphia (1886) to care for the sick at home. By the end of the century, most large cities had some form of visiting nursing program, and some headway was being made even in smaller towns (Heinrich, 1983). Industrial or occupational health nursing was first started in Vermont in 1895 by a marble company interested in the health and welfare of its workers and their families. Tuberculosis (TB) was a leading cause of death in the 1800s; nurses visited patients bedridden from TB and instructed persons in all settings about prevention of the disease (Abel, 1997).
Lillian Wald (Figure 1-2), a wealthy young woman with a great social conscience, graduated from the New York Hospital School of Nursing in 1891 and is credited with
creating the title “public health nurse.” After a year working in a mental institution, Wald entered medical school at Women’s Medical College in New York. While in medical school, she was asked to visit immigrant mothers on New York’s Lower East Side and instruct them on health matters. Wald was appalled by the conditions there. During one now famous home visit, a small child asked Wald to visit her sick mother. And the rest, as they say, is history (Box 1-1). What Wald found changed her life forever and secured a place for her in American nursing history. Wald (1915) said, “All the maladjustments of our social and economic relations seemed epitomized in this brief journey” (p. 6). Wald was profoundly affected by her observations; she and her colleague, Mary Brewster, quickly established the Henry Street Settlement in this same neighborhood in 1893. She quit medical school and devoted the remainder of her life to “visions of a better world” for the public’s health. According to Wald, “Nursing is love in action, and there is no finer manifestation of it than the care of the poor and disabled in their own homes” (Wald, 1915, p. 14).
Figure 1-2 A photo of Lillian Wald, taken by Harris and Ewing during the first half of the 20th- century.
Courtesy of Library of Congress, Prints & Photographs Division, photograph by Harris & Ewing, LC-DIG-hec-19537.
LILLIAN WALD TAKES A WALK
From the schoolroom where I had been giving a lesson in bed-making, a little girl led me one drizzling March morning. She had told me of her sick mother and gathering from her incoherent account that a child had been born, I caught up the paraphernalia of the bed-making lesson and carried it with me.
The child led me over broken roadways . . . between tall, reeking houses whose laden fire-escapes, useless for their appointed purpose, bulged with household
goods of every description. The rain added to the dismal appearance of the streets and to the discomfort of the crowds which thronged them, intensifying the odors, which assailed me from every side. Through Hester and Division Streets we went to the end of Ludlow; past odorous fish-stands, for the streets were a market-place, unregulated, unsupervised, unclean; past evil-smelling, uncovered garbage cans. . . .
All the maladjustments of our social and economic relations seemed epitomized in this brief journey and what was found at the end of it. The family to which the child led me was neither criminal nor vicious. Although the husband was a cripple, one of those who stand on street corners exhibiting deformities to enlist compassion, and masking the begging of alms by a pretense of selling; although the family of seven shared their two rooms with boarders—who were literally boarders, since a piece of timber was placed over the floor for them to sleep on—and although the sick woman lay on a wretched, unclean bed, soiled with a hemorrhage two days old, they were not degraded human beings, judged by any measure of moral values.
In fact, it was very plain that they were sensitive to their condition, and when, at the end of my ministrations, they kissed my hands (those who have undergone similar experiences will, I am sure, understand), it would have been some solace if by any conviction of the moral unworthiness of the family I could have defended myself as a part of a society which permitted such conditions to exist. Indeed, my subsequent acquaintance with them revealed the fact that miserable as their state was, they were not without ideals for the family life, and for society, of which they were so unloved and unlovely a part.
That morning’s experience was a baptism of fire. Deserted were the laboratory and the academic work of the college. I never returned to them. On my way from the sick-room to my comfortable student quarters, my mind was intent on my own responsibility. To my inexperience it seemed certain that conditions such as these were allowed because people did not know, and for me there was a challenge to know and to tell. When early morning found me still awake, my naive conviction remained that, if people knew things—and “things” meant everything implied in the condition of this family—such horrors would cease to exist, and I rejoiced that I had a training in the care of the sick that in itself would give me an organic relationship to the neighborhood in which this awakening had come.
Reproduced from Wald, L. D. (1915). The House on Henry Street. New York, NY: Henry Holt.
The Henry Street Settlement was an independent nursing service where Wald
lived and worked. This later became the Visiting Nurse Association of New York City, which laid the foundation for the establishment of public health nursing in the United States. The health needs of the population were met through addressing social, economic, and environmental determinants of health, in a pattern after Nightingale. These nurses helped educate families about disease transmission and emphasized the importance of good hygiene. They provided preventive, acute, and long-term care. As such, Henry Street went far beyond the care of the sick and the prevention of illness. It aimed at rectifying those causes that led to the poverty and misery. Wald was a tireless social activist for legislative reforms that would provide a more just distribution of services for the marginal and disadvantaged in the United States (Donahue, 1985). Wald began with 10 nurses in 1893, which grew to 250 nurses serving 1,300 clients a day by 1916. During this same period, the budget grew from nothing to more than $600,000 a year, all from private donations.
Wald hired African American nurse Elizabeth Tyler in 1906 as evidence of her commitment to cultural diversity. Although unable to visit white clients, Tyler made her own way by “finding” African American families who needed her service. In 3 months, Tyler had so many African American families within her caseload that Wald hired a second African American nurse, Edith Carter. Carter remained at Henry Street for 28 years until her retirement (Carnegie, 1991). During her tenure at Henry Street, Wald demonstrated her commitment to racial and cultural diversity by employing 25 African American nurses over the years, and she paid them salaries equal to white nurses and provided identical benefits and recognition to minority nurses (Carnegie, 1991). This was exceptional during the early part of the 1900s, a time when African American nurses were often denied admission to white schools of nursing and membership in professional organizations and were denied opportunities for employment in most settings. Because hospitals of this era often set quotas for African American clients, those nurses who managed to graduate from nursing schools found themselves with few clients who needed or could afford their services. African American nurses struggled for the right to take the registration examination available for white nurses.
Wald submitted a proposal to the city of New York after learning of a child’s dismissal from a New York City school for a skin condition. Her proposal was for one of the Henry Street Settlement nurses to serve free for 1 month in a New York school. The results of her experiment were so convincing that salaries were approved for 12 school nurses. From this, school nursing was born in the United States and became one of many community specialties credited to Wald (Dietz & Lehozky, 1963). In 1909, Wald proposed a program to the Metropolitan Life Insurance Company to provide nursing visits to their industrial policyholders. Statistics kept by the company
documented the lowered mortality rates of policyholders attributed to the nurses’ public health practice and clinical expertise. The program demonstrated savings for the company and was so successful that it lasted until 1953 (Hamilton, 1988).
Wald’s other significant accomplishments include the establishment of the Children’s Bureau, set up in 1912 as part of the U.S. Department of Labor. She also was an enthusiastic supporter of and participant in women’s suffrage, lobbied for inspections of the workplace, and supported her employee, Margaret Sanger, in her efforts to give women the right to birth control. She was active in the American Red Cross and International Red Cross and helped form the Women’s Trade Union League to protect women from sweatshop conditions.
Wald first coined the phrase “public health nursing” (Figure 1-3) and transformed the field of community health nursing from the narrow role of home visiting to the population focus of today’s community health nurse (Robinson, 1946). According to Dock and Stewart (1931), the title of public health nurse was purposeful: The role designation was designed to link the public’s health to governmental responsibility, not private funding. As state departments of health and local governments began to employ more and more public health nurses, their role increasingly focused on prevention of illness in the entire community. Discrimination developed between the visiting nurse, who was employed by the voluntary agencies primarily to provide home care to the sick, and the public health nurse, who concentrated on preventive measures (Figure 1-3) (Brainard, 1922).
Figure 1-3 Photo of Town & Country Rural Public Health Nurse carrying the black bag typical of public health nurses in the early 20th-century.
Early public health nurses came closer than hospital-based nurses to the autonomy and professionalism that Nightingale advocated. Their work was conducted in the unconfined setting of the home and community, they were independent, and they enjoyed recognition as specialists in preventive health (Buhler-Wilkerson, 1985). Public health nurses from the beginning were much more holistic in their practice than their hospital counterparts. They were involved with the health of industrial workers, immigrants, and their families and were concerned about exploitation of women and children. These nurses also played a part in prison reform and care of the mentally ill (Heinrich, 1983).
Considered the first African American public health nurse, Jessie Sleet Scales was hired in 1902 by the Charity Organization Society, a philanthropic organization, to visit African American families infected by TB. Scales provided district nursing care to New York City’s African American families and is credited with paving the way for African American nurses in the practice of community health (Mosley, 1996).
Dorothea Lynde Dix Dorothea Lynde Dix, a Boston schoolteacher, became aware of the horrendous conditions in prisons and mental institutions when asked to do a Sunday school class at the House of Correction in Cambridge, Massachusetts. She was appalled at what she saw and went about studying whether the conditions were isolated or widespread; she took 2 years off to visit every jail and almshouse from Cape Cod to Berkshire (Tiffany, 1890). Her report was devastating. Boston was scandalized by the reality that the most progressive state in the Union was now associated with such appalling conditions. The shocked legislature voted to allocate funds to build hospitals. For the rest of her life, Dorothea Dix stood out as a tireless zealot for the humane treatment of the insane and imprisoned. She had exceptional savvy in dealing with legislators. She acquainted herself with the legislators and their records and displayed the “spirit of a crusader.” For her contributions, Dix is recognized as one of the pioneers of the reform movement for mental health in the United States, and her efforts are felt worldwide to the present day (Dietz & Lehozky, 1963).
Dix was also known for her work in the Civil War, having been appointed superintendent of the female nurses of the army by the secretary of war in 1861. Her tireless efforts led to the recruitment of more than 2,000 women to serve in the army during the Civil War. Officials had consulted with Nightingale concerning military hospitals and were determined not to make the same mistakes. Dix enjoyed far more sweeping powers than Nightingale in that she had the authority to organize hospitals,
to appoint nurses, and to manage supplies for the wounded (Brockett & Vaughan, 1867). Among her most well-known nurses during the Civil War were the poet Walt Whitman and the author Louisa May Alcott (Donahue, 1985).
Clara Barton The idea for the International Red Cross was the brainchild of a Swiss banker, J. Henri Dunant, who proposed the formation of a neutral international relief society that could be activated in time of war. The International Red Cross was ratified by the Geneva Convention on August 22, 1864. Clara Barton, through her work in the Civil War, had come to believe that such an organization was desperately needed in the United States. However, it was not until 1882 that Barton was able to convince Congress to ratify the Treaty of Geneva, thus becoming the founder of the American Red Cross (Kalisch & Kalisch, 1986). Barton also played a leadership role in the Spanish- American War in Cuba, where she led a group of nurses to provide care for both U.S. and Cuban soldiers and Cuban civilians. At the age of 76, Barton went to President McKinley and offered the help of the Red Cross in Cuba. The president agreed to allow Barton to go with Red Cross nurses but only to care for the Cuban citizens. Once in Cuba, the U.S. military saw what Barton and her nurses were able to accomplish with the Cuban military, and American soldiers pressured military officials to allow Barton’s help. Along with battling yellow fever, Barton was able to provide care to both Cuban and U.S. military personnel and eventually expanded that care to Cuban citizens in Santiago. One of Barton’s most famous clients was young Colonel Teddy Roosevelt, who led his Rough Riders and who later became the president of the United States. Barton became an instant heroine both in Cuba and in the United States for her bravery and tenaciousness and for organizing services for the military and civilians torn apart by war. On August 13, 1898, the Spanish-American War came to an end. The grateful people of Santiago, Cuba, built a statue to honor Clara Barton in the town square, where it stands to this day. The work of Barton and her Red Cross nurses spread through the newspapers of the United States and in the schools of nursing. A congressional committee investigating the work of Barton’s Red Cross staff applauded these nurses and recommended that the U.S. Army Medical Department create a permanent reserve corps of trained nurses. These reserve nurses became the Army Nurse Corps in 1901. Clara Barton will always be remembered both as the founder of the American Red Cross and as the driving force behind the creation of the Army Nurse Corps (Frantz, 1998).
Birth of the Midwife in the United States Women have always assisted other women in the birth of babies. These “lay midwives” were considered by communities to possess special skills and somewhat of a “calling.” With the advent of professional nursing in England, registered nurses became associated with safer and more predictable childbirth practices. In England and in other countries where Nightingale nurses were prevalent, most registered nurses were also trained as midwives with a 6-month specialized training period. In the United States, the training of registered nurses in the practice of midwifery was prevented primarily by physicians. U.S. physicians saw midwives as a threat and intrusion into medical practice. Such resistance indirectly led to the proliferation of “granny wives” who were ignorant of modern practices, were untrained, and were associated with high maternal morbidity (Donahue, 1985).
The first organized midwifery service in the United States was the Frontier Nursing Service founded in 1925 by Mary Breckinridge. Breckinridge graduated from the St. Luke’s Hospital Training School in New York in 1910 and received her midwifery certificate from the British Hospital for Mothers and Babies in London in 1925. She had extensive experience in the delivery of babies and midwifery systems in New Zealand and Australia. In rural Appalachia, babies had been delivered for decades by granny midwives, who relied mainly on tradition, myths, and superstition as the bases of their practice. For example, they might use ashes for medication and place a sharp axe, blade up, under the bed of a laboring woman to “cut” the pain. The people of Appalachia were isolated because of the terrain of the hollows and mountains, and roads were limited to most families. They had one of the highest birth rates in the United States. Breckinridge believed that if a midwifery service could work under these conditions, it could work anywhere (Donahue, 1985).
Breckinridge had to use English midwives for many years and began training her own midwives only in 1939 when she started the Frontier Graduate School of Nurse Midwifery in Hyden, Kentucky, with the advent of World War II. The nurse midwives accessed many of their families on horseback. In 1935, a small 12-bed hospital was built at Hyden and provided delivery services. Under the direction of Breckinridge, the nurse midwives were successful in lowering the highest maternal mortality rate in the United States (in Leslie County, Kentucky) to substantially below the national average. These nurses, as at Henry Street Settlement, provided health care for everyone in the district for a small annual fee. A delivery had an additional small fee. Nurse midwives provided primary care, prenatal care, and postnatal care, with an emphasis on prevention (Wertz & Wertz, 1977).
Armed with the right to vote, in the Roaring Twenties American women found the new freedom of the “flapper era”—shrinking dress hemlines, shortened hairstyles, and the increased use of cosmetics. Hospitals were used by greater numbers of people, and the scientific basis of medicine became well established because most surgical procedures were done in hospitals. Penicillin was discovered in 1928, creating a revolution in the prevention of infectious disease deaths (Donahue, 1985; Kalisch & Kalisch, 1986). The previously mentioned Goldmark Report recommended the establishment of college- and university-based nursing programs.
Mary D. Osborne, who functioned as supervisor of public health nursing for the state of Mississippi from 1921 to 1946, had a vision for a collaboration with community nurses and granny midwives, who delivered 80% of the African American babies in Mississippi. The infant and maternal mortality rates were both exceptionally high among African American families, and these granny midwives, who were also African American, were untrained and had little education.
Osborne took a creative approach to improving maternal and infant health among African American women. She developed a collaborative network of public health nurses and granny midwives; the nurses implemented training programs for the midwives, and the midwives in turn assisted the nurses in providing a higher standard of safe maternal and infant health care. The public health nurses used Osborne’s book, Manual for Midwives, which contained guidelines for care and was used in the state until the 1970s. They taught good hygiene, infection prevention, and compliance with state regulations. Osborne’s innovative program is credited with reducing the maternal and infant mortality rates in Mississippi and in other states where her program structure was adopted (Sabin, 1998).
The Nursing Profession Responds to the Great Depression and World War II With the stock market crash of 1929 came the Great Depression, resulting in widespread unemployment of private-duty nurses and the closing of nursing schools with a simultaneous increase in the need for charity health services for the population. Nursing students who had previously been the primary source to staff hospitals declined in number. Unemployed graduate nurses were hired to replace them for minimal wages, a trend that was to influence the profession for years to come (MacEachern, 1932).
Other nurses found themselves accompanying troops to Europe when the United States entered World War II. Military nurses provided care aboard hospital ships and
were a critical presence at the invasion of Normandy in 1944 as well as in military operations in North Africa, Italy, France, and the Philippines. More than 100,000 nurses volunteered and were certified for military service in the Army and Navy Nurse Corps. The resulting severe shortage of nurses on the home front resulted in the development of the Cadet Nurse Corps. Frances Payne Bolton, congressional representative from Ohio, is credited with the founding of the Cadet Nurse Corps through the Bolton Act of 1945. By the end of the war, more than 180,000 nursing students had been trained through this act, and advanced practice graduate nurses in psychiatry and public health nursing had received graduate education to increase the numbers of nurse educators (Donahue, 1985; Kalisch & Kalisch, 1986).
Amid the Depression, many nurses found the expansion and advances in aviation as a new field for nurses. In efforts to increase the public’s confidence in the safety of transcontinental air travel, nurses were hired in the promising new role of “nurse- stewardess” (Kalisch & Kalisch, 1986). Congress created an additional relief program, the Civil Works Administration, in 1933 that provided jobs to the unemployed, including placing nurses in schools, public hospitals and clinics, public health departments, and public health education community surveys and campaigns. The Social Security Act of 1935 was passed by Congress to provide old-age benefits, rehabilitation services, unemployment compensation administration, aid to dependent and/or disabled children and adults, and monies to state and local health services. The Social Security Act included Title VI, which authorized the use of federal funds for the training of public health personnel. This led to the placement of public health nurses in state health departments and to the expansion of public health nursing as a viable career path.
While nursing was forging new paths for itself in various fields, during the 1930s Hollywood began featuring nurses in films. The only feature-length films to ever focus entirely on the nursing profession were released during this decade. War Nurse (1930), Night Nurse (1931), Once to Every Woman (1934), The White Parade (1934 Academy Award nominee for Best Picture), Four Girls in White (1939), The White Angel (1936), and Doctor and Nurse (1937) all used nurses as major characters. During the bleak years of the economic depression, young women found these nurse heroines who promoted idealism, self-sacrifice, and the profession of nursing over personal desires particularly appealing. No longer were nurses depicted as subservient handmaidens who worked as nurses only as a temporary pastime before marriage (Kalisch & Kalisch, 1986).
During the 1930s, the Association of Collegiate Schools of Nursing was formed to advance nursing education and to promote research related to educational criteria in nursing. Goals were aimed at changing the professional level of the nurse with a focus
on preparing nurses in the academic setting and thus preparing nurses for specialized roles, such as faculty, administrators of schools of nursing, and supervisors (Judd, 2014).
Science and Health Care, 1945–1960: Decades of Change Dramatic technologic and scientific changes characterized the decades following World War II, including the discovery of sulfa drugs, new cardiac drugs, surgeries, and treatment for ventricular fibrillation (Howell, 1996). The Hill-Burton Act, passed in 1946, provided funds to increase the construction of new hospitals. A significant change in the healthcare system was the expansion of private health insurance coverage and the dramatic increase in the birth rate, called the “baby boom” generation. Clinical research, both in medicine and in nursing, became an expectation of health providers, and more nurses sought advanced degrees. The first ANA Code of Ethics for Nurses was adopted in 1950, and in 1953 the International Council of Nurses (ICN) adopted an international Code of Ethics for Nurses. In 1952, the first scholarly journal, Journal of Nursing Research, was first published in the United States (Kalisch & Kalisch, 2004).
As a result of increased numbers of hospital beds, additional financial resources for health care, and the post–World War II economic resurgence, nursing faced an acute shortage and nurses confronted increasingly stressful working conditions. Nurses began showing signs of the strain through debates about strikes and collective bargaining demands.
The ANA accepted African American nurses for membership, consequently ending racial discrimination in the dominant nursing organizations. The National Association of Colored Graduate Nurses was disbanded in 1951. Males entered nursing schools in record number, often as a result of previous military experience as medics. Prior to the 1950s and 1960s, male nurses also suffered minority status and were discouraged from nursing as a career. A fact seemingly forgotten by modern society, including Florence Nightingale and early U.S. nursing leaders, is that during medieval times more than one-half of the nurses were male. The Knights Hospitallers, Teutonic Knights, Franciscans, and many other male nursing orders had provided excellent nursing care for their societies. Saint Vincent de Paul had first conceived of the idea of social service. Pastor Theodor Fliedner, teacher and mentor of Florence Nightingale at Kaiserwerth in Germany; Ben Franklin; and Walt Whitman during the Civil War all either served as nurses or were strong advocates for male nurses (Kalisch & Kalisch, 1986).
Years of Revolution, Protest, and the New Order, 1961– 2000 During the social upheaval of the 1960s, nursing was influenced by many changes in society, such as the women’s movement, organized protest against the Vietnam conflict, civil rights movement, President Lyndon Johnson’s “Great Society” social reforms, and increased consumer involvement in health care. Specialization in nursing, such as cardiac intensive care unit, nurse anesthetist training, and the clinical specialist role for nursing, became trends that affected both education and practice in the healthcare system. Medicare and Medicaid, enacted in 1965 under Title XVIII of the Social Security Act, provided access to health care for older adults, poor persons, and people with disabilities. The ANA took a courageous and controversial stand in that same year (1965) by approving its first position paper on nursing education, advocating for all nursing education for professional practice to take place in colleges and universities (ANA, 1965). Nurses returning from Vietnam faced emotional challenges in the form of PTSD that affected their postwar lives.
With increased specialization in medicine, the demand for primary care healthcare providers exceeded the supply (Christman, 1971). As a response to this need for general practitioners, Dr. Henry Silver, MD, and Dr. Loretta Ford, RN, collaborated to develop the first NP program in the United States at the University of Colorado (Ford & Silver, 1967). NPs were initially prepared in pediatrics, with advanced role preparation in common childhood illness management and well-child care (Figure 1-4). Ford and Silver (1967) found that NPs could manage as much as 75% of the pediatric patients in community clinics, leading to the widespread use of and educational programs for NPs. The first state in 1971 to recognize diagnosis and treatment as part of the legal scope of practice for NPs was Idaho. Alaska and North Carolina were among the first states to expand the NP role to include prescriptive authority (Ford, 1979). By the turn of the century, NP programs were offered at the master of science in nursing level in family nursing; gerontology; and adult, neonatal, mental health, and maternal–child areas and have expanded to include the acute care practitioner as well (Huch, 2001). Currently, the preferred educational preparation for advanced practice nurse is the doctor of nursing practice. Certification of NPs now occurs at the national level through the ANA and several specialty organizations. NPs are licensed throughout the United States by state boards of nursing.
Figure 1-4 The nurse with advanced preparation and certification as a nurse practitioner is able to diagnose and treat patients.
© KidStock/Getty Images
KEY OUTCOME 1-1
Example of applicable outcomes expected of the graduate from a baccalaureate program
Essential VIII: Professionalism and Professional Values
8.5 Demonstrate an appreciation of the history of and contemporary issues in nursing and their impact on current nursing practice (p. 28).
Reproduced from American Association of Colleges of Nursing. (2008). The essentials of baccalaureate
education for professional nursing practice. Retrieved from
In the late 1980s, escalating healthcare costs resulting from the explosion of advanced technology and the increased life span of Americans led to the demand for healthcare reform. The nursing profession heralded healthcare reform with an unprecedented collaboration of more than 75 nursing associations, led by the ANA and the National League for Nursing, in the publication of Nursing’s Agenda for Health Care Reform. In this document, the challenge of managed care was addressed in the context of cost containment and quality assurance of healthcare service for the nursing profession (ANA, 1991).
The New Century The new century began with a renewed focus on quality and safety in patient care. The landmark publication from the Institute of Medicine (IOM) published in November 1999, To Err Is Human, was the launching pad from which this movement began in earnest. This report is best known for drawing attention to the scope of errors in health care; for the conclusion that most errors are related to faulty systems, processes, and conditions that allow error rather than to individual recklessness; and for the recommendation to design healthcare systems at all levels to make it more difficult to make errors. Subsequent reports followed focusing on quality through healthcare redesign and health professions education redesign (IOM, 2001, 2003).
With the roles of nurses in the healthcare system expected to continue to expand in the future, the focus is placed on raising the educational levels and competencies of nurses and fostering interdisciplinary collaboration to increase access, safety, and quality of patient care. For example, the latest IOM report, The Future of Nursing: Leading Change, Advancing Health (2011), specifically calls for interdisciplinary education, decreasing barriers to nurses’ scope of practice, and increasing the educational levels of nurses. The Robert Wood Johnson Foundation sponsored the Quality and Safety Education for Nurses (QSEN) initiative with the overall goal of “preparing future nurses who will have the knowledge, skills and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work” (QSEN, 2018). The focus of QSEN is to develop the competencies of future nursing graduates in six key areas: patient-centered care, evidence-based practice, quality improvement, teamwork and collaboration, safety, and informatics.
KEY COMPETENCY 1-1
Examples of applicable Nurse of the Future: Nursing Core Competencies
Knowledge (K8a) Understands the responsibilities inherent in being a member of the nursing profession
Skills (S8a) Understands the history and philosophy of the nursing profession
Attitudes/Behaviors (A8a) Recognizes the need for personal and professional behaviors that promote the profession of nursing
Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future: Nursing
core competencies: Registered nurse. Retrieved from
In 2006, the Massachusetts Department of Higher Education (MDHE) and the Massachusetts Organization of Nurse Executives convened a working session of stakeholders titled Creativity and Connections: Building the Framework for the Future of Nursing Education and Practice. From this beginning, the Nurse of the Future: Nursing Core Competencies (MDHE, 2010) was developed in response to the goals of creating a seamless progression through all levels of nursing education and development of consensus on the minimum competency expectations for all nurses upon completion of prelicensure nursing education. In 2016, the Nurse of the Future: Nursing Core Competencies was revised to ensure that the competencies reflect the changes that have occurred in health care and nursing practice since the previous edition (MDHE, 2016). This movement to facilitate creation of a core set of entry-level nursing competencies and seamless transition in nursing education is not singular and reflects the current focus in the profession to increase the access, safety, and quality of health care.
U.S. healthcare system reform continues to be the topic of political debate, with the primary focus on federal coverage, access, and control of healthcare costs. Healthcare organizations in a managed care environment see economic and quality outcome benefits of caring for patients and managing their care over a continuum of settings and needs. Patients are followed more closely within the system, during both illness and wellness. Hospital stays are shorter, and more healthcare services are provided in outpatient facilities and through community-based settings.
KEY OUTCOME 1-2
Example of applicable outcomes expected of the graduate from a baccalaureate program
Essential V: Healthcare Policy, Finance, and Regulatory Environments
5.6 Explore the impact of sociocultural, economic, legal, and political factors influencing healthcare delivery and practice (p. 21).
Reproduced from American Association of Colleges of Nursing. (2008). The essentials of baccalaureate
education for professional nursing practice. Retrieved from
The Patient Protection and Affordable Care Act (PPACA) was signed into law on March 23, 2010 and was upheld as constitutional by the U.S. Supreme Court on June 28, 2012. The purpose of the PPACA is to provide affordable health care for all Americans, and overall, access to health care increased under the PPACA. The law included provisions for preventive care, such as cancer screenings and flu shots without cost sharing, and protections for consumers that included ending preexisting exclusions for children, ending lifetime limits, and preventing companies from arbitrarily dropping coverage (Shi & Singh, 2019). It was predicted that this legislation would have results through 2029 and its implementation would increase insurance coverage to 32 million additional uninsured people. In December 2017, a tax bill was passed with an effective date of 2019 that repeals the individual insurance mandate, one of the key elements of the PPACA, but leaves most of the other components of what has become known as Obamacare intact (Qiu, 2017).
As advocates for the public and in response to presidential campaign promises to repeal the PPACA, in December 2016, ANA delivered a letter to then President-elect Trump outlining ANA’s Principles for Health System Transformation. The principles outline system requirements, including that the system must (1) ensure universal access to a standard package of essential healthcare services for all citizens and residents; (2) optimize primary, community-based, and preventive services while supporting the cost-effective use of innovative, technology-driven, acute, hospital- based services; (3) encourage mechanisms to stimulate the economical use of healthcare services while supporting those who do not have the means to share costs; and (4) ensure a sufficient supply of a skilled workforce dedicated to providing high- quality healthcare services (ANA, 2016).
KEY OUTCOME 1-3
Example of applicable outcomes expected of the graduate from a baccalaureate program
Essential VII: Clinical Prevention and Population Health
7.12 Advocate for social justice, including a commitment to the health of vulnerable populations and health disparities (p. 25).
Reproduced from American Association of Colleges of Nursing. (2008). The essentials of baccalaureate
education for professional nursing practice. Retrieved from
International Council of Nurses A review of nursing history would not be complete without some discussion of the contributions of the International Council of Nurses (ICN). The ICN was founded in 1899 by women whose names are familiar to the student of nursing history—such names as Ethel Fenwick of Great Britain, Lavinia Dock of the United States, Mary Agnes Snively of Canada, and Agnes Karll of Germany—who believed in the link between women’s rights and professional nursing. They advocated for the creation of national nursing organizations that would allow women to self-govern the profession, and these early leaders from the United Kingdom, Canada, the United States, Germany, the Netherlands, and Scandinavia banded together in the ICN to encourage one another as they continued to build stronger national associations in their respective nations (Brush & Lynaugh, 1999).
KEY COMPETENCY 1-2
Examples of applicable Nurse of the Future: Nursing Core Competencies:
Knowledge (K8) Understands how healthcare issues are identified, how healthcare policy is both developed and changed
Skills (S8) Participates as a nursing professional in political processes and grassroots legislative efforts to influence healthcare policy
Attitudes/Behaviors (A8) Recognizes how the healthcare process can be influenced through the efforts of nurses and other healthcare professionals, as well as lay and special advocacy groups.
Reproduced from Massachusetts Department of Higher Education. (2016). Nurse of the future: Nursing
core competencies: Registered nurse. Retrieved from
World War I and World War II presented threats to the organization, but the ICN emerged with greater participation from nurses in nations that had not previously participated in the organization. New members after World War I included China, Palestine, Brazil, and the Philippines. After World War II, there was again an influx of new membership that included nations from Africa, Asia, and South America. With an increasingly diverse membership, the ICN implemented a more global agenda. During
the time of the Cold War when Russia, China, and nations in Eastern Europe did not participate, the ICN still defined the work of nurses worldwide and claimed the right to speak for nursing. During the decades that followed, the ICN forged closer links with the World Health Organization, added to its agenda the delivery of primary health care to people around the world, and actively supported the rights of nurses to fair employment and freedom from exploitation (Brush & Lynaugh, 1999).
Currently located in Geneva, Switzerland, the ICN has grown into a federation of more than 130 national nurses associations, representing the more than 16 million nurses worldwide. ICN is the world’s first and widest reaching international organization for health professionals, working to ensure high-quality nursing care for all, sound health policies globally, the advancement of nursing knowledge, and the presence worldwide of a respected nursing profession and a competent and satisfied nursing workforce (ICN, n.d.).
Conclusion Contemplating the progression of nursing as a profession, it becomes evident from the preceding pages that similar issues, barriers, challenges, and opportunities were simultaneously present in locations around the globe. In each circumstance, nursing leaders arose to initiate change; whether related to nurse registration, standards for nursing education, or safe work environments, their ultimate goal was the provision of high-quality patient care. The history of professional nursing began with efforts to reach that goal, and we continue in this quest as our nursing organizations endeavor to develop and revise accreditation standards for programs of nursing, examine practice competencies, and review criteria for licensure.
Consensus regarding basic education and the entry level of registered nurses has not occurred in the United States, although progress has been made in neighboring Canada. Changes in the advanced practice role continue to challenge the nurse education and healthcare systems around the world as the primary healthcare needs of populations compete with acute care for scarce resources. A global community demands that nurses remain committed to cultural sensitivity in care delivery. The history of health care and nursing provides ample examples of the wisdom of our forebears in the advocacy of nursing in challenging settings in an unknown future. By considering the lessons of our past, the nursing profession is positioned to lead the way in the provision of a full range of high-quality, cost-effective services required to care for patients in this century.
CRITICAL THINKING QUESTION
What do you think would be the response of such historical nursing leaders as Florence Nightingale, Lillian Wald, and Mary Breckinridge if they could see what the profession of nursing looks like today?
Classroom Activity 1-1
There are many theories about Nightingale’s chronic illness, which caused her to be an invalid for most of her adult life. Many people have interpreted this as hypochondriacal, something of a melodrama of the Victorian times. Nightingale was rich and could take to her bed. She became ill during the Crimean War in May 1855 and was diagnosed with a severe case of Crimean fever. Today Crimean fever is recognized as Mediterranean fever and is categorized as brucellosis. She developed spondylitis, or inflammation of the
spine. For the next 34 years, she managed to continue her writing and advocacy, often predicting her imminent death. Others have claimed that Nightingale suffered from bipolar disorder, causing her to experience long periods of depression alternating with remarkable bursts of productivity. Read about the various theories of her chronic disabling condition and reflect on your own conclusions about her mysterious illness. With supporting evidence, what are your conclusions about Nightingale’s health condition?
Data from Dossey, B. (2000). Florence Nightingale: Mystic, visionary, healer. Philadelphia, PA:
Lippincott Williams & Wilkins; Australian Nursing Federation. (2004). Nightingale suffered bipolar
disorder. Australian Nursing Journal, 12(2), 33.
Classroom Activity 1-2
What would Florence Nightingale’s résumé or curriculum vitae look like? Check out Nightingale’s curriculum vitae at www.countryjoe.com/nightingale/cv.htm.
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© James Kang/EyeEm/Getty Images
Frameworks for Professional Nursing Practice1 Kathleen Masters
After completing this chapter, the student should be able to:
1. Identify the four metaparadigm concepts of nursing. 2. Explain several theoretical works in nursing. 3. Discuss the Nurse of the Future concepts and core competencies. 4. Describe several nonnursing theories important to the discipline of nursing. 5. Begin the process of identifying theoretical frameworks of nursing that are
consistent with a personal belief system.
Key Terms and Concepts
Concept Conceptual model Propositions Assumptions Theory Metaparadigm Person Environment Health Nursing Philosophies
Although the beginning of nursing theory development can be traced to Florence Nightingale, it was not until the second half of the 1900s that nursing theory caught the attention of nursing as a discipline. During the decades of the 1960s and 1970s, theory development was a major topic of discussion and publication. During the 1970s, much of the discussion was related to the development of one global theory for nursing. However, in the 1980s, attention turned from the development of a global theory for nursing as scholars began to recognize multiple approaches to theory development in nursing.
Because of the plurality in nursing theory, this information must be organized to be meaningful for practice, research, and further knowledge development. The goal of this chapter is to present an organized and practical overview of the major concepts, models, philosophies, and theories that are essential in professional nursing practice.
It can be helpful to define some terms that might be unfamiliar. A concept is a term or label that describes a phenomenon (Meleis, 2004). The phenomenon described by a concept can be either empirical or abstract. An empirical concept is one that can be either observed or experienced through the senses. An abstract concept is one that is not observable, such as hope or caring (Hickman, 2002).
A conceptual model is defined as a set of concepts and statements that integrate the concepts into a meaningful configuration (Lippitt, 1973; as cited in Fawcett, 1994). Propositions are statements that describe relationships among events, situations, or actions (Meleis, 2004). Assumptions also describe concepts or connect two concepts and represent values, beliefs, or goals. When assumptions are challenged, they
become propositions (Meleis, 2004). Conceptual models are composed of abstract and general concepts and propositions that provide a frame of reference for members of a discipline. This frame of reference determines how the world is viewed by members of a discipline and guides the members as they propose questions and make observations relevant to the discipline (Fawcett, 1994).
A theory “is an organized, coherent, and systematic articulation of a set of statements related to significant questions in a discipline that are communicated in a meaningful whole” (Meleis, 2007, p. 37). The primary distinction between a conceptual model and a theory is the level of abstraction and specificity. A conceptual model is a highly abstract system of global concepts and linking statements. A theory, in contrast, deals with one or more specific, concrete concepts and propositions (Fawcett, 1994).
A metaparadigm is the most global perspective of a discipline and “acts as an encapsulating unit, or framework, within which the more restricted . . . structures develop” (Eckberg & Hill, 1979, p. 927). Each discipline singles out phenomena of interest that it will deal with in a unique manner. The concepts and propositions that identify and interrelate these phenomena are even more abstract than those in the conceptual models. These are the concepts that comprise the metaparadigm of the discipline (Fawcett, 1994).
The conceptual models and theories of nursing represent various paradigms derived from the metaparadigm of the discipline of nursing. Therefore, although each of the conceptual models might link and define the four metaparadigm concepts differently, the four metaparadigm concepts are present in each of the models.
The central concepts of the discipline of nursing are person, environment, health, and nursing. These four concepts of the metaparadigm of nursing are more specifically “the person receiving the nursing, the environment within which the person exits, the health–illness continuum within which the person falls at the time of the interaction with the nurse, and, finally, nursing actions themselves” (Flaskerud & Holloran, 1980, cited in Fawcett, 1994, p. 5).
Because concepts are so abstract at the metaparadigm level, many conceptual models have been developed from the metaparadigm of nursing. Subsequently, multiple theories have been derived from conceptual models in an effort to describe, explain, interpret, and predict the experiences, observations, and relationships observed in nursing practice.
Overview of Selected Nursing Theories To apply nursing theory in practice, the nurse must have some knowledge of the theoretical works of the nursing profession. This chapter is not intended to provide an in-depth analysis of each of the theoretical works in nursing but rather to provide an introductory overview of selected theoretical works to give you a launching point for further reflection and study as you begin your journey into professional nursing practice.
CRITICAL THINKING QUESTION
What are the specific competencies for nurses in relation to theoretical knowledge?
Theoretical works in nursing are generally categorized as either philosophies, conceptual models or grand theories, middle-range theories, or practice theories (which may also be referred to as situation-specific theories) depending on the level of abstraction. We begin with the most abstract of these theoretical works, the philosophies of nursing.
Selected Philosophies of Nursing Philosophies set forth the general meaning of nursing and nursing phenomena through reasoning and the logical presentation of ideas. Philosophies are broad and address general ideas about nursing. Because of their breadth, nursing philosophies contribute to the discipline by providing direction, clarifying values, and forming a foundation for theory development (Alligood, 2006).
Nightingale’s Environmental Theory Nightingale’s philosophy includes the four metaparadigm concepts of nursing (Table 2-1), but the focus is primarily on the patient and the environment, with the nurse manipulating the environment to enhance patient recovery. Nursing interventions using Nightingale’s philosophy are centered on the 13 canons, which follow (Nightingale, 1860/1969):
TABLE 2-1 Metaparadigm Concepts as Defined in Nightingale’s Model
Person Recipient of nursing care.
Environment External (temperature, bedding, ventilation) and internal
(food, water, and medications).
Health Health is “not only to be well, but to be able to use well every power we have to use” (Nightingale, 1860/1969, p. 24).
Nursing Alter or manage the environment to implement the natural laws of health.
Ventilation and warming: The interventions subsumed in this canon include keeping the patient and the patient’s room warm and keeping the patient’s room well ventilated and free of odors. Specific instructions included “keep the air within as pure as the air without” (Nightingale, 1860/1969, p. 10). Health of houses: This canon includes the five essentials of pure air, pure water, efficient drainage, cleanliness, and light. Petty management: Continuity of care for the patient when the nurse is absent is the essence of this canon. Noise: Instructions include the avoidance of sudden noises that startle or awaken patients and keeping noise in general to a minimum. Variety: This canon refers to an attempt at variety in the patient’s room to avoid boredom and depression. Taking food: Interventions include the documentation of the amount of food and liquids that the patient ingests. What food? Instructions include trying to include patient food preferences. Bed and bedding: The interventions in this canon include comfort measures related to keeping the bed dry and wrinkle-free. Light: The instructions contained in this canon relate to adequate light in the patient’s room. Cleanliness of rooms and walls: This canon focuses on keeping the environment clean. Personal cleanliness: This canon includes such measures as keeping the patient clean and dry. Chattering hopes and advices: Instructions in this canon include the avoidance of talking without reason or giving advice that is without fact. Observation of the sick: This canon includes instructions related to making observations and documenting observations.
The 13 canons are central to Nightingale’s theory but are not all inclusive. Nightingale believed that nursing was a calling and that the recipients of nursing care were holistic individuals with a spiritual dimension; thus, the nurse was expected to
care for the spiritual needs of the patients in spiritual distress. Nightingale also believed that nurses should be involved in health promotion and health teaching with the sick and with those who were well (Bolton, 2006).
Although Nightingale’s theory was developed long ago in response to a need for environmental reform, the nursing principles are still relevant today. Even as some of Nightingale’s rationales have been modified or disproved by advances in medicine and science, many of the concepts in her theory not only have endured but also have been used to provide general guidelines for nurses for more than 150 years (Pfettscher, 2006).
Virginia Henderson: Definition of Nursing and 14 Components of Basic Nursing Care Henderson made such significant contributions to the discipline of nursing during her more-than-60-year career as a nurse, teacher, author, and researcher that some refer to her as the Florence Nightingale of the 20th century (Tomey, 2006). She is perhaps best known for her definition of nursing, which was first published in 1955 (Harmer & Henderson, 1955) and then published in 1966 with minor revisions. According to Henderson (1966), the role of the nurse involves assisting the patient to perform activities that contribute to health, recovery, or a peaceful death, which the patient would perform without assistance if he or she possessed “the necessary strength, will, or knowledge” and to do so in a way that helps the patient gain independence rather than remain dependent on the nurse (p. 15). In her work, Henderson emphasized the art of nursing as well as empathetic understanding, stating that the nurse must “get inside the skin of each of her patients in order to know what he needs” (Henderson, 1964, p. 63). She believed that “the beauty of medicine and nursing is the combination of your heart, your head and your hands and where you separate them, you diminish them” (McBride, 1997).
Henderson identified 14 basic needs on which nursing care is based. These 14 needs are also referred to as the 14 components of basic nursing care. These needs include the following:
Breathe normally. Eat and drink adequately. Eliminate bodily wastes. Move and maintain desirable postures. Sleep and rest. Select suitable clothes; dress and undress.
Maintain body temperature within normal range by adjusting clothing and modifying the environment. Keep the body clean and well groomed and protect the integument. Avoid dangers in the environment and avoid injuring others. Communicate with others in expressing emotions, needs, fears, or opinions. Worship according to one’s faith. Work in such a way that there is a sense of accomplishment. Play or participate in various forms of recreation. Learn, discover, or satisfy the curiosity that leads to normal development and health and use the available health facilities (Henderson, 1966, 1991).
Although Henderson did not consider her work a theory of nursing and did not explicitly state assumptions or define each of the domains of nursing, her work includes the metaparadigm concepts of nursing (Table 2-2) (Furukawa & Howe, 2002). In recent years many have begun to refer to the 14 components of basic nursing care as Virginia Henderson’s Need Theory (Ahtisham & Jacoline, 2015).
TABLE 2-2 Metaparadigm Concepts as Defined in Henderson’s Philosophy and Art of
Person Recipient of nursing care who is composed of biological, psychological, sociological, and spiritual components.
Environment External environment (temperature, dangers in environment); some discussion of impact of community on the individual and family.
Health Based upon the patient’s ability to function independently (as outlined in 14 components of basic nursing care).
Nursing Assist the person, sick or well, in performance of activities (14 components of basic nursing care) and help the person gain independence as rapidly as possible (Henderson, 1966, p. 15).
Jean Watson: Philosophy and Science of Caring According to Watson’s theory (1996), the goal of nursing is to help persons attain a higher level of harmony within the mind–body–spirit. Attainment of that goal can potentiate healing and health (Table 2-3). This goal is pursued through transpersonal caring guided by carative factors and corresponding caritas processes.
TABLE 2-3 Metaparadigm Concepts as Defined in Watson’s Philosophy and Science of
Person (human) A “unity of mind–body–spirit/nature” (Watson, 1996, p. 147); embodied spirit (Watson, 1989).
Healing space and environment
A nonphysical energetic environment; a vibrational field integral with the person where the nurse is not only in the environment but also “the nurse IS the environment” (Watson, 2008, p. 26).
Health (healing) Harmony, wholeness, and comfort.
Nursing Reciprocal transpersonal relationship in caring moments guided by carative factors and caritas processes.
Watson’s theory for nursing practice is based on 10 carative factors (Watson, 1979). As Watson’s work evolved, she renamed these carative factors into what she termed clinical caritas processes (Fawcett, 2005). Caritas means to cherish, to appreciate, and to give special attention. It conveys the concept of love (Watson, 2001). The 10 caritas processes are summarized here:
Practice of loving kindness and equanimity for oneself and other Being authentically present and enabling and sustaining the deep belief system and subjective life world of self and the one being cared for Cultivating one’s own spiritual practices; going beyond the ego self; deepening of self-awareness Developing and sustaining a helping–trusting, authentic caring relationship Being present to, and supportive of, the expression of positive and negative feelings as a connection with a deeper spirit of oneself and the one being cared for Creatively using oneself and all ways of knowing as part of the caring process and engagement in artistry of caring–healing practices Engaging in a genuine teaching–learning experience within the context of a caring relationship while attending to the whole person and subjective meaning; attempting to stay within the other’s frame of reference Creating a healing environment at all levels, subtle environment of energy and consciousness whereby wholeness, beauty, comfort, dignity, and peace are potentiated Assisting with basic needs, with an intentional caring consciousness; administering human care essentials, which potentiate alignment of the mind–body–spirit,
wholeness, and unity of being in all aspects of care; attending to both embodied spirit and evolving emergence Opening and attending to spiritual, mysterious, and unknown existential dimensions of life, death, suffering; “allowing for a miracle” (Watson, 2008)
Watson (2001) refers to the clinical caritas processes as the “core” of nursing, which is grounded in the philosophy, science, and the art of caring. She contrasts the core of nursing with what she terms the “trim,” a term she uses to refer to the practice setting, procedures, functional tasks, clinical disease focus, technology, and techniques of nursing. The trim, Watson explains, is not expendable, but it cannot be the center of professional nursing practice (Watson, 1997).
Regarding the value system that is blended with the 10 carative factors, Watson (1985) states,
Human care requires high regard and reverence for a person and human life. . . . There is high value on the subjective–internal world of the experiencing person and how the person (both patient and nurse) is perceiving and experiencing health–illness conditions. An emphasis is placed upon helping a person gain more self-knowledge, self-control, and readiness for self-healing. (pp. 34, 35)
The carative factors described by Watson provide guidelines for nurse–patient interactions; however, the theory does not furnish instructions about what to do to achieve authentic caring–healing relationships. Watson’s theory is more about being than doing, but it provides a useful framework for the delivery of patient-centered nursing care (Neil & Tomey, 2006).
Patricia Benner’s Clinical Wisdom in Nursing Practice Benner’s work has focused on the understanding of perceptual acuity, clinical judgment, skilled know-how, ethical comportment, and ongoing experiential learning (Brykczynski, 2010). Also important in Benner’s philosophy is an understanding of ethical comportment. According to Day and Benner (2002), good conduct is a product of an individual relationship with the patient that involves engagement in a situation combined with a sense of membership in a profession where professional conduct is socially embedded, lived, and embodied in the practices, ways of being, and responses to clinical situations and where clinical and ethical judgments are inseparable.
Benner’s original domains and competencies of nursing practice were derived
inductively from clinical situation interviews and observations of nurses in actual practice. From these interviews and observations, 31 competencies and 7 domains were identified and described. The seven domains are the helping role, the teaching- coaching function, the diagnostic and patient monitoring function, effective management of rapidly changing situations, administering and monitoring therapeutic interventions and regimens, monitoring and ensuring the quality of healthcare practices, and organizational work role competencies (Benner, 1984/2001). Along with the identification of the competencies and domains of nursing, Benner identified five stages of skill acquisition based on the Dreyfus model of skill acquisition as applied to nursing along with characteristics of each stage. The stages identified included novice, advanced beginner, competent, proficient, and expert (Benner, 1984/2001).
Later, in an extension of her original work, Benner and her colleagues identified nine domains of critical care nursing. These domains are diagnosing and managing life-sustaining physiologic functions in unstable patients, using skilled know-how to manage a crisis, providing comfort measures for the critically ill, caring for patients’ families, preventing hazards in a technologic environment, and facing death: end-of- life care and decision making, communicating and negotiating multiple perspectives, monitoring quality and managing breakdown, using the skilled know-how of clinical leadership, and coaching and mentoring others (Benner, Hooper-Kyriakidis, & Stannard, 1999). In addition, the nine domains of critical care nursing practice are used as broad themes in data interpretation for the identification and description of six aspects of clinical judgment and skilled comportment. These six aspects are as follows:
Reasoning-in-transition: Practical reasoning in an ongoing clinical situation Skilled know-how: Also known as embodied intelligent performance; knowing what to do, when to do it, and how to do it Response-based practice: Adapting interventions to meet the changing needs and expectations of patients Agency: One’s sense of and ability to act on or influence a situation Perceptual acuity and the skill of involvement: The ability to tune into a situation and hone in on the salient issues by engaging with the problem and the person Links between clinical and ethical reasoning: The understanding that good clinical practice cannot be separated from ethical notions of good outcomes for patients and families (Benner et al., 1999)
Benner identifies and defines the four metaparadigm concepts of nursing in addition to the concepts previously discussed. The concepts of person, environment,
health, and nursing as defined by Benner are summarized in Table 2-4.
TABLE 2-4 Metaparadigm Concepts as Defined in Benner’s Philosophy
Person Embodied person living in the world who is a “self- interpreting being, that is, the person does not come into the world pre-defined but gets defined in the course of living a life” (Benner & Wrubel, 1989, p. 41).
A social environment with social definition and meaningfulness.
Health The human experience of health or wholeness.
Nursing A caring relationship that includes the care and study of the lived experience of health, illness, and disease.
Selected Conceptual Models and Grand Theories of Nursing Conceptual models provide a comprehensive view and guide for nursing practice. They are organizing frameworks that guide the reasoning process in professional nursing practice (Alligood, 2006). At the level of the conceptual model, each metaparadigm concept is defined and described in a manner unique to the model, with the model providing an alternative way to view the concepts considered important to the discipline (Fawcett, 2005).
Martha Rogers’s Science of Unitary Human Beings According to Rogers (1994), nursing is a learned profession, both a science and an art. The art of nursing is the creative use of the science of nursing for human betterment.
Rogers’s theory asserts that human beings are dynamic energy fields that are integrated with environmental energy fields so that the person and his or her environment form a single unit. Both human energy fields and environmental fields are open systems, pandimensional in nature and in a constant state of change. Pattern is the identifying characteristic of energy fields (Table 2-5).
TABLE 2-5 Metaparadigm Concepts as Defined in Rogers’s Theory
Person An irreducible, irreversible, pandimensional, negentropic energy field identified by pattern; a unitary human being develops through three principles: helicy,
resonancy, and integrality (Rogers, 1992).
Environment An irreducible, pandimensional, negentropic energy field, identified by pattern and manifesting characteristics different from those of the parts and encompassing all that is other than any given human field (Rogers, 1992).
Health Health and illness as part of a continuum (Rogers, 1970).
Nursing Seeks to promote symphonic interaction between human and environmental fields, to strengthen the integrity of the human field, and to direct and redirect patterning of the human and environmental fields for realization of maximum health potential (Rogers, 1970).
Rogers identified the principles of helicy, resonancy, and integrality to describe the nature of change within human and environmental energy fields. Together, these principles are known as the principle of homeodynamics. The helicy principle describes the unpredictable but continuous, nonlinear evolution of energy fields, as evidenced by a spiral development that is a continuous, nonrepeating, and innovative patterning that reflects the nature of change. Resonancy is depicted as a wave frequency and an energy field pattern evolution from lower to higher frequency wave patterns and is reflective of the continuous variability of the human energy field as it changes. The principle of integrality emphasizes the continuous mutual process of person and environment (Rogers, 1970, 1992).
Rogers used two widely recognized toys to illustrate her theory and constant interaction of the human–environment process. The Slinky illustrates the openness, rhythm, motion, balance, and expanding nature of the human life process, which is continuously evolving (Rogers, 1970). The kaleidoscope illustrates the changing patterns that appear to be infinitely different (Johnson & Webber, 2010).
Rogers (1970) identified five assumptions that support and connect the concepts in her conceptual model:
Man is a unified whole possessing his own integrity and manifesting characteristics more than and different from the sum of his parts (p. 47). Man and environment are continuously exchanging matter and energy with one another (p. 54). The life process evolves irreversibly and unidirectionally along the space–time continuum (p. 59). Pattern and organization identify man and reflect his innovative wholeness (p. 65).
Man is characterized by the capacity for abstraction and imagery, language and thought, sensation, and emotion (p. 73).
Rogers’s model is an abstract system of ideas but is applicable to practice, with nursing care focused on pattern appraisal and patterning activities. Pattern appraisal involves a comprehensive assessment of environmental field patterns and human field patterns of communication, exchange, rhythms, dissonance, and harmony through the use of cognitive input, sensory input, intuition, and language. Patterning activities can include such interventions as meditation, imagery, journaling, or modifying surroundings. Evaluation is ongoing and requires a repetition of the appraisal process (Gunther, 2006). This process of pattern appraisal continues as long as the nurse– patient relationship continues (Gunther, 2010).
Dorothea Orem’s Self-Care Deficit Theory of Nursing Orem describes her theory as a general theory that is made up of three related theories, the Theory of Self-Care, the Theory of Self-Care Deficit, and the Theory of Nursing Systems. The Theory of Self-Care describes why and how people care for themselves. The Theory of Self-Care Deficit describes and explains why people can be helped through nursing. The Theory of Nursing Systems describes and explains relationships that must exist and be maintained for nursing to occur. These three theories in relationship constitute Orem’s general theory of nursing known as the Self- Care Deficit Theory of Nursing (Berbiglia, 2010; Orem, 1990; Taylor, 2006).
Theory of Self-Care The Theory of Self-Care describes why and how people care for themselves and suggests that nursing is required in case of inability to perform self-care as a result of limitations. This theory includes the concepts of self-care agency, therapeutic self-care demand, and basic conditioning factors.
Self-care agency is an acquired ability of mature and maturing persons to know and meet their requirements for deliberate and purposive action to regulate their own human functioning and development (Orem, 2001). The concept of self-care agency has three dimensions: development, operability, and adequacy. According to Orem (2001), therapeutic self-care demand consists of the summation of care measures necessary to meet all of an individual’s known self-care requisites. Basic conditioning factors refer to those factors that affect the value of the therapeutic self-care demand or self-care agency of an individual. Ten factors are identified: age, gender, developmental state, health state, pattern of living, healthcare system factors, family
system factors, sociocultural factors, availability of resources, and external environmental factors (Orem, 2001).
Orem identifies three types of self-care requisites that are integrated into the Theory of Self-Care and that provide the basis for self-care. These include universal self-care requisites, developmental self-care requisites, and health deviation self-care requisites.
Universal self-care requisites are those found in all human beings and are associated with life processes. These requisites include the following needs:
Maintenance of sufficient intake of air Maintenance of sufficient intake of water Maintenance of sufficient intake of food Provision of care associated with elimination processes and excrements Maintenance of a balance of activity and rest Maintenance of a balance between solitude and social interaction Prevention of hazards to human life, human functioning, and human well-being Promotion of human functioning and development within social groups in accordance with human potential, known limitations, and the human desire to be normal (Orem, 1985, pp. 90–91)
Developmental self-care requisites are related to different stages in the human life cycle and might include such events as attending college, marriage, and retirement. Broadly speaking, the development self-care requisites include the following needs:
Bringing about and maintenance of living conditions that support life processes and promote the processes of development—that is, human progress toward higher levels of organization of human structures and toward maturation Provision of care either to prevent the occurrence of deleterious effects of conditions that can affect human development or to mitigate or overcome these effects from various conditions (Orem, 1985, p. 96)
Health-deviation self-care requisites are related to deviations in structure or function of a human being. There are six categories of health-deviation requisites:
Seeking and securing appropriate medical assistance Being aware of and attending to the effects and results of illness states Effectively carrying out medically prescribed treatments Being aware of and attending to side effects of treatment Modifying self-concept in accepting oneself in a particular state of health Learning to live with the effects of illness and medical treatment (Orem, 1985, pp.
Theory of Self-Care Deficit The Theory of Self-Care Deficit explains that maturing or mature adults deliberately learn and perform actions to direct their survival, quality of life, and well-being; put more simply, it explains why people can be helped through nursing. According to Orem, nurses use five methods to help meet the self-care needs of patients:
Acting for or doing for another Guiding and directing Providing physical or psychological support Providing and maintaining an environment that supports personal development Teaching (Johnson & Webber, 2010; Orem, 1995, 2001)
Theory of Nursing Systems The Theory of Nursing Systems describes and explains relationships that must exist and be maintained for the product (nursing) to occur (Berbiglia, 2010; Taylor, 2006). Three systems can be used to meet the self-requisites of the patient: the wholly compensatory system, the partially compensatory system, and the supportive- educative system.
In the wholly compensatory system, the patient is unable to perform any self-care activities and relies on the nurse to perform care. In the partially compensatory system, both the patient and the nurse participate in the patient’s self-care activities, with the responsibility for care shifting from the nurse to the patient as the self-care demand changes. In the supportive-educative system, the patient has the ability for self-care but requires assistance from the nurse in decision making, knowledge, or skill acquisition. The nurse’s role is to promote the patient as a self-care agent.
The system selected depends on the nurse’s assessment of the patient’s ability to perform self-care activities and self-care demands (Johnson & Webber, 2010; Orem, 1995, 2001). There are eight general propositions for the Self-Care Deficit Theory of Nursing (although each of the three individual theories also has its own set of propositions) (Meleis, 2004):
Human beings have capabilities to provide their own self-care or care for dependents to meet universal, developmental, and health-deviation self-care requisites. These capabilities are learned and recalled.
Self-care abilities are influenced by age, developmental state, experiences, and sociocultural background. Self-care deficits should balance between self-care demands and self-care capabilities. Self-care or dependent care is mediated by age, developmental stage, life experience, sociocultural orientation, health, and resources. Therapeutic self-care includes the actions of nurses, patients, and others that regulate self-care capabilities and meet self-care needs. Nurses assess the abilities of patients to meet their self-care needs and their potential of not performing their self-care. Nurses engage in selecting valid and reliable processes, technologies, or actions for meeting self-care needs. Components of therapeutic self-care are wholly compensatory, partly compensatory, and supportive-educative.
In addition to these other concepts, the four metaparadigm concepts of nursing are identified in Orem’s theory (Table 2-6). Orem’s theory clearly differentiates the focus of nursing and is one of the nursing theories that is most commonly used in practice.
TABLE 2-6 Metaparadigm Concepts as Defined in Orem’s Theory
Person (patient) A person under the care of a nurse; a total being with universal, developmental needs and capable of self- care.
Environment Physical, chemical, biologic, and social contexts within which human beings exist; environmental components include environmental factors, environmental elements, environmental conditions, and developmental environment (Orem, 1985).
Health “A state characterized by soundness or wholeness of developed human structures and of bodily and mental functioning” (Orem, 1995, p. 101).
Nursing Therapeutic self-care designed to supplement self-care requisites. Nursing actions fall into one of three categories: wholly compensatory, partly compensatory, or supportive–educative system (Orem, 1985).
Callista Roy’s Adaptation Model The Roy Adaptation Model presents the person as an adaptive system in constant
interaction with the internal and external environments. The main task of the human system is to maintain integrity in the face of environmental stimuli (Phillips, 2006). The goal of nursing is to foster successful adaptation (Table 2-7).
TABLE 2-7 Metaparadigm Concepts as Defined in Roy’s Model
Person “An adaptive system with cognator and regulator subsystems acting to maintain adaptation in the four adaptive modes” (Roy, 2009, p. 12).
Environment “All conditions, circumstances, and influences surrounding and affecting the development and behavior of persons and groups, with particular consideration of mutuality of person and earth resources” (Roy, 2009, p. 12).
Health “A state and process of being and becoming an integrated and whole that reflects person and environment mutuality” (Roy, 2009, p. 12).
Nursing The goal of nursing is “to promote adaptation for individuals and groups in the four adaptive modes, thus contributing to health, quality of life, and dying with dignity by assessing behavior and factors that influence adaptive abilities and to enhance environmental factors” (Roy, 2009, p. 12).
According to Roy and Andrews (1999), adaptation refers to “the process and outcome whereby thinking and feeling persons, as individuals or in groups, use conscious awareness and choice to create human and environmental integration” (p. 54). Adaptation leads to optimum health and well-being, to quality of life, and to death with dignity (Andrews & Roy, 1991). The adaptation level represents the condition of the life processes. Roy describes three levels: integrated, compensatory, and compromised life processes. An integrated life process can change to a compensatory process, which attempts to reestablish adaptation. If the compensatory processes are not adequate, compromised processes result (Roy, 2009).
The processes for coping in the Roy Adaptation Model are categorized as “the regulator and cognator subsystems as they apply to individuals, and the stabilizer and innovator subsystems as applied to groups” (Roy, 2009, p. 33). A basic type of adaptive process, the regulator subsystem responds through neural, chemical, and endocrine coping channels. Stimuli from the internal and external environments act as inputs through the senses to the nervous system, thereby affecting the fluid,
electrolyte, and acid–base balance as well as the endocrine system. This information is all channeled automatically, with the body producing an automatic, unconscious response to it.
The second adaptive process, the cognator subsystem, responds through four cognitive-emotional channels: perceptual and information processing, learning, judgment, and emotion. Perceptual and information processing includes activities of selective attention, coding, and memory. Learning involves imitation, reinforcement, and insight. Judgment includes problem solving and decision making. Defenses are used to seek relief from anxiety and to make affective appraisal and attachments through the emotions (Roy, 2009).
The cognator–regulator and stabilizer–innovator subsystems function to maintain integrated life processes. These life processes—whether integrated, compensatory, or compromised—are manifested in behaviors of the individual or group. Behavior is viewed as an output of the human system and takes the form of either adaptive responses or ineffective responses. These responses serve as feedback to the system, with the human system using this information to decide whether to increase or decrease its efforts to cope with the stimuli (Roy, 2009).
Behaviors can be observed in four categories, or adaptive modes: physiologic- physical mode, self-concept–group identity mode, role function mode, and interdependence mode. Behavior in the physiologic-physical mode is the manifestation of the physiologic activities of all cells, tissues, organs, and systems making up the body. The self-concept–group identity mode includes the components of the physical self, including body sensation and body image, and the personal self, including self- consistency, self-ideal, and moral-ethical-spiritual self. The role function mode focuses on the roles of the person in society and the roles within a group, and the interdependence mode is a category of behavior related to interdependent relationships. This mode focuses on interactions related to the giving and receiving of love, respect, and value (Roy, 2009).
In the Roy Adaptation Model, three classes of stimuli form the environment: the focal stimulus (internal or external stimulus most immediately in the awareness of the individual or group), contextual stimuli (all other stimuli present in the situation that contribute to the effect of the focal stimulus), and residual stimuli (environmental factors within or outside human systems, the effects of which are unclear in the situation) (Roy, 2009).
The propositions of Roy’s theory include the following:
Nursing actions promote a person’s adaptive responses.
Nursing actions can decrease a person’s ineffective adaptive responses. People interact with the changing environment in an attempt to achieve adaptation and health. Nursing actions enhance the interaction of persons with the environment. Enhanced interactions of persons with the environment promote adaptation (Meleis, 2004).
The Roy Adaptation Model is commonly used in nursing practice. To use the model in practice, the nurse follows Roy’s six-step nursing process, which is as follows (Phillips, 2006):
Assessing the behaviors manifested from the four adaptive modes (physiologic- physical mode, self-concept–group identity mode, role function mode, and interdependence mode) Assessing and categorizing the stimuli for those behaviors Making a nursing diagnosis based on the person’s adaptive state Setting goals to promote adaptation Implementing interventions aimed at managing stimuli to promote adaptation Evaluating achievement of adaptive goals
Andrews and Roy (1986) point out that by manipulating the stimuli rather than the patient, the nurse enhances “the interaction of the person with their environment, thereby promoting health” (p. 51).
Betty Neuman’s Systems Model The Neuman Systems Model is a wellness model based on general systems theory in which the client system is exposed to stressors from within and without the system. The focus of the model is on the client system in relationship to stressors. The client system is a composite of interacting variables that include the physiologic variable, the psychological variable, the sociocultural variable, the developmental variable, and the spiritual variable (Neuman, 2002). Stressors are classified as intrapersonal, interpersonal, or extrapersonal depending on their relationship to the client system.
The client system is represented structurally in the model as a series of concentric rings or circles surrounding a basic structure. These flexible concentric circles represent normal lines of defense and lines of resistance that function to preserve client system integrity by acting as protective mechanisms for the basic structure. The basic structure or central core consists of basic survival factors common to the species, innate or genetic features, and strengths and weaknesses of the system. The flexible line of defense forms the outer boundary of the defined client system; it
protects the normal line of defense. The normal line of defense represents what the client has become or the usual wellness state. Adjustment of the five client system variables to environmental stressors determines its level of stability. The concentric broken circles surrounding the basic structure are known as lines of resistance. They become activated following invasion of the normal line of defense by environmental stressors (Neuman, 2002). The greater the quality of the client system’s health, the greater protection is provided by the various lines of defense (Geib, 2006). In addition to these concepts, the four metaparadigm concepts of nursing are identified in Neuman’s theory (Table 2-8).
TABLE 2-8 Metaparadigm Concepts as Defined in Neuman’s Model
Person (client system)
A composite of physiological, psychological, sociocultural, developmental, and spiritual variables in interaction with the internal and external environment; represented by central structure, lines of defense, and lines of resistance (Neuman, 2002).
Environment All internal and external factors of influences surrounding the client system; three relevant environments identified are the internal environment, the external environment, and the created environment (Neuman, 2002, p. 18).
Health A continuum of wellness to illness; equated with optimal system stability (Neuman, 2002, p. 23).
Nursing Prevention as intervention; concerned with all potential stressors.
Basic assumptions of the Neuman Systems Model include the following (Meleis, 2004; Neuman, 1995):
Nursing clients have both unique and universal characteristics and are constantly exchanging energy with the environment. The relationships among client variables influence a client’s protective mechanisms and determine the client’s response. Clients present a normal range of responses to the environment that represent wellness and stability. Stressors attack flexible lines of defense and then normal lines of defense. Nurses’ actions are focused on primary, secondary, and tertiary prevention.
The Neuman Systems Model is health oriented, with an emphasis on prevention
as intervention, and has been used in a wide variety of settings. Perhaps one of the greatest attractions to this model is the ease with which it can be used for families, groups, and communities as well as the individual client. The use of the model in practice requires only moderate adaptation of the nursing process with a focus on assessment of stressors and client system perceptions.
Imogene King’s Interacting Systems Framework and Theory of Goal Attainment King, in her Interacting Systems Framework, conceptualizes three levels of dynamic interacting systems that include personal systems (individuals), interpersonal systems (groups), and social systems (society). Individuals exist within personal systems, and concepts relevant to this system include body image, growth and development, perception, self, space, and time. Interpersonal systems are formed when two or more individuals interact. The concepts important to understanding this system include communication, interaction, role, stress, and transaction. Examples of social systems include religious systems, educational systems, and healthcare systems. Concepts important to understanding the social system include authority, decision making, organization, power, and status (King, 1981; Sieloff, 2006).
King’s Theory of Goal Attainment was derived from her Interacting Systems Framework (Sieloff, 2006) and addresses nursing as a process of human interaction (Norris & Frey, 2006). The theory focuses on the interpersonal system interactions in the nurse–client relationship (Table 2-9). During the nursing process, the nurse and the client perceive each other, make judgments, and take action that results in reaction. Interaction results, and if perceptual congruence exists, transactions occur (Sieloff, 2006). Outcomes are defined in terms of goals obtained. If the goals are related to patient behaviors, they become the criteria by which the effectiveness of nursing care can be measured (King, 1989).
TABLE 2-9 Metaparadigm Concepts as Defined in King’s Theory
Person (human being)
A personal system that interacts with interpersonal and social systems.
Environment Can be both external and internal. The external environment is the context “within which human beings grow, develop, and perform daily activities” (King, 1981, p. 18); the internal environment of human beings transforms energy to enable them to adjust to continuous external environmental changes (King, 1981, p. 5).
Health “Dynamic life experiences of a human being, which implies continuous adjustment to stressors in the internal and external environment through optimum use of one’s resources to achieve maximum potential for daily living” (King, 1981, p. 5).
Nursing A process of human interaction, the goal of nursing is to help patients achieve their goals.
The propositions of King’s Theory of Goal Attainment are as follows (King, 1981):
If perceptual accuracy is present in nurse–client interactions, transactions will occur. If the nurse and client make transactions, goals will be attained. If goals are attained, satisfactions will occur. If goals are attained, effective nursing care will occur. If transactions are made in the nurse–client interactions, growth and development will be enhanced. If role expectations and role performance as perceived by the nurse and client are congruent, transactions will occur. If role conflict is experienced by the nurse or client or both, stress in nurse–client interactions will occur. If nurses with special knowledge and skills communicate appropriate information to clients, mutual goal setting and goal attainment will occur.
King’s theory can be implemented in practice using the nursing process where assessment focuses on the perceptions of the nurse and client, communication of the nurse and client, and interaction of the nurse and client. Planning involves deciding on goals and agreeing on how to attain goals. Implementation focuses on transactions made, and evaluation focuses on goals attained using King’s theory (King, 1992).
Johnson’s Behavioral System Model Dorothy Johnson’s model for nursing presents the client as a living open system that is a collection of behavioral subsystems that interrelate to form a behavioral system (Table 2-10). The seven subsystems of behavior proposed by Johnson include achievement, affiliative, aggressive, dependence, sexual, eliminative, and ingestive. Motivational drives direct the activities of the subsystems that are constantly changing because of maturation, experience, and learning (Johnson, 1980).
TABLE 2-10 Metaparadigm Concepts as Defined in Johnson’s Model
Person (human being)
A biopsychosocial being who is a behavioral system with seven subsystems of behavior.
Environment Includes internal and external environment.
Health Efficient and effective functioning of system; behavioral system balance and stability.
Nursing An external regulatory force that acts to preserve the organization and integrity of the patient’s behavior at an optimal level under those conditions in which the behavior constitutes a threat to physical or social health or in which illness is found (Johnson, 1980, p. 214).
The achievement subsystem functions to control or master an aspect of self or environment to achieve a standard. This subsystem encompasses intellectual, physical, creative, mechanical, and social skills. The affiliative or attachment subsystem forms the basis for social organization. Its consequences are social inclusion, intimacy, and the formation and maintenance of strong social bonds. The aggressive or protective subsystem functions to protect and preserve the system. The dependency subsystem promotes helping or nurturing behaviors.
The consequences include approval, recognition, and physical assistance. The sexual subsystem has the function of procreation and gratification and includes development of gender role identity and gender role behaviors. The eliminative subsystem addresses “when, how, and under what conditions we eliminate,” whereas the ingestive subsystem “has to do with when, how, what, how much, and under what conditions we eat” (Johnson, 1980, p. 213).
The nursing process for the Behavioral System Model is known as Johnson’s nursing diagnostic and treatment process. The components of the process include the determination of the existence of a problem, diagnosis and classification of problems, management of problems, and evaluation of behavioral system balance and stability. When using Johnson’s model in practice, the focus of the assessment process is obtaining information to evaluate current behavior in terms of past patterns, determining the effect of the current illness on behavioral patterns, and establishing the maximum level of health. The assessment is specifically related to gathering information pertaining to the structure and function of the seven behavioral subsystems as well as the environmental factors that affect the behavioral subsystems (Holaday, 2006). The ultimate goals of nursing using the model are to maintain or restore behavioral system balance (Johnson, 1980).
Selected Theories and Middle-Range Theories of Nursing Middle-range theory may be derived from a grand theory or a conceptual model or may originate from practice perspectives. Middle-range theories are narrower in scope than grand theories and include concepts that are less abstract and therefore more amenable to testing in research and use in nursing practice.
Rosemarie Parse’s Humanbecoming Theory Parse’s theory was originally called man-living-health (Parse, 1981). In 1992, Parse changed the name to human becoming and then in 2007 again changed the name to humanbecoming (Mitchell & Bournes, 2010) to coincide with Parse’s evolution of thought. The Humanbecoming Theory consists of three major themes: meaning, rhythmicity, and transcendence (Parse, 1998). Meaning is the linguistic and imagined content of something and the interpretation that one gives to something. Rhythmicity is the cadent, paradoxical patterning of the human–universe mutual process. Transcendence is defined as reaching beyond with possibles or the “hopes and dreams envisioned in multidimensional experiences powering the originating of transforming” (Parse, 1998, p. 29). The three major principles of the Humanbecoming Theory flow from these themes.
The first principle of the Humanbecoming Theory states, “Structuring meaning multidimensionally is cocreating reality through the languaging of valuing and imaging” (Parse, 1998, p. 35). This principle proposes that persons structure or choose the meaning of their realities and that the choosing occurs at levels that are not always known explicitly (Mitchell, 2006). This means that one person cannot decide the significance of something for another person and does not even understand the meaning of the event unless that person shares the meaning through the expression of his or her views, concerns, and dreams.
The second principle states, “Cocreating rhythmical patterns of relating is living the paradoxical unity of revealing—concealing and enabling—limiting while connecting— separating” (Parse, 1998, p. 42). This principle means that persons create patterns in life, and these patterns tell about personal meanings and values. The patterns of relating that persons create involve complex engagements and disengagements with other persons, ideas, and preferences (Mitchell, 2006). According to Parse (1998), persons change their patterns when they integrate new priorities, ideas, hopes, and dreams.
The third principle of the Humanbecoming Theory states, “Cotranscending with the possibles is powering unique ways of originating in the process of transforming”
(Parse, 1998, p. 46). This principle means that persons are always engaging with and choosing from infinite possibilities. The choices reflect the person’s ways of moving and changing in the process of becoming (Mitchell, 2006).
Three processes for practice have been developed from the concepts and principles in the Humanbecoming Theory, including the following (Parse, 1998, pp. 69, 70):
Illuminating meaning is explicating what was, is, and will be. Explicating is making clear what is appearing now through language. Synchronizing rhythms is dwelling with the pitch, yaw, and roll of the human– universe process. Dwelling with is immersing with the flow of connecting– separating. Mobilizing transcendence is moving beyond the meaning moment with what is not yet. Moving beyond is propelling with envisioned possibles of transforming.
In practice, nurses guided by the Humanbecoming Theory prepare to be truly present (Table 2-11) with others through focused attentiveness on the moment at hand through immersion (Parse, 1998).
TABLE 2-11 Metaparadigm Concepts as Defined in Parse’s Theory
Person An open being, more than and different from the sum of parts in mutual simultaneous interchange with the environment who chooses from options and bears responsibility for choices (Parse, 1987, p. 160).
Environment Coexists in mutual process with the person.
Health Continuously changing process of becoming.
Nursing A learned discipline, the nurse uses true presence to facilitate the becoming of the participant.
Madeleine Leininger’s Cultural Diversity and Universality Theory Leininger (1995) defined transcultural nursing as both an area of study and an area of nursing practice. The main features of the Cultural Diversity and Universality Theory focus on “comparative cultural care (caring) values, beliefs, and practices” (p. 58) for either individuals or groups of people with similar or different cultures. The goal of transcultural nursing is the provision of nursing care that is culture specific in order to either promote health or to assist individuals facing sickness or death “in culturally meaningful ways” (p. 58). Consistent with the focus of her theory, Leininger defined the metaparadigm concepts of nursing in a manner that causes the nurse to
specifically consider culture in the delivery of competent nursing care (Table 2-12).
TABLE 2-12 Metaparadigm Concepts as Defined in Leininger’s Theory
Person Human being, family, group, community, or institution.
Environment Totality of an event, situation, or experience that gives meaning to human expressions, interpretations, and social interactions in physical, ecological, sociopolitical, and/or cultural settings (Leininger, 1991).
Health A state of well-being that is culturally defined, valued, and practiced (Leininger, 1991, p. 46).
Nursing Activities directed toward assisting, supporting, or enabling with needs in ways that are congruent with the cultural values, beliefs, and lifeways of the recipient of care (Leininger, 1995).
According to Leininger (2001), three modalities guide nursing judgments, decisions, and actions to provide culturally congruent care that is beneficial, satisfying, and meaningful to the persons the nurse serves. These three modes include cultural care preservation or maintenance, cultural care accommodation or negotiation, and cultural care repatterning or restructuring. Cultural care preservation or maintenance refers to those assistive, supportive, facilitative, or enabling professional actions and decisions that help people of a specific culture to maintain meaningful care values for their well-being, recover from illness, or deal with a handicap or dying. Cultural care accommodation or negotiation refers to those assistive, supportive, facilitative, or enabling professional actions and decisions that help people of a specific culture or subculture adapt to or negotiate with others for meaningful, beneficial, and congruent health outcomes. Cultural care repatterning or restructuring refers to the assistive, supportive, facilitative, or enabling professional actions and decisions that help patients reorder, change, or modify their lifeways for new, different, and beneficial health outcomes (Leininger & McFarland, 2006).
The nurse using Leininger’s theory plans and makes decisions with clients with respect to these three modes of action. All three care modalities require coparticipation of the nurse and client working together to identify, plan, implement, and evaluate nursing care with respect to the cultural congruence of the care (Leininger, 2001).
Leininger developed the Sunrise Model, which she revised in 2004. She labeled this model as “an enabler,” to clarify that although it depicts the essential components of the Cultural Diversity and Universality Theory, it is a visual guide for exploration of
Hildegard Peplau’s Theory of Interpersonal Relations In her theory, Peplau addresses all of nursing’s metaparadigm concepts (Table 2-13), but she is primarily concerned with one aspect of nursing: how persons relate to one another. According to Peplau, the nurse–patient relationship is the center of nursing (Young, Taylor, & McLaughlin-Renpenning, 2001).
TABLE 2-13 Metaparadigm Concepts as Defined in Peplau’s Theory
Person Encompasses the patient (one who has problems for which expert nursing services are needed or sought) and the nurse (a professional with particular expertise) (Peplau, 1992, p. 14).
Environment Forces outside the organism within the context of culture (Peplau, 1952, p. 163).
Health “Implies forward movement of personality and other ongoing human processes in the direction of creative, constructive, productive, personal, and community living” (Peplau, 1992, p. 12).
Nursing The therapeutic, interpersonal process between the nurse and the patient.
Peplau (1952) originally described four phases in nurse–patient relationships that overlap and occur over the time of the relationship: orientation, identification, exploitation, and resolution. In 1997, Peplau combined the phase of identification and exploitation, resulting in three phases: orientation, working, and termination. Nevertheless, most other theorists still consider the phases of identification and exploitation to be subphases of the working phase. During the orientation phase, a health problem has emerged that results in a “felt need,” and professional assistance is sought (p. 18).
In the working phase, the patient identifies those who can help, and the nurse permits exploration of feelings by the patient. During this phase, the nurse can begin to focus the patient on the achievement of new goals. The resolution (termination) phase is the time when the patient gradually adopts new goals and frees himself or herself from identification with the nurse (Peplau, 1952, 1997).
Peplau (1952) also describes six nursing roles that emerge during the phases of the nurse–patient relationship: the role of the stranger, the role of the resource person, the teaching role, the leadership role, the surrogate role, and the counseling role. Over
the course of Peplau’s career, the nursing roles were refined to include teacher, resource, counselor, leader, technical expert, and surrogate. As a teacher, the nurse provides knowledge about a need or problem. In the role of resource, the nurse provides information to understand a problem. In the role of counselor, the nurse helps recognize, face, accept, and resolve problems. As a leader, the nurse initiates and maintains group goals through interaction. As a technical expert, the nurse provides physical care using clinical skills. As a surrogate, the nurse may take the place of another (Johnson & Webber, 2010, p. 125).
Peplau (1952) also described four psychobiologic experiences: needs, frustration, conflict, and anxiety. According to Peplau, these experiences “all provide energy that is transformed into some form of action” (p. 71) as well as a basis for goal formation and nursing interventions (Howk, 2002).
Peplau, as one of the first theorists since Nightingale to present a theory for nursing, is considered a pioneer in the area of theory development in nursing. Prior to Peplau’s work, nursing practice involved acting on, to, or for the patient such that the patient was considered an object of nursing actions. Peplau’s work was the force behind the conceptualization of the patient as a partner in the nursing process (Howk, 2002). Although Peplau’s book was first published in 1952, her model continues to be used extensively by clinicians and to provide direction to educators and researchers (Howk, 2002).
Nola Pender’s Health Promotion Model The Health Promotion Model is an attempt to portray the multidimensionality of persons interacting with their interpersonal and physical environments as they pursue health while integrating constructs from expectancy-value theory and social cognitive theory with a nursing perspective of holistic human functioning (Pender, 1996). A summary of the metaparadigm concepts of nursing as defined by Pender is presented in Table 2-14.
TABLE 2-14 Metaparadigm Concepts as Defined in Pender’s Model
Person The individual, who is the primary focus of the model.
Environment The physical, interpersonal, and economic circumstances in which persons live.
Health A positive high-level state.
Nursing The role of the nurse includes raising consciousness related to health-promoting behaviors, promoting self-
efficacy, enhancing the benefits of change, controlling the environment to support behavior change, and managing barriers to change.
There are three major categories to consider in Pender’s Health Promotion Model: (1) individual characteristics and experiences, (2) behavior-specific cognitions and affect, and (3) behavioral outcome. Personal factors include personal biological factors, such as age, body mass index, pubertal status, menopausal status, aerobic capacity, strength, agility, or balance. Personal psychological factors include such factors as self-esteem, self-motivation, and perceived health status; personal sociocultural factors include such factors as race, ethnicity, acculturation, education, and socioeconomic status. Some personal factors are amenable to change, whereas others cannot be changed (Pender, Murdaugh, & Parsons, 2006, 2011).
Behavior-specific cognitions and affect are behavior-specific variables within the Health Promotion Model. Such variables are considered to have motivational significance. In the Health Promotion Model, these variables are the target of nursing intervention because they are amenable to change. The behavior-specific cognitions and affect identified in the Health Promotion Model include (1) perceived benefits of action, (2) perceived barriers to action, (3) perceived self-efficacy, and (4) activity- related affect. Perceived benefits of action are the anticipated positive outcomes resulting from health behavior. Perceived barriers to action are the anticipated, imagined, or real blocks or personal costs of a behavior. Perceived self-efficacy refers to the judgment of personal capability to organize and execute a health-promoting behavior. It influences the perceived barriers to actions such that higher efficacy results in lower perceptions of barriers. Activity-related affect refers to the subjective positive or negative feelings that occur before, during, and following behavior based on the stimulus properties of the behavior. Activity-related affect influences perceived self- efficacy such that the more positive the subjective feeling, the greater the perceived efficacy (Pender et al., 2006, 2011; Sakraida, 2010, 2014).
Commitment to a plan of action marks the beginning of a behavioral event. Interventions in the Health Promotion Model focus on raising consciousness related to health-promoting behaviors, promoting self-efficacy, enhancing the benefits of change, controlling the environment to support behavior change, and managing the barriers to change. Health-promoting behavior, which is ultimately directed toward attaining positive health outcomes, is the product of the Health Promotion Model (Pender et al., 2006, 2011; 2015).
Afaf Ibrahim Meleis’s Transitions Theory Transitions are a central concept of interest to nursing (Meleis, 2007). Nurses interact with individuals experiencing transitions if those transitions relate to health, well-being, or self-care ability. Nurses also interact with individuals within environments that support or hamper personal, communal, familial, or population transitions (Meleis, 2010).
Transition is a process triggered by a change that represents a passage from a fairly stable state to another fairly stable state (Meleis, 2010). Transitions can be described in terms of types and patterns of transitions, properties of transition experiences, transition conditions, process indicators, outcome indicators, and nursing therapeutics Meleis et al., 2000).
Types of transitions include developmental, health and illness, situational, and organizational. Developmental transitions may include such events as the transition from childhood to adolescence or from adulthood to old age. Health and illness transitions may include such events as diagnosis of chronic illness. Birth and death are examples of events that may lead to situational transitions. Patterns of transitions reflect the experience of multiple simultaneous transitions in the lives of individuals rather than single, sequential transition events (Meleis et al., 2000).
Essential and interrelated properties of transition experiences have been identified that include awareness, engagement, change and difference, time span, and critical points and events (Meleis et al., 2000). Awareness is related to perception, knowledge, and recognition of the transition experience; it is often reflected in the congruency between what is known about the process and responses and what the expected perceptions and responses of individuals in similar transitions are. Engagement is related to the involvement of the individual in the transition process, which may be manifested by such activities as seeking information. Change and difference are properties of transitions that are similar but not interchangeable. Either change may be the result of transition or the transition may result in change. All transitions involve change, but not all change is related to transition (Meleis et al., 2000). Confronting difference in the context of transitions refers to “unmet or divergent expectations, feeling different, being perceived as different, or seeing the work and others in different ways” (Meleis et al., 2000, p. 20). Time span refers to the flow and movement over time that occurs with all transitions. Individuals experiencing long-term transitions do not necessarily constantly experience a state of flux; however, such a state “may periodically surface, reactivating a latent transition experience” (Meleis et al., 2000, pp. 20–21). Thus, it is important to consider the possibility of variability over time and to reassess outcomes.
Most transitions include critical points or marker events, such as birth, death, or diagnosis with an illness. Critical points are often associated with awareness of change or difference or increased engagement in the transition experience and may represent periods of heightened vulnerability. During the period of uncertainty, a number of critical points may occur depending on the nature of the transition. Final critical points are characterized by a sense of stabilization (Meleis et al., 2000).
Transition conditions include facilitators and inhibitors or the perceptions of and meanings attached to health and illness situations that facilitate or hinder progress toward achieving a healthy transition (Schumacher & Meleis, 1994). Perceptions and meanings are influenced by and in turn influence the conditions in which transitions occur. These facilitators and inhibitors include personal, community, or societal conditions. Personal conditions include meanings, cultural beliefs and attitudes, socioeconomic status, and preparation and knowledge. Community conditions may include community resources, support from family, and role models. Societal conditions may include stigmatization, marginalization, and cultural attitudes (Meleis et al., 2000).
Patterns of response include process indicators and outcome indicators. Because transitions occur over time, process indicators that direct individuals toward health or toward vulnerability and risk may be identified through early assessment to promote health outcomes. Assessment of outcome indicators may be used to ascertain whether a transition process is healthy and may include efforts to determine whether the individual is feeling connected, interacting, being situated, and developing confidence and coping (Meleis et al., 2000). Outcome indicators include mastery and development of identity. Mastery of new skills required to manage a transition and the development of a new fluid and integrative identity reflect a healthy outcome of the transition process.
Nursing therapeutics are conceptualized as measures applicable to therapeutic intervention during transitions. The first nursing therapeutic is an assessment of readiness; it includes an assessment of each transition condition to determine readiness and allows clinicians to determine patterns of the transition experience. Preparation for transition is the second nursing therapeutic. It includes education to generate the best condition for transition. The third nursing therapeutic is role supplementation (Schumacher & Meleis, 1994), a deliberative process that is applied when role insufficiency or potential role insufficiency is identified. In this process, the conditions and strategies of role clarification and role taking are used to develop preventive or therapeutic measures to decrease, improve, or prevent role insufficiency (Meleis, 2010). The metaparadigm concepts of nursing as defined by Meleis are
summarized in Table 2-15.
TABLE 2-15 Metaparadigm Concepts as Defined in Meleis’s Transitions Theory
Person Active beings who experience fundamental life patterns and who have perceptions of and attach meaning to transition experiences (Meleis et al., 2000, p. 21).
Environment Environmental conditions expose persons to potential damage, problematic recovery, or delayed or unhealthy coping, contributing to vulnerability related to transitions.
Health Consists of complex and multidimensional transitions that are characterized by flow and movement over time; healthy outcomes are defined in terms of the transition process.
Nursing Being the primary caregiver for individuals and their families during the transition process and applying nursing therapeutics during transitions to promote healthy outcomes.
Kristen Swanson’s Theory of Caring Swanson’s Theory of Caring (1991, 1993, 1999a, 1999b) offers an explanation of what it means to practice nursing in a caring manner. In this theory, caring is defined as a “nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility” (Swanson, 1991, p. 162). Swanson (1993) posits that caring for a person’s biopsychosocial and spiritual well-being is a fundamental and universal component of good nursing care.
Five additional concepts are integral to Swanson’s Theory of Caring and represent the five basic processes of caring: maintaining belief, knowing, being with, doing for, and enabling.
The concept of maintaining belief is sustaining faith in the other’s capacity to get through an event or transition and to face a future with meaning. This includes believing in the other’s capacity and holding him or her in high esteem, maintaining a hope-filled attitude, offering realistic optimism, helping to find meaning, and standing by the one cared for, no matter what the situation. The concept of knowing refers to striving to understand the meaning of an event in the life of the other, avoiding assumptions, focusing on the person cared for, seeking cues, assessing meticulously, and engaging both the one caring and the
one cared for in the process of knowing. The concept of being with refers to being emotionally present to the other. It includes being present in person, conveying availability, and sharing feelings without burdening the one cared for. The concept of doing for refers to doing for others what one would do for oneself, including anticipating needs, comforting, performing skillfully and competently, and protecting the one cared for while preserving his or her dignity. The concept of enabling refers to facilitating the other’s passage through life transitions and unfamiliar events by focusing on the event, informing, explaining, supporting, validating feelings, generating alternatives, thinking things through, and giving feedback (Swanson, 1991, p. 162).
These caring processes are sequential and overlapping. In fact, they might not exist separate from one another because each is an integral component of the overarching structure of caring (Wojnar, 2010). According to Swanson (1999b), knowing, being with, doing for, enabling, and maintaining belief are essential components of the nurse–client relationship, regardless of the context. A summary of the metaparadigm concepts of nursing as defined by Swanson is included in Table 2- 16.
TABLE 2-16 Metaparadigm Concepts as Defined in Swanson’s Theory of Caring
Person “Unique beings who are in the midst of becoming and whose wholeness is made manifest in thoughts, feelings, and behaviors” (Swanson, 1993, p. 352).
Environment “Any context that influences or is influenced by the designated client” (Swanson, 1993, p. 353).
Health Health and well-being is “to live the subjective, meaning-filled experience of wholeness. Wholeness involves a sense of integration and becoming wherein all facets of being are free to be expressed” (Swanson, 1993, p. 353).
Nursing Informed caring for the well-being of others (Swanson, 1991, 1993).
Katharine Kolcaba’s Theory of Comfort Comfort, as described by Kolcaba (2004) in the Theory of Comfort, is the immediate experience of being strengthened by having needs for relief, ease, and transcendence addressed in four contexts—physical, psychospiritual, sociocultural, and
environmental; it is much more than simply the absence of pain or other physical discomfort. Physical comfort pertains to bodily sensations and homeostatic mechanisms. Psychospiritual comfort pertains to the internal awareness of self, including esteem, sexuality, meaning in one’s life, and one’s relationship to a higher order or being. Sociocultural comfort pertains to interpersonal, family, societal relationships, and cultural traditions. Environmental comfort pertains to the external background of the human experience, which includes light, noise, color, temperature, ambience, and natural versus synthetic elements (Kolcaba, 2004).
According to Kolcaba, comfort care encompasses three components: an appropriate and timely intervention to meet the comfort needs of patients, a mode of delivery that projects caring and empathy, and the intent to comfort. Comfort needs include patients’ or families’ desire for or deficit in relief, ease, or transcendence in the physical, psychospiritual, sociocultural, or environmental contexts of human experience. Comfort measures refer to interventions that are intentionally designed to enhance patients’ or families’ comfort (Kolcaba, 2004).
The Theory of Comfort also addresses intervening variables—negative or positive factors over which nurses and institutions have little control but that affect the direction and success of comfort care plans. Examples of intervening variables are the presence or absence of social support, poverty, prognosis, concurrent medical or psychological conditions, and health habits (Kolcaba, 2004).
An additional concept within the theory comprises the health-seeking behaviors of patients and families. Health-seeking behaviors are those behaviors that patients and families engage in either consciously or unconsciously while moving toward well- being. Health-seeking behaviors can be either internal or external and can include dying peacefully. It is posited that enhanced comfort results in engagement in health- seeking behaviors (Kolcaba, 2004). The metaparadigm concepts of nursing as defined by Kolcaba are summarized in Table 2-17.
TABLE 2-17 Metaparadigm Concepts as Defined in Kolcaba’s Theory of Comfort
Person Recipients of care may be individuals, families, institutions, or communities in need of health care (Kolcaba, Tilton, & Drouin, 2006).
Environment The environment includes any aspect of the patient, family, or institutional setting that can be manipulated by the nurse, a loved one, or the institution to enhance comfort (Dowd, 2010, p. 711).
Health Health is considered optimal functioning of the patient,
the family, the healthcare provider, or the community (Dowd, 2010, p. 711).
Nursing Nursing is the intentional assessment of comfort needs, design of comfort interventions to address those needs, and reassessment of comfort levels after implementation compared to baseline (Dowd, 2010, p. 711).
Pamela Reed’s Self-Transcendence Theory Three major concepts are central to the Theory of Self-Transcendence: self- transcendence, well-being, and vulnerability. Self-transcendence is the capacity to expand self-boundaries intrapersonally, interpersonally, temporally, and transpersonally (Reed, 2008, 2014). The capacity to expand self-boundaries intrapersonally refers to a greater awareness of one’s philosophy, values, and dreams. The capacity to expand interpersonally relates to others and one’s environment. The capacity to expand temporally refers to integration of one’s past and future in a way that has meaning for the present. Finally, the capacity to expand transpersonally refers to the capacity to connect with dimensions beyond the typically discernible world. Self- transcendence is a characteristic of developmental maturity that is congruent with enhanced awareness of the environment and a broadened perspective on life. Self- transcendence is expressed through behaviors, such as sharing wisdom with others, integrating physical changes of aging, accepting death as a part of life, and finding spiritual meaning in life (Reed, 2008).
Well-being is the second major concept of Reed’s theory. Well-being is a sense of feeling whole and healthy, according to one’s own criteria for wholeness and health. The definition of well-being depends on the individual or population. Indeed, indicators of well-being are as diverse as human perceptions of health and wellness. Examples of indicators of well-being are life satisfaction, positive self-concept, hopefulness, happiness, and having meaning in life. Well-being is viewed as a correlate and an outcome of self-transcendence (Reed, 2008, 2014).
The third major concept, vulnerability, is the awareness of personal mortality and the likelihood of experiencing difficult life situations. Self-transcendence emerges naturally in health experiences when a person is confronted with mortality and immortality. Life events, such as illness, disability, aging, childbirth, or parenting—all of which heighten a person’s sense of mortality, inadequacy, or vulnerability—can trigger developmental progress toward a renewed sense of identity and expanded self- boundaries (Reed, 2014). According to Reed (2008), self-transcendence is evoked
through life events and can enhance well-being by transforming losses and difficulties into healing experiences.
Additional concepts in Reed’s theory include moderating-mediating factors and points of intervention. Moderating-mediating factors are personal and contextual variables, such as age, gender, life experiences, and social environment, that can influence the relationships between vulnerability and self-transcendence and between self-transcendence and well-being. Nursing activities that facilitate self-transcendence are referred to as points of intervention (Coward, 2010). Two points of intervention are intertwined with the process of self-transcendence: Nursing actions can focus either directly on a person’s inner resource for self-transcendence or indirectly on the personal and contextual factors that affect the relationship between vulnerability and self-transcendence and the relationship between self-transcendence and well-being. The metaparadigm concepts of nursing as defined by Reed are summarized in Table 2-18.
TABLE 2-18 Metaparadigm Concepts as Defined in Reed’s Self-Transcendence Theory
Person Persons are human beings who develop over the life span through interactions with other persons and within an environment (Coward, 2010, p. 622).
Environment The environment is composed of family, social networks, physical surroundings, and community resources (Coward, 2010, p. 622).
Health Well-being is a sense of feeling whole and healthy, according to one’s own criteria for wholeness and health (Reed, 2008).
Nursing The role of nursing activity is to assist persons through interpersonal processes and therapeutic management of their environment to promote health and well-being (Coward, 2010, p. 622).
Merle Mishel’s Uncertainty in Illness Theory The purpose of the Uncertainty in Illness Theory is to “describe and explain uncertainty as a basis for practice and research” (Mishel, 2014, p. 54). Uncertainty, the central concept of the theory, is defined as “the inability to determine the meaning of illness- related events inclusive of inability to assign definite value and/or to accurately predict outcomes” (p. 56). The second central concept in the theory, cognitive schema, is defined by Mishel as a “person’s subjective interpretation of illness-related events” (p.
56). The Uncertainty in Illness Theory is organized around three themes: antecedents
of uncertainty, appraisal of uncertainty, and coping with uncertainty. Antecedents of uncertainty include the stimuli frame, cognitive capacities, and structure providers. According to the model, uncertainty is a result of these antecedents, with the major path to uncertainty being through the stimuli frame variables (Mishel, 2014). The stimuli frame encompasses the form, composition, and structure of the stimuli that the person perceives. It has three components: symptom pattern, event familiarity, and event congruence. The symptom pattern refers to the degree to which symptoms occur with enough consistency to be perceived as following a pattern. Event familiarity refers to the degree to which a situation is repetitive or contains recognized cues. Event congruence refers to the consistency between what is expected and what is experienced (Mishel, 1988). The stimuli frame is the foundation for cognitive schema or the person’s interpretation of the events (Bailey & Stewart, 2014). Cognitive capacities refer to the information-processing ability of the person, and structure providers refer to the resources, such as education, social support, and credible authority, available to assist the person as he or she interprets the stimuli frame. Thus, cognitive capacities and structure providers influence the components of the stimuli frame (Mishel, 2014).
The second theme, appraisal of uncertainty, refers to the process of placing a value on the uncertain event or situation. Appraisal of uncertainty has two components: inference and illusion. Inference refers to the evaluation of uncertainty by using examples; it is predicated on personality disposition, experience, knowledge, and contextual cues. Illusion comprises the construction of beliefs to create a positive outlook (Mishel, 2014).
The third theme, coping with uncertainty, includes the concepts of danger, opportunity, coping, and adaptation. Danger refers to the possibility of a harmful outcome, whereas opportunity is the possibility of a positive outcome. Coping in the context of a danger appraisal encompasses activities directed toward reducing uncertainty and managing emotions; coping in the context of an opportunity appraisal comprises activities directed toward maintaining uncertainty (Mishel, 2014). Adaptation in the context of the uncertainty theory is defined as biopsychosocial behavior occurring within a person’s range of usual behavior and is the outcome of coping.
The reconceptualized Uncertainty in Illness Theory presents the process of moving from uncertainty appraised as danger to uncertainty appraised as an opportunity and resource for a new view of life. The revised theory incorporates two new concepts: self-organization and probabilistic thinking. Self-organization refers to the reformulation
of a new sense of order resulting from the integration of continuous uncertainty into self-structure, where uncertainty is accepted as the natural rhythm of life. Probabilistic thinking refers to the belief in a conditional world in which the expectation of certainty is abandoned (Bailey & Stewart, 2014; Mishel, 2014).
The metaparadigm concepts of nursing as defined by Mishel are summarized in Table 2-19.
TABLE 2-19 Metaparadigm Concepts as Defined in Mishel’s Uncertainty in Illness Theory
Person The concept of person is the central focus of the theory and may be an individual or the family of an ill individual (Mishel, 2014, p. 54); the individual is viewed as a biopsychosocial being who is an open system, exchanging energy with the environment.
Environment Not explicitly defined but is acknowledged to exchange energy with the person system.
Health Defined in terms of uncertainty in the context of the illness experience, with the concept of health or well- being congruent with the formulation of a new life view and probabilistic thinking.
Nursing Nurses are viewed as a part of the antecedent variable of structure providers (Mishel, 2014, p. 71).
Cheryl Tatano Beck’s Postpartum Depression Theory Two major concepts are included in the Postpartum Depression Theory: postpartum mood disorders and loss of control. Postpartum mood disorders include postpartum depression, maternity blues, postpartum psychosis, postpartum obsessive–compulsive disorder, and postpartum-onset panic disorder (Beck, 2002). The second major concept in Beck’s theory describes the experience of loss of control in all areas of women’s lives. Loss of control is a basic psychosocial problem with which women attempt to cope through a four-stage process labeled by Beck as “teetering on the edge,” referring to what women describe as walking a fine line between sanity and insanity. The four stages of the coping process consist of (1) encountering terror in the form of symptoms, such as anxiety attacks, fogginess, and obsessive thinking, that hit unexpectedly and suddenly; (2) dying of self, as mothers who no longer know who they have become isolate themselves and contemplate and sometimes attempt self- destruction; (3) struggling to survive, as they battle the healthcare system and seek help from support groups and prayer; and (4) regaining control of their lives during
transition and guarded recovery while mourning lost time with their infant (Beck, 1993). Additional concepts in Beck’s theory include predictors or risk factors for
postpartum depression. These concepts include prenatal depression, childcare stress, life stress, social support, prenatal anxiety, marital satisfaction, history of depression, infant temperament, maternity blues, self-esteem, socioeconomic status, marital status, and unplanned or unwanted pregnancy (Beck, 2003). Concepts that are used for screening in the Postpartum Depression Screening Scale include sleeping and eating disturbances, anxiety and insecurity, emotional lability, mental confusion, loss of self, guilt and shame, and suicidal thoughts (Beck & Gable, 2000). Modifications to the Postpartum Depression Theory have occurred as research reveals new information. In addition to these concepts, the four metaparadigm concepts of nursing are presented in the context of Beck’s Postpartum Depression Theory. These concepts are summarized in Table 2-20.
TABLE 2-20 Metaparadigm Concepts as Defined in Beck’s Postpartum Depression
Person Described in terms of wholeness with biological, sociological, and psychological aspects, with personhood understood in the context of family and community (Maeve, 2014, p. 678).
Environment Viewed broadly in terms of individual factors and external factors (Maeve, 2014, p. 678).
Health Not defined explicitly; traditional ideas of physical and mental health are viewed as a consequence of women’s responses to the contexts of their lives and environments (Maeve, 2014, p. 678).
Nursing A caring profession with caring obligations; the nurse accomplishes the goals of health and wholeness through interpersonal interactions (Maeve, 2014, p. 678).
The American Association of Critical-Care Nurses’ Synergy Model for Patient Care The Synergy Model is a conceptual framework for designing practice competencies to care for critically ill patients with a goal of optimizing outcomes for patients and families. Optimal outcomes are realized when the competencies of the nurse match the patient and family needs.
The Synergy Model for Patient Care is the result of the American Association of
Critical-Care Nurses (AACN) envisioning a new paradigm for clinical practice. In 1993, the AACN Certification Corporation convened a think tank that included nationally recognized experts to develop a conceptual framework for certified practice. The initial work resulted in the description of 13 patient characteristics based on universal needs of patients and 9 characteristics required of nurses to meet patient needs. The patient characteristics identified were compensation, resiliency, margin of error, predictability, complexity, vulnerability, physiologic stability, risk of death, independence, self- determination, involvement in care decisions, engagement, and resource availability. The characteristics of nurses were engagement, skilled clinical practice, agency, caring practices, system management, teamwork, diversity responsiveness, experiential learning, and being an innovator–evaluator. The think tank suggested that the synergy emerging from the interaction between the patient needs and the nurse characteristics should result in optimal outcomes for the patient and that these characteristics of the nurse would determine competencies for certified practice (Hardin, 2005).
In 1995, the AACN Certification Corporation decided to refine this model, to conduct a study of practice and job analysis of critical care nurses, and to test the validity of the concepts in critical care nurses. The group refined the patient characteristics into eight concepts, merged the nurse characteristics into eight concepts, and delineated a continuum for the characteristics. The eight patient characteristics identified in the current model are resiliency, vulnerability, stability, complexity, resource availability, participation in care, participation in decision making, and predictability. The eight nurse characteristics are clinical judgment, advocacy, caring practices, collaboration, systems thinking, response to diversity, clinical inquiry, and facilitation of learning (Hardin, 2005, 2013). Each patient characteristic is placed on a scale from one to five, with the level of each patient characteristic being critical in terms of the competency required of the nurse (Hardin, 2005). The eight nurse characteristics can be considered essential competencies for providing care for critically ill patients. All eight competencies reflect an integration of knowledge, skills, and experience of the nurse. Each nurse characteristic can be understood on a continuum from one to five (Hardin, 2005).
The Synergy Model delineates three levels of outcomes: outcomes derived from the patient, outcomes derived from the nurse, and outcomes derived from the healthcare system. Outcomes data derived from the patient include functional changes, behavioral changes, trust, satisfaction, comfort, and quality of life. Outcomes data derived from nursing competencies include physiologic changes, the presence or absence of complications, and the extent to which treatment objectives are attained
(Curley, 1998). Outcomes data derived from the healthcare system include readmission rates, length of stay, and cost utilization (Hardin, 2005). The metaparadigm concepts of nursing as defined in the Synergy Model for Patient Care are summarized in Table 2-21.
TABLE 2-21 Metaparadigm Concepts as Defined in the Synergy Model for Patient Care
Person Persons are viewed in the context of patients who are biological, social, and spiritual entities who are present at a particular developmental stage.
Environment The concept of environment is not explicitly defined; however, included in the assumptions is the idea that environment is created by the nurses for the care of the patient.
Health The concept of health is not explicitly defined; an optimal level of wellness as defined by the patient is mentioned as a goal of nursing care.
Nursing The purpose of nursing is to meet the needs of patients and families and to provide safe passage through the healthcare system during a time of crisis (Hardin, 2005, p. 8).
Overview of Selected Nonnursing Theories Nursing as a discipline with a distinct body of theoretical knowledge has developed over time, but nonnursing theories have influenced and still do influence nursing theory, research, and practice. Brief overviews of nonnursing theories that are commonly used in nursing follow.
General System Theory Von Bertalanffy (1968) emphasized that systems are open to and interact with their environments and that they can evolve as they acquire new properties. Rather than reducing an entity to the properties of its parts or elements, system theory focuses on the arrangement of and relations between the parts that connect them into a whole. This particular organization defines a system. Major concepts of general system theory include a system–environment boundary, input and output processes, and the organizational state of the system. General System Theory is founded on the premise that the world is composed of systems that are interconnected and influenced by one another. The two primary assumptions of the theory are that energy is needed to maintain an organizational state and that dysfunction in one system has an effect on other systems (Boulding, 1956). Roy’s Adaptation Model, King’s Interacting Systems Framework and Theory of Goal Attainment, and Neuman’s System Model are all nursing theories that have foundations in general system theory.
Social Cognitive Theory Social Cognitive Theory explains human behaviors in terms of dynamic reciprocal interactions among cognitive, behavioral, and environmental influences. According to Albert Bandura (1986), human behavior is learned observationally through modeling or observing others. Once a behavior is observed, the person forms an idea of how the new behavior is performed; on a later occasion, this coded information serves as a guide for action. Principles derived from Social Cognitive Theory are often used to promote behavior change.
Bandura incorporated the concept of self-efficacy into Social Learning Theory (now called Social Cognitive Theory) in 1977. The concept of self-efficacy refers to a person’s confidence in his or her ability to take action and to persist in that action to reach goals. The concept of self-efficacy can be important in influencing health behavior change (Bandura, 1997) and is frequently used by nurses engaged in health
education and behavior modification. Nola Pender is a nurse theorist who identifies Social Learning Theory as central to her Health Promotion Model, with the concept of self-efficacy being included as a central construct of the model (Sakraida, 2014).
Stress and Coping Process Theory Richard Lazarus suggested that stress might be an organizing concept for understanding a wide range of phenomena rather than a variable. Stress as conceptualized by Lazarus emphasizes the relationship of the person to the environment, with the judgment of whether a specific person–environment relationship is stressful dependent on cognitive appraisal (Lazarus & Folkman, 1984). He identified three types of cognitive appraisal: primary, secondary, and reappraisal. Vulnerability is related to the concept of cognitive appraisal because the vulnerable individual is one whose coping resources are deficient (Lazarus & Folkman, 1984). Patricia Benner credits Richard Lazarus with mentoring her in the area of stress and coping.
KEY OUTCOME 2-1
Examples of applicable outcomes expected of the graduate from a baccalaureate program
Essential I: Liberal Education for Baccalaureate Generalist Nursing Practice
1.1 Integrate theories and concepts from liberal education into nursing practice (p. 12).
1.2 Synthesize theories and concepts from liberal education to build an understanding of the human experience (p. 12).
Reproduced from American Association of Colleges of Nursing. (2008). The essentials of baccalaureate
education for professional nursing practice. Retrieved from
General Adaptation Syndrome Hans Selye introduced the notion of a general adaptation syndrome in 1950 (Selye, 1950). In 1974, Selye defined stress as the nonspecific response of the body to any demand for change. General adaptation syndrome is based on physiologic and psychobiologic responses to stress. According to Selye, a stressor results in a three- stage response that includes alarm, resistance, and exhaustion, also known as coping with stress. The goals of coping with stress are adaptation and homeostasis (Selye, 1950, 1974).
Betty Neuman used Selye’s definition of stress in her Systems Model (Lawson, 2014). Sister Callista Roy also used concepts from Selye in the refinement of her Adaptation Model (Phillips & Harris, 2014).
Relationship of Theory to Professional Nursing Practice How will theory affect your nursing practice? Using a theoretical framework to guide your nursing practice assists you as you organize patient data, understand and analyze patient data, make decisions related to nursing interventions, plan patient care, predict outcomes of care, and evaluate patient outcomes (Alligood & Tomey, 2002). Why? The use of a theoretical framework provides a systematic and knowledgeable approach to nursing practice. The framework also becomes a tool that assists you to think critically as you plan and provide nursing care.
How do you begin? Now that you know why nursing theory is important to your nursing practice, it is time to identify a theoretical framework that fits you and your practice. Alligood (2006) presented guidelines for selecting a framework for theory- based nursing practice. Following are the steps:
1. Consider the values and beliefs in nursing that you truly hold. 2. Write a philosophy of nursing that clarifies your beliefs related to person,
environment, health, and nursing. 3. Survey definitions of person, environment, health, and nursing in nursing models. 4. Select two or three frameworks that best fit with your beliefs related to the
concepts of person, environment, health, and nursing. 5. Review the assumptions of the frameworks that you have selected. 6. Apply those frameworks in a selected area of nursing practice. 7. Compare the frameworks on client focus, nursing action, and client outcome. 8. Review the nursing literature written by persons who have used the frameworks. 9. Select a framework and develop its use in your nursing practice.
CRITICAL THINKING QUESTION
Think about the definitions of the metaparadigm concepts and the assumptions or propositions of each of the theories presented. Which of the theories most closely matches your beliefs?
Conclusion As demonstrated by the descriptions of the philosophies, conceptual models, and theories presented in this chapter, there is a wide variety of perspectives and frameworks from which to practice nursing. There is no one right or wrong answer. Various nursing theories represent different realities and address different aspects of nursing (Meleis, 2007). For this reason, the multiplicity of nursing theories presented in this chapter should not be viewed as competing theories but rather as complementary theories that can provide insight into different ways to describe, explain, and predict nursing concepts and/or prescribe nursing care. Curley (2007) describes this understanding in an interesting way by comparing the multiplicity of nursing theories to a collection of maps of the same region. Each map might display a different characteristic of the region, such as rainfall, topography, or air currents. Although all the maps are accurate, the best map for use depends on the information needed or the question being asked. This is precisely the case with the nurse’s choice of nursing theories for practice.
Begin with whichever theoretical framework seems to “fit,” and then practice using it as you provide nursing care. “The full realization of nursing theory–guided practice is perhaps the greatest challenge that nursing as a scholarly discipline has ever faced” (Cody, 2006, p. 119 ). Be patient; developing your nursing practice guided by nursing theory takes time and practice. All nursing theories require in-depth study over time to master them fully (this chapter provides only a brief introduction), but the incorporation of theory into your practice can transform your nursing practice. The end result of this process will be seen in the excellent nursing care that you can provide to patients over the course of your professional nursing career.
CASE STUDY 2-1 ▪ MR. M.
Mr. M. is a 34-year-old Caucasian male who presents to the mental health clinic with depression and complaints of fatigue. An interview reveals that his wife and both of his children were killed in a traffic accident 6 months ago. The nurse knows that Mr. M. is vulnerable as a result of the loss of his family but that self-transcendence is evoked through life events and that well-being can be enhanced by transforming losses and difficulties into healing experiences.
Case Study Questions
The nurse uses Reed’s Self-Transcendence Theory to focus nursing activity for Mr. M. on facilitating self-transcendence. Based on the assessment, what intrapersonal strategies might be appropriate?
Which interpersonal strategies might be appropriate during follow-up visits to facilitate connecting to others?
Classroom Activity 2-1
Divide into small groups and give each group a copy of the same case study. Assign a different nursing theory to each group and ask the groups to develop a plan of care using the assigned nursing theory as the basis for practice. Each group should share its plan of care with the class. Discuss the differences and similarities in the foci of care based on each of the selected theories.