1. Nursing and the Health Care System
Chapter 1
Nursing and the Health Care System
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

2. Lesson 1.1 Historical Context
Theory
Describe Florence Nightingale’s influence on nurses’ training.
Explain why nursing is both an art and a science.
Define evidence-based practice and explain why it is important in nursing.
Trace the growth of nursing in the United States from the Civil War to the present.
Clinical Practice
Write your own definition of nursing.
Discuss how the standards of practice for the LPN/LVN are applied in the clinical setting.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

3. Historical Overview: Nursing in England and Europe
With growth of Christianity, caring for sick became function of religious orders
Nurses under direction of priest-physicians
Christian St. Paul introduced deaconess named Phoebe, a practical nurse, to Rome
Nursing became recognized vocation during the Crusades (1100 to 1200 AD)
Illness was often believed to be caused by sin or the gods' displeasure.
After the break between King Henry VIII of England and the Catholic Church in the 1500s, care of the sick was left to the government.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

4. Florence Nightingale
In the mid-1800s, experienced a calling by God to become a nurse
Studied in Germany with a Protestant order of women who cared for the sick
Cleaned up the wards and improved ventilation, sanitation, and nutrition
Kept records and statistics that reinforced her theories of care
During the Crimean War, Florence Nightingale asked the Secretary of War to allow her to train women to care for the sick and wounded.
Lowered the death rate from 60% to 1%.
The Nightingale nurses made their rounds after dark with the aid of a lighted oil lamp. The lamp became the official symbol of nursing.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

5. Florence Nightingale (cont’d)
First Nightingale training school for nurses, in England at St. Thomas Hospital
Based her curriculum on the following beliefs:
Nutrition is important part of nursing care
Fresh, clean air is beneficial to the sick
Nurses should identify and meet patients’ needs
Nursing should be directed toward health and illness
Nursing distinct and separate from medicine and should be taught by nurses
Nurses need continuing education
Which of Florence Nightingale’s curriculum principles still apply today in the treatment of illness? All of them.
Modern nursing has gone to great lengths to distinguish itself from medicine. Each is a distinctly different profession, yet they are codependent for optimal patient outcomes.
Nightingale’s influence still exists in twenty-first century nursing practice. Her nursing school curriculum addressed many of the same things included in modern nursing education.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

6. Nursing in North America
The Union government appointed Dorothea Dix to organize women volunteers to provide nursing care for soldiers
Clara Barton took volunteers into the field hospitals to care for soldiers of both armies
Lillian Wald took nursing out into the community
Clara Barton founded the American Red Cross.
Who established the Henry Street Settlement Service in New York City? Mary Brewster
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

7. A Red Cross public health nurse poses with Model T Ford before setting out on rounds
Textbook figure 1-1
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

8. Nursing in North America
Ballard School
Started by New York Young Women's Christian Association (YWCA) in 1892
3-month course in practical nursing
Students trained to care for infants, children, and older adults in the home
Household Nursing School in Boston
Later called Shepard Gill School of Practical Nursing
The Shepard Gill School was established to train nurses to care for the sick at home.
A legacy left by Thomas Thompson allowed Richard Bradley, the executor of the will, to open a practical nursing school in Brattleboro, Vermont, in 1907.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

9. Some of the first African American nurses to serve with the U.S. Army
Textbook figure 1-2
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

10. Nursing in North America
Students staffed hospitals and worked long hours without pay
No formal classes
No formal curriculum
Education achieved through work
Instruction performed bedside by physician
Training in the Nightingale schools was well-organized, with classes held separately from practical experience. In the United States, training occurred bedside, with no formal classes or curriculum.
What are the advantages and/or disadvantages of teaching nursing classes from a standardized curriculum? All cover uniform content.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

11. Nursing in North America (cont’d)
In the 20th century, nurses:
Moved out into the community
Worked with the poor in the cities
Provided midwifery services, and taught prenatal, obstetric, and child care
Were present during wartime, providing essential care on all fronts
In World War I, nurses tended to the wounded and sick behind the front lines.
First African-American nurses serving in the U.S. Army paved the way for others to follow.
In World War II, demand for nurses to serve in military hospitals increased significantly.
Nurses continue to serve in times of military crisis, including Operation Iraqi Freedom.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

12. A group of nursing students during the 1930s or 1940s
Textbook figure 1-3
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

13. Nurses caring for patients on a hospital ship
Textbook figure 1-4
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

14. A nurse dispensing medication for a civilian patient in Iraq
Textbook figure 1-5
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

15. Common Goals of Nursing
To promote wellness
To prevent illness
To facilitate coping
To restore health
To accomplish these goals, the practical nurse takes on the role of caregiver, educator, collaborator, and manager.
The nurse’s goal is to encourage growth toward wellness so that the patient can once again be self-reliant.
What are interventions? Interventions are actions taken to improve, maintain, or restore health or prevent illness.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

16. Roles of the Practical Nurse
Caregiver
Implement interventions to improve, maintain, or restore health
Educator
Heath teaching and counseling to promote wellness, prevent illness
Collaborator
Work with RN and health care team to provide continuity of care
Advocate
Champion for the patient’s best interests
Manager
Assign minor tasks to nurse assistant or other ancillary personnel
Provide the highlights of the practical nurse’s various roles
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

17. Evidence-Based Nursing
Using the best research evidence to guide clinical decision-making
Helps determine “best practices”
The promotion of evidence-based nursing has become stronger around the world over the past decade.
Students are being taught the skills to discriminate between high-quality and flawed research and to interpret the study results.
What is used to establish the best practices? Evidence-based nursing is used to help determine “best practices.”
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

18. Question 1
Florence Nightingale’s beliefs are still the foundation of nursing today. She was responsible for:
founding the Ballard School of Practical Nursing.
the belief that continuing education is necessary for nurses.
apprenticeship training.
founding the American Red Cross.
Answer: 2
Rationale: Florence Nightingale believed in the value of education for nurses. She started the first school of nursing in England and encouraged nurses to continue their education after graduation.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

19. Question 2
The training in the Nightingale schools varied considerably from that of the U.S. nursing schools. Which statement is correct concerning the differences?
The Nightingale program was less organized.
Student nurses in the United States worked for minimum wage.
Curriculum in American nursing schools was more standardized.
Instruction was done at the bedside by a physician in the United States.
Answer: 4
Rationale: The training in the Nightingale schools was well-organized with classes held separately from practical experience. The United States held no formal classes and no set curriculum. Instruction was accomplished at the bedside by a physician and therefore came from a medical viewpoint.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

20. Lesson 1.2 Nursing Education and the Nursing Environment
Theory
Discuss the ways in which the desirable attributes of the nurse might be demonstrated.
Identify the educational ladder that is available to nurses.
Describe educational pathways open to the LPN/LVN after graduation.
Compare methods of delivery of nursing care.
List four practice settings in which LPNs/LVNs may find employment.
Discuss today’s health care system, its components, and changes proposed.
Explain how an HMO and a PPO differ.
Relate how the recent health care legislation has affected your own health care.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

21. Learning Objectives Clinical Practice
List the practice areas in the community in which you could be employed as a vocational nurse.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

22. Current Nursing Practice
Nurse practice acts
Established in each U.S. state and Canadian province
Regulate the practice of nursing
Designed to protect the public and define legal scope of practice
The nurse practice acts generally define activities in which nurses may engage, state the legal requirements and titles for nursing licensure, and establish the education needed for licensure.
What are the Standards of Nursing Practice? These contain 17 standards of national practice of nursing, describing all facets of nursing practice: who, what, when, where, and how. These standards for the professional RN protect the nurse, the patient, and the health care agency where nursing care is given.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

23. Nursing Process
Organized, deliberate, systematic way to deliver nursing care
Provides a way to implement caregiving
Combines science and art of nursing
Focuses nurse on the patient as an individual
The nursing process emerged during the 1970s and 1980s.
It is a circular process involving ongoing assessment.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

24. Nursing Education Pathways: Practical Nursing
Provide direct patient care under supervision of registered nurse, physician, or dentist
Offered in vocational schools, hospitals, proprietary schools, and community colleges
Practical nursing was created to fill a gap left by nurses who enlisted in the military services during World War II.
Practical or vocational nursing programs generally take months to complete.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

25. Nursing Education Pathways: Registered Nursing
Graduates of three different programs are qualified to take the NCLEX-PN Examination:
Hospital-based diploma program
2-year associate degree at community college
4-year baccalaureate nursing program at a college or university
RNs may provide bedside care or care in the community, or supervise others in managing care of multiple patients
What caused the ANA to propose that the baccalaureate degree be necessary for entry into professional nursing practice? The push toward professionalism, unification, and higher educational standards/consistencies for nursing has caused the ANA to propose that the baccalaureate degree be necessary for entry into professional nursing practice.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

26. Nursing Education Pathways: Advanced-Practice Nursing
Graduate programs for master's and doctorate degrees
Nurses prepared as specialists in various clinical branches of nursing, in research, or in administration
Nurse practitioner programs
RNs continue their training in a specialty
Nurse practitioners may specialize in family practice, pediatrics, maternity, psychiatry, adult health nursing, or geriatrics, and once licensed can practice more independently than as a registered nurse.
The ANA set up a separate American Nurses Credentialing Center to enhance the professional image of nursing.
From whom can a LVN/LPN receive a specialty certification? After completion of an LPN/LVN curriculum and/ or licensure, the graduate can seek certification by NAPNES in pharmacology, long-term care, and/or IV therapy.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

27. Delivery of Nursing Care: Functional Nursing Care
First care delivery system for the practical nurse
Practical nurses performed tasks, such as administration of medication and treatments
Under functional nursing care, care of the patient was rather fragmented.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

28. Delivery of Nursing Care: Team Nursing
Registered nurse was the team leader who coordinated care for a group of patients
Work tasks assigned to the other team members, practical nurses, and nurse’s aides
When did team nursing evolve? Team nursing evolved in the 1950s and extended into the mid-1970s.
Team nursing worked fairly well as long as there was excellent communication among the members and the team leader evaluated care delivered.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

29. Delivery of Nursing Care: Total Patient Care
One nurse carried out all nursing functions for the patient, including medication administration
To provide less fragmented care for the patient
Highlight the benefits and inefficiencies in this particular system of nursing care delivery
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

30. Delivery of Nursing Care: Primary Nursing
One nurse plans and directs care for a patient over a 24-hour period
Eliminated fragmentation of care between shifts
Often modified with use of cross-trained personnel assigned to help with duties
Appeared in the late 1960s and 1970s.
Because research is showing better patient outcomes with more of the care being delivered by nurses, there is a trend back to total patient care.
How is the productivity level increased with primary nursing? To increase the level of productivity, ancillary workers supervised by the RN are trained in multiple functions, such as clerical and housekeeping tasks, vital sign measurement, and phlebotomy.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

31. Practice Settings Hospitals Subacute and extended care facilities
Restorative care provided to ill or injured patients
Subacute and extended care facilities
Intermediate- or long-term care for rehabilitation or custodial care
Assisted-living facilities
Provide housekeeping, prepared meals, and some nursing care
Physicians’ offices
Ambulatory patients receive preventive care or treatment of illness or injury
The difference in practice setting provides patient contact with health care according to patient’s stage of wellness.
Often patients do not realize what level of care is needed and will use emergency rooms as non-urgent care resources.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

32. Practice Settings (cont’d)
Ambulatory clinics
Ambulatory patients come for preventive care or treatment of an illness or injury
Renal dialysis centers
Patients with kidney failure receive renal dialysis treatments
Hospice and palliative home care
Supportive treatment for patients who are terminally ill
Specialized facilities allow patient care at reduced rates by not having all patient treatment services.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

33. Practice Settings (cont’d)
Home health agencies
In-home care provided by nurses who visit the home
Neighborhood emergency center
Minor emergency care provided to patients within the community setting
Having care provided in the patient’s home or nearby emergency centers offers patients with limited transportation options care that may not be available otherwise.
Palliative care and long-term in-home care or support by home health agencies.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

34. Practice Settings (cont’d)
Correctional facilities
Physical exams, medication administration, and medical treatments
School nurse
Triage, medication administration, first aid, and limited care of students with diabetes
Surgical centers
Same day surgery on healthier individuals
Having care provided in the patient’s home or nearby emergency centers offers patients with limited transportation options care that may not be available otherwise.
Palliative care and long-term in-home care or support by home health agencies.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

35. Today’s Health Care System: Levels of Health Care
Preventive
Primary
Secondary
Tertiary
Restorative
Continuing care
Different levels of care also allow opportunities for the patient to receive care without the expense.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

36. Today’s Health Care System: Health Maintenance Organizations (HMOs)
Enroll patients for a set fee per month
Provide limited network of physicians, hospitals, and other providers from which to choose
One goal is to keep patients healthy and out of the hospital
What are the names of two national HMOs? Two national HMOs are Kaiser Permanente and US Family Health Plan.
Patients must be referred by their primary physician for diagnostic tests, hospitalization (including emergency room visits), and consultation with a specialist.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

37. Today’s Health Care System: Preferred Provider Organizations (PPOs)
Offer discount on fees in return for large pool of potential patients
Allow insurance companies to keep premium rates lower and make insurance coverage of employees less expensive for employers
There are usually a larger number of physicians to choose from in a PPO than in an HMO.
Who may contract with PPOs? Large businesses and insured groups may contract with preferred provider organizations (PPOs).
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

38. Today’s Health Care System: The Managed Care Environment
Considerable controversy about effectiveness of this approach
Nurses must constantly think about cost-containment while trying to give optimal care to patients
Documentation is exacting because every treatment and each use of equipment must be documented with evidence showing it is needed.
Why is vigilant assessment with documentation more important than ever? Vigilant assessment with documentation is more important than ever to catch beginning complications before they become serious.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

39. The Patient Protection and Affordable Care Act
Requirement for uninsured people to purchase health insurance are face penalty on income taxes
Provisions in the bill prevent denial of coverage based on pre-existing conditions and young adults are allowed to remain on their parents’ insurance through age 26
The national uninsured rate has fallen from 16% to 11%
Discuss some of the controversies of the bill highlighting the pros and cons
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

40. Question 3
Assisting a patient with daily hygiene needs is an example of a/an:
intervention.
invasive procedure.
standard of practice.
nursing goal.
Answer: 1
Rationale: Caregiving skills are interventions aimed at restoring and maintaining a person’s health. Interventions are actions taken to improve, maintain, or restore health or prevent illness.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

41. Question 4
As the role of the practical nurse expands, employment opportunities have increased as well. All of the following are appropriate practice settings for the LPN except:
a physician’s office.
home health agencies.
public health.
ambulatory clinics.
Answer: 3
Rationale: Practical nurses work in the areas where there is supervision by a registered nurse, physician, or dentist. Community nursing, school nursing, and public health nursing presently are primarily the arenas of the professional registered nurse.
Copyright © 2018, 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.