1. Chapter 1 Nursing Today Nursing is both an art and a science.
The science is based on a body of knowledge that is constantly changing and evolving.
The art is based on the practice of compassion, respect, and dignity rendered to the patient and family members alike.
Remember, even though the patient is the center of your care, the family, significant others, and community will have needs.
When rendering care, you will be guided by a code of ethics developed by the American Nurses Association and practiced by nurses.
As you begin your practice, you will incorporate ANA standards, evidence-based practice, and critical thinking skills.
As the weeks unfold, you will read further on these topic areas in:
Chapter 5: Evidence-Based Practice
Chapter 15: Critical Thinking in Nursing Practice

2. Historical Perspective Highlights
Nurses:
Respond to needs of patients
Actively participate in policy
Respond and adapt to challenges
Make clinical judgments and decisions about patients’ health care needs based on knowledge, experience, and standards of care
Nursing:
Care is provided according to standards of practice and a code of ethics.
•Nursing responds to the health care needs of society, which are influenced by economic, social, and cultural variables of a specific era.
Nurses exert great influence in social policy and political arenas. We have a strong organization (American Nurses Association) and strong lobbyists who propose legislation to care for our patients.
Through nursing research and evidenced-based practice (see Chapter 5), nurses have been able to carry on the traditions that Florence Nightingale began in the Crimean War. Florence dealt with battlefield conditions that gave rise to infection, illness, and mortality. The twenty-first century nurse deals with pain management, nutrition management, care of the elder population, and care of the infant and the underserved child.
As the health care system changes, the art, science, and practice of nursing continues to evolve. Nursing draws not only from science, but also from the humanities and social sciences. As nurses use and adapt this body of knowledge, nursing practice grows and evolves.
•Nursing definitions reflect changes in the practice of nursing and help bring about changes by identifying the domain of nursing practice and guiding research, practice, and education.

3. Development of a Profession
Nursing has struggled with its definition, its image, and its role in the healthcare delivery system
Due in part to its history
Fact that it has both theoretical and practical aspects
Role of the nurse in the healthcare delivery system has probably never been more important than it is today.

4. Historical Influences on the Development of Nursing
Healthcare in ancient cultures
Historic perspectives and early images of nursing
Folk image
Religious image
Servant image

5. The Beginning of Change
Early providers of nursing care
Sisters of charity in France and the United States
Sisters of the holy cross in France and the United States
Catholic religious orders in Mexico and South America
Ursuline sisters in Canada
Deaconesses at Kaiserwerth, Germany and Pittsburgh, Pennsylvania
Nursing sisters in England and Ireland

6. The Nightingale Influence
Dramatically changed the form and direction of nursing
Set standards for nursing education and made significant recommendations for changes in how hospitals operated and how nursing was practiced
Many of her recommendations are valid today
Wrote Notes on Nursing

7. Florence Nightingale’s Basic Principles of Nursing Education
Trained teaching hospitals are associated with medical schools
Nurses reside in nurses’ houses
School matron is final authority in:
Curriculum
Living arrangements
All aspects of the school
Education includes theoretical material and practical experience
Teachers are paid for instruction
Records are kept on students

8. Florence Nightingale First practicing epidemiologist
Organized first school of nursing
Improved sanitation in battlefield hospitals
Her practices remain a basic part of nursing today.
Florence Nightingale believed that the role of nurses was to help the body recover, and then remain free, from disease.
Nightingale was the first practicing epidemiologist. She used her keen mind and statistical analysis to show the connection between poor sanitation and diseases like cholera and dysentery.
In 1860, Florence organized the first school of nursing, the Nightingale Training School for Nurses, at St. Thomas’ Hospital in London.
Known as the Lady with the Lamp, Nightingale crossed the battlefields of the Crimean War with her lantern. By improving sanitation in battlefield hospitals, she showed how effective fresh air, hygiene, and nutrition were in the treatment of wounded soldiers.
The practices she advocated remain a basic part of nursing care in the twenty-first century.

9. Civil War to the Beginning of the Twentieth Century
The growth of nursing in the United States:
Clara Barton founded the American Red Cross.
Dorothea Lynde Dix
Mother Bickerdyke
Harriet Tubman
Mary Mahoney
Isabel Hampton Robb
Lillian Wald and Mary Brewster: Henry Street Settlement
The Civil War, fought from 1861 to 1865, made nursing a necessity. Clara Barton tended to soldiers on the battlefield.
Dorothea Lynde Dix was the supervisor of female nurses in the Union Army.
Mother Bickerdyke organized ambulance service, supervised nurses, and searched for abandoned, wounded soldiers on the battlefield.
Harriet Tubman was a prominent female in the Underground Railroad movement to free slaves.
Mary Mahoney was the first professionally educated African-American. She may be one of the first proponents of better relationships between cultures and races and respect for individuals regardless of background, race, color, or religion.
Isabel Hampton Robb helped found the American Nurses Association in She was an influential author with the following titles:
Nursing: Its Principles and Practice for Hospital and Private Use; Nursing Ethics; and Educational Standards for Nurses. She was one of the original founders of the American Journal of Nursing.
In 1893, nursing expanded in the community owing to the influence of Lillian Wald and Mary Brewster. Nurses working in the settlement they established were some of the first to demonstrate autonomy in practice because they frequently encountered situations that required quick and innovative problem solving and critical thinking without the supervision or direction of a health care provider.

10. The Establishment of Early Schools
Nursing services provided by most hospitals during the 1860s were disorganized and inadequate.
In 1869 the American Medical Association established a committee to study the issue of training for nurses.
The New England Hospital for Women and Children is often credited with being the first hospital to establish a formal 1 year program to train nurses in 1872.

11. Characteristics of the Early Schools
Primarily apprenticeships
Long hours during which students provided much of the workforce of the hospital with little time left for study
Job description 1887

12. The Twentieth Century
Movement toward scientific, research-based practice and defined body of knowledge
1901: Army Nurse Corps established
1906: Mary Adelaide Nutting, first professor of nursing at Columbia University
1908: Navy Nurse Corps established
: Study of nursing education
1940s and 1950s: Associations emerged
1970: Emergency Room Nurses Organization
A number of events began to shape nursing education in the twentieth century.
In 1901, the Army Nurse Corps was established, followed by the Navy Nurse Corps in 1908.
Under the influence of Mary Adelaide Nutting, nursing education moved into U.S. universities in the early twentieth century. In 1906, Nutting became the first professor of nursing at Columbia University Teachers College.
Another important development in nursing history occurred when the Rockefeller Foundation approached Nutting, along with Lillian Wald and Annie Goodrich, to study nursing education. Their study, conducted in 1920 and published in 1923, concluded that nursing education needed financial support and should be centered in university schools of nursing.
In the 1920s, nursing education continued to develop as specialty areas of nursing began to emerge. However, organizations supporting these areas would not develop until the 1940s and 1950s. These organizations include the Association of Operating Room Nurses, The American Association of Critical Care Nurses, and the Oncology Nursing Society. In 1970, the Emergency Room Nurses Organization was formed, which changed its name to Emergency Nurses Association in 1995.

13. Nursing Image Struggle with image Groups waging campaigns to:
Improve image
Attract individuals to profession
Critical issue because of nursing shortage
A positive image is needed to attract qualified individuals into the profession

14. The Twenty-First Century
Nursing code of ethics
Changes in curriculum
Nursing in multiple care settings
Advances in technology and informatics
End-of-life care
The American Nurses Association established the Center for Ethics and Human Rights in the 1990s. This center helps nurses at large address complex ethical and human rights issues.
In 2001, the code of ethics was revised to reflect current ethical issues that affect nursing practice. (See also Chapter 22, Ethics and Values.)
The nursing curriculum has continued to change to meet changing societal needs. Issues such as bioterrorism, emerging infections, disaster management, and technology advances were not included in the curriculum as late as 10 years ago.
Today, nurses work in multiple settings. Nurses also work in non–patient care environments to support the needs of nursing, nursing education, and patient care.
[Ask students in what other areas nurses can work and still support nursing, nursing education, and the patient? Answer: politics, lobbying groups, not-for-profit agencies]
The End-of-Life Nursing Education Consortium (ELNEC), offered collaboratively by the American Association of Colleges of Nursing (AACN) and the City of Hope Medical Center, has brought end-of-life care and practices into nursing curricula and professional continuing education programs for practicing nurses.

15. Influences on Nursing Changes in society lead to changes in nursing:
Health care reform
Demographic changes
Medically underserved
Threat of bioterrorism
Rising health care costs
Nursing shortage
[Demographics: What types of changes affect health care? Answers: people moving from rural to urban centers, increased life span, increase in patients living with chronic illnesses (we have better drugs and therapy available), increases in alcoholism and lung cancer (and other cancers)]
Nurses have always cared for patients inside and outside of the medical system. We promote the rights of minorities, immigrants, the underinsured, and the uninsured to receive high-quality health care. The rising rates of unemployment, mental illness, and homelessness make our advocacy more important than ever. Nurses can be proud that they created bills of rights for dying, hospitalized, and pregnant patients.
To prepare for the threat of terrorism, the nursing curriculum and health care agencies are training future and practicing nurses to deal with nuclear, chemical, and biological events.
As a nurse, you are responsible for providing the patient with the best-quality care in an efficient and economically sound manner.
The nursing shortage affects all aspects of nursing such as patient care, administration, and nursing education, but it also presents challenges and opportunities for the profession.
[What other factors have influenced nursing? Discuss technology, consumerism, health promotion, and the effects of the women’s and human rights movements on nursing.]

16. Nursing as a Profession
A profession has characteristics:
Requires an extended education
Requires a body of knowledge
Provides a specific service
Has autonomy
Incorporates a code of ethics
No one factor absolutely differentiates a job from a profession, but the difference is important in terms of how you practice. To act professionally, you administer quality patient-centered care in a safe, conscientious, and knowledgeable manner.
Nursing is a profession because we share the characteristics of a profession.
You will be educated and trained to care for others. You will be required to take college/university courses to complete general education requirements.
You will use a theoretical body of knowledge that guides you to develop skills and define your abilities and practice according to a clear set of norms.
You will be providing a service to others.
You will have autonomy in decision making and practice.
A code of ethics will guide your practice.
Your skills, the body of knowledge you will have mastered, the norms you will adhere to, and the service you provide will make you a member of a profession.

17. Scope and Standards of Practice
Nursing: Scope and Standards of Practice
1960: Documentation began
Standards of Practice
Standards of Professional Performance
Goal
To improve the health and well-being of all individuals, communities, and populations through the significant and visible contributions of registered nursing using standards-based practice
Since 1960, the ANA has been documenting the scope of nursing and developing Standards of Practice.
[Discuss Box 1-1, ANA Standards of Nursing Practice (p. 4 of the text).]
Within this document are the Standards of Practice and the Standards of Professional Performance.

18. Standards of Practice
Nursing standards provide the guidelines for implementing and evaluating nursing care.
Six standards of practice:
Assessment
Diagnosis
Outcomes identification
Planning
Implementation
Evaluation
These Standards of Practice are also referred to as nursing process, and are discussed further in Chapters 16 through 20. [Discuss each.]
[Refer students to Box 1-1 for more info (p. 4 of the text).]
These Standards of Care, the nursing process, will guide the care you render to your patients in all health care facilities.
Implementation includes coordination of care, health teaching and health promotion, consultation, and prescriptive authority and treatment.

19. Standards of Professional Performance
Ethics
Quality of Practice
Professional Practice Evaluation
Education
Communication
Resources
Evidence-Based Practice and Research
Leadership
Environmental Health
Collaboration
The ANA has identified 10 Standards of Professional Performance. [Refer students to Box 1-2 (on p. 5 of the text).]
These standards serve as objective guidelines for nurses to follow. They help nurses be accountable for their actions, their patients, and their peers.

20. Code of Ethics
A code of ethics is the philosophical ideals of right and wrong that define principles used to provide care.
It is important for you to incorporate your own values and ethics into your practice.
Ask yourself: How do your ethics, values, and practice compare with established standards?
The last component of what makes nursing a profession is our code of ethics.
It will be important to incorporate the ANA code of ethics, as well as your personal values and ethics, into your nursing practice. [Advise students that this topic is discussed further in Chapter 22, Ethics and Values.]

21. Quick Quiz!
1. Nursing is defined as a profession because nurses A. Perform specific skills. B. Practice autonomy. C. Utilize knowledge from the medical discipline. D. Charge a fee for services rendered.
Answer: B

22. Programs that Prepare Graduates for RN Licensure
Three major avenues to preparation for licensure as a registered nurse exist in the United States:
Diploma or hospital-based diploma
Associate degree
College-based baccalaureate degree
Master’s and doctoral prelicensure programs
Nontraditional prelicensure programs

23. Nursing Practice Nurses practice in a variety of settings. Nurses:
Protect, promote, and optimize our patients’ health
Prevent illness and injury
Alleviate suffering through the diagnosis and treatment of human responses
Advocate for the care of our patients
Various state and provincial Nurse Practice Acts establish legal regulations for practice in a specified area, and professional organizations establish Standards of Practice.
The American Nurses Association is concerned with legal aspects of nursing practice, public recognition of the significance of nursing practice to health care, and implications for nursing practice generated by trends in health care. (The ANA definition of nursing is summarized on the slide.)
Compare and discuss the ANA and ICN definitions of nursing:
The American Nurses Association (ANA) definition of nursing: The protection, promotion, and optimization of health and abilities; prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, communities, and populations.
The International Council of Nurses (ICN) definition: Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups, and communities, sick or well and in all settings. Nursing includes promotion of health; prevention of illness; and the care of ill, disabled, and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.

24. Nursing Practice Nurse Practice Acts Licensure and certification
Science and art of nursing practice
Benner’s stages of nursing proficiency:
Novice
Advanced beginner
Competent
Proficient
Expert
In the United States, individual State Boards of Nursing oversee Nurse Practice Acts. The Nurse Practice Acts regulate the scope of nursing practice and protect public health, safety, and welfare. They also specify the training needed for nurse practitioners and other advanced practice professionals.
Licensure: RN candidates must pass the NCLEX-RN, a standardized examination for all candidates.
Certification: Minimal practice requirements are set, based on the certification the nurse is seeking. Common certification is for medical-surgical nurse, diabetic nurse educator, gerontological nurse, and many more.
You will begin to learn how to develop your critical thinking abilities and your ability to practice autonomously. You will gradually acquire clinical expertise.
Patricia Benner has done extensive work on the development of proficiency of nurses. (See Box 1-3 on p. 6 of the text.)
Novice: Beginning nursing student or any nurse entering a situation in which there is no previous level of experience.
Advanced Beginner: A nurse who has had some level of experience with the situation.
Competent: A nurse who has been in the same clinical position for 2 to 3 years.
Proficient: A nurse with more than 2 to 3 years of experience in the same clinical position.
Expert: A nurse with diverse experience who has an intuitive grasp of an existing or potential clinical problem.

25. Professional Responsibilities
Nurses are responsible for obtaining and maintaining specific knowledge and skills.
In the past:
To provide care and comfort
Now:
To provide care and comfort and to emphasize health promotion and illness prevention
As health care changes, the nursing profession must also change to meet the needs of an increasingly complex patient population.
To meet these needs, nurses must demonstrate their ability to be autonomous and accountable.

26. Autonomy and Accountability
Professional Roles
Autonomy and Accountability
Caregiver
Advocate
Educator
Communicator
Manager
Autonomy is an essential element of professional nursing that involves the initiation of independent nursing interventions without medical orders.
Caregiver: Nurses help their patients regain health and find their maximum level of independent function through the healing process. Healing involves the body, mind, and spirit. [See Chapter 35 for more information on spiritual health.]
Advocate: Nurses protect the human and legal rights of their patients and help patients assert those rights when needed. [See Chapter 9 for more information on cultural and ethnic issues.]
Educator: Your teaching can be formal or informal and will involve the patient, family, significant other, or other support systems. [Chapter 25 reviews Patient Education.]
Communicator: [See Chapter 24.] You know that communication is central to the nurse-patient relationship. Again, it is important to develop a communication style for use with patients and members of their support system, as well as a style for communicating with other members of the health care team.
Manager: As a manager, you will collaborate with others to help your patients meet their established outcomes and will evaluate the manner in which care is administered. As a manager of care, you will evaluate staff nurses to determine whether they meet professional and health care facility standards.

27. Career Development
Nursing provides an opportunity for you to commit to lifelong learning and career development.
{Fig 1-2 here}
Ask students to discuss career opportunities available to them.
Some answers may include:
•Staff nurse in med-surg, OR, PACU, ED, Short Stay unit, ICU, CCU, TCU, OB, PEDS, or L&D, or in an outpatient setting.
•Advanced practice nurse: Requires additional education and experience. APNs can be nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, or nurse midwives.
•Nurse educator: Requires additional education and experience.
•Nurse administrator: Requires additional education and experience.
•Nurse researcher
[Photo is on p. 8 of the text.]

28. Professional Nursing Organizations
National League for Nursing (NLN)
American Nurses Association (ANA)
International Council of Nursing (ICN)
National Student Nurses Association (NSNA) or Canadian Student Nurses Association (CSNA)
Other professional organizations focus on specific areas.
Professional nursing organizations deal with issues of concern to specialist groups within the nursing profession.
The NLN sets standards for excellence and innovation in nursing education.
The purpose of the ANA is to improve standards of health and the availability of health care to foster high standards for nursing and to improve the professional development and general and economic welfare of nurses.
The ANA is part of the ICN. The objectives of the ICN are parallel to those of the ANA: To promote national association of nurses, improve standards of nursing practice, and seek a higher status for nurses by providing an international power base for nurses.
The NSNA considers issues of importance to nursing students, such as career development and preparation for licensure.
Some professional organizations focus on specific areas such as critical care, nursing administration, nursing research, or nurse midwifery.

29. Quick Quiz!
2. The NLN and the ANA are professional organizations that deal with A. Nursing issues of concern. B. Political and professional issues affecting health care. C. Financial issues affecting health care. D. All of the above issues.
Answer: D

30. Forces for Change in Nursing Education
Incorporation of computer technology in nursing education
Computer technology in the classroom
Computers in the hospital environment
Distance learning options
Establishment of programs that provide for educational mobility
Increase in community-based practice experiences
Increase in emphasis on research
Education supporting evidence-based practice

31. Additional Nursing Trends
Genomics
Public perception of nursing
Impact of nursing on politics and health policy
Future trends
The nursing profession will continue to evolve and grow, and so must individual nurses.
How has genomics affected nursing? [Discuss the impact of gene research on nursing practice.]
Today great emphasis is placed on nurses and nursing. We are highlighted, as in TV ads by the Johnson and Johnson Foundation campaign to draw individuals into the profession. [Ask students: How will this publicity affect your role?]
Nurses are becoming more politically sophisticated and, as a result, are able to increase the influence of nursing on health care policy and practice.
What other trends do you anticipate? [Discuss.]

32. The Health Care Delivery System
Chapter 2
The Health Care Delivery System
Nursing is constantly evolving and changing. This change is driven by the U.S. health care system, which is very complex and is changing.

33. Challenges to Health Care
Reducing health care costs while maintaining high-quality care for patients
Improving access and coverage for more people
Encouraging healthy behaviors
Earlier hospital discharges result in more patients needing nursing homes or home care.
To meet these changing conditions, organizations must run as businesses. Technology, new medications, and shortened lengths of stay increase the cost of doing business.
The health care system is faced with rising costs, increased access to services, growing populations, improved quality outcomes, and threats of bioterrorism.
Nurses face major challenges to prevent gaps in health care across health care settings, so individuals remain healthy and well within their own homes and communities.

34. Emphasis on Population Wellness
Health Services Pyramid
Managing health instead of illness
Emphasis on wellness
Injury prevention programs
{Fig 2-1 here}
The Core Functions Project developed the Health Services Pyramid.
The shift from managing illness to managing health includes an emphasis on wellness, and the environment has enhanced quality of life.
The emphasis has led to improvements in water, sewage, immunizations, and living conditions. Patient teaching has promoted better diet habits, decreased tobacco use, and improved blood pressure control. Injury prevention programs advocating seatbelt use, child seats, restraints, and helmet laws have enhanced quality of life and decreased mortality rates.
[See Box 2-1 (on text p. 17) for common health care definitions that should help students begin to integrate terminology.]
[Figure is on text p. 17.]

35. National Priorities Partnership
Patient and family engagement
Population health
Safety/eliminating errors as possible
Care coordination
Palliative care for advanced illnesses
Overuse/reducing waste
How is health care changing? One example can be seen in the National Priorities Partnership, a group of 28 organizations from a variety of health care disciplines that have joined together to work toward transforming health care.
They bring an increased focus on wellness and prevention, working through a six-part approach.

36. Institute of Medicine (IOM)
Nurses need to be transformed by:
Practicing to the full extent of their education and training
Achieving higher levels of education and training through an improved education system that provides seamless progression
Becoming full partners, with physicians and other providers, in redesigning the health care system
Improving data collection and the information infrastructure for effective workforce planning and policy making
Nursing is a caring profession with a set of ethics, values, and standards.
Nurses will change with the times; however, nurses will always keep patient needs first as they are challenged with new roles and responsibilities.
[What are some ways you can see yourself implementing the IOM recommendations?]

37. Case Study
Amy Sue Reilly is a 15-year-old white female of Irish descent. She is a freshman at a Catholic high school. Although her parents are divorced, Amy Sue reports that her family (she has two brothers and lives with her mother) is very close, and that her parents work together to meet all their children’s needs.
Amy Sue has had asthma since she was 5 years old. She has been able to control her asthma by taking oral medications and by using inhalers when needed.
What concerns would you have if you were Amy Sue’s school nurse about Amy Sue getting the medical care she needs? [Discuss transferring medication to and from school, keeping her inhalers with her when she visits her dad, acclimating to a new routine in high school, etc.]

38. Health Care Regulation and Competition
Regulatory and competitive approaches
Professional standards review organizations (PSROs)
Created to review the quality, quantity, and cost of hospital care provided through Medicare and Medicaid
Utilization review committees (URs)
Review admissions, diagnostic testing, and treatments provided by physicians who cared for patients receiving Medicare
As health care costs have risen out of control, regulatory and competitive approaches have had to control health care spending.
PSROs (created by the federal government) and URs are two outgrowths of the attempt to control cost.
Many hospitals have added nursing case managers to meet the guidelines established by Medicare, Medicaid, and other payers.

39. Health Care Regulation and Competition (cont’d)
Prospective payment system (PPS)
Diagnosis-related groups (DRGs)
Capitation
Resource utilization groups (RUGs)
Profitability
Managed care
The prospective payment system was established in 1983 to eliminate cost-based reimbursement.
Each DRG has a fixed reimbursement amount with adjustments.
Health care facilities (hospitals) began to receive a specific dollar amount instead of basing their fees on cost.
Capitation is the payment mechanism by which providers receive a fixed amount per patient or enrollee of a health care plan.
Resource utilization groups are utilized in long-term care settings.
In all settings, health care providers try to manage costs so the organizations remain profitable.
Managed care describes the health care system that provides administrative control over primary care services for a defined patient population.

40. Health Care Regulation and Competition (cont’d)
Patient Protection and Affordable Care Act
Access to health care for all
Reducing costs
Improving quality
Provisions include
Insurance industry reforms
Increased funding for community health centers
Increased primary care services
Improved coverage for children
The Patient Protection and Affordable Care Act, passed in 2010, focuses on major goals.
As a professional registered nurse, it will be important for you to understand the basics of health care, so you can assist your patients and be an advocate for them.
Table 2-1 presents examples of health care plans.

41. Health Care Settings and Services
1. Preventive
2. Primary
3. Secondary
4. Tertiary
5. Restorative
6. Continuing
[Lead a discussion on what level or type of care is offered in each of these health care settings.]
Larger health care systems have integrated delivery networks (IDNs) that include a set of providers and services organized to deliver a continuum of care to a population of patients at a capitated cost in a particular setting.
Nurses are especially important as patient advocates in maintaining continuity of care throughout the levels of care.

42. Health Care Accreditation/ Certification
Reasons:
To demonstrate quality and safety
To evaluate performance, identify problems, and develop solutions
Accreditation earned by the entire organization
Specific programs or services within an organization earn certifications.
The Joint Commission and others
The Joint Commission (formerly The Joint Commission on Accreditation of Healthcare Organizations) accredits health care organizations across the continuum of care, including hospitals and ambulatory care, long-term care, home care, and behavioral health agencies.
Other accrediting agencies have a specific focus, such as the Commission on Accreditation of Rehabilitation Facilities (CARF) and the Community Health Accrediting Program (CHAP).

43. Preventive and Primary Health Care
Preventive Care
Primary care
Focuses on improved health outcomes for an entire population
Requires collaboration among health professionals, health care leaders, and community members
Health promotion lowers overall costs:
Reduces incidence of disease
Minimizes complications
Reduces the need for more expensive resources
Occurs in home, work, and community settings
Preventive care focuses on reducing and controlling risk factors for disease through activities such as occupational health programs.
[Ask the class for some examples of primary care. Discuss health education, proper nutrition, maternal/child health care, family planning, immunizations, and control of diseases.]
Table 2-2 presents examples of preventive and primary care services.

44. Secondary and Tertiary Care
Also called acute care
Focus: Diagnosis and treatment of disease
Disease management is the most common and expensive service of the health care delivery system.
20% require 80% of health care spending.
Fastest growing age group of uninsured?
Postponement of care by uninsured
Disease management is the most common and expensive service of a health care delivery system.
The acutely and chronically ill represent 20% of all people in the United States and consume 80% of health care spending.
What age group is the fastest growing of the uninsured? [Ask students if they know.] Young adults: 19 to 29 years old. Why? College years, leaving home, first time in the job market, and may be without health insurance.
People who do not have health care insurance often wait longer before presenting for treatment; thus they are usually sicker and need more complex health care. As a result, secondary care and tertiary care (also called acute care) are more costly.

45. Secondary and Tertiary Care (cont’d)
Settings
Resource efficiency, word redesign
Discharge planning—nurses’ role
Hospitals
Intensive Care Units
Rural Hospitals
Psychiatric Care
Hospital emergency departments, urgent care centers, critical care units, and inpatient medical-surgical units provide secondary and tertiary levels of care.
Because of work redesign, more services are available on nursing units, thus minimizing the need to transfer and transport patients across multiple diagnostic and treatment settings.
Discharge planning is a centralized, coordinated, multidisciplinary process that ensures that the patient has a plan for continuing care after leaving a health care agency. [What are some ways that nurses help with discharge planning? Discuss.]
An ICU is the most expensive health care delivery site because each nurse usually cares for only one or two patients at a time, and because patients in the ICU require complex treatments and procedures.
Patients who suffer emotional and behavioral problems such as depression, violent behavior, and eating disorders often require special counseling and treatment in psychiatric facilities.
The Balanced Budget Act of 1997 changed the designation for rural hospitals to critical access hospital (CAHs) if certain criteria were met. The CAH provides inpatient care to acutely ill or injured people before transferring them to better-equipped facilities.

46. Restorative Care
Serves patients recovering from an acute or chronic illness/disability
Helps individuals regain maximal function and enhance quality of life
Promotes patient independence and self-care abilities
Requires multidisciplinary approach
Settings:
Discharge planning and case management are equally important with restorative care as with acute care.
The intensity of care has increased in restorative care settings because patients leave hospitals earlier.
Patients and families are more likely to follow treatment plans and achieve optimal functioning when they are involved in restorative care.
Home Care
Rehabilitation
Extended Care

47. Restorative Care: Home Care
Provision of medically related professional and paraprofessional services and equipment to patients and families in their homes for health maintenance, education, illness prevention, diagnosis and treatment of disease, palliation, and rehabilitation
Involves coordination of services
Focuses on patient and family independence
Usually reimbursed by government (such as Medicare and Medicaid in the United States), private insurance, and private pay sources
[Ask students to name services commonly provided by home health nurses. Wound care, respiratory care, vital signs monitoring, elimination needs (ostomy, skin care, irrigation, insertion of catheters, peritoneal dialysis), nutrition, rehabilitation, medication administration and education, IV therapy, and laboratory studies]
Nursing is one service most patients use in home care. However, home care also includes medical and social services; physical, occupational, speech, and respiratory therapy; and nutritional therapy.
Most important, nurses need to be aware of other areas that directly affect home health care.
[Ask students: What other knowledge is needed when you walk into a patient’s home to render care? Mention cultural practices, family dynamics, communication principles, and spiritual values.]

48. Restorative Care: Rehabilitation
Focus: To restore patients to their fullest physical, mental, social, vocational, and economic potential
Includes physical, occupational, and speech therapy, as well as social services
Occurs in many health care settings, both inpatient and outpatient
[Ask students in which settings rehabilitation occurs? Hospitals, rehabilitation centers, outpatient settings, home]
[What types of patients require rehabilitation? Stroke, spinal cord injury, sports injuries, cardiac events]
Most important, patients and families need to learn to adapt to injury and illness

49. Restorative Care: Extended Care
Extended care facility
Provides intermediate medical, nursing, or custodial care for patients recovering from acute illness or disabilities
Skilled nursing facility (intermediate care)
Provides care for patients until they can return to their community or residential care location
Discuss how extended care facilities differ from skilled nursing facilities.
Extended care used to be available primarily for older adults, but because hospitals discharge their patients sooner, the need for intermediate care settings for patients of all ages has increased.

50. Continuing Care
For people who are disabled, functionally dependent, or suffering a terminal disease
Available within institutional settings or in the home:
Nursing Centers or Facilities
Assisted Living
Respite Care
Adult Day Care Centers
Hospice
The need for continuing care is increasing because people are living longer.
Many of these people do not have family or others to care for them.

51. Continuing Care: Nursing Centers or Facilities
Provide 24-hour intermediate and custodial care
Nursing, rehabilitation, diet, social, recreational, and religious services
Residents of any age with chronic or debilitating illness
Regulated by standards: Omnibus Budget Reconciliation Act of 1987
Interdisciplinary functional assessment is the focus of clinical practice: MDS, RAIs
Residence can be temporary or permanent.
According to the U.S. Census Bureau, 5% of those over 65 years of age live in nursing centers or other facilities.
Nursing facilities succeed when they recognize residents as active participants and decision makers in their care and life in institutional settings.
Staff must complete the Resident Assessment Instrument (RAI) on all residents. The RAI consists of the Minimum Dataset (MDS), Resident Assessment Protocols, and utilization guidelines of each state.
Box 2-2 (on text p. 21) lists major regulatory requirements defined by OBRA [Discuss.]
Box 2-3 (on text p. 21) describes the minimum data set and resident assessment protocols. [Discuss.]

52. Continuing Care: Assisted Living
—Offers a long-term care setting with a home environment and greater resident autonomy
—Provides services such as laundry, assistance with meals, personal care, housekeeping, and 24-hour oversight
—Allows residents to live in their own units
As one of the fastest growing industries within the United States, assisted living offers privacy, independence, and security.
Some facilities provide assistance with medication administration, although nursing care services are not available directly.
However, this industry has little regulation, no fee cap. It may not be the most financially sound plan for some individuals.
[Photo is on text p. 22.]

53. Respite Care
The service provides short-term relief or “time off” for persons providing home care to an ill, disabled, or frail older adult.
Settings include home, day care, or health care institution with overnight care.
Trained volunteers allow family caregivers to leave the home for errands or social time.
The family caregiver usually not only has the responsibility for providing care to a loved one but often has to maintain a full-time job, raise a family, and manage the routines of daily living as well.

54. Quick Quiz!
1. A patient who needs nursing and rehabilitation following a stroke would most benefit from receiving care at a A. Primary care center. B. Restorative care setting. C. Assisted-living center. D. Respite center.
Answer: B

55. Adult Day Care Centers
Provide a variety of health and social services to specific patient populations who live alone or with family in the community
May be associated with a hospital or nursing home or may operate independently
Offer services to patients such as daily physical rehabilitation and counseling
Adult day care centers allow patients to retain more independence by living at home, which reduces costs of health care.
Nurses working in day care centers provide continuity between care delivered in the home and that provided by the center.

56. Hospice
Family-centered care that allows patients to live and remain at home
Focuses on palliative (not curative) care: comfort, independence, and dignity
Provides patient and family support during terminal illness and time of death
Many hospice programs provide respite care, which is important in maintaining the health of the primary caregiver and family.
Hospice care can be provided at home, within a homelike setting, or within the hospital setting.

57. Case Study (cont’d)
Recently, Amy Sue has had some difficulty breathing, especially during gym class.
Corrine is a 45-year-old African American nurse, who recently accepted a job as a school nurse for the four Catholic schools in the area. Three of the schools are grade schools, and one is Amy Sue’s high school. Before she took this job, Corrine worked at a pediatrician’s office.
How will Corrine’s work experience help her help Amy Sue to access the health care delivery system?
What barriers to care might they face as a team?

58. Issues in Health Care Delivery
Nursing shortage
Competency
Evidence-based practice
Quality and safety in health care/ Patient-centered care
Health care organizations are being evaluated on the basis of outcomes such as prevention of complications, patients’ functional outcomes, and patient satisfaction.
In spite of the large number of practicing nurses, a critical shortage of nurses is projected in the United States.
Box 2-4 (on text p. 23) presents the IOM’s competencies for the twenty-first century. The health care practitioner competencies are an excellent tool for measuring how well a nurse practices nursing and can serve as a guide for the development of a professional nursing career.
Evidence-based practice involves the conscientious use of current best evidence, along with clinical expertise and patient preferences and values in making decisions about patient care. [See Box 2-6 on text p. 24: Nursing Work Environment and Patient Safety.]
Health care providers define the quality of their services by measuring health care outcomes. Ten rules of performance in a redesigned health care system are shown in Box 2-5 (on text p. 23).
Pay for performance programs and public reporting of hospital quality data are designed to promote quality, effective, safe patient care.
Box 2-7 (on text p. 25) reviews Dimensions of Patient-Centered Care. [Discuss.] By learning early what a patient expects with regard to information, comfort, and availability of family and friends, nurses are able to better plan patient care.

59. Issues in Health Care Delivery (cont’d)
Magnet Recognition Program
Nursing-sensitive outcomes
Nursing informatics and technological advancements
Globalization of health care
The American Nurses Credentialing Center (ANCC) established the Magnet Recognition Program to recognize health care organizations that achieve excellence in nursing practice. [See Boxes 2-8, Magnet Model and Forces of Magnetism, and 2-9, Nursing Quality Indicators (both on text p. 26).]
Nursing informatics uses information and technology to communicate, manage knowledge, mitigate error, and support decision making.
Nurses gain or use information when they organize, structure, or interpret data. Knowledge develops when nurses combine and identify relationships between different pieces of information.
Technological advancements influence where and how nurses provide care to patients and can help nurses improve direct care processes, patient outcomes, and work environments. [Ask students what they think of recent technological advancements—do they help or hinder the nurse’s effectiveness?]
Globalization, the increasing connectedness of the world’s economy, culture, and technology, is one of the forces reshaping the health care delivery system.
Children, women, and older adults are vulnerable populations most threatened by urbanization.

60. Case Study (cont’d)
Amy Sue’s difficulty managing her asthma is significant for Corrine because Corrine’s oldest daughter has asthma.
In addition, because of her job in the pediatrician’s office, Corrine has had experience with caring for children with asthma and with helping patients access the health care delivery system.
The American Nurses Credentialing Center (ANCC) established the Magnet Recognition Program to recognize health care organizations that achieve excellence in nursing practice. [See Boxes 2-8, Magnet model and forces of magnetism, and 2-9 (both on text p. 26), Nursing Quality Indicators.]
Nursing informatics uses information and technology to communicate, manage knowledge, mitigate error, and support decision-making.
Nurses gain or use information when they organize, structure, or interpret data. Knowledge develops when nurses combine and identify relationships between different pieces of information.
Technological advancements influence where and how nurses provide care to patients and can help nurses improve direct care processes, patient outcomes, and work environments. [Ask students what they think of recent technological advancements—do they help or hinder the nurse’s effectiveness?]
Globalization—the increasing connectedness of the world’s economy, culture, and technology—is one of the forces reshaping the health care delivery system.
Children, women, and older adults are vulnerable populations most threatened by urbanization.

61. Quick Quiz!
2. Technological advances in health care A. Make the nurse’s job easier. B. Depersonalize bedside patient care. C. Threaten the integrity of the health care industry. D. Do not replace sound personal judgment.
Answer: D

62. The Future of Health Care
Change opens up opportunities for improvement.
Health care delivery systems need to address the needs of the uninsured and the underserved.
Health care organizations are striving to become better prepared to deal with these and other challenges in health care.
The solutions necessary to improve the quality of health care depend largely on the active participation of nurses.
[Discuss: Is health care in the United States better or worse than that in other industrialized nations?]
Nurses need to remain knowledgeable and proactive about issues in the health care delivery system to provide quality patient care and positively affect health.

63. Community-Based Nursing Practice
Chapter 3
Community-Based Nursing Practice
Community-based health care is a collaborative, evidence-based model designed to meet the health care needs of the community.

64. New Stimulus for Community-Based Nursing Practice
Because patients spend less time in acute care settings, there is a growing need to have organized health care services where the population lives, works, and learns.
As community health care partnerships develop, nursing is in a strategic position to play an important role in health care delivery and to improve the health of the community.
Changes in health care financing move patients more quickly to the community setting.

65. Focus of Community-Based Nursing
Health Promotion
Disease Prevention
Restorative Care
Patients are moving from acute health care and hospital-based settings to community-based settings that focus on health promotion, disease prevention, and restorative care.
A healthy community includes elements that maintain a high quality of life and productivity, such as safety and access to health care services.
Focus on health promotion and disease prevention is essential for the holistic practice of professional nursing.

66. Community-Based Health Care
A model of care to reach all in a community
Focuses on assisting individuals and communities with achieving a healthy living environment
Occurs outside of traditional health care facilities
Provides services for acute and chronic conditions
Community-based health care focuses on
Primary rather than institutional or acute care
Providing knowledge about health and health promotion and models of care to the community

67. Challenges Public health problems influenced by:
Social lifestyles
Political policy
Economic initiatives
Current medical and social problems
What are some problems that health care providers face in communities? [Discuss. Include:
Increases in homelessness
Increases in immigrants
Increases in STIs
Underimmunized infants and children
Chronic and/or life-threatening diseases such as HIV and emerging infections]

68. Achieving Healthy Populations and Communities
Healthy People Initiative (by USDHHS)
Establishes ongoing health care goals
Healthy People 2020
Goals are to increase life expectancy and quality of life, and to eliminate health disparities through improved delivery of health care services
U.S. Dept of Health and Human Services Public Health Service designed the Healthy People Initiative.
Nursing is a profession, and as professionals we are in a position to set and influence policy. Health professionals can provide leadership in developing public policies to support health care for the U.S. population.

69. Improved Delivery of Health Care
Improved delivery of health care occurs through
1. Assessment of health care needs of individuals, families, and communities
2. Development and implementation of public health policies
3. Improved access to care
Improved access to care ensures that essential community-wide health services are available and accessible for the total community.

70. Assessment Examples: Examples of program results:
Systematic data collection (such as
incident rates) on the population
Monitoring the health status of the population
Accessing available information about the health of the community
Examples of program results:
Adolescent smoking prevention
Sex education
Proper nutrition
Gathering information on incident rates for identifying or reporting new infections or diseases is an example of data collection.

71. Public Health Policy Development + Implementation
Health professionals provide leadership in
Developing public policies to support the health of a population
Strong policies are driven by community assessment:
Example: Assessment of level of lead poisoning in young children
Example: Assessment of the number of people in the community who need end-of-life care
[Ask the class: What other examples of community assessment can drive development of strong public policy?]
Box 3-1 (on text p. 32) describes management of chronic leg ulcers in a community setting as an example of evidence-based practice.

72. Improved Access to Care
Ensures that community-wide health services are
Available to the total community
Accessible to the total community
Example: Five-level Health Services Pyramid
Role of community services near acute care services
Healthy environments
[Ask the class: What are some examples of programs that meet the goals of disease prevention, health protection, and health promotion? Discuss.]
[Ask the class: What is the difference between availability and accessibility? Discuss.]
The five-level Health Services Pyramid (from Chapter 2) is an example of how to provide community-based services within existing health care services in a community.
Community services complement acute care services. [Discuss.]
[Discuss healthy work versus home environments.]

73. Case Study
Kim Callahan is a student in a community health nursing course. She is working in a community nursing service within a large city. Most of the patients in this agency are Bosnian immigrants.
A major care initiative in this agency is to provide well-child examinations and immunizations to get children ready to enter the public school system.
[Ask the class: What are some challenges that Kim may face?]
[Ask the class: What goal/s would Kim want to set?]

74. Community Health Nursing
Nursing practice in the community
Primary focus is on health care of individuals, families, and groups.
Similar to public health nursing
Requires
Understanding the needs of a population
A set of skills and knowledge
Community health nursing and public health nursing are used interchangeably, and they have similarities.
Public health nursing requires an understanding of the needs of a population or a collection of individuals who have common characteristics.
[Ask students to identify characteristics of subpopulations. High-risk populations, older adults, cultural groups]
A public health nurse needs to understand factors that influence health promotion and health maintenance, trends and patterns that influence incidence of disease, political processes that affect public policy, and environmental factors that contribute to health and illness.

75. Community Health Nursing (cont’d)
Essential public health functions:
Community assessment
Policy development
Access to resources
Goal is to preserve, protect, promote, or maintain health.
Provides direct care services to subpopulations in a community
Competencies needed
The emphasis of nursing care is on improving the quality of health and life within the community.
[Discuss examples of direct care services to subpopulations, such as following older adults recovering from stroke or providing immunizations.]
Competence requires the nurse’s ability to use interventions that include broad social and political context of the community.
Not all hiring agencies require an advanced degree, although practitioners with graduate degrees are considered community health nurse specialists, regardless of their experience.

76. Nursing Practice in Community Health
Expert community health nurses:
Understand the needs of a population or community
Use critical thinking skills to apply knowledge
Understand resources
Needed skills:
Patient advocacy
Communicating people’s concerns
Designing new systems that cooperate with existing systems
By knowing the community’s members, the community health nurse is able to understand the needs of the population and can respond to changes in the community.

77. “Double Vision” Community health nurses: Successful practice involves:
Building relationships with the community
Being responsive to changes within the community
Care for the community as a whole
Assess the individual or family within the context of the community
Interactions occur between patient, family, and their environment. Care for both individuals and the community as a whole requires nurses to look from both perspectives.
When effective, population-based health care services increase the likelihood that higher levels of services will contribute efficiently to improved health of the population.

78. Community-Based Nursing
Occurs in community settings
Involves acute and chronic care
Enhances individuals’ capacity for self-care
Promotes autonomy in decision making
Uses critical thinking skills
Reduces costs for the patient by providing care near homes
Requires knowledge of family theory, communication, group dynamics, and cultural diversity
Community-based nursing takes place in the home or clinic, where the focus is on the needs of the individual or family.
While caring for these patients, you will utilize knowledge in upcoming chapters on cultural diversity, family theory, and principles of communication.
Table 3-1 (on text p. 35) presents common health problems in older adults. [Discuss nursing roles and interventions for these problems: hypertension, cancer, arthritis, states of confusion, Alzheimer’s disease, medication use and abuse.]

79. Vulnerable Populations
Examples:
Immigrants
Poor and homeless
Abused
Substance abusers
Mentally ill
Older adults
Special needs of vulnerable populations are a challenge.
A vulnerable population includes patients who are more likely to develop health problems as a result of excess risks, who have limited access to health care services, or who are dependent on others for care.
[Discuss the needs of and possible interventions for each population group on the slide.]
Box 3-2 (on text p. 34) presents how to assess members of a vulnerable population.

80. Multilevel Intervention
Multilevel intervention can also be viewed as a “ripple effect” of improving health in the community at large.

81. Case Study (cont’d)
Kim and her classmates conducted an assessment of the community’s health care needs and practices.
This is a close community that is facing many challenges, although chronic disease is absent in this population.
General preventive health care practices, including well examinations and basic screenings, are lacking.
[How can Kim convince this population of the value of well care? Discuss.]

82. Competency in Community-Based Nursing
Competency is based on decision making at the level of the individual patient.
Patients and families can receive care in a community-based care center.
[Photo is on p. 33 of text.]

83. Competency in Community-Based Nursing (cont’d)
Nurses utilize a variety of skills and talents:
Caregiver
Case Manager
Change Agent
Patient Advocate
Collaborator
Counselor
Educator
Epidemiologist
Nurses need to develop a solid set of skills and talents to be successful in the community.
[Ask students how each of these skills or talents can be utilized in the community by nurses. Discuss.]

84. Quick Quiz!
1. Vulnerable populations of patients are those who are more likely to develop health problems as a result of
A. Living at home.
B. Abusive habits.
C. Immigration.
D. Middle age.
Answer: B

85. Case Study (cont’d)
Many members of the Bosnian community are suspicious of free/low-cost care.
Kim attends community meetings with her community nurse preceptor to assess the beliefs and concerns of the community.
Misunderstandings and fears about health care services in this country are identified.
Kim uses beneficence—wanting to do the most good for the most people.
Kim respects the community’s beliefs.
[Ask the class: How would you respond to a community that feared the health care you were offering? Discuss.]
[Ask the class: How do you respect people’s beliefs when offering a different set of beliefs? Discuss.]

86. Community Assessment Assesses the community at large
Nurses care for patients from diverse backgrounds and settings, but all communities have three components:
Structure or Locale
People
Social Systems
Box 3-3 (on text p. 37) includes areas to assess within the context of structure, population, and social systems. [Ask students to suggest areas of assessment within structure, population, and social systems.]
[Ask students what nurses can do with the information obtained.]
How can this information assist patients and family members?

87. Case Study (cont’d)
One single-parent family in the community is 30-year-old Katrina Dudek and her two children (aged 3 years and 6 months).
Kim and the community health nurse work with Mrs. Dudek to determine the health care needs of her children and herself.
So far, Mrs. Dudek and her children have not received any care.
Kim and Mrs. Dudek discuss the need for immunizations of the children and set that as a goal.
Questions for discussion:
1. What information does Kim need about this Bosnian community?
2. What elements would be helpful in initiating care for this family?
3. Mrs. Dudek is fearful about providing an immunization history about her children. What should be Kim’s actions?
4. What factors within her community increase Mrs. Dudek’s vulnerability to health care problems?

88. Quick Quiz!
2. In identifying needs for health policy and health program development and services, a community assessment focuses on which of the following elements?
A. Structure
B. People
C. Social systems
D. Environments
E. All of the above
Answer: E

89. Changing Patients’ Health
Nurses need an accurate assessment of patients to design interventions that promote health and prevent disease.
Patients are more likely to accept a change if it is:
The challenge is to promote and protect a patient’s health within the context of the community.
It is imperative to understand the patient’s life by establishing strong, caring relationships with patients and their families.
More Advantageous
Compatible
Realistic
Easy to Adopt

90. Case Study (cont’d)
Kim identifies community leaders to serve as key persons in educational programs.
Kim spends 12 weeks working with the community agency and leaders to explain how the clinic provides services and the confidentiality of these services.
Kim presented information in three homes as well.
A gradual increase was noted in the use of services, including fewer “missed” appointments.
Kim learned the importance of including the community and community leaders in all aspects of program building.
[Ask the class: How would you measure progress in acceptance of health care services?]