Professional Nursing: Introduction, History, and Theories
Introduction to Professional Nursing (NSG 310)
Topic 1: Introduction to the Nursing Profession and Historical Foundations
Objectives
Identify the historical foundations of the nursing profession.
Discuss key figures in the development of the art and science of nursing practice.
Discuss how caring forms the foundation of the art and science of nursing practice.
Compare and contrast various nursing theories and theoretical frameworks that underpin nursing practice.
Content References
Interpersonal Relationships: Professional Communication Skills for Nurses - Chapter 1
Professional Nursing: Concepts & Challenges - Chapters 2 and 9
Communication Theories and Nursing Concepts
Definition of Communication
Communication is the sending and receiving of information to help people understand one another and their environment.
It is a social process that connects people and ideas through words, nonverbal behaviors, and actions.
Types of Communication
Verbal Communication: Words chosen to convey a message.
Nonverbal Communication: Body language such as facial expressions, making eye contact, or nodding the head to show attentiveness.
The majority of communication is nonverbal.
Verbal and nonverbal messages need to be congruent (consistent).
Written Communication: Emails, handouts.
Communication Theoretical Concepts
Interpersonal Communication:
Communication between two or more individuals.
A continual social process where at least two people exchange ideas with the intent to influence the behavior or actions of the other.
Message Barriers:
Communication is complex.
Challenges can arise with message meaning, encoding and decoding, and message transmission.
Components of Communication
(Based on Figure 1.1 for a graphic depiction)
Messages: Factual transfer of information.
Sender: Person who conveys a specific message.
Symbols: Words as concrete or abstract symbols representing thoughts.
Transmission: Verbally spoken ideas with non-verbal messages.
Meaning: Interpretation of the message by the receiver.
Receiver: The message is heard by the receiver, who decodes the message.
Feedback: Acknowledgement of the receipt of the message and understanding of its meaning.
Environment: Time and place, historical context, cultural background, or prior experiences the client has had with healthcare workers.
Theories of Communication
Systems Theory:
Applies to communication among human clients, families, healthcare providers, and organizations.
Conceptualization: Message sender and environment give output to the receiver (input), who processes the message (throughput), interprets its meaning, then responds (output, perhaps changing behavior), and gives back information to the sender validating the message's meaning (feedback).
Social Penetration Theory:
Conveying some personal information about oneself can deepen a relationship.
Professional Boundaries: Generally, nurses do not share personal information unless it can help deepen a nurse-client relationship.
Models of Communication
Linear Models:
Focus only on the sending and receiving of the message.
Components: Sender, receiver, communication channels, and context.
Example Application: Emergency situations where rapid, unidirectional information flow is critical.
Transactional Models:
Describe interpersonal communication as a reciprocal interaction where both sender and receiver influence each other's messages and responses.
Effective Communication: A two-way process in which messages are negotiated until both parties correctly understand.
Influences: Communication is influenced by learned patterns of behavior, cultural expectations, personal beliefs, prior experiences, and environmental context.
The Healthcare System
Client-Centered Care
The client is at the center of a team of healthcare workers across various organizations.
Nurses require skillful communication not just with clients but also with management and colleagues.
Healthcare organizations' primary mission is to promote, maintain, or restore health.
At the organizational level, communication focuses on interrelationships across agencies.
Principles of Client-Centered Care:
Client and family actively participate in planning care and decision-making.
Respect for client preferences.
Support for clients and families.
Access to care.
Care coordination across departments and agencies.
Informs and educates clients.
Provides physical comfort.
Communicates accurately, frequently, and in a timely manner.
Advocates for access to care.
Nursing Functions
Encompasses both autonomous and collaborative care functions.
Focus: Promotion of health, prevention of illness, and care of ill clients.
Caring: Viewed as one of the main tenets of the nursing role.
Nursing's Metaparadigm
Person: Recipient of nursing care.
Includes individuals, family units, the community, and selected target populations.
Attributes: Gender, lifestyle, coping styles, habits, cultural background.
Nurses have a legal and ethical responsibility to protect each client's integrity and health rights to self-determination in healthcare.
Environment: Context in which health relationships take place.
Examples: Socio-environmental factors, poverty, education, religious and spiritual beliefs, type of community, family strengths and challenges, level of social support, health resource availability, ease of care access.
"The registered nurse integrates the principles of environmental health for nursing in all areas of practice" (ANA, 2015).
Health: "A state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity."
Influences: Perception, age-related factors, shifted focus, quality of life.
A healthy person is one who is able to productively strive toward vital goals.
Nursing:
Science of Nursing: Practice discipline, client as center, concepts, and skills.
Art of Nursing: Intuitive thinking from the client's perspective, focus on the uniqueness of each client.
Science and Art Integration: Knowledge represents the science of nursing, and caring represents the art of nursing. Both are needed to support the safety and quality of skilled care.
Attributes of Caring
Giving of self.
Involved presence.
Intuitive knowing and empathy.
Supporting the client's integrity.
Professional competence.
Outcomes of Effective Communication
Impacts the way care is delivered.
Is as important as the care itself.
Relates to higher client satisfaction and productive health changes.
Clients are more likely to understand their conditions through meaningful communication.
Clients are more likely to alert providers when something isn't working.
Interprofessional Education and Practice
How health providers use collaborative and networking skills to achieve clinical outcomes is a measure of system-based team competence.
Principles of Team-Based Healthcare:
Sharing Goals
Clear Roles
Mutual Trust
Effective Communication
Measurable Processes and Outcomes
Nursing Care Communication Competencies
Communicate with clients to determine their preferences, care plan, and preferred goals.
Communicate openly and clearly, verifying client understanding.
Adapt to client's communication style.
Communicate responsibly to provide safe care.
Use informatics to aid in communication with team members and assist in decision-making.
The History and Social Context of Nursing
Historical Context of Nursing
The nursing profession has been influenced by and reacted to the social, political, and economic climate, as well as advances in science and technology.
Forces Influencing Nursing Demands:
Social forces
Political forces
Economic climate
Scientific advances
Technological advances
Mid-19th-Century Nursing in England and the Crimean War
Florence Nightingale:
Trained in basic nursing at Kaiserswerth, Germany, and with the Sisters of Charity in Paris.
Care of the sick was often the purview of religious orders.
Crimean War (1854–1856): Took 38 nurses to the British hospital in Scutari, Turkey.
Organized and cleaned the hospital and provided care to wounded soldiers.
Collected detailed data on morbidity and mortality, leading to reform of the entire British Army medical system.
Established the first training school for nurses at St. Thomas' Hospital in London in 1860.
Published Notes on Nursing: What It Is and What It Is Not in 1859, establishing a body of nursing knowledge.
Mary Seacole (1805–1881):
Jamaican nurse and businesswoman.
Voted "the greatest Black Briton" in a 2003 poll.
Funded her own travel to the Crimea after being rejected by Nightingale's team.
Established a hotel for injured soldiers and visited battlefields to tend to the sick and injured.
Expert on cholera, which caused a huge percentage of soldier deaths.
The American Civil War (1861–1873)
No available professional nurses at the start of the war.
Catholic orders served as nurses.
The war led to the emergence of many nurses and nurse leaders.
Post-Civil War
The first training schools for nurses emerged.
Professionalization through organization began.
Nursing's Focus on Social Justice: Henry Street Settlement:
Lillian Wald (1867–1940): Nurse and social activist.
Established the Henry Street Settlement in New York City in 1895, initiating public health/community health nursing.
Provided care to families living in poverty, facing substandard living conditions, poor health, and limited healthcare access.
An early proponent of nurses in public schools.
The Henry Street Settlement nurses were undeterred in their daily visits.
Played a major role in the widespread public acceptance of nurses and is still in operation today.
Lillian Wald was a founder of the National Association for the Advancement of Colored People (NAACP).
Common cause, but still segregated nursing practices.
The Spanish-American War
Highlighted the need for nurses.
Professionalization and Standardization of Nursing through Licensure
Early 20th Century: Early efforts at licensure.
ICN Resolution: Each country and state to provide for the licensure of nurses.
1903: Permissive licensure laws enacted; nurses did not have to be registered to practice but could not use the title of Registered Nurse (RN) unless registered.
1923: All states required examination for permissive licensure.
1947: New York fully mandated licensure.
1950: The National League for Nursing (NLN) introduced the first nationwide State Board Test Pool Examination.
1917–1930: World War I and the Flu Epidemic
Challenges of World War I:
Charged with supplying nurses.
Establishment of the Army School of Nursing and Vassar Training Camp for Nurses.
1918 Flu Epidemic:
Increased the importance of public health nursing.
1931–1945: The Great Depression and World War II
Challenges of the Great Depression:
Many families could no longer afford private duty nurses, leading to widespread unemployment for nurses.
1933: President Franklin D. Roosevelt's Civil Works Administration provided some employment.
Social Security Act of 1935: Enhanced the practice of public health nursing.
Purpose: To strengthen public health services and provide medical care for children with disabilities and blind persons.
World War II:
Needed more nurses.
Congress enacted substantial support for nursing education.
Military and collegiate programs formed the Cadet Nurse Corps, offering schooling in exchange for a commitment to serve.
1954–1960: The Rise of Hospitals
Hospitals became the preferred setting for care and work.
1961–1982: Era of Specialty Care and Vietnam War
1960: Era of specialty care and clinical specialization began.
1965 Social Security Act Amendment: Introduced Medicare and Medicaid, significantly changing healthcare access and funding.
Vietnam War:
Rise of mobile hospitals and nurses working beyond traditional roles.
Recognition of Post-Traumatic Stress Disorder (PTSD) among nurses and soldiers.
1983–2000: HIV/AIDS and Life Support Technologies
Early 1980s: HIV/AIDS Epidemic:
Led to the implementation of universal precautions.
Changes in equipment: improved needles, IV catheters, gloves.
1980s–1990s: Advances in medical technology and life support.
Increased focus on advance directives and patient autonomy for end-of-life care.
2001–2020: The Post–9/11 Era, Natural Disasters, and Health Care Reform
2001: World Trade Center Attack: Disaster management with a focus on saving many lives.
2005: Hurricane Katrina: Provision of care under horrendous conditions.
2006: ANA Statement: Nursing actions in "unfamiliar and unusual conditions" defined.
2010: Affordable Care Act (ACA): Incremental implementation leading to significant healthcare reform.
Continued advances in information and medical technologies.
2021 and Beyond: SARS-CoV-2, the COVID Pandemic, and its Aftermath
COVID-19: First emerged in late 2019.
By late 2021: 246 million cases reported globally, with at least 5 million deaths.
Long COVID: Ongoing health problems and symptoms.
Tremendous stress on healthcare providers.
Exposed huge disparities in health, standards of healthcare, and access to healthcare.
Social Context of Nursing
Gender
Gender is a social construction of behaviors, roles, beliefs, and values specific to women, girls, boys, and men.
Mid-1800s: Women's social roles were limited, with stereotypes presenting women as intellectually inferior and not expected to make decisions.
11th, 12th, 13th Centuries: Men served as nurses under military and religious orders.
Stereotype for Men: Men supply strength or control clients when needed (e.g., psychiatric nursing).
Modern Male Nurses: More likely to be younger, employed full-time, have non-nursing education, and nursing as a second career.
Reasons Men Become Nurses:
Desire to help people.
Nursing is a growth profession with career paths.
Desire for a stable career.
1974: American Association for Men in Nursing (AAMN): Organized to address, discuss, and influence factors affecting men in nursing.
Open to men and women, with local chapters.
Goals for AAMN:
Encourage men of all ages to become nurses and strengthen/humanize healthcare.
Encourage men who are nurses to grow professionally and demonstrate contributions.
Support members' full participation in the nursing profession and its organizations.
Currently, about 11\% of students enrolled in undergraduate nursing programs are men.
The Image of Nursing
Media depictions (advertisements, television) form initial and lasting impressions of nursing, affecting public attitudes.
Most people do not appreciate the complexity and range of work of today's professional nurses.
Nursing Caps: A historical symbol of the profession.
Other Identification: Attire, scrubs with distinct colors/styles, ID badges.
Gallup Report (2019): Nurses rated highest for honesty and ethics for 18 consecutive years, and 20 of the past 21 years.
2002 Johnson & Johnson Campaign for Nursing's Future:
A multi-million-dollar campaign.
Goal: To enhance the image of the nursing profession, recruit new nurses and educators, and retain current nurses.
The Truth about Nursing:
A non-profit organization.
Mission: To "promote more accurate, balanced and frequent media portrayals of nurses and increase the media's use of nurses as expert sources."
Nursing, as a profession, can take responsibility for its public image.
National Population Trends
Aging in America:
People are living longer, increasing healthcare demands.
The number of elderly people is increasing while the number of adults in early midlife is decreasing, straining healthcare capacity.
Current Nursing Strategies:
Integration of care for the elderly in nursing programs.
Gerontology courses.
Development of gerontological clinical nurse specialists and nurse practitioners (NPs).
Diversity:
The U.S. population is diverse racially, ethnically, and culturally.
Nursing must adapt to meet the requirements of persons with varying ethnicities and cultural responses to health and illness.
Certain illnesses and health conditions occur disparately across race, ethnicity, and sex.
A diverse workforce is needed to be responsive to differing needs.
Nurse Education: Nurses need to be educated to be aware and respectful of cultural differences, fostering cultural competence, cultural sensitivity, and cultural humility.
Technological Advances
Genetics, Genomics, and Epigenetics:
Human Genome Project: Funded by the National Institutes of Health, mapped 20,000 to 25,000 genes on the human genome.
Significantly affects the understanding of health and illness.
Pharmacogenetics: Mechanism of action for drugs can be determined by genetic structures.
Biomedical Technology: Complex machines or implantable devices.
Information Technology (IT):
Computer-based applications used to communicate, store, manage, retrieve, and process information.
Meaningful Use: Criteria for incentivizing EHR adoption.
Moves towards paperless systems.
Challenges related to access and confidentiality.
Knowledge Technology: Refers to using information to create new knowledge.
Telehealth: Delivery of health-related services via telecommunication technologies.
Nursing Shortage
Causes of Shortages:
Internal Causes: Salary issues, long hours, increased responsibility for unlicensed workers, significant responsibility with little authority.
External Causes: Changes in demand for nursing services, the increasing age of the American population, greater acuity (degree of illness) of hospitalized individuals, public perceptions of nursing as a profession, and ever-widening career options for women.
Shortage of Nursing Faculty:
Doctoral-prepared and master's-prepared faculty are often over 50 years of age.
Nurses with advanced degrees are hired in more lucrative private sector positions.
Not enough doctoral- or master's-prepared nurses are produced to meet demands.
Contributing Factors: Aging nurses and aging population.
Solutions for Shortage of RNs:
Increase the supply of nurses (e.g., importing from English-speaking countries, travel nursing).
Create less-trained workers to supplement the nursing workforce (shorter training and education).
Initiatives for a Stable Workforce of Registered Nurses
1. American Recovery and Reinvestment Act of 2009:
Goal: Stimulate the U.S. economy.
Provision for 500 million to strengthen the U.S. healthcare workforce, including training and education of nurses and physicians.
2. The Robert Wood Johnson Foundation (RWJF):
A private foundation funding innovative healthcare initiatives.
Committed tens of millions of dollars to programs helping nursing schools, hospitals, and other agencies create regional workforce development systems (e.g., Colleagues in Caring initiative).
3. Corporate Support (e.g., Johnson & Johnson):
Partners with the National Student Nurses Association (NSNA), the NLN, the ANA, the Association of Nurse Executives (AONE), and the STTI Honor Society of Nursing.
4. ANCC Magnet Recognition Program:
A model for employers to earn the designation "employer of choice" by attracting and retaining nurses in acute hospital settings.
Nursing Theory: The Basics for Professional Nursing
What is Theory?
Definition: A group of related concepts, definitions, and statements that describe a certain view of nursing phenomena from which to describe, explain, or predict outcomes.
Nursing as a profession is strengthened when its knowledge is built on sound theory.
Theory is a useful tool for reasoning, critical thinking, and decision-making.
Philosophies of Nursing
Philosophy: A set of beliefs about the nature of how the world works.
Provides a broad, general view of nursing that clarifies values and expands on the definition of nursing.
Answers broad disciplinary questions.
Nightingale's Philosophy:
Began professional nursing.
Focus: Relationship of clients to their surroundings.
Metaparadigm Application: Person (client), health (as opposed to illness), environment (how it affects health/recovery), and nursing (as opposed to medicine).
Promoted changing client environments to effect positive health changes.
Nurses' primary responsibility was to protect clients via careful environmental management (e.g., clean air, water, adequate ventilation, sunlight).
Henderson's Philosophy:
Unique Function of the Nurse: "…to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge."
Defined nursing and specified the nurse's role related to the client.
Emphasized nurse functions through a list of 14 basic client needs (Table 9.2 and Box 9.2), categorized as physical, psychological, emotional, sociological, spiritual, or developmental, representing a holistic view.
Watson's Philosophy:
Emphasis: The caring aspects of nursing.
Nursing is based on human values and interest in the welfare of others, concerned with health promotion, health restoration, and illness prevention.
Health: Harmony, resulting from the unity of body, mind, and soul, for which the client is primarily responsible.
Illness or Disease: Lack of harmony within the mind, body, and soul experienced in internal or external environments.
Metaparadigm: Environment (supports human caring), person (client and nurse), health (promotion/prevention), and nursing (nurse contributions to client encounter).
Caring is considered a central concept of the discipline of nursing (Box 9.3: Watson's 10 Caritas Processes).
Conceptual Models of Nursing
Provide organizational structures for critical thinking about nursing processes.
Less abstract and more formalized than philosophies, but more abstract than theories.
Orem's Self-Care Model:
Core Idea: "Ordinary people in contemporary society want to be in control of their lives."
Nursing is needed when an actual or potential self-care deficit exists, meaning clients cannot adequately provide their own care.
Nurses assess the client's baseline ability for self-care to determine the extent of limitation and need for intervention.
King's Interacting Systems Framework and Theory of Goal Attainment:
Focus: People, their interpersonal relationships, and social contexts, with three interacting systems (personal, interpersonal, and social).
Unique view from the perspective of interactions (verbal and nonverbal) with others at these three levels.
Nurses focus on goal attainment for and by the client.
Roy's Adaptation Model:
Focus: The client's adaptation and the environment.
Individual: A biopsychosocial adaptive system with physiologic, self-concept, role function, and interdependent modes.
Nursing: A humanistic discipline emphasizing the person's adaptive or coping abilities.
Adaptation and adaptive behavior are produced by altering the environment.
The individual and environment are sources of stimuli requiring modification to promote client adaptation.
Grand-to-Middle Range Theories
Grand Theory: A broad conceptualization of nursing phenomena.
Middle-Range Theory: Narrower in focus, making connections between grand theories and nursing practice.
Theories are less abstract than models and usually propose specific outcomes.
Peplau's Theory of Interpersonal Relations in Nursing:
Core: Nursing care focuses on the client-nurse relationship.
Goals of Therapeutic Relationship: The survival of the client and the client's understanding of health problems, learning from them, and developing new behavior patterns.
Orlando's Nursing Process Theory:
Specific to nurse-client interactions.
Goal: Determine and meet clients' immediate needs and improve their situation by relieving distress or discomfort.
Leininger's Theory of Culture Care Diversity and Universality:
Also known as the theory of cultural care.
Nursing Outcome: Culturally congruent nursing care leading to health and well-being for the client.
Middle Range Theories of Nursing
Neither overly broad nor narrow in scope.
Incorporate a limited number of concepts and focus on a specific aspect of nursing.
More focused than grand theories, typically merging practice and research.
Based in empirical research and often embedded within a larger theory, or developed from theories in other disciplines.
Examples:
Swanson's Caring Theory
Mishel's Uncertainty in Illness Theory
Jezewski's Cultural Brokering Theory
Nursology
The science and body of knowledge created by and for the discipline of nursing.
It is not the study of nurses, but the study by nurses of phenomena of concern to nursing.
Theory-Based Education
Nursing curricula are built on one or more specific conceptual models or concepts.
Pioneered by Beavis and Watson (2000) and Lewis (2006).
The nursing profession evolved from an applied vocation dependent on knowledge from other disciplines to its current stage with its own knowledge base.
Theory-Based Practice
Occurs when nurses intentionally structure their practice around a particular nursing theory.
Uses theory to guide the nursing process (assess, plan, diagnose, intervene, evaluate).
Benefits:
Shapes theoretical orientation to practice.
Facilitates the transmission of nursing knowledge.
Contributes to professional autonomy, serving as a nursing-based guide for practice, education, and research.
Helps develop analytical skills, challenges thinking, and clarifies values and assumptions.
Theory-Based Research
Nursing research tests and refines the knowledge base of nursing.
Research findings enable nurses to improve the quality of care and understand how evidence-based practice influences improved client outcomes.