Comprehensive Nursing Foundations: Profession, History, Process, and Clinical Standards
Nursing Practice and the Professional Nurse
A profession is defined as an occupation or calling that requires advanced training and experience in a specialized body of knowledge, ultimately providing a service to society in that specific field. Nursing specifically is viewed as an occupation requiring a unique body of knowledge and skills dedicated to serving society. It is categorized as a calling that demands specialized education, a distinct body of knowledge, a code of ethics, and autonomy. The criteria for a profession include a strong service orientation characterized by altruism, which is the selfless concern for others. Despite this altruism, professional practice must be guided by specific rules or a code of ethics, where assistance is provided within the professional's capacity. Legal protections such as the Good Samaritan Law exist to protect people in service from liability when providing reasonable assistance during an emergency.
Nursing practice is underpinned by ongoing research and evidence-based or outcome-based approaches. Chronologically, the 1940s marked the early development of nursing research, followed by increased funding and professional support in the 1950s. By the 1960s, research was frequently related to the nature of the knowledge base underlying nursing practice. During the 1970s, the focus shifted to related issues within nursing practice. Professional organizations like the Philippine Nurses Association (PNA) serve as accredited associations that help maintain political, economic, and social arrangements under professional affairs while protecting the rights of the nurse.
Nursing is characterized as both a science, representing knowledge and systemic methods, and an art, representing skills and the treatment of human responses physically, mentally, emotionally, and spiritually. Historically, the word is derived from the Latin "nutrix," meaning to nourish, and "vita," meaning life. It is also a social science where the primordial concern is humanity and the well-being of the patient. Republic Act 9173, also known as the Philippine Nursing Act of 2002, provides for a more responsive nursing profession and guarantees the delivery of quality basic health services through an adequate nursing personnel system. A professional nurse is a person whose name and registration or professional license number is entered into the Commission’s registry book and computerized database, legally authorizing them to practice. To qualify, a nurse must hold a Bachelor of Science degree in Nursing (BSN), be a registered nurse with a current PRC ID, be physically, mentally, and psychologically fit, and must not have been convicted of any moral turpitude. Member in an Accredited Professional Organization (APO) is also required.
Personal qualities essential for a nurse include an interest and willingness to work and learn with individuals and groups in various settings, a warm personality, and resourcefulness. A nurse must possess creativity, well-balanced emotional health, and the capacity to work cooperatively. Initiative for self-improvement, competence in the nursing process, and skill in decision-making, communication, and relating with others are vital. Active participation in issues confronting the nursing profession is also expected.
Historical Evolution of Nursing
The recorded history of nursing dates back to . In primitive societies, mother-nurses worked alongside priests. Records from Babylonia and Assyria in document the use of wet nurses. In Ancient Greece, temples were built to honor Hygeia, the goddess of health; these were more like health spas governed by priests, where priestesses attended to those housed within. Asclepius was the Greek God of Medicine and the patron saint of physicians; early physicians were known as Asclepiads. Treatments included medications, diets, exercise, fasting, and bathing in varied water temperatures. Hippocrates, practicing during Greece’s Golden Age (), developed systems for patient assessment and recording, established ethical standards, and advocated for conservative treatment and the physician-patient relationship.
Rome’s major contribution was the development of hospitals. St. Jerome, through his disciple Fabiola, introduced hospitals to the West. During the 3rd and 4th centuries, wealthy matrons like Fabiola converted to Christianity and used their wealth to provide houses of care and healing for the poor, sick, and homeless. Hospitals first appeared in the Eastern Roman Empire. During the Early Christian Era, Christianity became the official religion of Rome, placing sanctity on life. Deaconesses functioned as visiting nurses. Phoebe is identified as the first deaconess and the founder of visiting nursing. Olympias, a young widow, erected a convent and supervised 40 deaconesses. Marcella converted her home into a monastery, and Fabiola founded the first free hospital in Rome. Early hospitals were managed by deacons and supervised by bishops to care for those unable to be cared for at home.
During the Middle Ages, or the Period of Apprentice Nursing, there was political unrest and a decline in deaconesses, who eventually became extinct despite flourishing trade, famine, and disease. During the Renaissance (), interest in arts and science emerged and universities were established, though women were not encouraged to leave home. The Protestant Reformation led to the dissolution of Catholic hospitals. The Industrial Revolution introduced technology and a proliferation of factories, but conditions for workers were deplorable with no attention paid to their health status. Medical schools were founded during this time.
Foundations of Modern Nursing and the US Civil War
Elizabeth Fry was a prison and mental asylum reformer who founded the Protestant Sisters of Charity in 1840. Members received rudimentary education and observed patients in London hospitals. In 1848, St. John’s House was founded, requiring sisters to participate in a two-year nursing education program and work for five years in return for room, board, and a small salary. Theodor Fliedner, a German Lutheran pastor impressed by Fry, established a Deaconess Home and Hospital in Kaiserswerth. Florence Nightingale, known as the "Lady with the Lamp," was a philanthropist who studied under Fliedner. She was the superintendent of Upper Harley Street Hospital and volunteered during the cholera epidemic. In 1854, she led a group of women to Crimea to care for wounded troops. Her documentation of care became the foundation for evidence-based practice. She established the Nightingale School of Nursing at St. Thomas’s Hospital in London, combining theory with clinical experience.
During the American Civil War, Clarissa “Clara” Harlowe Barton founded the American Red Cross and was known as the "Angel of the Battlefield." She distributed supplies and tended to the wounded; notably, a bullet once tore through her sleeve and killed a man she was treating without harming her. Mary Ann Biekerdyke volunteered medical skills to treat those dying from typhoid and dysentery. Harriet Tubman, called "Moses," was a scout and spy for the US Army who never lost a passenger. Mary Mahoney was the first African American to graduate as a professionally trained nurse in 1879, challenging discrimination. Lilian Wald and Mary Brewster founded public health nursing, establishing the Henry Street Settlement in New York slums to provide nursing, social services, and educational activities.
Philippine Nursing History
Early beliefs in the Philippines were rooted in mysticism and superstitions, with priest-physicians known as "word doctors." Herb doctors were called "herbolarios," while those believed to practice witchcraft were "herbicheros." Illnesses were often attributed to being bewitched by "mangkukulam" or caused by "nunos." During the Spanish Regime, interventions came from "babaylan" (priest-physicians) or "albularyo" (herb doctors). In 1578, male nurses called "practicante" or "enfermero" were acknowledged as Spanish Friars' assistants.
Key hospitals established during the Spanish Regime include: Hospital Real de Manila (1577) for soldiers; San Lazaro Hospital (1578) established by Brother Juan Clemente exclusively for leprosy patients; Hospital de Indios (1586) by the Franciscans; Hospital de Aguas Santas (1590) near a medicinal spring in Laguna; and San Juan de Dios Hospital (1596) for general health service. During the Philippine Revolution in the late 1890s, women took on nursing roles, leading to the development of the Philippine Red Cross.
Heroines of this era include Josephine Bracken, who installed a field hospital in Tejeros; Rosa Sevilla de Alvero, who converted her house into quarters for soldiers and became the first Dean of Women at the University of Santo Tomas; Dona Hilaria de Aguinaldo, who organized the Hijas de la Revolución (forerunners of the Red Cross); Dona Maria Agoncillo de Aguinaldo; and Melchora Aquino ("Tandang Sora"), known as the "Mother of the Philippine Revolution," who died at age 107. Others included Capitan Salome, Agueda Kahabagan (the only woman in the roster of generals in 1899), and Trinidad Tecson, known as "Ina ng Biak-na-Bato."
Formal training began with the Iloilo Mission Hospital in 1906, established by Baptist Missionaries, where Rose Nicolet was the first superintendent. Other schools followed: St. Paul’s Hospital (1907), Philippine General Hospital (1907—advocated by Mary Coleman Masters), St. Luke’s Hospital (1907), Mary Johnston Hospital (1907—organized by Rebecca Parrish), and Mary Chiles Hospital (1911). Southern Islands Hospital in Cebu opened in 1918 with Anastacia Giron-Tupas as organizer. The first nursing board exam was given in 1920. The Philippine Nurses Association (PNA) was established with Rosario Delgado as the first president. Early colleges included UST (1946), MCU (1947), and UP Manila (1948), where Julita Sotejo served as the first dean. Legal milestones include RA 877 (1953), the migration of 25,000 nurses to the US between 1966 and 1985, and RA 9173 (2002).
Patterns of Knowing and Professional Theory
Carper’s Fundamental Ways of Knowing is a typology classifying knowledge sources in nursing. Empirical knowing involves factual, descriptive, and theoretical knowledge verifiable through science (e.g., performing handwashing as learned in a course). Evidence-Based Practice (EBP) involves clinical judgment based on research outcomes. Aesthetic knowing relates to understanding the creative and expressive styles of nursing and the unique feelings of patients, emphasizing empathy (e.g., using toys to explain a procedure to a child). Ethical knowing involves moral frameworks and the Code of Ethics, focusing on human dignity and respect for life (e.g., explaining organ donation). Personal knowing is the most difficult to master, focusing on self-awareness and the therapeutic use of self in the nurse-patient relationship.
Benner’s Novice to Expert Theory describes five levels of proficiency. The Novice has no prior experience and follows rigid rules. The Advanced Beginner demonstrates marginally acceptable performance based on some prior experience. The Competent nurse usually has on the job and can plan for long-term goals. The Proficient nurse views the patient holistically and can modify plans as needed. Finally, the Expert nurse no longer relies on rules but performs fluidly and intuitively. Performance at the expert level comes naturally.
Roles and Responsibilities of the Nurse
Nurses fulfill multiple roles. As a Caregiver, the nurse provides physical and psychological care while preserving dignity. This includes full care for dependent clients (e.g., those with Alzheimer's), partial care, or supportive-educative care. As a Client Advocate, the nurse protects human and legal rights and supports the client's decisions. The Teacher role involves assessing learning needs and providing information to promote health and intellectual growth. The Counselor helps clients cope with stress and develop new behaviors, while the Advisor gives personal opinions. Other roles include Change Agent, Manager (making decisions and allocating resources), Leader (influencing others toward goals), Communicator (verbal/written exchange), and Case Manager (overseeing specific caseloads with a multidisciplinary team).
The Communication Process
Communication is the exchange of thoughts and ideas on verbal and nonverbal levels. The process involves: Ideation (developing an idea), Encoding (putting meaning into symbols), Transmission (sending the message), Receiving (activating senses), Decoding (interpreting meaning based on intent), and Response (feedback). Verbal communication includes pace, intonation, simplicity (using layman's terms), clarity, brevity, timing, and relevance. Credibility is the most important criterion, while humor and adaptability based on patient cues are also key.
Nonverbal communication, or body language, includes personal appearance, facial expressions, and gestures. Posture and gait are reliable indicators of mood and health. Proxemics, the study of personal space, identifies four distances: Intimate (), Personal (), Social (), and Public (). Territoriality refers to the space an individual considers their own. Factors affecting communication include culture, gender (females seek intimacy; males seek status), and environmental distractions like noise or temperature extremes. Electronic communication is fast and legible but presents privacy and socioeconomic challenges.
Nursing Process and Critical Thinking
The nursing process is a systematic framework aimed at promoting, protecting, and restoring health, or providing a peaceful death. It is problem-oriented, goal-oriented, and orderly. Critical thinking is required, utilizing logic, intuition, and creativity. Skills in critical thinking include Critical Analysis (using Socratic Questioning to look beneath the surface), Inductive Reasoning (generalizations from specific facts), and Deductive Reasoning (conclusions from general premises). Important attitudes include intellectual humility, courage, integrity, and fair-mindedness. Standards of critical thinking include clarity, accuracy, relevance, and logicalness.
The history of the nursing process includes developments by Yurn and Walsh (1967), Little and Carnevali (1969), and the introduction of functional health patterns by Marjory Gordon in 1982. The six ANA standards of practice are Assessment, Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation.
Assessment involves data collection (Objective/Signs vs. Subjective/Symptoms), validation, and organization. Methods include interviewing (Directive, Non-directive, or Combined) and Physical Examination using Inspection, Palpation, Percussion, and Auscultation. Percussion sounds vary by density: Flatness (muscle/bone), Dullness (organs), Resonance (normal lungs), Hyperresonance (emphysema), and Tympany (gastric air bubble). Nursing diagnosis differs from medical diagnosis by focusing on human responses; types include Actual, Risk, Possible, Wellness, and Syndrome diagnoses. Implementation involves Dependent, Independent, or Interdependent (collaborative) interventions. Evaluation measures the response to actions and may involve Quality Assurance and Nursing Audits.
Documentation and Health Concepts
Documentation, founded by Florence Nightingale, must be clear, concise, and organized. Legal and ethical considerations include the Data Privacy Act (Republic Act 10173). Documentation purposes include planning care, legal evidence, research, education, and reimbursement. Records can be source-oriented or problem-oriented (POMR), the latter containing a database, problem list, plan, and progress notes. Formats include SOAP (Subjective, Objective, Assessment, Plan), SOAPIE (including Implementation and Evaluation), and Focus Charting (FDAR: Focus, Data, Action, Response). Guidelines require accuracy, conciseness, and the use of blue/black ink. Mistaken entries are corrected by drawing a single line and writing "mistaken entry" (M.E.); "error" is not used.
Health is defined by the WHO as a state of physical, mental, and social well-being. Disease is an objective pathologic process, classified as Acute (rapid onset) or Chronic (permanent change). Suchman's five stages of illness behavior are: Symptom experience, Sick role assumption, Medical care contact, Dependent client role, and Recovery/Rehabilitation. Wellness dimensions include Physical, Emotional, Intellectual, Environmental, Socio-cultural, and Spiritual. Models like Dunn’s High-Level Wellness Grid (Health vs. Environment axes), Travis’ Illness-Wellness Continuum, and Rosenstock’s Health Belief Model help illustrate the movement between health and death.
Death, Dying, and Post-Mortem Care
Terminal illness refers to an irreversible condition. Grief is mental anguish, while mourning is the ritualized behavioral process of resolution. Sources of loss include aspects of self, objects, environment, or loved ones. Developmental concepts of death vary: children under 5 see death as reversible, while those 12-18 may defy death through reckless behavior. Kubler-Ross’s five stages are Denial, Anger, Bargaining, Depression, and Acceptance. Engel’s stages include Shock/Disbelief, Developing Awareness, Restitution, Resolving the Loss, Idealization, and Outcome.
Physiologically, dying involves the failure of pulmonary and cardiovascular systems, leading to cell death. Signs include drenching sweat, weak/irregular pulse, and "mottled" skin. Nursing care for failing systems includes moisture for dry mouths () and checking for incontinence. Indicators of death include a total lack of response, no reflexes, and a flat ECG. Post-mortem changes include Rigor Mortis (stiffening, post-death due to lack of ), Algor Mortis (temperature drop of per hour), and Livor Mortis (discoloration from hemoglobin release). Nursing interventions involve placing the body in a supine position, arms at sides, with one pillow under the head to prevent facial discoloration. Validation through identification tags and preparation for family viewing is essential.