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B. Sc., (Nursing)







Unit I
- Development of Nursing as a
- Development of nursing education
in India and Trends in Nursing
- Professional organization
- Code of ethics
Unit II
- Ethical and legal aspects of
- Concept of health and illness
- Stress and adaptation
- Theory of nursing practice
Unit III
- Nursing process
- Assessment
- Planning
- Implementation and
- Evaluation
Unit IV
- Quality Assurance
- Nursing standard
- Nursing audit
Unit V
- Primary health care concept
- Community oriented nursing
- Holistic Nursing
- Primary nursing





Family oriented nursing process

- Problem oriented nursing
- Progressive nursing care
- Team nursing


This course will help students develop an understanding of the philosophy, objectives and
responsibilities of nursing as'' a profession. The purpose of the course is to orient to the
current concepts involved in the practice of nursing and developments in the nursing
At the end of the course, the student will
1. identify professional aspects of nursing.
2. explain theories of nursing.
3. identify ethical aspects of nursing profession.
4. utilize steps of nursing process.
5. identify the role of the nurse in various levels of health services.
6. appreciate the significance of quality assurance in nursing.
7. explain current trends in health and nursing,
*Development of nursing as a profession
.-its philosophy
-objectives and responsibilities of a graduate nurse.

Trends influencing nursing practice.

Expanded role of the nurse

Development of nursing education in India and trends in nursing


Professional organizations, career planning

Code of ethics and professional conduct for nurses.

Ethical, legal and other issues in nursing

Concepts of health and illness, effects on the person

Stress and adaptation

Mastery of content in this chapter will enable the student to:

define the key terms listed.

discuss the historical development of professional nursing roles

describe educational programs available for professional registered nurse


describe the roles and career opportunities for nurses.

list the five characteristics of a profession and discuss how

nursing demonstrates these characteristics.

discuss the influence of social and economic changes on nursing

Nursing is an art and a science. This means that a professional nurse learns

to deliver care artfully with compassion, caring, and a respect for i; each client's
dignity and personhood. As a science, nursing is based upon a body of knowledge
that is always changing with new discoveries and innovations. When nurses
integrate the science and art of nursing into their practice, .the quality of care
provided to clients is at a level of excellence that benefits clients in innumerable

It is an exciting time to become a nurse. The opportunities for a nursing career

are limitless. A new professional may choose any number of careers, including clinical
practice, education, research, management, administration, and even entrepreneurship.
There are many excellent health care facilities and educational institutions in this country
to prepare nurses with the very best skills and knowledge. As a student beginning his or
her career, it is important to understand the scope of nursing practice and how nursing
influences the lives of the clients we care for.

At the center of a nurse's practice is the client, which includes the individual,
family, and /or community. Clients enter a health care facility with a wide variety of
health care problems, experiences, vulnerabilities, and expectations. But that is what
makes nursing both challenging and rewarding. Making a difference in a client's life can
be very fulfilling: helping a dying client find relief from pain, helping a young child and
her parents learn to adjust to a disability, finding ways for an older adult to remain in the
home to manage his or her own daily care. Nursing offers personal and professional
rewards every day. This chapter presents a contemporary approach to the evolution of
nursing and nursing practice. This approach presents to the reader elements of the
historical, practical, social, and political influences on the discipline of nursing.

When giving care, a professional registered nurse provides a specified service

according to standards of practice and follows a code of ethics. The foundation for
professional practice arises from theories of nursing, scientific knowledge, relevance to
basic social values, professional autonomy, a sense of commitment, a sense of
community, and a code of ethics (Bernhard and Walsh, 1995). Nursing has many different
philosophies and definitions.

The following definition was developed by the American Nurses Association (ANA):
Nursing is 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 (ANA, 2003).
This definition asserts the prominence and importance nursing holds in providing
health care to people of our global community.
Expert clinical nursing practice is a result of a commitment to the application of
knowledge and clinical experience. The expertise required to interpret clinical situations
and make complex decisions is the essence of nursing care and is the basis for the
advancement of nursing practice and the development of nursing science (Benner, 1984;
Carnevali and Thomas, 1998). Critical thinking skills are essential to nursing (see
Chapter 14). When providing nursing care, the nurse makes clinical judgments about the

care needed for clients based on fact, experience, and standards of care (Alfaro-LeFevre,
1995). Knowledge, expertise, and lifelong learning are gained through the continual
process of critical thinking.

Historical Perspective Highlights

Nursing has responded to and always will continue to respond to the needs of its
clients. In times of war, nursing has responded by meeting needs of the wounded in the
combat zones and in military hospitals in the United States and abroad. When
communities face health care crises, such as those that occur from infectious diseases or
a lack of health care resources, nursing is there to establish community-based
immunization and screening pro- grams, treatment clinics, and health promotion
Our clients are most vulnerable when they are injured, sick, or dying. Historically
nursing has been there and will continue to be there not only to meet the needs of the
client, but also to assist in meeting the needs of the client's friends and families.
Nurses are active in social policy and political. Nurses and their professional
organizations lobby for health care legislation to meet the needs of clients, particularly
the medically underserved. For example, nurses in communities provide home visits to
newborns of high- risk mothers (e.g., adolescent, poorly educated mothers, or medically
underserved). The results of these visits document fewer emergency department visits,
fewer new- born infections, and reduced infant mortality. Changes in health care
legislation allow these services to be paid by public and private insurance. Nurses are
active in local government planning to ensure that health care re- sources are available in
all clients' communities.
Throughout the nursing profession's history, nurses have studied and tested new
and better ways to help their clients, their families, and their communities. Nurses have
been leaders in expanding knowledge in nursing and other health care disciplines through
health care research. Early in nursing history during the Crimean War, Florence
Nightingale studied and implemented methods to improve battlefield sanitation, which
ultimately reduced illness, infection, and mortality. Today nurses are active in
determining the best practices for skin care management, pain control, nutritional
management, and care of older adults, to cite just a few examples.

Nursing continuously responds and adapts to new challenges as they arise.

However/ for nurses to under- stand and prepare for the future direction of nursing/ the
past shows how nursing evolved to meet the needs of the service community. The
evolution of nursing has brought the profession to one of the most challenging and
exciting times in history.
The historical roots of nursing enable both students and practicing professionals
to prepare for the health care needs of the twenty-first century. Nursing is a combination
of knowledge from the physical sciences/ humanities/ and social changes, along with
clinical competencies needed to meet the individual needs of clients and their families.
Knowledge of the profession/s history increases the nurse's awareness and promotes an
understanding of the social and intellectual origins of the discipline (Keeling and Ramos/
1995) (Box 1-1). Although it is not feasible to describe all of the historical aspects of
professional nursing/ some of the more significant milestones are described below.

Florence Nightingale
The founder of modern nursing/ Florence Nightingale, established the first nursing
philosophy based on health maintenance and restoration in Notes on Nursing: What It Is
and What It Is Not (Nightingale/ 1860). Her views on nursing were derived from a
spiritual philosophy/ developed in her adolescence and adulthood (Macrae 1995), and
reflected the changing needs of society. She saw the role of nursing as having 'charge of
somebodys health based on the knowledge of how to put the body in such a state to be
free of disease or to recover from disease" (Nightingale/ 1860). During the same year, she
developed the first organized program for training nurses, the Nightingale Training
School for Nurses at St. Thomas' Hospital in London.
Nightingale was the first practicing nurse epidemiologist (Cohen, 1984). Her
statistical analyses connected poor sanitation with cholera and dysentery. She viewed
nursing as a search for truth in finding answers to health care questions or discovering
and using God's laws of healing in nursing practice (Macrae, 1995). In 1853 Nightingale
went to Paris to study with the Sisters of Charity and was later appointed superintendent
of the English General Hospitals in Turkey. During this period she brought about major
reforms in hygiene, sanitation, and nursing practice and reduced the mortality rate at the
Barracks Hospital in Scutari, Turkey, from 42.7% to 2.2% in 6 months (Woodham Smith, 1983; Donahue, 1996).

The Civil War to the Beginning of the Twentieth Century

The Civil War (1860 to 1865) stimulated the growth of nursing in the United States. Clara
Barton, founder of the American Red Cross, tended soldiers on the battlefields, cleansing
their wounds, meeting their basic needs, and comforting them in death. The U.S.
Congress ratified the American Red Cross in 1882 after 10 years of lobbying by Barton.
Dorothea Lynde Dix, Mary Ann Ball (Mother Bickerdyke), and Harriet Tubman also
influenced nursing during the Civil War (Donahue, 1996). As superintendent
Milestones in Nursing History
300 A.D

Entry of women into nursing.


Formation of charitable institutions to care for the aged, sick, and poor.
These included the I
Hospital Brothers of St. Anthony's, Brothers of Misericordia (Italy), and
the Alexian Brothers.


Sisters of Charity founded by Louise de Marillac. Established the first

educational program to be
affiliated with a religious nursing order.
Mother Elizabeth Seton introduced the Sisters of Charity into America,
later known as the
Daughters of Charity.
Deaconess Institute of Kaiserwerth, Germany, founded. This is the
institute where Florence
Nightingale received her initial education in nursing.

i 1836


Florence Nightingale received the Yearbook of the Institution of

Deaconess at Kaiserwerth.


Establishment of the Nightingale Training School for Nurses at St.

Thomas' Hospital in London,
England. This was the first organized program for "training nurses.


Florence Nightingale published Notes on Nursing: What It Is and What It

Is Not. This was the
first nursing philosophy based on health maintenance and restoration of


Dorthea Lynde Dix served as superintendent of the Union Army female

nurses Mary Ann Ball
(Mother Bickerdyke) organized ambulance services, searched for
wounded, and supervised
nurses Harriett Tubman tended to soldiers and led over 300 slaves to
freedom through the
Underground Railroad movement.


First nurses training school in Canada founded: St. Catherine's, Ontario.


United States ratified the American Red Cross, founded by Clara Barton.


Mary Agnes Snively assumed directorship of Toronto General Hospital

and began to form the
Canadian National Association of Trained Nurses, which was to become
the Canadian Nurses Association (CNA).


Establishment of the Nurses' Associated Alumni of the United States and

Canada (NAAUSC).
This group was an initial nursing professional group. It later became the
American Nurses Association.


First community health service for the poor: Henry Street Settlement
opened by Lillian Wald and
Harriet Brewster.


Isabel Hampton Robb, RN, was the first superintendent of the Johns
Hopkins Training School in
Baltimore, Maryland.


Initial discussion of nursing code of ethics.


First university-affiliated nursing program.


The Army Nurse Corps was established.


Sigma Theta Tau, National Honor Society of Nursing, was formed by six
student nurses from
Indiana University.


First professor of nursing, Mary Adelaide Nursing.


Navy Nurse Corps established; Canadian National Association of Trained

Nurses (later changed to
the Canadian Nurses Association, 1924) founded.


NAAUSC became the American Nurses Association (ANA).


Graduate nurse-midwifery programs were established.


Goldmark Report: Rockefeller Foundation-funded survey identified need

for increased financial
sup- port to university-based schools of nursing.


ANA Code of Ethics proposed.


Brown Report: Dr. Esther Lucille Brown. concluded that all nursing
education programs should be affiliated with universities and have their
own bud- gets. She recommended a broad academic education within a
university and 2 years of nursing education focused on technical skills.


Association of Operating Room Nurses formed.


Dr. Mildred Montag established the first associate degree nursing

program. Nursing Research, a journal reporting on the scientificc
investigations of nursing, was established.


National League for Nursing (NLN), in collaboration with universities,

developed graduate nursing


Yale University School of Nursing defined nursing as a profession,

interaction, and relationship between two human beings.


Jerome Lysaught directed the National Com- mission on Nursing and

Nursing Education Report, which recommended that nursing roles and
responsibilities ,be clarified in relation to other health care professionals
and that in. creased financial support and career opportunities were needed
to attract and retain nurses; ANA position paper defined nursing.


American Association of Critical Care Nurses formed. -

Oncology Nursing Society formed. NLN required theory-based
curriculum for ac. creditation.

ANA published Code for Nurses With Interpretive Statements.


Health care reform.


The Pew Report: Looking at future nursing needs and shortages. Institute
of Medicine (IOM) Report. Parallel to the Pew Report.

Of the female nurses of the Union Army, Dix organized hospitals, appointed nurses, and
oversaw and regulated supplies to the troops. Mother Bickerdyke organized ambulance
services, supervised nurses, and walked abandoned battlefields at night, looking for
wounded soldiers. Harriet Tubman was active in the Underground Railroad movement
and assisted in leading over 300 slaves to freedom (Donahue, 1996).
The first African-American professional nurse was Mary Mahoney, RN. She was
concerned with relation- ships between cultures and races, and as a noted nursing leader,
she brought forth an awareness of cultural diversity and respect for the individual,
regardless of back- ground, race, color, or religion.
Isabel Hampton Robb, a graduate of St. Catherine's in Ontario, was the first
superintendent of the Johns Hopkins Training School in Baltimore, Maryland, in 1894.
As one of her many contributions to nursing, she helped found the Nurses' Associated
Alumnae of the United States and Canada in 1896. This organization became the
American Nurses Association (ANA) in 1911. She authored many nursing textbooks,
including Nursing: Its Principles and Practice for Hospital and Private Use (1894),
Nursing Ethics (1900), and Educational Standards for Nurses (1907), and was one of the
original founders of the American Journal of Nursing (AJN) (Donahue, 1996). Today, the
AJN continues to present current insights into nursing practice and professional issues.
Nursing in hospitals expanded in the late nineteenth century. However, nursing in
the community did not increase significantly until 1893, when Lillian Wald and Mary
Brewster opened the Henry Street Settlement, which focused on the health needs of poor
people who lived in tenements in New York City (Donahue, 1996). Nurses working in
this settlement 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 physician. The poor people also
needed nursing therapies aimed at maintaining wellness through proper nutrition,


hygiene, and shelter. Wald described her activities with the Henry Street Settlement in the
textbooks The House on Henry Street (1915) and Windows on Henry Street (1934).

Twentieth Century
In the early twentieth century a movement toward a scientific, research-based
defined body of nursing knowledge and practice was evolving. Nurses began to assume
expanded and advanced practice roles. Mary Adelaide Nutting, a member of the first
graduating class at Johns Hopkins Hospital and successor to Isabel Hampton Robb as
superintendent of the Johns Hopkins Training School, was instrumental in the affiliation
of nursing education with universities. She became the first professor of nursing at
Columbia University Teachers College in 1907 (Donahue, 1996). In addition, a landmark
report, the Goldmark Report, concluded that nursing education needed increased financial
support and suggested that the money be given to university schools of nursing.
As nursing education developed, nursing practice also expanded. In 1901 the
Army Nurse Corps was established, followed in 1908 by the Navy Nurse Corps. By the
1920s nursing specialization was developing. Graduate nurse-midwifery programs were
initiated, and in the late 1940s and early 1950s specialty nursing organizations, such as
the Association of Operating Room Nurses, American Association of Critical Care
Nurses, and Oncology Nursing Society, were formed.
Twenty-first Century
Nursing practice and education must continue to evolve to meet the needs of society. In
1990 the American Nurses Association established the Center for Ethics and Human
rights. The Center provides a forum to address the complex ethical and human rights
issues confronting nurses and designs activities and programs to increase ethical
competence in nurses (ANA, 2001). Nursing code of ethics was revised in 2001 to reflect
current ethical issues affecting health care and nursing practice.
Today the profession is faced with multiple challenges. Nurses and nurse
educators are revising nursing practice and school curricula to meet the ever-changing
needs of society, including bioterrorism, emerging infections, and disaster management.
Advances in technology, the rising acuity of hospitalized clients, and early discharge
from health care institutions require nurses in all settings to have a strong and current
knowledge base from which to practice. In addition, nursing along with the Robert Wood
Johnson Foundation, through the Last Acts Campaign, is taking a leadership role in


developing standards and policies for end-of-life care. 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-oflife care and practices into the nursing curricula (ANA, 2002d).
Nursing practice can now be found in multiple care settings, including health care
institutions and foundations, the community, and the home. In addition, nurses are active
in political and lobbying groups, social and not-for-profit agencies, and work on
establishing social health care policies. These' activities increase nursing 's public
viability and, at the same time, increase the public's awareness of professional nursing.
The challenge now is to prepare professional nurses to deliver complex, multifaceted care
in the client's home.
There are many external forces that affect nursing. These include demographic changes
of the population, human rights, increasing numbers of medically underserved,. and the
threat of bioterrorism.
Demographic Changes
Demographic changes affect the population as a whole. Changes that have influenced
health care in recent decades include the population shift from rural areas to urban
centers; the increasing life span; the higher incidence of chronic, long-term illness; and
the increased incidence of diseases such as alcoholism and lung cancer. Nursing as a
profession responds to such changes by exploring new methods for providing care, by
changing educational emphases, and by establishing practice standards in new areas.
Women's Health Care Issues
The women's movement has brought about many changes in society as women have
increasingly sought economic, political, occupational, and educational equality. As a
result, there is greater sensitivity to the health care needs of women and the role of
women in health care research. There are and continue to be emerging health care
specialties dealing with the needs of women.
These new specialties expand on the traditional obstetrical specialty. These new
specialties address issues ranging from well women's examinations, to ontological sub
specialties, and management of menopause. In addition, health care researchers
acknowledge the prior lack of female subjects in biomedical research, and now the


federal government mandates that women must be routinely included in research, unless
specific exception criteria are met. For example, research focusing on management of
prostatic cancer is such an exception.
Nursing is responding in two ways to women's health care issues and the women's
movement. Because most nurses are "women, they are increasingly asserting their equal
rights as human beings, employees, and health care professionals. The women's
movement has encouraged nurses to seek greater autonomy and responsibility in
providing care. The women's movement has caused female clients to seek more
responsibility for and control for their bodies, health, and lives in general. As women
become more aware of their own unique needs and qualities, they seek health care that
can help them meet those needs and reach their full potential.
Human Rights Movement
The human rights movement is changing the way society views the rights of all of its
members, including minorities, clients with terminal illness, pregnant women, and older
adults. Many groups have special health care needs, and nursing has responded by
respecting all clients as individuals with a right to quality care and by supporting basic
human rights. Nurses advocate the rights of all clients, but they have also recognized the
special needs of some groups and thus have created bills of rights for dying, hospitalized,
and pregnant clients, as well as other groups, to ensure that quality care is provided
without sacrificing these rights.
Medically Underserved
The rising rates of unemployment, homelessness, and health care costs all contribute to
an increase in the medically underserved population. The medically under- served
population may be poor and on Medicaid or may be part of the working poor in that they
cannot afford their own insurance but make too much money to qualify for Medicaid. In
addition, there is an increase in the mentally ill population who have little or no access to
health care. Nurses work in many rural, neighborhood, and community-based settings
providing health promotion and disease management (Masson, 2001). Frequently these
nurses have advanced preparation and function as advanced practice nurses, giving them
the capability to provide direct health care. This area of nursing is rapidly expanding as
more nurses are seeking to work with this population in need.
Threat of Bioterrorism


The world is a changing place; the treats of bioterrorism are no longer fictitious. Many
health care agencies and communities have educational programs for nurses to prepare
them in the event of nuclear, chemical, or biological attack. Nurses are active in disaster
preparedness. For example, nurses work in conjunction with community disaster
preparedness groups and hospitals to determine what specific nursing activities are
needed before the disaster. This activity may range from participating in vaccine research,
decontamination in the event of biological attack, triage for mass casualty, to crisis
response units. It should also be remembered that if a disaster were to occur nurses would
also be essential in evaluating the strengths and weaknesses of any disaster plan that was

Needs of the Consumer.

The consumers' movement is a heightened public awareness of the value and costs of
products and services. It has influenced health care by calling for new kinds of health
care agencies, such as health maintenance organizations, demanding culturally sensitive
care, creating new forms of health insurance, and voicing concern about the rising costs
of health care. Consumers are also more knowledgeable about health and illness and are
becoming more vocal in their desire for high-quality care. Because nurses generally
interact with clients more than other health care professionals do, they must often answer
questions about the quality and costs of health care.
Cultural Diversity
As the people of the world move about, nurses are con- fronted with caring for clients of
many cultures different from their own. The nurse must now have an awareness of how
different cultures view health and illness . Nurses are challenged to be culturally aware
and competent. Care that is not culturally competent may be more costly and may be
ineffective (Sullivan, 1999). Healthy People 2010, a federal document that out- lines
health care goals for the public, is one example of meeting the health of multiple, cultures
by defining goals and objectives for health (U.S. Department of Health and Human
Services [USDHHS], 2002).
Health Promotion and Wellness
Today there is a great emphasis on health promotion, health maintenance, and-illness
prevention. Exercise, nutrition, and healthy lifestyles are subjects that interest many
people. Nursing has responded to this greater concern for health promotion by providing

programs in the community such as health fairs and wellness programs; educational
programs for specific diseases; and client and family teaching activities in hospitals,
clinics, primary care facilities, and other health care settings. Health promotion activities
are an important part of the role of a nurse.
Influence of Today's Health Care Delivery System
Today's health care delivery system is a complex and highly regulated system. Nurses
working in the system must be aware of their roles in containing health care costs,
providing the best evidenced-based practice, and participating in nursing and biomedical
research. In addition, today's health care system is further challenged by the nursing
Rising Health Care Costs
Skyrocketing health care costs present challenges to the nursing profession, consumer,
and the health care delivery system as well. Nursing responsibility is to provide the
consumer with the best-quality care in an efficient and economically sound manner.
Nurses are challenged to use health care and client resources wisely. For example, clients
may be taught to perform procedures in the home with clean versus sterile equipment.
This does not compromise care because clients are in their home environments, which are
cleaner, and without the risks of nosocomial infections. However, nurses heed to
clinically evaluate each client to determine which clients can perform procedures safely
using clean technique. Nurses also playa role in managing health care costs by
participating in product evaluation. Most health care institutions invite nurses to
participate in product re- view committees to select the most clinically effective,
reasonable-cost items for clinical use.
Evidenced-Based Practice
Consumers of health care are more informed than ever, and with the Internet consumers
have access to more health care and treatment information. As a result consumers expect
and should receive the most current effective, state-of-the-art care in a rapidly changing
health care system. As providers of health care, nurses are faced with the challenge of
providing safe, effective care. One way to achieve this goal is to provide evidence-based
practice. Evidence-based practice is defined as "the integration of best research evidence
with clinical expertise and patient values" (Sackett and others, 2000). Evidence- based


nursing practice involves accurate and thoughtful decision making about health care
delivery for clients.
Nursing and Biomedical Research
Nursing knowledge, scientific knowledge, and research findings have rapidly expanded
over the last few years. Nurses share a "commitment to the advancement of nursing
science and the ethical conduct of nursing science" (ANA, 1997). The scientific
knowledge base for professional practice is developed through scholarly inquiry of
nursing and biomedical research literature, utilization of research findings, and
conducting research. Through nursing research, nurses base their care on scientific
sfindings, rather than tradition. The beneficiary of this care is the client. Through
research, nursing practice changes to provide the highest-quality state- of-the-art nursing
Nursing Shortage
Although there is much in the professional and public media about the nursing shortage,
this shortage also represents challenges and opportunities for the profession. Vast health
care dollars are being invested in strategies aimed at recruiting a well-educated, critically
thinking, motivated, and dedicated nursing work force (Boychuk, 2001). Research
documents the direct link between nursing care and positive client outcomes, reduced
complication rate, and a more rapid return of the client to the pre illness state (Roming
2001; Blendon and others, 2002; Consumer Reports, 2003).
Like it or not, the nursing shortage affects the needs of the consumer (Roming, 2001;
Consumer Reports, 2003). With fewer nurses in the workplace, nurses must use their
client contact time efficiently and professionally. Time management, therapeutic
communication, client education, and compassionate implementation of psychomotor
skills are just a few of the essential skills needed for the provision of quality nursing care.
For example, using a well-organized approach to prepare a client to self- administer
blood pressure medication at home results in a scenario in which the client adheres to
medication, blood pressure remains within the target range, and most importantly the
client leaves the health care setting with a positive image of nursing and a feeling that
quality care was provided. The client should never feel rushed or that he or she was one
of many clients or tasks for the nurse. If a certain aspect of client care requires 15 minutes
of contact, it will take the same time to deliver the care in an organized manner as it
would in a rushed, harried manner. However, the impression left with the client will be


far different. As nurses we all have the opportunities and obligation to present our
profession and practice in the best possible manner.

Nursing as a profession
Nursing is not simply a collection of specific skills, and the nurse is not simply a person
trained to perform specific tasks. Nursing is a profession. No one factor absolutely
differentiates a job from a profession, but the difference is important in terms of how
nurses practice. When we say a person acts "professionally," for example, we imply that
the person is conscientious in actions, knowledgeable in the subject, and responsible to
self and others. Professions possess the following primary characteristics:

A profession requires an extended education of its members, as. well as a basic

liberal foundation.

A profession has a theoretical body of knowledge leading to defined skills,

abilities, and norms.


A profession provides a specific service. .Members of a profession have

autonomy in decision making and practice.


The profession as a whole has a code of ethics for practice.

The practice of professional nursing and nursing knowledge has been developed over
time through development of nursing theories and research. Theoretical models serve as
frameworks for nursing curricula and clinical practice. Nursing research in- creases the
scientific basis of nursing practice through the systematic inquiry into health care
problems and issues.
Standards of Professional Performance
The ANA Standards of Professional Performance describes a competent level of behavior
in the professional role, including activities related to quality of care,
Quality of

The registered
nurse sys- of
enhances the
quality and
of nursing

The registered nurse:

Demonstrates quality by documenting the
application of the nursing process in a responsible,
accountable, and ethical manner.
Uses the results of quality improvement activities
to initiate changes in nursing practice and in the
health care delivery system.
Uses creativity and innovation in nursing practice
to improve care delivery. Incorporates new
knowledge to initiate changes in nursing practice if
desired outcomes are not achieved.
Participates in quality improvement activities. Such
activities may include: identifying aspects of practice
important for quality monitoring such as:


Using indicators developed to monitor quality and

effectiveness of nursing practice
Collecting data to monitor quality and
effectiveness of nursing practice. Analyzing quality
data to identify opportunities for improving
nursing practice
Formulating recommendations to improve nursing
practice or outcomes Implementing activities to
enhance the quality of nursing practice
Developing, implementing, and evaluating
policies, procedures and/or
guidelines to improve the quality of practice
Participating on interdisciplinary teams to evaluate
clinical care or health services
Participating in efforts to minimize costs and
unnecessary duplication Analyzing factors related
to safety, satisfaction, effectiveness, and cost/
benefit options
Analyzing organizational systems for barriers
Implementing processes to remove or decrease
barriers within organi- zational systems
Additional Measurement Criteria for the Advanced
Practice Registered Nurse: The advanced practice
registered nurse:
Obtains and maintains professional certification if
available in the area of expertise.
.Designs quality improvement initiatives.
.Implements initiatives to evaluate the need for
.Evaluates the practice environment and quality of nursing
care rendered in relation to existing evidence, identifying
opportunities for the generation and use of research.
Additional Measurement Criteria for the Nursing
Role Specialty: The registered nurse in a nursing
role specialty
.Obtains and maintains professional
certification if available in the area of
.Designs quality improvement initiatives.
.Implements initiatives to evaluate the need for
.Evaluates the practice environment in relation to
existing evidence, identifying opportunities for the generation
and use of research.




The registered nurse: -Participates in ongoing educational activities

related to appropriate knowledge bases and
The registered professional issues.
Demonstrates a commitment to lifelong learning
nurse attains
through self-reflection and inquiry to identify
learning needs.
Seeks experiences that reflect current practice in
that reflects
order to maintain skills and competence in clinical
practice or role performance.
nursing I
Acquires knowledge and skills appropriate to the
specialty area, practice setting, role, or situation.
Maintains professional records that provide
evidence of competency and lifelong learning.
Seeks experiences and formal and independent
learning activities to maintain and develop clinical
and professional skills and knowledge.
Additional Measurement Criteria for the Advanced
Practice Registered Nurse: The advanced practice
registered nurse: .
Uses current healthcare research findings and other
evidence to expand clinical knowledge, enhance
role performance, and increase knowledge of
professional issues.
Additional Measurement Criteria for the Nursing
Role Spedalty: The registered nurse in a nursing
role spedalty:
.Uses current research findings and other evidence
to expand knowledge, enhance role performance,
and increase knowledge of professional issues.

The registered The registered nurse:

.The registered nurse's practice reflects the
application of knowledge of cur- rent practice
standards, guidelines, statutes, rules, and
The registered nurse:
practice use
Provides age-appropriate care in a culturally and
ethnically sensitive manner. .Engages in selfone's own
evaluation of practice on a regular basis,
identifying areas
nursing in
of strength as well as areas in which professional
development would be beneficial.
relation to
Obtains informal feedback regarding one's own
practice from patients, peers, professional
colleagues, and others.
Participates in systematic peer review as
standards and Takes action to achieve goals identified during the
evaluation process. .Provides rationales for
guide- lines,
practice beliefs, decisions, and actions as part of
the informal and formal evaluation processes.
Additional Measurement Criteria fljr the Advanced
Practice Registered Nurse:
statutes, rules, .The advanced practice registered nurse engages in
a formal process seek- ing feedback regarding
one's own practice from patients, peers,
professional colleagues, and others.
Additional Measurement Criteria fljr the Nursing
Role Specialty
The registered nurse in a nursing role specialty
engages in a formal process seeking feedback
regarding role performance from individuals,

professional colleagues, representatives and

administrators of corporate entities, and others.
The registered nurse:
Shares knowledge and skills with peers and
colleagues as evidenced by such activities as
patient care conferences or presentations at formal
or informal meetings.
Provides peers with feedback regarding their
practice and/or role performance. '
Interacts with peers and colleagues to enhance
X: Collegiality

The registered
interacts with
and contributes to the
peers and

one's own professional nursing practice and/or role

Maintains compassionate and caring relationships
with peers and colleagues.
Contributes to an environment that is conductive to
the education of health care professionals.
Contributes to a supportive and healthy work
Additional Measurement Criteria for the Advanced
Practice Registered Nurse: The advanced practice
registered nurse:
Models expert practice to interdisciplinary team
members and health care consumers.
Mentors other registered nurses and colleagues as




demonstrates accountability to the client' and to the

nursing profession, since the effectiveness of 'I
nursing actions can be evaluated.
2. Use category headings: "Nursing Diagnoses



Interventions: and Evaluation." Include a date

for the evaluation of each goal.
3. Use standardized medical or English symbols
and key words rather than complete sentences to


communicate your

ideas. For example, write

"Turn and reposition q2h" rather than "Turn and

reposition the client every two hours." Or -.. write
"Clean wound c H2O2 bid" rather than "Clean the '
client's wound with hydrogen peroxide twice a day,
morning and evening." See Table 20-4 (g) on

343 for a list

of standard medical

4. Be specific. Because nurses are now working
shifts of different lengths, some working l2-hour
shifts, and some working 8-hour shifts, it is even
more important to be specific about expected
timing of an intervention. If the order reads
"change incisional dressing shift," it could mean
either twice in 24 hours, or three times in 24 hours,







miscommunication be- comes even more serious

when medications are ordered to be given "q shift."
Writing down specific times during the 24-hour
period will help clarify.
5. Refer to procedure books or other sources of
information rather than including all the steps on a
written plan. For example, write "See unit
procedure book for tracheostomy care," or attach a
standard nursing plan about such procedures as
radiation-implantation care and preoperative or
postoperative care.
6. Tailor the plan to the unique characteristics of
the client by ensuring that the client's choices, such
as preferences about the times of care and the
methods used, are included- This reinforces the
client's individuality and sense of control. For
example, the written nursing intervention "Provide
prune juice at breakfast rather than other juice"


indicates that the client was given a choice of

7. Ensure that the nursing plan incorporates
preventive and health maintenance aspects as well
as restorative ones, For example, carrying out the
order "Provide active assistance ROM (range-ofmotion) exercises to affected limbs q2h" prevents
joint contractures and maintains muscle strength
and joint mobility.
8. Ensure that the plan contains interventions for
ongoing assessment of the client (e.g., "Inspect
incision q8h").
9. Include collaborative and coordination activities
in that pain. For example, the nurse may write
orders to ask a nutritionist or physical therapist
about specific aspects of the client's care.
10. Include plans for the client's discharge and
home care needs. It is often necessary to consult
and make arrangements with the community health
nurse, social worker, and specific agencies that
supply client information and needed equipment.
Add teaching and discharge plans as addenda if
they are lengthy and complex.
Participates with interdisciplinary teams that
contribute to role development and advanced
nursing practice and health care.
Additional Measurement Criteria for the Nursing
Role Spedalty: The registered nurse in a nursing
role spedalty:
.Participates on multiprofessional teams that
contribute to role development and, directly or
indirectly, advance nursing practice and health
.Mentors other registered nurses and colleagues as

The registered
with patient,
family, and

The registered nurse: regarding patient care and

the nurse's role in the provision of that care.
.Collaborates in creating a documented plan
focused on outcomes and decisions related to care
and delivery of services that indicates


others in
the conduct of

XII: Ethics

communication with patients, families, and others.

.Partners with others to effect changes and
generates positive outcomes through knowledge of
the patient or situation.
Documents referrals, including provisions for
continuity of care. Additional Measurement
Criteria for the Advanced Practice Registered
Nurse: The advanced practice registered nurse:
Partners with other disciplines to enhance patient
care through interdisciplinary activities, such as
education, consultation, management,
technological development, or research
Facilitates an interdisciplinary process with other
members of the health care team.
Documents plan of care communications,
rationales for plan of care changes, and
collaborative discussions to improve patient care.
Additional Measurement Criteria for Nursing Role
Specialty: The registered nurse in a nursing role
.Partners with others to enhance health care, and
ultimately patient care, through interdisciplinary
activities such as education, consultation,
management, technological development, or
research opportunities.
.Documents plans, communications, rationales for
plan changes, and collaborative discussions
The registered The registered nurse:
.Uses the Code of Ethics for Nurses With
Interpretive Statements (ANA, 2001) to guide
provisions in Delivers care in a manner that preserves and
all areas of
protects patient autonomy, dignity, and rights.
Maintains patient confidentiality within legal and
regulatory parameters. .Serves as a patient
advocate assisting patients in developing skills for
Maintains a therapeutic and professional patientnurse relationship with appropriate professional
role boundaries.
Demonstrates a commitment to practicing selfcare, managing stress, and connecting with self and
others. t
Contributes to resolving ethical issues of patients,
colleagues, or systems as evidenced in such
activities as participating on ethics committees.
Reports illegal, incompetent, or impaired practices.
Additional Measurement Criteria for the Advanced
Practice Registered Nurse: The advanced practice
registered nurse:


Informs the patient of the risks, benefit, and

outcomes of health care regimens.
Participates in interdisciplinary teams that address
ethical risks, benefits, and outcomes.
Additional Measurement Criteria for the Nursing
Role Specialty: The registered nurse in a nursing
role specialty:
Participates on multidisciplinary and
interdisciplinary teams that address ethical risks,
benefits, and outcomes.
Informs administrators or others of the risks,
benefits, and outcomes of programs and decisions
that affect health care delivery.

XIII: Research

The registered
findings into

The registered nurse:

Utilizes the best available evidence, including
research findings, to guide
practice decisions.
Actively participates in research activities at
various levels appropriate to the nurse's level of
education and position. Such activities may
Identifying clinical problems specific to nursing
research (patient care and nursing practice).
Participating in data collection (surveys, pilot
projects, formal studies). Participating in a formal
committee or program.
Sharing research activities and/or findings with
peers and others. Conducting research.
Critically analyzing and interpreting research for
application to practice. Using research findings in
the development of policies, procedures,
and standards of practice in patient care.
Incorporating research as a basis for learning.
Additional Measurement Criteria for the Advanced
Practice Registered Nurse: The advanced practice
registered nurse:


.Contributes to nursing knowledge by conducting

or synthesizing re- search that discovers, examines,
and evaluates knowledge, theories, criteria, and
creative approaches to improve health care
.Formally disseminates research findings through
activities such as presentations, publications,
consultation, and journal clubs.
Additional Measurement Criteria for the Nursing
Role Specialty: The registered nurse in a nursing
role specialty:
.Contributes to nursing knowledge by conducting
or synthesizing re- search that discovers, examines,
and evaluates knowledge, theories, criteria, and
creative approaches to improve health care.
Formally disseminates research findings through
activities such as presentations, publications,
XIV: Resource

consultation, and journal clubs

The registered nurse:


Evaluates factors such as safety, effectiveness,

availability, cost and benefits, efficiencies, and
impact on practice when choosing practice options
that would result in the same expected outcome.
.Assists the patient and family in identifying and
securing appropriate and available services to
address health-related needs.
Assigns or delegates tasks, based on the needs and
condition of the patient, potential for harm,
stability of/the patient's condition, complexity of
the task, and predictability of the outcome.
Assists the patient and family in becoming
informed consumers about the options, costs, risks,
The registered and benefits of treatment and care.
Additional Measurement Criteria for the Advanced
factors related
Practice Registered Nurse: The advanced practice



registered nurse:


Utilizes organizational and community resources to

cost, and

formulate multidisciplinary or interdisciplinary

impact on

plans of care.

practice in the

Develops innovative solutions for patient care

planning and

problems that address effective resource utilization

delivery of

and maintenance of quality.


Develops evaluation strategies to demonstrate cost


effectiveness, cost benefit, and efficiency factors

associated with nursing practice.
Additional Measurement Criteria for the Nursing
Role Specialty: The registered nurse in a nursing
role specialty:
Develops innovative solutions and applies
strategies to obtain appropriate resources for
nursing initiatives.
Secures organizational resources to ensure a work
environment conducive to completing the
identified plan and outcomes.
Develops evaluation methods to measure safety
and effectiveness for interventions and outcomes.
Promotes activities that assist others, as
appropriate, in becoming in- formed about costs,

risks, and benefits of care or the plan and solution.

The registered The registered nurse:
V: Leadership

nurse pro-

Engages in teamwork as a team player and a team



leadership in

Works to create and maintain healthy work


environments in local, regional, national, or


international communities.

practice set-

Displays the ability to define a dear vision, the

ting and the

associated goals, and a plan to implement and


measure progress.
Demonstrates a commitment to continuous,
lifelong learning for self and others.

Teaches others to succeed by mentoring and other

strategies. .Exhibits creativity and flexibility
through times of change. .Demonstrates energy,
extolment, and a passion for quality work.
Willingly accepts mistakes by self and others,
thereby creating a culture
in which risk-taking is not only safe, but expected.
Inspires loyalty through valuing of people as the
most predous asset in an organization.
Directs the coordination of care across settings and
among caregivers, including oversight of licensed
and unlicensed personnel in any as- signed or
delegated tasks.
Serves in key roles in the work setting by
participating on committees, councils, and
administrative teams.
Promotes advancement of the profession through
participation in professional organizations.
Additional Measurement Criteria for the Advanced
Practice Registered Nurse: The advanced practice
registered nurse:
.Works to influence decision-making bodies to
improve patient care. Provides direction to enhance
the effectiveness of the health care team. .Initiates
and revises protocols or guidelines to reflect
evidence-based practice, to reflect accepted
changes in care management, or to address
emerging problems.
.Promotes communication of information and
advancement of the profession through writing,
publishing, and presentations for professional or
lay audiences.
Designs innovations to effect change in practice
and improve health outcomes.
Additional Measurement Criteria for the Nursing

Role Spedalty: The registered nurse in a nursing

role spedalty:
Works to influence decision-making bodies to
improve patient care, health services, and policies.
Promotes communication of information and
advancement of the profession through writing,
publishing, and presentations for professional or
lay audiences.
.Designs innovations to effect change in practice
and outcomes. .Provides direction to enhance the
effectiveness of the multidisciplinary
or interdisciplinary team.
Performance appraisal, education, collegiality, ethics, collaboration, research, and
resource utilization. This document serves as objective guidelines for nurses to be
accountable. In their actions, their patients, and their peers (ANA, 998). The standards
provide a method to assure clients hat they are receiving high-quality care, that the nurses
now exactly what is necessary to provide nursing care, and that measures are in place to
determine whether the are meets the standards.
Standards of Care
The Standards of Care in the ANA Nursing: Scopes and Standards of Practice (2004)
describe a competent level of nursing care. The levels of care are demonstrated through
the nursing process: assessment, diagnosis, out- come identification and planning,
implementation, and evaluation. The nursing process is the foundation of clinical decision
making and includes all significant actions taken by nurses in providing care to clients.
Within these standards are the responsibilities for diversity, safety, education, health
promotion, treatment, self-care, and planning for the continuity of care (ANA, 1998).
Standards of care are important if a legal dispute arises over whether a nurse practiced
appropriately in a particular case.
1: Assessment

The registered nurse:

The registered nurse .Collects data in a systematic and ongoing process.


.Involves the patient, family, other healthcare providers, and



data environment, as appropriate, in holistic data collection.

the .Prioritizes data collection activities based on the patient's

patient's health or the immediate condition, or anticipated needs of the patient or




.Uses appropriate evidence-based assessment techniques and

instruments in collecting pertinent data.
Uses analytical models and problem-solving tools.
Synthesizes available data, information, and knowledge
relevant to the situation to identify patterns and variances.
Documents relevant data in a retrievable format.
Additional Measurement Criteria for the Advanced Practice
Registered Nurse: The advanced practice registered nurse
initiates and interprets diagnostic tests and procedures relevant
to the patient's current status
The registered nurse:
.Derives the diagnoses or issues based on assessment data.
.Validates the diagnoses or issues with the patient, family, and
other health care providers when possible and appropriate.
.Documents diagnoses or issues in a manner that facilitates the

determination of the expected outcomes and plan.

The registered nurse Additional Measurement Criteria for the Advanced Practice
the Registered Nurse: The advanced practice registered nurse:


diagnoses or issues.

to .Systematically compares and contrasts clinical findings with

the normal and abnormal variations and developmental events in
formulating a differential diagnosis.
Utilizes complex data and information obtained during






identifying diagnoses.
Assists staff in developing and maintaining competency in the
diagnostic process.


The registered nurse:

Involves the patient, family, and other health care providers in
formulating expected out- comes when possible and

3: Outcomes

.Derives culturally appropriate expected outcomes from the



The registered nurse Considers associated risks, benefits, costs, current scientific
expected evidence, and clinical expertise when formulating expected
outcomes for a plan outcomes.
individualized to the



.Defines expected outcomes in terms of the patient, patient

values, ethical considerations, environment, or situation with
such consideration as associated risks, benefits and costs, and
current scientific evidence. .Includes a time estimate for





outcomes that provide direction for continuity of care.

Modifies expected outcomes based on changes in the status of
the patient or evaluation of the situation. .Documents expected
outcomes as measurable goals.
Additional Measurement Criteria for the Advanced Practice
Registered Nurse: The advanced practice registered nurse:
Identifies expected outcomes that incorporate scientific
evidence and are achievable through implementation of
evidence-based practices.
Identifies expected outcomes that incorporate cost and clinical






consistency among providers.

Supports the use of clinical guidelines linked to positive
patient outcomes.

The registered nurse:







characteristics or the situation (e.g., age and culturally


appropriate, environmentally sensitive).

.Develops the plan in conjunction with the patient, family, and
others, as appropriate
The Includes strategies within the plan that address each of the
nurse identified diagnoses or issues, which may include strategies
develops a plan that
prescribes strategies for promotion and restoration of health and prevention of
and alternatives to
expected illness, injury, and disease.
.Provides for continuity within the plan.
.Incorporates an implementation pathway or timeline within
the plan.
.Establishes the plan priorities with the patient, family, and
others as appropriate. .Utilizes the plan to provide direction to
other members of the health care team.
.Defines the plan to reflect current statutes, rules and
regulations, and standards. -. .Integrates current trends and
research affecting care in the planning process. .Considers the
economic impact of the plan.
.Uses standardized language or recognized terminology to
document the plan.
Additional Measurement Criteria for the Advanced Practice
Registered Nurse: The advanced practice registered nurse:
.Identifies assessment, diagnostic strategies, and therapeutic
interventions within the plan that reflect current evidence,
including data, research, literature, and expert clinical
.Selects or designs strategies to meet the multifaceted needs of
complex patients.
.Includes the synthesis of patients' values and beliefs
regarding nursing and medical thera- pies within the plan.
Additional MeastITemel1t Criteria for the Nursing Role
Specialty: The registered nurse in a nursing role spedalty:







multidisciplinary and interdisciplinary processes to address

the situation or issue.
.Contributes to the development and continuous improvement

of organizational systems that support the planning process.

.Supports the integration of clinical, human, and finandal
resources to enhance and com- plete the dedsion-making
Ie registered nurse
imple- ,nents the The registered nurse:
identified plan.
.Implements the plan in a safe and timely manner.
.Documents implementation and any modifications, including
changes to or omissions of the identified plan.
.Utilizes evidence-based interventions and treatments specific
to the diagnosis or problem. .Utilizes community resources
and systems to implement the plan.
.Collaborates with nursing colleagues and others to implement
the plan. Additional Measurement Criteria for the Advanced
Practice Registered Nurse: The advanced practice registered
.Facilitates utilization of systems and community resources to
implement the plan. .Supports collaboration with nursing
colleagues and other disciplines to implement the plan.
.Incorporates new knowledge and strategies to initiate change
in nursing care practices if







Measurement Criteria for the Nursing Role Spedalty: The

registered nurse in a nursing role spedalty:
.Implements the plan using prindples and concepts of project
or systems management. .Fosters organizational systems that
support implementation of the


The registered nurse:

.Coordinates implementation of the plan. .Documents the
coordination of the care.
Measurement Criteria for the Advanced Practice Registered
Nurse: The advanced practice registered nurse:
.Provides leadership in the coordination of multidisdplinary
health care for integrated de- livery of patient care services.
l: Coordination of .Synthesizes data and information to prescribe necessary
system and community support measures, including
Ie registered nurse
coordi- lates care environmental modifications.
.Coordinates system and community resources that enhance
delivery of care across
Health Teaching and
health promotion
The registered nurse:
.Provides health teaching that addresses such topics as healthy
lifestyles, risk-redudng be- haviors, developmental needs,
activities of daily living, and preventive self-care.
.Uses health promotion and health teaching methods
appropriate to the situation and the patient's developmental
level, learning needs, readiness, ability to learn, language
prefer- ence, and culture. .
.Seeks opportunities for feedback and evaluation of the
effectiveness of the strategies used. Additional Measurement
Criteria for the Advanced Practice Registered Nurse: The
advanced practice registered nurse:
.Synthesizes empirical evidence on risk behaviors, learning
theories, behavioral change the. ories, motivational theories,
epidemiology, and other related theories and frameworks
when designing health information and patient education.
.Designs health information and patient education appropriate


to the patient's develop- mental level, learning needs,

readiness to learn, and cultural values and beliefs.
.Evaluates health information resources, such as the Internet,
within the area of practice for ac- curacy, readability, and
comprehensibility to help patients access quality health
The advanced practice Measurement Criteria for the Advanced Practice Registered
registered nurse and Nurse: The advanced practice registered nurse:



role Synthesizes clinical data, theoretical frameworks, and

provide evidence when providing consultation. .Facilitates the
to effectiveness of a consultation by involving the patient in
the decision-making
plan, and negotiating role responsibilities.

enhance and abilities

of others and effect

Communicates consultation recommendations that facilitate

change. Measurement Criteria for the Nursing Role Specialty:
The registered nurse in a nursing role spedalty:
Synthesizes data, information, theoretical frameworks and
evidence when providing consultation.
Facilitates the effectiveness of a consultation by involving the
stakeholders in the decision- making process.
Communicates consultation recommendations that influence
the identified plan, facilitate understanding by involved
stakeholders, enhance the work of others, and effect change.

Prescriptive Authority
and Treatment

Measurement Criteria for the Advanced Practice Registered

The advanced practice Nurse: The advanced practice registered nurse:

registered nurse uses .Prescribes





prescriptive authority, procedures considering the patient's comprehensive health

procedures, referrals, care needs. treatments,

and .Prescribes pharmacological agents based on a current

in knowledge of pharmacology and physiology.

accordance with state .Prescribes specific pharmacological agents and/or treatments

and federal laws and based on clinical indicators, the patient's status and needs, and

the results of diagnostic and laboratory tests.


Evaluates therapeutic and potential adverse effects of

pharmacological and non-pharmacological treatments.
Provides patients with information about intended effects and
potential adverse effects of proposed prescriptive therapies.
.Provides information about costs, alternative treatments and
procedures, as appropriate.
The registered nurse The registered nurse:
progress Conducts a systematic,




towards attainment of evaluation of the outcomes in relation to the structures and

processes prescribed by the plan and the indicated timeline.
Includes the patient and others involved in the care or
situation in the evaluative process. .Evaluates the effectiveness
of the planned strategies in relation to patient responses and
the attainment of the expected outcomes.
Evaluation contd
.Documents the results of the evaluation.
.Uses ongoing assessment data to revise the diagnoses,
outcomes, the plan, and the implementation as needed.
.Disseminates the results to the patient and others involved in
the care or situation, as appropriate, in accordance with state
and federal laws and regulations.
Additional Measurement Criteria for the Advanced Practice
Registered Nurse: The advanced practice registered nurse:
.Evaluates the accuracy of the diagnosis and effectiveness of
the interventions in relation- ship to the patient's attainment of
expected outcomes.
Synthesizes the results of the evaluation analyses to determine
the impact of the plan on the affected patients, families,
groups, communities, and institutions.
Uses the results of the evaluation analyses to make or
recommend process or structural changes including policy,


procedure, or protocol documentation, as appropriate.

Additional Measurement Criteria for the Nursing Role
Specialty: The registered nurse in a nursing role specialty:
.Uses the results of the evaluation analyses to make or
recommend process or structural changes including policy,
procedure, or protocol documentation, as appropriate.
.Synthesizes the results of the evaluation analyses to
determine the impact of the plan on the affected patients,
families, groups, and communities, and on institutions,
networks, and organizations.
Code of Ethics. Nursing has a code of ethics that defines the principles by which nurses
provide care to their clients. In addition, nurses incorporate their own values and ethics
into practice. The ANA has a number of publications that address ethics and human rights
in nursing. The Code of ethics for Nurses with interpretive statements provides a guide
for carrying out nursing responsibilities that provide quality nursing care and provides for
the ethical obligations of the profession (ANA, 2001). In addition, the ANA established.
The Center for Ethics and Human Rights to ad- tress the complex and ethical human
rights issues confronting nursing (ANA, 2002d). gives several examples of specific
statements of nursing's code of ethics and how nurses apply ethics in their everyday

Nursing Education:
As a profession, nursing requires that its members possess. A significant amount of
education. The issue of standardization of nursing education and entry into practice remains a major controversy. In 1965 the ANA published a position paper on nursing
education that emphasizes the role of education in the profession. Most nurses agree that
nursing education is important to practice and that it must respond to changes in health
care created by scientific and technological advances. There are various education
preparations for the registered nurse. In addition, there is graduate nurse education and
continuing and in-service education for the practicing nurse.
Professional Registered Nurse Education:


There are various educational routes for becoming a professional registered nurse (RN).
Initially, hospital schools of nursing were developed to educate nurses to work within
those institutions. As nursing increasingly defined its own body of knowledge, formalized
educational processes developed to ensure a consistent level of education in institutions.
Such consistency was also necessary for RN licensure.
Currently in the United States the most frequent route an individual can choose to
become an RN is through completion of an associated degree or baccalaureate degree
program. Graduates of both programs are eligible to take the National Council Licensure
Examination for Registered Nurses (NCLEX-RN) to become registered nurses in the
state in which they will practice.
The associate degree program in the United States is a 2-year program that is usually
offered by a university or junior college. This program focuses on the basic sciences and
theoretical and clinical courses related to the practice of nursing. Graduates of this type of
program take the state board examination for RN licensure.
The baccalaureate degree program usually encompasses 4 years of study in a college or
university. The program focuses on the basic sciences and on theoretical and clinical
courses, as well as courses in the social sciences, arts, and humanities to support nursing
theory. In Canada the degree of Bachelor of Science in Nursing BSc (N) or Bachelor in
Nursing (BN) is equivalent to the degree of Bachelor of Science in Nursing (BSN) in the
United States. The AACN published the Essentials of Baccalaureate Education for
Professional Nursing: A Final Report (1998). This document delineated essential
knowledge, practice and values, attitudes, personal qualities, and professional behavior
for the baccalaureate-prepared nurse and guides faculty on the structure and evaluation of
the curriculum and the performance of the graduate (American Association of Colleges of
Nursing, 1998).
Nursing is a helping profession and, as
such, provides services which contribute to
the health and well-being of people.
Nursing is of vital consequence to the
individual receiving ser- vices; it fills needs
which cannot be met by the person, by the
family, or by other persons in the

Education for those in the health

professions must increase in depth and
breadth as scientific knowledge expands.
In addition to those licensed as nurses, the
health care of the public, In the amount and
to the extent needed and demanded,


The demand for services of nurses will
continue to increase. The professional
practitioner is responsible for the nature
and quality of all nursing care that clients

requires the services of large numbers of

health occupation workers to function as
assistants to nurses. These workers are
presently designated: nurses' aides,
orderlies, assistants, attendants, etc.

receive. The services of professional

The professional association must concern

practitioners of nursing will continue to be

itself with the nature of nursing practice,

supplemented and complemented by the

the means for improving nursing practice,

services of nurse practitioners who will be

the education necessary for practice, and


the standards for membership in the

professional association.

Graduate Education:
Master's Education. After obtaining a baccalaureate degree in nursing, a nurse can pursue
further education in any number of graduate fields, including nursing. A nurse completing
a graduate program can receive the degree of Master of Arts (MA) in nursing, Master in
Nursing (MN), or Master of Science in Nursing (MSN). The graduate degree provides the
advanced clinician with strong skills in nursing science and theory with emphasis in the
basic sciences and research-based clinical practice. A master's degree in nursing can be
valuable for nurses seeking roles of nurse educator, clinical nurse specialist, nurse
administrator, or nurse practitioner.
Doctoral Preparation: Professional doctoral programs in nursing (DSN or DNS c)
emphasize the application of re- search findings to clinical nursing. Other programs
emphasize more basic research and theory and award the degree of Doctor of Philosophy
(PhD) in nursing. The need for nurses with doctorate degrees is rising. Expanding clinical
roles, new areas of nursing such as nursing informatics, and rapidly advancing
technology are just a few reasons for increasing the number of doctorally prepared
nurses. It is important to continue to do research in areas such as nursing theory" basic
science and clinical practice to expand nursing knowledge. Doctorally prepared nurses
are needed to educate the beginning nurse and those seeking advanced academic and
clinical preparation.


Continuing and In-Service Education: Because nursing is a dynamic profession,

continuing education programs help nurses remain current in nursing skills, knowledge,
and theory.
Continuing education: involves formal, organized, and educational programs offered by
State Nurses Associations and educational and health care institutions. For example, a
State Nurses' Association might offer a class on caring for older adults with dementia. As
expressed by the ANA (1994), the goals of continuing education in nursing are to
improve and maintain nursing practice, promote and exercise leadership in effecting
change in health care delivery systems, and fulfill professional learning needs. Other
goals include helping nurses become specialized in a particular area of practice and
teaching nurses new skills and techniques.
An in-service education program is instruction or training provided by a health care
agency or institution. An in-service program is held in the institution and is de- signed to
increase the knowledge, skills, and competencies of nurses and other health care
professionals employed by the institution. For example, a hospital might offer an inservice program to inform nurses about primary nursing before it is implemented at the
hospital or a program on the newest safety syringes for administering parenteral
Continuing and in-service education continues to be important after the nurse begins
practice, whether the practice setting focuses on the adult or child, the chronically or
acutely ill, or the home or hospital. Nursing encompasses an ever-widening range of
roles. Multiple career paths and goals are open to new and experienced practitioners.
Nursing practice:
nurses practice in a variety of settings, in many roles within those settings, and with other
caregivers in the allied health professions. Administrators in hospitals and other health
care agencies and institutions guide the practice of nursing only in part. State and
provincial nurse.

Practice Acts establish specific legal regulations for practice, and

professional organizations establish standards of practice as criteria for nursing care

The Congress of Nursing Practice is the part of the NA concerned with legal aspects of
nursing practice, public recognition of the significance of nursing practice, health care,
and implications for nursing practice of ends in health care. In 1980 the Congress for

Nursing practice defined nursing as the diagnosis and treatment f human responses to
actual or potential health problems (ANA, 1980, 1995). This definition illustrates the
consistent orientation of nurses to the provision of care) promote the well-being of their
clients. Today the nursing profession remains committed to the care and nurturing of both
healthy and ill people, individually or 1 groups and communities (ANA, 1995).
Nurse Practice Acts : all states in the United States, Nurse Practice Acts regulate the
licensure and practice of nursing. Each state or province defines for itself the scope of
nursing practice, But most have similar practice acts. The definition of nursing practice
published by the ANA is in some ways representative of the scope of nursing practice as
defined 1 most states. In the last decade, however, many states have revised their Nurse
Practice Acts to reflect nursing's growing autonomy and the expanded roles of nurses in
Licensure and Certification: censure. In the United States, RN candidates must pass Ie
NCLEX.RN, which is administered by the individual state Boards of Nursing. Regardless
of educational preparation, the examination for RN licensure is exactly the same in every
state in the United States. This provides a standardized minimum knowledge base for the
client population nurses serve.
Certification. Beyond the NCLEX-RN, the nurse may choose to work toward
certification in a specific area of nursing practice. Minimum practice requirements are
set, based on the certification the nurse is seeking. National nursing organizations, such
as the ANA, have many types f certification that the nurse can work toward. After passing
the initial examination, the nurse maintains certification by ongoing continuing education
and clinical or administrative practice.
Science and Art of Nursing Practice: Nursing is a multidimensional profession.
Nursing reflects the needs and values of society, implements the standards of professional
performance and the standards of care, meets the needs of each client, and integrates current research and evidence-based findings to provide the highest level of care. Although
nursing has a specific body of knowledge, socialization into the profession and practice
are essentials components of the discipline. Clinical expertise takes time and
commitment. According to Benner (1984), an expert nurse passes through five levels of
proficiency when acquiring and developing generalist or specialized nursing skills.


Nurses use the competencies of critical thinking to integrate information from the
scientific and nursing knowledge bases, derive knowledge from past and present
experiences, apply critical thinking attitudes to a clinical situation, and implement
intellectual and professional standards. Providing well thought out care with the
compassion and caring attributes of the profession enables nurses to provide eacl1 client
the best of the science and art of nursing care.
Novice: Beginning nursing student, or any nurse entering a situation in which there is no
previous level of experience, for example, an experienced operating room nurse chooses
to now practice in home health. The learner learns via a specific set of rules or
procedures, which are usually stepwise and linear.
Advanced Beginner-A nurse who has had some level of experience with the situation.
This experience may only be observational in nature. But the nurse is able to identify
meaningful aspects or principles of nursing care.
Competent-A nurse who has been in the same clinical position for 2-3 years. This nurse
understands the organization and the specific care required by the type of clients, e.g.,
surgical, oncology, or orthopedic clients. This nurse is a competent practitioner who is
able to anticipate nursing care and establish long-range goals. In this phase, the nurse has
usually had experience with all types of psychomotor skills required by this specific
group of clients.
Proficient-A nurse with greater than 2-3 years of experience in the same clinical position.
This nurse perceives a client's clinical situation as a whole, is able to assess an en- tire
situation, and can readily transfer knowledge gained from multiple previous experiences
to a situation. This nurse focuses on managing care as opposed to managing and
performing skills.
Expert-A nurse with diverse experience who has an intuitive grasp of an existing or
potential clinical problem. This nurse is able to zero in on the problem and focus on
multiple dimensions of the situation. This nurse is skilled at identifying client-centered
problems, as well as problems related to the health care system or perhaps the needs of
the novice nurse.
Professional Responsibilities and Roles: Contemporary nursing requires that the nurse
possess knowledge and skills for a variety of professional roles and responsibilities. In
the past, the principal role of nurses was to provide care and comfort as they carried out


specific nursing functions. However, changes in nursing have expanded the role to
include increased emphasis on health promotion and illness prevention, as well as
concern for the client as a whole.
Autonomy and Accountability: Autonomy is an essential element of professional
nursing. Autonomy means that a person is reasonably independent and self-governing in
decision making and practice. In the case of nursing, there are independent nursing
measures a nurse can initiate without medical orders. A professional nurse also actively
collaborates with health professionals to pursue the best treatment plan for a client.
Nurses attain increased autonomy through higher levels of education. In the changing
health care system, advanced practice nurses are increasingly taking on independent roles
in nurse-run clinics, collaborative practice, and advanced nurse practice settings.
With increased autonomy come greater responsibility and accountability. Accountability
means that the nurse is responsible, professionally and legally, for the type and quality of
nursing care provided. The nurse is account- able for keeping current and competent in
technical skills and informed of the knowledge needed to perform nursing care. The
nursing profession itself regulates accountability through nursing audits and standards of
Caregiver: As caregiver, the nurse helps the client regain health through the healing
process. Healing is more than just curing a specific disease, although treatment skills that
promote physical healing are important to caregivers. The nurse addresses the holistic
health care needs of the client, including measures to restore emotional, spiritual, and
social well-being. The caregiver helps the client and families set goals and meet those
goals with a minimal cost of time and energy.
Advocate: In the role of client advocate, the nurse protects the client's human and legal
rights and provides assistance in asserting those rights if the need arises. The nurse
advocates for the client, keeping in mind the client's religion and culture. For example,
the nurse may provide additional information for a client who is trying to decide whether
or not to accept a treatment, or the nurse may assist with communication within the
family. The nurse may also defend clients' rights in a general way by speaking out against
policies or actions that might endanger their well-being or conflict with their rights.


Educator: As an educator, the nurse explains to clients concepts and facts about health,
demonstrates procedures such as self- care activities, determines that the client fully
under- stands, reinforces learning or client behavior, and evaluates the client's progress in
learning. Some client teaching can be unplanned and informal, such as when a nurse
responds to a question about a health issue in casual conversation. Other teaching
activities may be planned and more formal, such as when the nurse teachers client with
diabetes to self-administer insulin injections. The nurse uses teaching methods that match
the client's capabilities and needs and incorporates other resources, such as the family, in
teaching plans.
Communicator: The role of communicator is central to all nursing roles and activities.
Nursing involves communication with clients and families, other nurses and health care
professionals, resource persons, and the community. Without clear communication, it is
impossible to give care effectively, make decisions with clients and families, protect
clients from threats to well-being, coordinate and man. age client care, assist the client in
rehabilitation, offer comfort, or teach. The quality of communication is a critical factor in
meeting the needs of individuals, families, and communities.
Manager: As a manager, the nurse coordinates the activities of other members of the
health care team, such as nutritionists and physical therapists, when managing care for a
group of clients. To effectively manage a single client or group of clients the nurse
implements solid clinical decision- making skills. As a clinical decision maker, the nurse
uses critical thinking skills throughout the nursing process to provide effective care.
Before undertaking any nursing action, whether it is assessing the client's condition,
giving care, or evaluating the results of care, the nurse plans action by deciding the best
approach for each . The nurse makes these decisions alone or in collaboration with the
client and in each of these situations, the nurse collaborates and consults with other
health care professionals (Keeling and Ramos, 1995).
Career Development: Innovations in health care, expanding health care systems and
practice settings, and the increasing needs of clients have been a stimulus for hew nursing
roles. Today nurses need to commit to lifelong learning and career development in order
to provide clients with the state-of- the-art care they need.


Career roles are specific employment positions or paths. Because of increasing

educational opportunities for nurses, the growth of nursing as a profession, and a greater
concern for job enrichment, the nursing profession offers expanded roles and different
kinds of career opportunities. A nurse's career path can be limitless. Examples of career
roles include nurse educators, advanced practice nurses, nurse managers and
administrators, nurse researchers, nurse risk managers, quality improvement nurses,
consultants, and even business owners.
Clinical most nurses enter the profession with the goal of providing direct client care.
The nurse providing direct client care accounts for the majority of practicing nurses. Until
recently, this has been in the acute care hospital set- ting. As health care returns to the
home care setting, there are increased opportunities for nurses to provide direct care in
the client's home. The clinical nurse provides' direct care to the client, using the nursing
process and critical thinking skills. The focus is restorative and curative. The clinical
nurse provides education to the client and family to promote health maintenance and selfcare. In collaboration with other health care team members, the clinician focuses on
returning the client to his or her home and usual state of health.
In the hospital, nurses may choose to practice in a medical-surgical setting or concentrate
on a specific area of practice, such as critical care or emergency care. Most specialty care
areas require some experience as a medical- surgical nurse and additional continuing or
in-service education. Many intensive care unit (ICU) and emergency department nurses
are required to have training in advanced cardiac life support and certification in critical
care, emergency nursing, or trauma nursing. Hospital- based nurses may also choose to
practice in specialty areas such as transplantation, rehabilitation, or oncology. Larger
medical centers offer more opportunity to concentrate practice in a single area.
Advanced Practice Nurses. The advanced practice nurse (APN) is generally the most
independent functioning nurse. An APN has a master's degree in nursing,
Licensed nurses

2,239,816 million 1,853,024 million

Employed nurses Gender





90% 4%




Asian/pacific Islanders


American Indian/Alaska Natives
<30 years
30-49 years

11% >



Diploma program
Associate degree Bachelor's degree


Master's degree




Site of Employment

66% 7% 10% 8%' 10%

Nursing homes/extended care

Community/public health
Ambulatory care
Other (physician office, nursing education)
Advanced education in pharmacology and physical assessment, and certification and
expertise in a specialized area of practice (ANA, 1996). The APN may work in primary,
acute, or restorative care settings. The APN functions as a clinician, educator, case
manager, consultant, and researcher within his or her area of practice, to plan or improve
the quality of nursing care for the client and family. For example, a nurse practitioner in a
community clinic will manage the health care of a group of clients by monitoring their
chronic health problems and diagnosing and treating any new developing problems. The
term advanced practice nurse is an umbrella term for an advanced clinical nurse that
includes nurse practitioners, clinical nurse specialists, certified registered nurse
anesthetists, and nurse-midwives.
Clinical nurse Specialist:
The clinical nurse specialist (CNS) is an APN with nursing expertise in a specialized
area of practice and may work in any practice setting. Traditionally, the CNS has
practiced most often in the hospital setting. The CNS may specialize in a specific disease,

such as diabetes mellitus, cancer, or cardiac problems, or in a specific field, such as

pediatrics or gerontology. The CNS functions as an expert clinician, educator, case
manager, consultant, and researcher to plan or improve the quality of care provided to the
client and family.
Nurse Practitioner: The nurse practitioner provides health care to clients, usually in
an outpatient, ambulatory care, or community-based setting. Nurse practitioners provide
care for clients with complex problems and provide a more holistic approach, attending to
symptoms of non pathological conditions, comfort, and comprehensiveness of care. A
significant percentage of primary care visits by clients extend beyond the boundaries of
medicine and demand the expertise of the nurse. The nurse practitioner is able to establish
a collaborative provider client relationship. A nurse practitioner may work with a specific
group of clients or with clients of all ages and health care needs. The major nurse
practitioner categories are adult, family, pediatric, obstetrics-gynecology, and geriatric. A
nurse practitioner has the knowledge and skills necessary to detect and manage selflimiting acute and chronic stable conditions.
An adult nurse practitioner (ANP) provides primary, ambulatory care to adults with a non
emergent acute or chronic illness and in some settings tertiary care. ANPs work
collaboratively with one or more primary care physicians; for example, in a fivephysician primary care practice, a nurse practitioner may exclusively manage all diabetic
clients who have a foot ulcer. In this example, the nurse practitioner is working
collaboratively with all physicians. A family nurse practitioner (FNP) provides primary
ambulatory care for families, usually in collaboration with a family care physician. The
FNP meets the family's general health care needs, manages some ill- nesses by providing
direct care, and guides or counsels the family as needed.
A pediatric nurse practitioner (PNP) provides health care to infants and children. PNPs
practice in hospital, ambulatory care, emergency care, and physicians' offices. A women's
health nurse practitioner (WHNP) provides primary ambulatory care to women seeking
obstetrical or gynecological health care.
An acute care nurse practitioner functions in collaboration with a physician or house
staff physician in an acute care setting, such as a hospital or specialty clinic. The acute
care nurse practitioner is a generalist, usually based in internal medicine, focusing on the
care of the hospitalized patient.


The geriatric nurse practitioner (GNP) is an ANP with specialization in care of the
older adult. GNPs are trained in the special needs of the aging adult, with emphasis on
health promotion, health maintenance, and functional status. The GNP works with the
client and family to manage existing health problems so as to pro- mote independence
and self-care. The client population is usually age 65 and older.
Certified Nurse-Midwife
A certified nurse-midwife is an RN who is also educated in midwifery and is certified
by the American College of Nurse-Midwives. The practice of nurse-midwifery involves
providing independent care for women during normal pregnancy, labor, and delivery, as
well as care for the newborn. It may include some gynecological services such as routine
Papanicolaou (pap) smears, family planning, and treatment for minor vaginal infections.
A CNM practices with a health care agency that provides medical consultation,
collaborative management, and referral)
Certified Registered Nurse Anesthetist:

A certified registered nurse anesthetist

(CRNA) is an RN who has received advanced training in an accredited program in

anesthesiology. Nurse anesthetists provide surgical anesthesia under the guidance and
supervision of an anesthesiologist, who is a physician with advanced knowledge of
surgical anesthesia.
Nurse Educator: A nurse educator works primarily in schools of nursing, staff
development departments of health care agencies, and client education departments.
Nursing educators need experience in clinical practice to provide them with practical
skills and theoretical knowledge. A faculty member in a school of nursing educates
students to become professional nurses. Nursing faculty members are responsible for
teaching current nursing practice, trends, theory, and necessary skills in laboratories and
clinical settings. Nurse educators in nursing schools are usually required to have graduate
degrees in nursing and additional education in the educational process. Many hold
doctorate or advanced degrees in nursing, education, or administration, such as a master's
degree in business administration MBA), Generally they have a specific clinical,
administrative, or research specialty and advanced clinical experience.
Nurse educators in staff development departments of health care institutions provide
educational programs for nurses within their institution. These programs include
orientation of new personnel, critical care nursing courses, assisting with clinical skill


competency, safety training, and instruction about new equipment or procedures. These
nursing educators often participate in the development of nursing policies and
The primary focus of the nurse educator in an agency's apartment of client education is to
teach ill or disabled clients and their families how to provide care in the home. These
nurse educators may be specialized and certified, such as a certified diabetic educator
(CDE) or an os- )my care nurse, and see only a discrete population of clients, In most
health care agencies, however, the budget does not permit a separate client education
department therefore the responsibility usually falls to the staff nurse
plan and provide client and family education.
Nursing Administrator: A nurse administrator manages client care and the delivery of
specific nursing services within a health care agency. Nursing administration begins with
positions such as the charge nurse or assistant nurse manager. Experience and additional
education may d to a middle-management position, such as nurse manager of a specific
patient care area(s) or house super- or, or to an upper management position, such as assist
or associate director or director of nursing services. Nurse manager's positions usually
require at least a baccalaureate degree in nursing, and director and nurse executive
positions generally require a master's degree. Chief nurse executive and vice president
positions in large health care organizations often require preparation at the doctorate
level. Nurses may have advanced degrees such a master's degree in business
administration (MBA), hospital administration (MHA), or public health (MPH).
In today's health care organizations, directors may have responsibility for more than
nursing personnel responsibilities may include a particular service or product line, such
as medicine or cardiology, and include supportive functions and personnel such as
medicine clinics, cardiac diagnostics, or outpatient services such as cardiac the
catheterization. In addition, the director may be responsible for ancillary personnel such
as cardiology technicians, respiratory therapists, social workers, and dietitians.
Vice presidents of nursing or chief nurse executives of have responsibilities for all
clinical functions within the hospital. This may include all ancillary personnel who
provide and support patient care services. The nursing administrator needs to be skilled in
business and management, as well as understand all aspects of nursing d client care.


Functions of administrators include budgeting staffing, strategic planning of programs

and services, employee evaluation, and employee development. (Douglas 1996).
Nurse Researcher: The nurse researcher investigates problems to improve nursing care
and to further define and expand the scope of nursing practice nurse researcher may be
employed in an academic setting, hospital, or independent professional or community
service agency. The minimum educational requirement is a doctoral degree, with at least
a master's degree in nursing.

Professional Nursing Organizations: A professional organization is created to deal with

is- sues of concern to those practicing in the profession. In North America the major
professional nursing organizations are the National League for Nursing (NLN) and
American Nurses Association (ANA). The NLN is concerned with the improvement of
nursing education, nursing service, and health care delivery in the United States.
ANA was formed in the late nineteenth century to improve standards of health and the
availability of health care, to foster high standards for nursing, and to promote the
professional development and general and economic welfare of nurses. The ANA is part
of the International Council of Nursing (ICN). The objectives of the ICN parallel those
of the ANA: promoting national associations of nurses, improving standards of nursing
practice, seeking a higher status for nurses, and providing an international power base for
The ANA is active in political, professional, and financial issues affecting health care and
the nursing profession. ANA is a strong lobbyist in professional practice issues, such as
limits of overtime hours. In this example, ANA extensively lobbied state legislatures to
restrict the length of overtime anyone nurse's shift can be extended. This was due to the
safety risk of 12 to 16 hours on client and nurse safety. There is an increased risk of
treatment errors and nurse injury when the nurse's workday is extended.
Nursing students take part in organizations such as the National Student Nurses
Association (NSNA) in the United States and the Canadian Student Nurses Association
(CSNA) in Canada. These organizations consider issues of importance to nursing
students, such as career development and preparation for licensing. NSNA often
cooperates in activities and programs with the professional organizations.


Some professional organizations focus on specific areas such as critical care, nursing
administration or research, or nurse-midwifery. These organizations seek to improve the
standards of practice, expand nursing roles, and foster the welfare of nurses within the
specialty areas. In addition, professional organizations present education programs and
publish journals.

Future Trends in Nursing: This chapter has emphasized that nursing is not a static,
unchanging profession but is continuously growing and evolving as society changes, as
health care emphases and methods change, as lifestyles change-and as nurses themselves
change. To speak of nursing at all is to speak of nursing as it is at a given time, and in this
sense, this chapter is about trends in nursing.

The current philosophies and definitions of nursing demonstrate the holistic trend in
nursing-to address the whole person in all dimensions, in health and illness, and in
interaction with the family and community. Nursing continues to draw on the social
sciences and other fields as the focus of nursing care expands.
Expansion of Employment Opportunities: Nursing practice trends include a growing
variety of employment settings in which nurses have greater independence, autonomy,
and respect as members of the health care team. Nursing roles continue to expand and
develop, broadening the focus of nursing care and providing a more holistic and allencompassing domain. Nursing therapies are not only drawing from traditional nursing
and medicine, spiritual, and emotional realms, but also expanding into alternative
therapies such as healing touch, massage therapy, and use of natural herbs and vitamins:
Nursing's Public Perception: Any member of society who has been ill, hospitalized, or
visited an emergency department has experienced nursing care; as an ANA campaign
noted, "Everybody needs a Nurse." The Johnson and Johnson Foundation has developed
a compelling, attention-getting media campaign on the nursing profession. These media
clips show nursing practice, and the nurses featured in the advertisements describe their
satisfaction with the profession.
Nursing is a pivotal health care profession; as frontline health care providers, nurses
practice in all health care settings and constitute the largest number of professionals.


Nurses are essential to provide skilled, specialized, knowledgeable care; to improve the
health status of the public; and to ensure safe, effective quality care (ANA, 2002c). In
addition, the American public rated nurses high in honesty and ethics in their professional
Nursing's Impact on Politics and Health Policy:
The ability to influence or persuade an individual holding a government office to exert
the power of that office to affect a desired outcome is known as political power or
influence. Nurses' involvement in politics is receiving greater emphasis in nursing
curricula, professional organizations, and health care settings. Professional nursing
organizations have employed lobbyists to urge state legislatures and the U.S. Congress to
improve the quality of health care.
The ANA works for the improvement of health standards and the availability of health
care services for all people, fosters high standards of nursing, stimulates and promotes the
professional development of nurses, and advances their economic and general welfare.
The purposes are unrestricted by considerations of nationality, race, creed, lifestyle, color,
sex, or age. The ANA employs RNs as lobbyists at the federal level, and state nursing
organizations also hire lobbyists and legislative specialists to work on state nursing issues
and assist with federal efforts. Finally, lobbyists working on behalf of nursing are
employed in Washington, D.C., by professional organizations such as the American
Federation of Teachers,

NLN, American College of Nurse-Midwives, American Public Health Association, and

AACN. These groups aim to remove financial barriers to health care, increase the' quality
of nursing care available, increase economic rewards to nurses, and expand professional
nursing roles.
In addition, individual nurses can influence policy decisions at all governmental levels,
and organized nursing's unified efforts, such as With Nursing's Agenda for Health Care
Reform (ANA, 1991) and Nursings Agenda for the Future: A Call to the Nation (ANA,
2002c), will be critical to exert nurses' influence early in the political process. If nurses
become serious students of social needs, activists in influencing policy to meet those


needs, and generous contributors of time and money to nursing and their organizations
and to candidates working for universal good health care, then the future is bright indeed.
Nurses are becoming more involved in health care reform. Nursing's Agenda for Health
Care Reform supports the creation of a health care system that ensures access, quality,
and services at affordable costs. The plan for reform focuses on primary health care
services and the pro- motion, restoration, and maintenance of health. Healthy People
2010 (USDHHS, 2002) is a document for public health policy for the new millennium
(see Chapter 6). It outlines goals for vulnerable populations, such as low-income groups,
minorities, and persons With disabilities (Lancaster, 1999).
Political activism and commitment are a part of professionalism, however, and politics
are an important aspect of the delivery of health care. Therefore nurses should view
politics as a reality that includes the arts of influence, compromise, and social interaction.
Nurses have been involved in a different sort of politics in schools of nursing and in
health care settings when seeking additional resources, more self-direction, and
accountability with authority. The skills gained in such experiences can be transferred to
the politics of health care policy making.
As long as nurses maintain involvement in health care policy and practice, misinformed
outsiders cannot attempt to impose their Will on nursing and nursing practice. Non
nursing groups, often led by other health care providers, have made attempts to impose
institutional licensure, mandatory continuing education, curtailment of advanced nursing
practice, and other constraints on the nursing profession. Nursing should have its own
voice in decisions made in these and numerous other areas affecting the practice and
quality of nursing care. Although nurses have often successfully prevented infringement
on the profession's self-governance, the future of nursing requires that nurses individually
and collectively seek a greater influence on health care polices affecting nursing practice.
Historical Development of Nursing Education in India:

In 1871, training for midwives were given for a period of six' months with
supervised nursing practice.

In 1918, first Lady Health Visitors course was started in Lady Reading


Health School, Mumbai.

Later diploma in General Nursing and Midwifery course was started with 3
years 9 months and later it was condensed to 3 years duration.

In 1946, 4 years basic nursing training programme started at RAK College,

New Delhi and CMC Vellore.

In 1953, post basic degree programme was started in Thiruvananthapuram.

In 1959, the first master's programme in nursing was started at RAK College
of Nursing, New Delhi.

In 1986, M Phil at RAK College of nursing, New Delhi was started.

In 1991, the first doctoral programme in nursing was established in Institute

of Nursing sciences, MV Shetty Memorial College, Mangalore.
Pattern of nursing training programmes in India are:

Vocational nursing (at 10+2 level)

Multi-purpose health assistants (after 10+2; 18 months duration).

Diploma in General Nursing and Midwifery course (after 12 years of schooling,

for 3years).

Basic BSc, Nursing (10+2 with sciences, 4 years duration)

Post basic BSc Nursing (after diploma nursing with 2 years experience and 2
years duration).

MSc (N) with any speciality (after BSc nursing with 2 years of experience and 2
years duration).

M Phil in nursing (after MSc nursing 1 Y2 years-regular; 2 years-part-time).

PhD. in nursing (after MSc nursing 3 yearsduration-regular; after M Phil nursing2 years duration).

Trends in Nursing Education.

Records of civilization in ancient India exist from 2500 BC when the Indus valley
civilization flourished. The sacred 'books of learning' the Veda were produced in the
Vedic period from 1500 BC. The history of nursing in India goes back through the
centuries to about 1500 BC. The beginnings are shrouded in the mist of ancient
myths (Wilkinson A. 1965).
The advent of Christianity .and the teachings of Christ, which included the
statements such as 'love thy neighbour as thy self', 'I was sick and he visited me


enjoined the care of the sick and the helpless. Charaka and Susruta leading
authorities on the ancient Hindus system of Ayurveda (the science of life) though
lived in the Christian era, they were not influenced by the Christianity. The
following reference is found regarding the nurse in Charaka. Samhita:
Nurse: Knowledge of the manner in which drugs should be prepared and
compounded for administration, cleverness, devotedness to the. patient waited upon,
and purity (both of mind and body) are the four qualifications of the attending nurse.
Subsequently, monastic' orders further emphasized knowledge based health and nursing
care. Nuns, monks had to acquire special knowledge and skills before being assigned to
take care of the sick. The renounced Roman Matrons, Fabiola, Marceba and Paula stand
out as early intellectuals associated with organisation of hospitals and nursing. Later, the
many Christian religious orders emphasized the special knowledge needed by caregivers.
Modern Scientific Nursing: Nightingale's
Model of Nursing Education
Florence Nightingale emphasized on cognitive knowledge and skills (1909).
Preparation of nurses in Florence Nightingale's school of nursing at St. Thomas
hospital included a years training with instruction by the Matron, the ward sister and
the physician before assignment for 2-year hospital apprenticeship experience, during
which students were granted stipends. These students were called 'ordinary
probationers'. Those who did not receive stipend, but paid tuition for the first year
were educated for higher positions and were called 'lady nurses'. Nightingale model of
nursing education, the hospital based diploma school appears to have been the first
model in almost all countries.
The most conspicuous and widespread modification of the Nightingale system had
occurred, in the United States and Canada and this is referred to as 'American system' or
professional model in contrast to the British or Nightingale's apprenticeship model. A
span of 60 odd years since nursing schools were first established in US divides itself into
three periods of about 20 years each.
1. A pioneering period: 1873.1898
The immediate problem was not to build a finished educational structure but to clear the
ground, to provide decent conditions for both patients and nurses, and to lay the

foundations of an adequate nursing service.

2. Boom period in nursing education: 1893-1913
Every hospital wanted to have a school of its own. The number of schools of nursing
increased tremendously. The young nursing profession organized its forces and tried
its level best to control over expansion with the resulting slump in standards. Though
laws were passed, variations existed in admission standards, in programs of
instruction and also in the product of these schools.
Collaboration of nurse leaders in England and the US resulted in the funding of the
International Council of Nurses in 1899, under the leadership of Ethal Fon Wick and
Isabel Hampton. From its inception, the council worked toward professionalization of
nursing in many countries and promoted national licensing, accreditation laws, and
improvement in nursing education.
3. Period of standard setting and stock taking: 1913-1933
National League of Nursing Education under the leadership of Miss A Adelaide
Nutting published standard curriculum for nursing schools in 1917. ~ Nursing students'
preparation was services oriented rather than education oriented, as nurse educators did
not hold advanced educational preparation. Gold Mark report identified many I
inadequacies in the education and concluded that advanced. educational preparation
was essential for teachers, administrators and public health nurses.

1940s-1960s: This period is considered as basic science era. Brown (1948) a social
anthropologist, reassessed nursing education at the request of national nursing council
for war service, supported Winslow-Gold Mark report stressing on inadequacies in
nursing education and stated that within 50 years, the education of nurses should
occur in collegiate settings.
Indian Nursing Council:
The Indian Nursing Council was established under an Act of Parlian1ent, known as the
Indian Nursing Council Act, 1947 following a recommendation made by the Shore
Committee in 1946. The Act was subsequently amended in 1950 and 1957.
The Indian Nursing Council was constituted in 1949. Section 3(1) of the Indian
Nursing Council Act describes the constitution and composition of the council.


There are 25 elected members through different registration councils and institutions, 26 ex-offices members including superintendent of nursing service and
Directors of Health Services of various states, 4 nominated members of the
Government of India and 3 elected members of Parliament, making a total of 55
members. The 55 members include 31 nurses, 19 doctors and 5 others. The
President and Vice-Presidents are elected by the Council. Secretary is usually the
nursing adviser of the Directorate General of Health Services.
The Executive Committe consists of 7 elected members of the council. The
President and Vice-President are ex-officio men1bers. The official address of the
Indian Nursing Council is: Indian Nursing Council, Combined Councils Building,
Temple Lane, Kotla Road, New Delhi. The council meets once a year, and the
executive more frequently.
The functions of the council are:
1. Prescribing minimum syllable for the training of nurses,

midwives and health

visitors, and regulations for the institutions conducting there courses.

2. Inspecting schools of nursing and the conduct of examinations.
3. The recognition of examining bodies.
4. The maintenance of a register of Indian nurses. The Indian Nursing Council has a
statutory obligation to see that the minimum standards, which are prescribed are
being met. In order to fulfil this function, schools of nursing are inspected and the
conduct of examinations is regulated. A report of each inspection is seen by the
executive committee. The council has the power to withdraw recognition if the
minimum requirements are not met. The submission of annual reports by the
schools of nursing to the council is another means of exercising control to ensure
that the minimum requirements laid down are met. The Indian Nursing Council is
an autonomous body and its official relationship with the state is through the state
State Nursing Councils
All the states in India now have a Nursing Council. Each has its own registrar and is
responsible for the registration of nurses, midwives, health visitors and auxiliary nurse
midwives. Some of the state Nursing Councils are recognized as examining bodies by the
Indian Nursing Council. The state councils are legally empowered by the nurses Act to


under take responsibility to exert general supervision over the performance of the nurses
within their jurisdiction. This includes checking substandard nursing service, negligence
of duty and unethical behaviour of registered nurses. State councils act in close cooperation with the State Governments.

Nurse Practice Act

In Some countries there is a separate "Nurse Practice Act" which lays down the detailed
functions which nurses of different categories in different practice areas need to perform.
Such an Act will provide legal protection to nurses, and safe nursing practices for the
community. The possibility of introducing such an Act in India is under active
Trained Nurses Association of India
The Trained Nurses Association is an non-sectarian, nonpolitical, professional
organisation whose membership in open to all registered nurses who have received a full
3 years training in general nursing and hold certificates which are recognized by the
Indian Nursing Council.
The Trained Nurses Association (TNAI) has its origin in the Association of Nursing
Superintendents of India which was formed in 1905 by a small group of a nursing
superintendents from different parts of the country who fall the need and importance of
the development of nursing as an honorable progression. Within 3 years, it was
considered essential to enlist the cooperation of the trained nurses to advance the cause of
nursing. For the reason, a second association known as the trained nurses association of
India was was formed in 1908. In 1912, the TNAI was affliated to the international
council of nurses, in 1917 it was registered. In 1922, the two associations were
amalgamated under the banner Trained Nurses Association of India. In 1922, the student
nurses association of TN AI was formed which continues to be an important wing of the
The aims of the TNAI which are set out in its constituation are as follows:
a. To uphold in every way the dignity and honour of the nursing profession.
b. To promote a sence of esprit de corps among all nurses.
c. To enable members to take council together, on matters affecting their professions.


d. To elevate nursing education and to raise the standard of I training. e. To strive to bring
about a more uniform system of education, examination, certification and registration.
f. To donate can subscribe to, an otherwise and any institution on organisation in, or
outside, India connected with nursing.
g. To promote and provide for welfare of, and to give relief by grants of money on other
aid, on otherwise as the association may thing fit.
Some of the important achievements of the TNAI are (1) raising the standard of training,
of both general and midwifery training, (2) the establishment of nurse registration
councils in many states, (3) the establishment of the college of nursing in Delhi, (4)
formation of the Health Visitor's, League, the Midwives Association and the Student
Nurses Association. A detailed account of the TNAI will be found in the booklet TNAI
handbook, the TNAI in the only professional association of nurses devoted to work for
the welfare of nurses throughout the country on a national level.
International Council 'of Nurses:
The International Council of Nurses (ICN) was founded in 1899 by Mrs. Bedford
Fenwick, an Englishwoman. The ICN is the oldest international association of
professional women. Membership is open' to all self-governing national nurses
associations. The Indian Nursing Council was affiliated to the ICN in 1912. The
headquarters of the ICN are located in Geneva, Switzerland. Currently, the ICN is a
federation of 95 National Nurse Association representing over a million nurses
throughout the world.
Nurses of national association are automatically members of the ICN. Under the
auspices of the ICN, nurses from national association may attend international
conferences visit other countries for study, employment. On observation the rough the
ICN exchange of privileges programme obtain advice an assistance through the ICN
headquarters and may draw on the resources of the ICN information centre. The
international council of nurses 'is in official relationship with the WHO, UNICEF, ILO
and other international bodies. The ICN publishers a quarterly journal, the International
Nursing Review. An international conference of ICN is held every four years. May 12
is usually celebrated around the world as International Nurses Day, as on this day
Florence Nightingale, founder of modern nursing was born But the national association

are free to choose another date of special significance to the nursing profession within
their own country.



Ethics is the study of good conduct, character, and motives. It is concerned with
determining what is good or valuable for all people. Acts that are ethical often reflect a
commitment to standards beyond personal preferences-standards on which individuals,
professions, and societies agree.
Basic Terms
To discuss ethics, it is helpful to establish a basic vocabulary. Although the terms may
have a certain meaning in a larger context, they provide specific meanings within the
context of ethics that further the understanding and discussion about ethical matters.
These basic terms include autonomy, beneficence, non maleficence, justice, and fidelity.
In his essay Autonomy under duress, Leonard harris (1992).Challenges the notion that
respect for autonomy guarantees respect for all persons. Most researchers investigating
the concept of autonomy focus on appreciating culture differences. For example,
investigators on a Navajo reservation identified a cultural tradition where thought and
language are considered to have the power to shape reality. As a result, the discussion of a
poor prognosis, often considered a duty out of respect for autonomy, can have a
devastating effect for a client who is from a Navajo tradition. Harris is also concerned
that the definition of autonomy is influenced by the culture of the people using the term.
His concerns, however, led him to conclude that there can be limits in other more subtle
ways to the value of respect for autonomy. His argument is based on his experience as an
African-American. If race-targeted advertising such as cigarette and alcohol" advertising
elicits less social consternation than we might hope, one reason may be that the target is
not invested by physicians and society in general with ties of affection, compassion, and
value among those empowered to create change. II Society may claim respect for
autonomy, I and health care providers specifically commit to this respect in their
professional practices. Nonetheless, Harris argues, certain groups of poor or historically
underserved peoples , may not enjoy equal respect for autonomy. The respect they enjoy
is lessened as a result of racial prejudice. Respect for autonomy applied in this way


promotes harm. Harris does not argue to abandon the concept of autonomy. He does
warn, " however, that an honest appraisal of its use is critical.
Implications for Practice:
Harris recommends a thorough self-examination to ensure that when the term autonomy
is applied, it is applied with respect, compassion, and value, as though no differences
existed between classes or races of people.

Autonomy refers to a person's independence. As a standard in ethics, autonomy
represents an agreement to respect another's right to determine a course of action. Respect
for another's autonomy is fundamental to the practice of health care. It serves to justify
the inclusion of clients in all aspects of decision making regarding their health care. The
agreement to respect autonomy involves the recognition that clients are "in charge of
their own destiny in matters of health and illness" (O'Neil, 1995). For example, the
purpose of the preoperative con- sent that clients must read and sign before surgery is the
assurance in writing that the health care team respects the client's independence by
obtaining permission to proceed.
The consent process implies that a client may refuse treatment, and in most cases the
health care team must agree to follow the client's wishes. Health care professionals agree
to abide by a standard of respect for the clients autonomy.
Beneficence refers to taking positive actions to help others. The practice of beneficence
encourages the urge to do good for others. Commitment to beneficence helps to guide
difficult decisions wherein the benefits of a treatment may be challenged by risks to the
client's well-being or dignity. A child's immunization may cause discomfort during
administration, but the benefits of protection from disease, both for the individual and for
society, outweigh the temporary discomforts. The agreement to act with beneficence also
requires that the best interests of the client remain more important than self-interest. For
example, a nurse will not simply follow medical orders but will act thoughtfully to
understand client needs and then work actively to help meet those needs.


Maleficence refers to harm or hurt; thus non maleficence is the avoidance of harm or
hurt. In health care ethics it is important to remember that ethical practice involves not
only the will to do good, but also the equal commitment to do no harm. The health care
professional tries to balance the risks and benefits of a plan of care while striving to do
the least harm possible. This principle is often helpful in guiding discussions about new
or controversial technologies. For example, a new bone marrow transplant procedure may
promise a chance at cure. The procedure, however, may require long periods of pain and
suffering. These discomforts should be considered in light of the suffering that the disease
itself might cause, and in light of the suffering that other treatments might cause. The
commitment to provide least harmful interventions illustrates the term non- maleficence.
The standard of non maleficence promotes a continuing effort to consider the potential for
harm even when it may be necessary to promote health. ,
Justice refers to fairness. Health care providers agree to strive for justice in health care.
The term often is used during discussions about resources. What constitutes a fair
distribution of resources may not always be clear. In these cases national discussion about
just distribution of resources often helps to clarify methods for achieving fairness. For
example, in the United States the number of candidates awaiting liver transplants is
approximately 3 times larger than the number of available organs for transplantation.
Decisions about who should receive available organs are always difficult. Criteria set by
a national multidisciplinary committee strive for justice by ranking recipients according
to need. These criteria are preferable to resorting to selling organs for profit, which would
favor recipients with the most money, and preferable to distributing them by lottery,
which would result in random distribution without regard to justice.
Fidelity refers to the agreement to keep promises. A commitment to fidelity explains the
reluctance to abandon clients, even when disagreement arises about decisions that a client
may make. The standard of fidelity also includes an obligation to follow through :with
care offered to clients. For example, if a nurse assesses a client for pain and then offers a
plan to manage the pain standard of fidelity encourages the nurse to monitor the client's
response to the plan. Professional behavior by the nurse includes revision of the plan as
necessary to keep the promise to reduce pain.


Professional Nursing
Code of Ethics. A code of ethics is a set of ethical principles that are accepted by all
members of a profession. A profession's ethical code is a collective statement about the
group's expectations and standards of behavior. Codes serve as guidelines to assist nurses
and other professional groups when questions arise about correct practice or behavior.
The nursing code of ethics, as in other 'professions, sets forth ideals of conduct. The
American nurses Association (ANA) and the International Council 'of nurses (ICN) have
established widely accepted codes professional nurses attempt to follow. These codes
differ somewhat in specific emphasis, but they reflect the same basic principles, including
responsibility, accountability, advocacy, confidentiality, and veracity. Nurses agree to
responsibility for specific actions and accountability for the consequences. To practice
responsibly, professional nurses also agree to maintain competence in their practice and
to use competence the application of judgment.

Accountability refers to the ability to answer for one's own actions. The nurse balances
accountability to the client, the profession, the employer, and society. For example, a
nurse may know that client who will be discharged soon remains confused about how to
administer insulin. The action that a nurse takes in response to this situation will be
guided by the sense of accountability. The client, the institution, and society rely on the
good judgment of the nurse and trust that the nurse will take action in response to this
situation. The nurse may request more hospitalization to provide further teaching or
arrange home care to continue teaching at home. The goal is the prevention of injury to
the client. The nurse's sense of accountability guides actions '1'thatachieve this goal.
To remain accountable to society, nursing professionals agree to evaluate practices and
actions and to take action to preserve nursing excellence the joint commission on
accreditation association, recommends standards for the delivery of nursing care. These
standards provide a basic structure against which nursing care is objectively measured.
Accountability is best ensured and measured. When quality of care has been defined.
National organizations such as the JCAHO and ANA provide these definitions and offer
standards of practice to achieve quality as well as a structure for evaluation of continuing
practice a CAHO, 2002). The following activities serve to : support standards of the
JCAHO and ANA in the nursing professions:


Evaluation of new professional practices and reassessment of existing ones

Maintenance of standards of health care

Facilitation of personal reflection, ethical thought, and personal growth

Provision of a basis for ethical decision making

The nurse, in all professional relationships, practices with compassion and respect for the
inherent dignity, worth and uniqueness of every individual, unrestricted by considerations
of social or economic status, personal attributes, or the nature of health problems.
The nurse's primary commitment is to the patient, whether an individual, family, group,
or community.
The nurse promotes, advocates for, and strives to protect the health, safety, and rights of
the patient. The nurse is responsible and accountable for individual nursing practice and
determines the appropriate delegation of tasks consistent with the nurse's obligation to
provide optimum patient care.
The nurse owes the same duties to self as to others, including the responsibility to
preserve integrity and safety, to maintain competence, and to continue personal and
professional growth.
The nurse participates in establishing, maintaining, and improving health care
environments and conditions of employment conducive to the provision of quality health
care and consistent with the values of the profession through individual and collective
The nurse participates in the advancement of the profession through contributions to
practice, education, administration, and knowledge development.
The nurse collaborates with other health professionals and the public in promoting
community, national, and inter- national efforts to meet health needs.
The profession of nursing, as represented by associations and their members, is
responsible for articulating nursing values, for maintaining the integrity of the profession
and its practice, and for shaping social policy.


The term responsibility refers to the characteristics of reliability and dependability. The
term implies an ability to distinguish between right and wrong. In professional nursing,
responsibility includes a duty to perform actions well and thoughtfully. When
administering a medication, for example, a nurse is responsible for assessing the client's
need for the drug, for giving it safely and correctly, and for evaluating the response to it.
By agreeing to act responsibly, the nurse gains trust from clients, colleagues, and society.
The concept of confidentiality in health care enjoys widespread acceptance in the United
States. Federal legislation known as HIPAA (Health Insurance Portability and
Accountability Act of 1996) requires it. The legislation defines the rights and privileges
of clients for protection of privacy without diminishing access to quality care. In addition
to a requirement for education of all employees in health care about the HIPAA
protections, the legislation establishes fines for infractions (HHS fact sheet, 2002).
Medical records may not be copied or forwarded without a client's consent. Health care
information, including laboratory results, diagnosis, and prognosis, is not shared with
others without specific client consent. This practice even includes preventing other family
members or friends of the client from acquiring health care information. Conflicting
obligations may arise when a client wants to keep information from insurance companies
to preserve coverage or from employers to preserve a job. The commitment to
confidentiality is particularly challenged as medical records become computerized.
Preservation of confidentiality is often in competition with the need to facilitate access to
information. In the case of computer access, health care institutions work to protect
confidentiality by using special access codes that limit what certain employees can find
on a computer system.



fundamental Nurses and Practice

responsibilities: to promote health, to The nurse carries personal responsibility

prevent illness, to restore health, and to and accountability if ! nursing practice and
alleviate suffering. The need for nursing is for maintaining competence by COI
Inherent in nursing is respect for human The nurse maintains a standard of personal
rights, including the right to life, to dignity health such the, .the ability to provide care
and to be treated with respect. Nursing care is not compromised.

is unrestricted by considerations of age, The




colour, creed, culture, disability or illness, individual competence

gender, nationality, politics or social status.


.when accepting

and delegating responsibility.

Nurses render health services to the 1be nurse at all. times maintains standards
individual, the family, and the community of personal conduct which reflect well on
and coordinate their services with those of the profession
related groups.




Nurses and the Profession

Nurses and People

The nurse's primary responsibility is to The nurse assumes the major role in
determining and implementing acceptable
those people requiring nursing care.
In providing care, the nurse promotes an standards of critical nursing practice,
environment in which the human rights, management, research, and education.
values, customs, and spiritual beliefs of the The nurse is active in developing a core of
individual, family, and community are research-based professional knowledge.
The nurse, acting through the professional.


The nurse ensures that the individual organization, participates in creating and
receives sufficient in- formation on which maintaining equitable social and economic
to base consent for care and related working conditions in nursing.
The nurse holds in confidence personal

Nurses and Co-workers

information arid uses judgment in sharing The nurse sustains a cooperative

relationship with co-workers in nursing and
this information.






other fields.

responsibility for initiating and supporting The nurse takes appropriate action to
action to meet the health and social needs safeguard individuals when their care Is
of the public, in particular those of endangered by a co-worker or any other
vulnerable populations.
The nurse also shares responsibility to
sustain and protect the natural environment
from depletion, pollution, degradation and


Older people may not be as familiar with the concept of autonomy as people from
younger generations. As a result, older adults may be uncomfortable disagreeing
with doctors or nurses. They may view assertiveness as a violation of trust.

.As people age, they may develop clinical conditions that affect the
communication process: hearing deficits; memory impairments, chronic illness,
isolation. Clients may become incapacitated by stroke or disease. Most older
adults take multiple medications, some of which may affect cognitive skills in
subtle ways. It is important to evaluate the competence of a client to make
decisions, and to provide assistance where necessary, especially when treatment
choices, consent, or ethical issues arise.

.Consensus about medical goals for clients ; the geriatric population can be hard
to achieve. When is a position so diminished by old age that a treatment plan not
orily prolongs life, it also prolongs suffering? Working to ensure dignity and
comfort can be as important as achieving medical success.

A part of the ANA code of conduct addresses the issue of veracity, another aspect of
reliability. Veracity in general means accuracy or conformity to truth. As a part of the
nursing code of ethics, veracity guides nurses to practice truthfulness. Although in most
circumstances veracity is an odious asset, the practice of truthfulness may be challenged
during the delivery of health care. A nurse may have to balance competing interests in
certain cases. For example, a spouse may make an urgent plea that a client not be given
news of a poor prognosis. In this case, principles generally in effect that may take
precedence over the spouse's wishes include respect for the client's autonomy and the
principle of veracity. In some in may be tempting to tell a child that a medicine when it
does not or that a procedure will not it probably will, to achieve a level of compliance
codes of ethics guide the nurse to tell however, and it is a rare circumstance where other
principles would support another behavior.


Professional nurses must understand the legal limits influencing their daily practice. This,
coupled with good judgment and sound decision making, ensures safe and appropriate
nursing care.
Sources of Law
The legal guidelines that nurses must follow are derived from statutory law, regulatory
law, and common law. Statutory law is created by elected legislative bodies such as state
legislatures and the U.S. Congress. An example of state statutes are the Nurse Practice
Acts found in all 50 states. These nurse practice acts describe and define the legal
boundaries nursing practice within each state, An example of a federal statute enacted by
the U.S. Congress is the Americans with Disabilities Act (ADA) (1995). This statute
products the rights of handicapped individuals in the work place, in educational
institutions, and throughout our society, Regulatory law, or administrative law, is created
by administrative bodies such as State Boards of nursing when they pass rules and
regulations. An example regulatory law is the duty to report incompetent or un ethical
nursing conduct to the State Board of Nursing common law is created by judidal
dedsions made in courts when individual legal cases are decided. An example common
law is informed consent and the client's right to refuse treatment.
Statutory law is either civil or criminal. Criminal laws prevent harm to society and
provide punishment for crimes (Black, 1999). There are two classifications of crime. A
felony is a crime of a serious nature that has a penalty ally of imprisonment for greater
than 1 year or even death. A misdemeanor is a less serious crime that has a penalty of a
fine or imprisonment for less than 1 year an example of criminal conduct for nurses
would be misuse of a controlled substance.
Civil laws protect the rights of individual persons within our society and encourage fair
and equitable treatment among people (Black, 1999). Generally, violations of civil laws
cause harm to an individual or property. The damages for civil laws involve the payment
of money, unlike criminal laws, which are punished by imprisonment however under
many federal and state laws, sanctions for violations may include both civil and criminal
Standards of Care:


Standards of care are the legal guidelines for nursing practice, Nursing standards of care
are defined in the nurse practice. Acts and by the State Board of Nursing of each state,
by the federal and state laws regulating hospitals and other health care institutions, by the

and specialty nursing organizations, and by the written policies and

procedures of employing institutions (Illinois Nursing Practice Act, 1997). In a

malpractice lawsuit, nursing standards of care are used to measure nursing conduct and to
determine whether the nurse acted as any reasonably prudent nurse would act under the
same or similar circumstances. A breach of the nursing standard of care is one element
that must be proven in the tort of nursing negligence or malpractice.
The law defines the standards of care that nurses must follow. All state legislatures have
passed Nurse Practice acts that define the scope of nursing practice. Since assistive
personnel (e.g., nurse assistants) have been employed, some State Boards of Nursing
have defined the restarted nurse's responsibilities specifically and developed position
statements and guidelines to help licensed nurses delegate safely (Sheehan, 2001). Nurse
Practice Acts establish educational requirements for nurses distinguish between nursing
and medical practice, and generally define the scope of nursing practice. The rules and
regulations enacted by the State Board of Nursing define the practice of nursing more
specifically. For example, a state board may develop a rule regarding intravenous therapy
as well as the rules and regulations enacted by the State Board of Nursing and other
regulatory administrative bodies.
Professional organizations are another source for defining standards of care. The
American Nurses Association (ANA) has developed standards for nursing practice,
policy statements, and similar resolutions. The standards delineate the scope, function,
and role of the nurse in practice. For example, the standards for community health
nursing practice include guidelines for data collection, diagnosis, planning, treatment, and
evaluavation. Nursing specialty organizations also have standards of practice defined for
certifying nurses who work in specialty areas such as the operating room (OR) or critical
care. These same standards also serve as practice guide- lines for defining safe and
appropriate nursing care in specialty areas.
The Joint Commission on Accreditation of Healthcare Organizations a CAHO) (2003)
requires that accredited hospitals have written nursing polices and procedures. The
written policies and procedures of the employing in situation detail how nurses are to

perform their duties. These internal standards of care are quite specific and should be
accessible on all nursing units. For example, a policy/procedure outlining the steps that
should be taken when changing a dressing or administering medication provides specific
information about how nurses are to perform these tasks. Some hospitals are also now
using commercially published procedural textbooks to reference the institution's general
policy and procedures. Nurses must know the polices and procedures of their employing
institution because the same standard of care should be used by all nurses in the health
care institution institutional policies and procedures must conform to state and federal
laws, as well as community standards, and cannot conflict with legal guidelines that
defines acceptable standards of care.
In a lawsuit for malpractice or nursing negligence, a nursing expert is called to testify to
the jury about the standards of nursing care as applied to the facts of the case. The
standards of care are used by the jury to determine whether the nurse acted appropriately.
Nurse experts must base their opinions on existing standards of practice established by
Nurse practice Act,

professional organizations, institutional policies and procures,

federal and state hospital licensing laws, standards of the JCAHO, job descriptions, and
current nursing re- search literature.
Usually, general duty nurses are responsible for meeting the same standards as other
general duty nurses in similar settings. However, specialized nurses such as nurse
anesthetists, OR nurses, intensive care nurses, or certified nurse midwives are held to
standards of care and skill exercised by those in the same specialty as defined by
applicable standards. All nurses should know the standards of care that they are expected
to meet within their specific specialty and work setting. Ignorance of the law or of
standards of care is not a defense against malpractice. However, at the time of trial the
standard of care is what the nurse experts testify that standard to be and ultimately what
the jury believes.





The Experts: The plaintiff selects experts to

plaintiff outlines what the defendant nurse establish the essential legal elements of the
did wrong and how as a result of that case against the defendant. The defendant
alleged negligence the plaintiff was injured. selects





Answer: The nurse admits or denies each appropriateness of the nursing care.
allegation in the petition. Anything that is
Trial Usually occurs at least 2 to 3 years,

not admitted must be proved.

and sometimes as long as 6 to 8 years, after

Discovery Interrogatories: Written

the filing of the petition. (Only about 5% of

questions requiring answers under oath.

cases are tried. Most are dismissed or

Usual questions concern witnesses,

settled. Settlement means that money has

insurance experts, and which health care

been paid for the case to be dismissed,

providers the plaintiff has seen before and

usually without any admission of liability.)

after the incident.

Proof of Negligence
The nurse owed a duty to the client.

Medical records: The defendant obtains all The nurse did not carry out the duty or
of the plaintiff's relevant medical records breached the duty (failure to use that degree
for treatment before and after the incident.



of skill and learning ordinarily used under

are the same or similar circumstances by

posed to the witness under oath to obtain members of his or her profession).
all relevant, non privileged information The client was injured: Medical bills, lost
about the case.

wages Pain and suffering Perianal damages

Wrongful death damages.

Parties' depositions: The plaintiff and




hospital The client's injury was caused by the

personnel) are almost always deposed.

nurse's failure to carry out that duty ("but

Other witlessness: Factual witnesses, both for" the breach of duty the client would not
neutral and biased, are deposed to obtain have been injured).
information and their version of the case.
This may include family members on the
plaintiff's side and other medical personnel
(e.g., nurses) on the defendant's side.
Treating physicians' depositio/1S: Before



depositions may be taken to establish issues

such as those concerning preexisting
conditions, causation, the nature and extent
of injuries, and permanency.

One of the first and most important cases to discuss a nurse's liability was Darling v
Charleston Community Memorial Hospital. This 1966 Illinois Supreme Court case has
been adopted in almost every state. It involved an 18 year old man with a fractured leg.
The emergency department physician applied a cast with insufficient padding. The man's
toes became swollen and discolored, and he developed decreased sensation. He
complained to the nursing staff many times. Although the nurses recognized the
symptoms as signs of impaired circulation, they failed to tell their supervisor that the
physician did not respond to their calls or the client's needs. Gangrene developed, and the
man's leg had to be amputated. Although the physician was held liable for incorrectly
applying the cast, the nursing staff was also held liable for failing to adhere to the
standards of care for monitoring and reporting the client's symptoms. Even though the
nurses attempted to contact the physician, this case holds that when the physician fails to
respond, the nurse must go over the physician's head to make sure that the client is
appropriately treated.

The nurse is obligated to seek appropriate treatment for the client not only ethically but
legally. The nurse bears a fiduciary relationship to the client. A fiduciary relation- ship is
one in which a professional, the nurse, provides services which by their nature cause the
recipient, the client, to trust in the specialized knowledge, the integrity, and the fidelity of
the professional. The nurse is obligated in the fiduciary relationship to provide
knowledgeable, safe care to the client. The nurse is obligated to behave honestly and
truthfully with regard to the client. Last, the nurse must be faithful to provide care in the
best interests of the client.
The best way for nurses to keep up with the current legal issues affecting nursing practice
is to read the nursing literature in their practice area. Current nursing literature deals with
the changing obligations and standards of care for nurses, explains pertinent state and
federal laws, and keeps the nurse up to date on any new rules or regulations and case law.
Federal Statutory Issues in Nursing Practice
Americans With Disabilities Act:
The Americans with Disabilities Act (ADA) (1995) is a very broad-reaching civil rights
statute. It protects the rights of disabled people. It is also the most extensive law on how
employers must treat health care workers and clients infected with the human


immunodeficiency virus (HIV). The Supreme Court ruled in 1998 in Bragdon v Abbott
that even asymptomatic HIV constitutes a disability within the meaning of the ADA. This
means that the HIV-positive individual who does not have acquired immunodeficiency
syndrome (AIDS) is still protected by the ADA. The ADA regulations protect the privacy
of infected people by giving individuals the opportunity to decide whether to disclose
their disability. However, several cases have held that the health care provider may be
obligated to disclose the fact that he or she is infected with HIV. Despite these rulings.
health care workers with disabilities, such as HIV Infection, are protected in the
workplace under the ADA. :likewise, health care workers may not discriminate. against
HIV-positive clients.

Emergency Medical Treatment And Active Labor Act

:As a result of clients being transferred from private hospitals to public hospitals without
appropriate screening , and stabilization (referred to as "patient dumping")congress
enacted the Emergency Medical Treatment and ;"Active Labor Act (EMTALA) (1986).
This act provides that when a client comes to the emergency department or the hospital,
an appropriate medical screening must be done (within the hospital's capacity. If an
emergency condition 'exists, the client may not be discharged or transferred un- "Iii the
condition is stabilized. The client can be discharged or transferred before he is stable. For
example, if '.the client requests in writing to be transferred or discharged after being
informed of the benefits and risks, or if a physician certifies that the benefits of transfer
out weigh the risks, the client may be transferred without an EMTALA violation. The
transfer must always be appropriate, which means (1) that the receiving facility agrees
to : the transfer, has space for the client, and has qualified 'personnel to receive the client;
(2) the medical records ;must be forwarded to the receiving hospital; and (3) the 'client
must be transported by qualified personnel and transportation equipment.
Mental health parity Act:
Health insurance plans are free to eliminate coverage for certain specialties and can
impose limits on the amount ,of coverage that they will pay for certain illnesses.
However, if mental health benefits are provided, a recent 'federal statute regulates
restrictions on mental health benefits. The Mental Health Parity Act of 1996 forbids
'health plans from placing lifetime or annual limits on mental health coverage that are less
generous than those placed on medical or surgical benefits.


A client can be admitted to a psychiatric unit involuntarily or on a voluntary basis. A

petition for involuntary \detention must be filed with the court within 96 hours of the
client's initial detention. A hearing must be conducted within 2 days of the filing of the
involuntary petition. If the judge determines that the client is a danger lose!! or others, the
judge will grant the involuntary detention, and the client can be detained for 21 more
days for psychiatric treatment.

Potentially suicidal clients are admitted to psychiatric units. If the client's history and
medical records indicate suicidal tendencies, the client must be kept under supervision.
Lawsuits result from clients' attempts at suicide within the hospital. The allegations in the
lawsuits are that he health care provider failed to provide adequate supervision and failed
to safeguard the facilities documentation of precautions against suicide is essential.
Advance Directives:
There are two basic advance directives: living wills and durable powers of attorney for
health care. Many clients have living wills or have signed a durable power of attorney for
health care. The Patient Self-Determining Act (PSPA) (1991) requires health care
institutions to provide written information to clients concerning the clits rights under state
law to make decisions, including the right to refuse treatment and formulate advance
directives. Under the act, it must be documented in the client's record whether the, client
has signed an advance directive. The hospital is also required to ensure that state law is
followed and provide education: for the staff and the public concerning living wills and'
durable powers of attorney. It is especially important understand clients' cultural beliefs
when explaining advance directives. Regulatory mandates to benefit the public are based
on the dominant value in American society of self determination. This may be in conflict
with a client's cultural heritage (In order for living wills or durable powers of attorney for
health care to. be enforceable, the client must be legally incompetent or lack decisional
capacity to make decisions regarding health care treatment (Furrow and others, 1991).
The determination of legal competency is made by a judge, and the determination of
decisional capacity is usually made by the physician and family. Therefore the
implementation of the advance directive is done within the context of the health care
team and the health care institution. The nurse should be familiar with the institution's
policies complying with the act.


Living Wills. Living wills are written documents that direct treatment in accordance with
a client's wishes in the event of a terminal illness or condition Living wills may be
difficult to interpret and not clinically specific in unforeseen circumstances. Each state
providing for living wills has its own requirements for executing them. Generally, two
witnesses, neither of whom can be a relative or physician, are needed when the client
signs the document. If health care workers follow the directions of the living will, they
are immune from liability.
A durable power of attorney for health care designates an agent, surrogate, or proxy to
make health care decisions if and when the client is no longer able to make decisions on
his or her own behalf. This agent is appointed to make health care treatment decisions
based on the client's wishes
Addition to federal statutes, the ethical doctrine of autonomy ensures the client the right
to refuse medical treatment. This right to refuse medical treatment was up held in the
Bouvia v superior court case in 1986. That case allowed the discontinuation of the client's
tube feedings at her request. The courts have also upheld the right of a legally competent
client to refuse medical treatment for religious reasons. Christian Scientists refuse
medical treatment based on religious beliefs, and Jehovah's Witnesses accept medical
treatment but refuse blood transfusions for religious beliefs. In the absence of a truly
compelling reason otherwise, the right to make those choices are protected. The U.S.
Supreme Court stated in the Cruzan v Director Missouri Department of Health case in
1990 that "we assume that the U.S. Constitution would grant a constitutionally protected
competent person the right to refuse lifesaving hydration and nutrition." In cases
involving the client's right to refuse or withdraw medical treatment, the courts balance the
client's interest with the state's interest in protecting life, preserving medical ethics,
preventing suicide, and protecting innocent third parties. Children are generally
considered innocent third parties. Although the courts will not force adults to undergo
treatment that is refused for religious reasons, they will grant an order al- lowing
hospitals and doctors to treat children of Christian Scientists or Jehovah's Witnesses who
have denied consent for treatment of their minor children.
Where clients are legally incompetent and are unable to make health tare decisions, the
courts balance the state's interest with what the client would have wanted. The courts
attempt to substitute their judgment as to what the client would have chosen if the client

were competent. The Supreme Court held in the Cruzan case that states had the right to
require "clear and convincing evidence" of a legally incompetent client's prior wishes
when making determinations to discontinue life-sustaining treatment. In that case
nutrition and hydration were recognized as life-sustaining medical treatment that could be
Every state now requires "clear and convincing" evidence of the client's choice, but
individual states differ as to what standard satisfies the amount of evidence required. If
there is no evidence of the client's prior choice, most states allow treatment to be stopped
based on other factors, including the best interest of the client balanced with the state's
In addition to client refusals of treatment, the nurse will frequently encounter the DNR
order. DNR means "do not resuscitate" or "no code." The DNR order was first developed
in 1976 and marks an important change in health care because it was the first order to
withhold treatment instead of deliver treatment (Bums and others, 2003). A DNR order
should be written, not given verbally. The physician should routinely review DNR orders
in case the client's condition warrants a change. "Slow codes" or "partial" codes may be
defined differently by various institutions and may be interpreted as not performing
resuscitative procedures as a competent person would. If resuscitative procedures are
performed more slowly than recommended by the American Heart Association, they may
be interpreted as being below the standard of care and therefore become the basis for a
Cardiopulmonary resuscitation (CPR) is an emergency treatment that is provided without
client consent. It is a procedure that is performed on an appropriate client un- less a DNR
order is written in the client's chart. Since 1988; when New York first adopted legislation
regarding DNR orders, over 20 states have drafted similar statutes (New York DNR
Statute, 1988). The statutes assume that all clients will be resuscitated unless there is a
written DNR order in the chart. Legally competent adult clients may consent to a DNR
order verbally or in writing after being given the appropriate information by the
physician. A verbal consent requires two witnesses, one of whom must be a physician
affiliated with the hospital. A written consent requires two adult witnesses. If the client
lacks the decisional capacity to give consent, a surrogate may give consent for the client


if two physicians say that within reasonable medical certain the client has a terminal
condition, the client is terminally unconscious, resuscitation would be medically futile, or
resuscitation would impose extraordinary burden on the client in light of the client's
medical condition and the expected out- come of resuscitation. If no surrogate is available
to give consent, the DNR order can still be written but only if the physician is reasonably
medically certain that the resuscitation would be futile. The statutes provide that the attending physician must review the DNR orders every 3 days for hospitalized clients or
every 60 days for client residential health facilities.
Uniform Anatomical Gift Act:
An individual who is at least 18 years of age may make an anatomical gift or organ
donation (defined as a "donation of all or part of a human body to take effect upon or
after death"). The gift must be made in writing and signed by the donor. If the donor
cannot sign, the document must be signed by another individual and two witnesses. In
many states adults may sign the back of their driver's license, indicating consent to organ
donation. Pursuant to the Uniform Anatomical Gift Act of 1987, which has been adopted
in nearly 20 states, unless the gift is revoked by the donor before death, no further consent is required after the donor's death.
In most states Required Request laws mandate that at the time of admission to a hospital,
a qualified health care provider must ask each client over 18 whether they are an organ or
tissue donor. If the answer is affirmative, a copy of the document should be obtained. If
the answer is negative and the attending physician consents, the option to make or refuse
an anatomical gift should be discussed. Documentation should be placed in the client's
medical record. Required Request laws came about be- cause of the shortage of suitable
organs for transplantation. Required requested laws are also part of the Uniform
Anatomical Gift Act (1987), which addresses many issues involving organ donation,
including the rights and duties at death. The physician who certifies death shall not be
involved in the removal or transplantation of organs.
The National organ Transplant Act of 1984 prohibits the purchase or sale of organs. The
act also provides civil and criminal immunity to the hospital and physician who acts in
accordance with the act. The act also protects the donor's estate from liability for injury or
dam- age that may result from the use of the gift. Organ transplantation is extremely
expensive. Clients ill end-stage renal disease are eligible for Medicare coverage for a


kidney transplant, but other transplants have to be paid for by private insurance. The
United Network for Organ Sharing has a contract with the federal government and sets
policies and guidelines for the procurement of organs. Most clients who require organ
transplantation have to be placed on a waiting list for an organ in their geographical area.
Recently, the geographical system has changed to give priority to clients who
demonstrate the greatest need. Nurses must be familiar with their employing institution's
policies and procedures regarding organ donation.
Health Insurance Portability and Accountability Act:
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) limits the
extent to which health plans may impose preexisting condition limitations and prohibits
discrimination in health plans against individual anticipants and beneficiaries based on
health status. One of the ways that insurance companies keep costs down is y not insuring
certain preexisting conditions that clients are when they obtain group health insurance
coverage for example, if a client has heart disease, an insurer may to be provide health
insurance for the client for all medical problems except heart disease. HIPAA requires
Insurers to only limit coverage for a preexisting condition for 12 months in most cases.
This means that if an employee has group health insurance coverage with his job for at
least 12 months and then changes jobs, the second employer cannot impose preexisting
condition exclusion n the individual. The advantages of HIPAA are that employees can
change jobs without losing coverage as a result of preexisting coverage exclusion as long
as they have had .12 months of continuous group health insurance coverage.
HIPAA also contains a section that sets standards regarding the electronic exchange of
private and sensitive health information. Known as the Privacy Standards Rosati, 2002),
these rules create client rights to consent J use and disclose protected health information,
to in- pert and copy one's medical record, and to amend mistaken or incomplete
information. In addition, the standards require all hospitals and health agencies to have
specific policies and procedures in place to ensure compliance with the standards. These
policies and procedures must provide reasonable safeguards to protect written and verbal
communications about clients. Student nurses ,who visit patient care units before caring
for clients usually prepare by reading clients' charts. However, no part If the chart can be
copied. Although HIPAA will not require such measures as soundproof rooms in
hospitals, it does mean that nurses and all health care providers should avoid discussing
clients in public hallways and. should provide reasonable levels of privacy in

comminuting with and about clients in any manner. Message boards used in clients'
hospital rooms to post daily nursing care information can no longer contain information
revealing the client's medical condition. HIPAA viola- ions have civil and criminal
sanctions. All nurses must understand the HIPAA policies of their organization.
The Resident's Rights section of the Medicaid Statute: 1988) regulates the use of physical
or chemical restraints n nursing facilities. In addition, the FDA has set forth Guidelines
for the use of restraints (U.S. Department of health and Human Services, 1992). The
statutes provide hat restraints may be imposed (1) only to ensure the physical safety of
the resident or other residents and (2) only on the written order of a physician that
specifies the duration (usually 24 hours) and circumstances until such an order could
reasonably be obtained). The most frequent indications for restraints are as follows.
1. Unanticipated risk of injury to self falls or others, 2/ interference with treatment, and 3.
clinically disruptive or disturbing behavior. (Martin 2002). The nurse must know when
and how to use restraints correctly. After a client is restrained, the nurse is required to
make frequent client assessments and to periodically release restraints. Liability for
improper or unlawful restraint, as well as liability for client injury from unprotected falls,
lies with the nurse and the health care institution.
State Statutory Issues in nursing practice:
All registered nurses are licensed by the State Board of nursing of the state in which they
practice. The requirements for licensure vary among states, but most states have
minimum education requirements and require a licensure examination. All states use the
National Council Licensure examinations for registered nurse and licensed practical nurse
examinations. Licensure permits persons to offer special skills to the public, but it also
provides legal guidelines for protection of the public.
A license can be suspended or revoked by the state board of nursing if a nurses conduct
violates provisions in the licensing statute based on administrative law rules that
implement and enforce the statute. For example controlled substances jeopardize their
license status. Because a license is viewed as a property right, due process must be
followed before a license can be suspended or revoked. Due process means that nurses
must be notified of the charges brought against them and that the nurses have an


opportunity to defend against the charges in a hearing. Hearings for suspension or

revocation of a license do not occur in court but are usually conducted by a hearing panel
of professionals. Some states provide administrative and judicial review of such cases
after nurses have exhausted all other forms of appeal.
Good Samaritan laws:
Nurses may act as Good Samaritans by providing emergency assistance at an accident
scene. Good Samaritan laws have been enacted in almost every state to encourage health
care professionals to assist in emergency situations (Good Samaritan law, 1998). These
laws limit liability and offer legal immunity for nurses who help at the scene of an
accident. They also provide that a nurse can assist a minor in an emergency at the scene
of an accident or competitive sport event before obtaining the parents consent. If a nurse
stops at the scene of an automobile accident and gives appropriate emergency care, such
as applying pressure to stop hemorrhage, the nurse is acting within accepted standards
even though proper equipment was not available. If the client subsequently develops
complications as a result of the nurses actions the nurse is immune from liability as long
as he or she acted without gross negligence. Nurses should check their own states Good
Samaritan statute, because some states require nurses to stop and help in an emergency.

Public Health Laws:

It is important that nurses, especially those employed in community health settings,
understand the public health laws. State legislatures enact statutes under the health code,
which describes the reporting laws for communicable diseases, school immunizations,
and laws intended to promote health and reduce health risks in communities. The Centers
for Disease Control and Prevention and the Occupational Health and Safety Act (OHSA)
also provide guidelines on a national level for safe and healthy communities and work
environments. The purposes of public health laws are protection of the public's health,
advocating for the rights of people, regulating health care and health care financing, and
ensuring professional accountability for the care provided. Community health nurses
have the legal responsibility to enforce the laws enacted to protect the public's health.
These laws may include reporting suspected abuse and neglect, such as child abuse, elder
abuse, or domestic violence, reporting communicable diseases, ensuring that required
immunizations have been received by clients in the community, and reporting of other
health-related issues enacted to protect the public's health.


Every state with child abuse legislation requires that. suspected child abuse or neglect
must be reported. Health care professionals such as nurses are mandated to report
suspected cases. To encourage reports of suspected cases, states provide legal immunity
for the reporter if the report is made in good faith. Health care professionals who do not
report suspected child abuse or neglect may be held liable for civil or criminal legal
As in all areas of nursing practice, negligence involving pediatric clients is possible, and
the nurse is responsible for preventing a child in his or her care from accidentally coming
to harm. Cribs, which sometimes have a restraining device over the top, are designed to
keep infants and toddlers from climbing out of bed and injuring themselves. All
poisonous substances and sharp objects should be kept out of the reach of small children.
When possible, small children should be kept under constant watch to minimize
opportunities for accidental harm.

The Uniform Determination of death act:

Many legal issues surround the event of death, including a basic definition of the actual
point at which a person is considered dead. There are essentially two standards for the
determination of death. The cardiopulmonary standard requires irreversible cessation of
circulatory and respiratory functions. The whole-brain standard requires irreversible
cessation of all functions of the entire brain, including the brain stem. The reason for the
development of different definitions is to facilitate recovery of organs for transplantation.
Even though the client may be legally "brain dead," the client's organs may be healthy for
donation to other clients. The Uniform Determination of Death Act (1980) has been
adopted in most states and provides that either the cardiopulmonary definition or the
whole-brain .definition may be used to determine death. Nurses must be aware of legal
definitions of death because they must document all events that occur when the client is
in their care. Nurses have a specific legal obligation to treat the deceased person's
remains with dignity. Wrongful handling of a deceased person's remains could cause
emotional harm to the serving family.
Consent for an autopsy must have been given previously by the decedent before death or
may be given by a close family member at the time of death. In many states there is an


order of priority for the giving of consent for autopsies, such as (1) decedent, in writing;
(2) durable power of attorney; (3) surviving spouse; and (4) surviving child, parent,
brother, or sister in the order named (Autopsy Consent, 1998). It is important to know a
client's cultural heritage. In some cultures, the accepted family social hierarchy may
differ from what is expected by law. Nurses must help clients under- stand the law and
what, if any, options are available. Death is to be reported and investigated by the coroner
when there are reasonable grounds to believe that the person died as a result of violence,
homicide, suicide, accident, or death occurring in any unusual or suspicious manner. The
coroner should be also be contacted if a client's death is unforeseen and sudden and the
client has not been seen by a physician in over 36 hours.
Physician Assisted Suicide
In 1994 the State of Oregon passed the Oregon Death with Dignity Act, which was the
first statute that permitted physician-assisted suicide. The statute provided that a
competent individual with a terminal disease defined as an "incurable and irreversible
disease that has been medically confirmed and will, within reasonable medical judgment,
produce death within 6 months" could make an oral and written request for medication to
end his or her life in a humane and dignified manner. The written request had to be signed
and witnessed by two individuals. The attending physician had to refer the individual to a
consulting physician and refer the individual for counseling, if appropriate. The attending
physician also had to have the individual notify his or her next of kin and provide
information regarding the medication so that an informed decision could be made. There
was a day waiting period between the initial oral request and the writing of the
prescription and no less than a 48-hour waiting period between the written request and
the writ- ing of the prescription. The individual had a right to rescind the request at any
time and had to be able to self- administer the medication. Despite efforts by the Oregon
state legislature and the U.S. attorney general, the Oregon Death with dignity Act went
into effect in November 1997. However, it remains the object of several challenges in
federal court.
In Compassion in Dying v Washington (1996) and Quill Vacco (1996), challenges to state
statutes that made assist- ing in suicide a criminal act in Washington and New York,
respectively, were filed with the courts. The lower courts both held that the criminal
statutes were unconstitutional. The cases were heard by the Supreme Court, and on June
26, 1997, the Supreme Court held in Washington


Glucksberg that there is no

fundamental constitutional right to assisted suicide. In making its ruling, the Supreme
Court did not preclude the states from passing legislation legalizing assisted suicide. The
Supreme Court also relied on the fact that there are no legal barriers to obtaining pain
medication and that dying persons in Washington and New York could "obtain palliative
care, even when doing so would hasten their deaths."
Other states have proposed similar legislation. Legally, nurses must know their State
Nurse Practice Act and their state laws regarding physician-assisted suicide. The
American Nurses Association has stated that nurses should not participate in assisted
suicide because it is an act that violates the Code for Nurses and the ethical traditions of
the profession.

Civil and Common Law Issues in Nursing Practice - Torts

A tort is a civil wrong made against a person or property. 'Torts may be classified as
unintentional or intentional. An example of an unintentional tort is negligence or malpractice. Malpractice is negligence committed by a professional such as a nurse or
physician. Intentional torts are willful acts that violate another's rights. Examples are
assault, battery, invasion of privacy, and defamation of character.
Intentional Torts
Assault. Assault is any intentional threat to bring about harmful or offensive contact. No
actual contact is necessary. The law protects clients who are afraid of harmful contact. It
is an assault for a nurse to threaten to give a client an injection or to threaten to restrain a
client for an x-ray procedure when the client has refused consent. The. key issue is the
client's consent. In a lawsuit wherein assault is alleged, the client's consent would bar the
claim of assault against a nurse.
Battery. Battery is any intentional touching without consent. The consent can be harmful
to the client and cause an injury, or it can be merely offensive to the client's personal
dignity. A battery always includes an assault, which is why the terms assault and battery
are commonly combined. In the example of a nurse threatening to give a client an
injection without the client's consent, if the nurse actually gives the injection, it is
considered battery. Battery can also result if the health care provider per- forms a
procedure that exceeds the client's consent. For example, if the client gives consent for an


appendectomy and the physician performs a tonsillectomy, battery has occurred. Once
again, the key issue is the client's consent.
In some situations consent is implied. For example, if a client gets into a wheelchair or
transfers to a stretcher after being advised that it is time to be taken for an x-ray
procedure the client has given implied consent to the procedure. If the client learns that
an x-ray film of the head instead of the foot is to be taken and the client refuses to have
the x-ray film taken, the consent has been revoked or withdrawn.
Invasion of Privacy.
The tort of invasion of privacy protects the client's right to be free from unwanted
intrusion into his or her private affairs. The four types of invasion of privacy torts are
intrusion on seclusion, appropriation of name or likeness, publication of private or
embarrassing facts, and publicity placing one in a false light.

Clients are entitled to confidential health care. For example, in a classic case, reporters
published photographs of a female client in her hospital room without her consent. A
claim for invasion of privacy was upheld. This case is an example of intrusion on
seclusion publication of private, embarrassing facts.
Another form of invasion of privacy is the release of a client's medical information to an
unauthorized person, such as a member of the press or the client's employer. The
information that is contained in a client's medical record is a confidential communication.
It should be shared with health care providers for the purpose of medical treatment only.
client's medical record is confidential. The nurse should not disclose the client's
confidential medical information without the client's consent. For example, a nurse
should respect a wish not to inform the client's family of a terminal illness. Similarly, a
nurse should not assume that a client's spouse or family members know all of the client's
history, particularly with respect to private issues such as mental illness, medications,
pregnancy, abortion, birth control, or sexually transmitted diseases.
An individual's right to privacy may conflict with the public's right to know. In one case a
married couple was filmed by a television crew while attending a hospital program in


which they participated. The couple had previously told no one but their immediate
family that they were involved in the in vitro fertilization program and had been assured
that there would be no publicity or public exposure. After the newscast they were
subjected to phone calls and embarrassing questions. The couple filed a lawsuit. The
court held that the husband and wife stated a claim for invasion of privacy and that even
though the in vitro fertilization program may have been of public interest, the identity of
the plaintiffs was a private matter.
Many states, through their respective public health departments, require that certain
infectious or communicable diseases be reported. Sometimes the client is a public figure
whose physical condition is considered newsworthy. There are also cases in which
information is given out about a scientific discovery or a major medical breakthrough, as
with the first heart transplant case or the first artificial heart recipient. If an event falls
into any of these categories, information should be channeled through the public relations
department of the institution to ensure that invasion of privacy does not occur. The nurse
should not independently attempt to decide the legality of disclosing information.
Nursing standards for what constitutes confidential in- formation are based on
professional ethics and the common law. The ideals of privacy and sensitivity to the
needs and rights of clients who may not choose to have nurses intrude on their lives, but
who depend on nurses for their care, guide the nurse's judgment. The nurse's fiduciary
duty requires that confidential information not be shared with others.
Defamation of Character.
Defamation of character is the publication of false statements that result in damage to a
person's reputation. The statements must be published with malice in the case of a public
official or public figure. Malice means that the person publishing the information knows
it is false and publishes it anyway or that it is published with reckless disregard as to the
truth or falsity of the statement. If the statement is presented orally, it is called slander. If
the statement is made in writing, it is called libel. For example, if a nurse tells people
erroneously that a client has venereal disease and the disclosure affects the client's
business, the nurse could be held liable for slander.
Unintentional Torts


Negligence negligence is conduct that falls below the standard of care. The standard of
care is established by law for the protection of others against an unreasonably great risk
of harm. For example, if a driver of a car acts unreasonably in failing to stop at a stop
sign, it is negligence. In general, courts define negligence in car accident cases and other
negligence cases as that degree of care that an ordinarily careful and prudent person
would use under the same or similar circumstances.
Malpractice is one type of negligence; it is referred to as professional negligence. Nursing
malpractice results when nursing care falls below the standard of care. Nurses can be
found liable for malpractice if the following criteria are established: (1) the nurse
(defendant) owed a duty to the client (plaintiff) (2) the nurse did not carry out that duty;
(3) the client was injured; and (4) the nurse's failure to carry out the duty caused the
injury. Even though nurses do not intend to injure clients, if nurses give care that does not
meet the appropriate standards, they may be held liable for negligence. Negligence may
involve failing to check a client's arm band and then administering medication to the
wrong client. Negligence may also involve administering a medication to a client even
though it has been documented that the client has an allergy to that medication. In
general, courts define nursing negligence as the failure to use that degree of skill or
learning ordinarily used under the same or similar circumstances by members of the
nursing profession (Missouri Approved Instructions.
The best way for nurses to avoid being liable for negligence is to follow standards of
care, give competent health care, communicate with other health care providers, develop
a caring rapport with the client, and document assessments, interventions, and evaluations
fully. If a nurse is brought into a lawsuit, careful, complete, and thorough documentation
is one of the best defenses. Nurses should also know the current nursing literature in their
areas of practice. They should know and follow the policies and procedures of the
institution in which they work. Nurses should be sensitive to common sources of client
injury, such as falls and medication errors. Finally, nurses must communicate with the
client, explain the tests and treatment to be performed, document that specific
explanations were provided to the client, and listen to the client's concerns about the
treatment. Any significant changes in the client's condition must be reported to the
physician and documented in the chart. Timely and truthful documentation is important to


provide the communication necessary among the health care team members. Good
documentation also keeps other health care providers up-to-date on the most recent
treatments received by the client so that ongoing care can be safely provided. Nurses
must be certain that documentation is legible and signed.
A number of courts have stated that when a health care provider negligently alters or
loses medical records relevant to a malpractice claim, the health care provider must
demonstrate why these events occurred. An institution has a duty to maintain nursing
records. These duties are established by statutes and accreditation regulations. Nursing
notes contain substantial evidence needed to understand the care received by a client. If
records are lost or incomplete, there is a presumption that the care was negligent and
.therefore the cause of the client's injuries. In addition, incomplete or illegible records
undermine the credibility or believability of the health care provider.
A signed consent form is required for all routine treatment, hazardous procedures such as
surgery, some treatment programs such as chemotherapy, and research involving clients A
client signs general consent forms when admitted to the hospital or other health care
facility. Separate special consent or treatment forms must be signed by the client or a
representative before specialized procedures or treatments are performed.
State statutes provide the designation of individuals who are legally able to give consent
to medical treatment. Nurse should know law in their own states be familiar with the
policies and procedures of their employing in situation regarding consent.

If a client is deaf, illiterate, or speaks a foreign language, an official interpreter must be

available to explain the terms of consent. A family member or acquaintance that is able to
speak a clients language should not be used to interpret health information. A client
under the effects of a sedative is not able to clearly understand the implications of an
invasive procedure. Every effort should be made to assist the client in making an
informed choice.
Nurses must be sensitive to the cultural issues of consent. The nurse must understand the
way in which clients and their families communicate and make important. It is essential
for nurses to understand the various cultures with which they interact. The cultural beliefs


and values of the client may be very different from those own cultural values on the
client. Insensitivity toward concern. A conscious awareness of the different values and
beliefs held by various cultures is essential for sensitive nursing care.


I. I hereby request and authorize Doctor to perform a diagnostic amniocentesis (pass a

needle through the abdominal wall and withdraw some of the amniotic fluid). I further
request that an attempt be made to perform the following test(s) on my unborn child:









Acetylcholinesterase (Initial)
(If indicated) D (Initial)
II. I consent to the performance of an ultrasound examination for the purpose of dating
the pregnancy, locating the placenta and selecting a site for placement of the needle.
III. I understand that


A. the procedure of amniocentesis involves a small risk to both mother and fetus and
that these risks include; discomfort at the site where the needle was inserted. cramping,
bloody spotting, leakage of amniotic fluid, intrauterine Infection and miscarriage.
B. there is a possibility that growing the fetal cells may not be successful and that
repeat amniocentesis would then be required.
C. although the likelihood of an error is considered to be extremely small, a complete
and correct diagnosis of the condition of the fetus based on the test(s) performed
cannot be guaranteed.
D. the results provided of normal chromosomes or normal biochemical status of the
fetus does not eliminate the possibility that the child may have birth defects and/or
mental retardation because of other disorders.
E. in the case of twins, the results may apply to only one of the pair.
F. in some Rh negative mothers Rh sensitization has occurred following amniocentesis.
IV. I have had my questions answered and understand and accept the risks and
limitations of this test.
Signed: (patient)
Sample consent form for a special procedure.
Abortion Issues
In 1973 in the case of Roe

Wade, the U.S. Supreme Court ruled that there is a

fundamental right to privacy, which includes a woman's decision to have an abortion. The
court ruled that during the first trimester a woman could end her pregnancy without state
regulation because the risk of natural mortality from abortion is less than with normal
childbirth. During the second trimester the state has an interest in protecting maternal
health, and the state may enforce regulations regarding the person per- forming the
abortion and the abortion facility. By the third trimester, when the fetus becomes viable,
the state's interest is to protect the fetus, so the state can therefore prohibit abortion except
when necessary to save the mother.


In 1989 in the case of Webster v Reproductive Health Services, the court substantially
narrowed the Roe

Wade case. States may require viability tests before conducting

abortions if the fetus is thought to be over 28 weeks' gestational age. States may also
require a minors parental consent or a judicial decision that 'the minor is mature and can
In the case of Planned Parenthood of Southeastern Pennsylvania Casey (1992), informed
consent was up-held in that the physician must present the woman with a description of
the nature of the abortion procedure, the health risk related to abortion and childbirth, the
probable gestational age of the fetus, and the availability of state-published material
about medical assistance, adoption agencies, and child support from the father. The court
also upheld a mandatory 24-hour waiting period between when the materials are provided
to the client and when the abortion is performed. An emendated mi- nor must get
informed consent of one parent or a judicial determination that the minor is mature and
can give her own informed consent.
Student Nurses
Student nurses are liable if their actions cause harm to clients. If a client is harmed as a
direct result of a nursing student's actions or lack of action, the liability for the in- correct
action is generally shared by the student, instructor, hospital or health care facility, and
university or educational institution. Student nurses should never be assigned to perform
tasks for which they are unprepared, and they should be carefully supervised by
instructors as they learn new skills. Although student nurses may not be considered
employees of the hospital, the institution has a responsibility to monitor the acts of
student nurses. Student nurses are expected to perform as professional nurses would in
providing safe client care. Faculty members are usually responsible for instructing and
observing students, but in some situations staff nurses serving as preceptors may share
these responsibilities. Every nursing school should provide clear definitions of preceptor
and faculty responsibility.
When students are employed as nursing assistants or nurses' aides when not attending
classes, they should not perform tasks that do not appear in a job description for a nurses'
aide or assistant. For example, even if a student has learned to administer intramuscular
medications in class, this task may not be performed by a nurse's aide. If a staff nurse
overseeing the nursing assistant or aide knowingly assigns work without regard for the


person's ability to safely conduct the task defined in the job description, the staff nurse
will also be liable. If students employed as nurse's aides are requested to perform tasks
that they are not prepared to safely complete, this information should be brought to the
supervisor's attention so that the needed help can be obtained.

Malpractice Insurance

Malpractice or professional liability insurance is a contract

between the nurse and the insurance company. Malpractice insurance provides for a
defense when a nurse is sued for professional negligence or medical malpractice as port
of the insurance contract, the insurance company pays for any judgment or settlement of
the case and also pays for the attorney's fees generated in the t representation of the nurse.
Nurses employed by health t care institutions generally are covered by that institution's
insurance and do not need to purchase any supplemental insurance unless the nurse plans
to practice nursing outside of the employing institution. The employing Institutions
insurance, however, only covers nurses while; they are working within the scope of their
employment. : Because nurses are professionals and it is often difficult to separate their
private lives from their professional skills, they should 'consider purchasing individual
professional liability insurance, even if the employing institution has coverage. A nurse
who is called on by neighbors and" friends to provide nursing care on a volunteer basis
would not be covered by the hospital's policy if the neighbor or friend filed suit.
Nurses should consult their lawyers on what types of I policies to purchase and what
rights or duties; if any, exist , 1st under the policy. If the employing institution and the
nurse are sued in a professional liability case, even though the nurse has insurance with
the hospital, the nurse should notify his or her private insurance carrier of " the lawsuit. If
both the hospital policy and the private. Policy are considered primary and the hospital
loses as a result of the nurse's acts, theoretically the hospital could sue the nurse's private
insurer to recover its losses. Most private insurance policies for nurses, however, are
considered excess policies and only begin covering the nurse after all of the primary
hospital insurance coverage has been exhausted. Because the hospital insurance coverage
is generally much greater than the private insurance coverage, hospitals very rarely sue
nurses' private insurers.
Abandonment and Assignment Issues:
Short Staffing. During nursing shortages or staff down- sizing periods, the issue of
inadequate staffing may arise. The ]CAHO (2003) requires institutions to have guide91

lines for determining the number (staffing ratios) of nurses required to give care to a
specific number of clients. Legal problems may arise if there are not enough nurses to
provide competent care. If nurses are, assigned to care for more clients than is reasonable,
they should bring this information to the attention of the nursing supervisor. If nurses are
required to accept assignments, they should make written protests to nursing
administrators. Although these protests may not relieve nurses of responsibility if a client
suffers an injury because of inattention, it would show that the nurses were attempting to
act reasonably. Whenever a written protest is made, nurses should keep a copy of this
document in their own personal file. Most administrators recognize that knowledge of a
potential problem shifts some of the responsibility to the institution. Nurses should not
walk out when staffing is inadequate, because charges of abandonment could be made. A
nurse who refuses to accept an assignment may be considered insubordinate and clients
will not benefit from having even less staff available. It is important to know the
institution's policies and procedures on how to handle such reports before the situation
Nurses are sometimes required to "float" from the area in which they normally practice
to other nursing units. In one case a nurse in obstetrics was assigned to an emergency
department. A client entered the emergency department and complained of chest pain.
The client was given an incorrect dosage of lidocaine by the obstetrical nurse and died
after suffering irreversible brain damage and cardiac arrest. The nurse lost the malpractice
lawsuit who float should inform the supervisor of any lack of experience in caring for the
type of clients on the nursing. They should also request and be given orientation to the
unit. A supervisor can be held liable if a staff nurse is given an assignment he or she
cannot safely handle. In the case of Winkelman Beloit Memorial Hospital the court
remarked that if an employer wishes to rotate nurses to areas outside of their. usual area
of expertise the employer should provide the training and education to prepare nurses to
work in an area outside of their normal assignment. Before accepting employment nurses
should find out the institutors policies regarding floating and have an understanding as to
what is expected. For example, nurses should not be floated to areas
where they have not been adequately cross trained.
Physicians' Orders.


The physician is responsible for directing medical treatment. Nurses are obligated to
follow physicians' orders unless they believe the orders are or in error would harm
clients. Therefore all orders must be assessed, and if one is found to be erroneous or
harmful, further clarification from the physician is necessary. If the physician confirms
the order and the nurse still believes it is inappropriate, the supervising nurse should be
informed. A nurse should not proceed to perform a physician's order if it is foreseeable
that harm will come to the client. The nursing supervisor should be informed and given a
written memorandum detailing the events in chronological order; the reasons for refusing
to carry out the order should also be written to protect the nurse from disciplinary action.
The supervising nurse should help re- solve the questionable order. A medical consultant
may be called in to help clarify the appropriateness or inappropriateness of the order. A
nurse carrying out an inaccurate or inappropriate order may be legally responsible for any
harm suffered by the client.
In a malpractice lawsuit against a physician and a hospital, one of the most frequently
litigated issues is whether the nurse kept the physician informed of the client's condition.
To inform a physician properly, nurses must per- form a competent nursing assessment of
the client to determine the signs and symptoms that are significant in relation to the
attending physician's tasks of diagnosis and treatment. Nurses must be certain to
document that the physician was notified and document his or her response, the nurse's
follow-up, and the client's response.
The physician should write all orders, and the nurse must make sure that they are
transcribed correctly. Verbal orders are not recommended because they increase the
possibilities for error. If a verbal order is necessary (e.g., during an emergency), it should
be written and signed by the physician as soon as possible, usually within 24 hours. The
nurse should be familiar with the institution's policy and procedures regarding verbal

Risk Management:

Risk management is a system of ensuring appropriate nursing care that attempts to

identify potential hazards and eliminate them before harm occurs (Guido, 2001). The
steps involved in risk management. include identifying possible risks, analyzing them,
acting to reduce the risks, and evaluating the steps taken. One tool used in risk
management is the incident report or occurrence report.
Risk management also requires good documentation. The nurse's documentation can be
the evidence of what actually was done for a client and can serve as proof that the nurse
acted reasonably and safely. Documentation should be thorough, accurate, and performed
in a timely manner. To protect the nurse and the client, the nurse should document the
care given and the details associated with it (Guido, 2001). Charting the statement
"physician notified" may be insufficient if at the time the nurse is being questioned about
the lawsuit, he or she does not recall which physician and what specific facts were told to
the physician. When a lawsuit is filed, very often the nurse's notes are the first thing reviewed by an attorney. The nurse's assessments and the reporting of significant changes
in the assessments are very important factors in defending a lawsuit. Therefore the nurse
should identify the physician contacted, the in- formation communicated to the physician,
and the physician's response.
For nurses in practice, the underlying rationale for .quality improvement and risk
management programs is the highest possible quality of care. Some insurance companies,
medical and nursing organizations,. and the ]CAHO require the use of quality
improvement and risk management procedures.
One area of potential risk is associated with the use of electronic monitoring devices. No
monitor is totally reliable, and the nurse must not completely depend on it. Therefore the
nurse's continual assessment of a client is necessary to help document the accuracy of
electronic monitoring. There may also be electrical hazards to the nurse and the client.
The equipment should be checked routinely by biomedical engineers to ensure that it is in
proper working order and to make sure that a client will not an electrical shock.
In the operating room, sponge, needle, and instrument counts are routine surgical
standards to prevent client injury and lawsuits. Even though it is the physician who
inserts sponges and instruments into the surgical wound, the physician relies on the
nurse's counts at the end of the procedure. Generally, when the chart records a correct

sponge count and the client suffers an injury be- cause of a retained sponge, the hospital
is liable because the nurse charted a correct count when it was not correct.
Every piece of equipment must be carefully used to prevent injury to the client. There can
also be liability for nurses because of incorrect positioning or insufficient padding placed
when positioning the client. All nurses need to be risk managers.
Professional Involvement
Nurses must be involved in their professional organizations and on committees that
define the standards of care for nursing practice. If current laws, rules and regulations, or
policies under which nurses must practice do not reflect reality, nurses must become
involved as advocates to see that the scope of nursing practice is accurately de- fined.
Nurses must be willing to represent nursing and the client's perspective in the community
as well. The voice of nursing can be powerful and effective when the organizing focus is
the protection and welfare of the public entrusted to their care.
Health is a common theme in most cultures. In fact, all communities have their concepts
of health, as part of their culture. Among definitions still used, probably the oldest is that
health is the "absence of disease". In some cultures, health and harmony are considered
equivalent, harmony being defined as "being at peace with the self, the community, god
and cosmos". The ancient Indians and Greeks shared this concept and attributed disease
to disturbances in bodily equilibrium of what they called "humors".
Modern medicine is often accused for its preoccupation with the study of disease, and
neglect of the study of health. Consequently, our ignorance about health continues to be
profound, as for example, the determinants of health are not yet clear; the current
definitions of health are elusive; and there is no single yardstick for measuring health.
There is thus a great scope for the study of the "epidemiology" of health.
Health continues to be a neglected entity despite lip service. At the individual level, it
cannot be said that health occupies an important place; it is usually subjugated to other
needs defined as more important, e.g., wealth, power, prestige, knowledge, security.
Health is often taken for granted, and its value is not fully understood until it is lost. At
the international level, health was "forgotten" when the covenant of the League of
Nations was drafted after the First World War. Only at the last moment, was world health

brought in. Health was again '!forgotten" when the charter of the United Nations was
drafted at the end of the Second World War. The matter of health had to be introduced ad
hoc at the United Nations Conference at San Francisco in 1945 (1).

However, during the past few decades, there has been a reawakening that health is a
fundamental human right and a world -wide social goal; that it is essential to the
satisfaction of basic human needs and to an improved quality of life; and, that it is to be
attained by all people. In 1977, the 30th World Health Assembly decided that the main
social target of governments and WHO in the coming decades should be "the attainment
by all citizens of the world by the year 2000 of a level of health that will permit them to
lead a socially and economically productive life", for brevity, called "Health for All" (2).
With the adoption of health as an integral part of socio-economic development by the
United Nations in 1979 (3), health, while being an end in itself, has also become a major
instrument of overall socio-economic development and the creation of a new social order.
An understanding of health is the basis of all health care. Health is not perceived the
same way by all members of a community including various professional groups (e.g.,
biomedical scientists, social science specialists, health administrators, ecologists, etc)
giving rise to confusion about the concept of health. In a world of continuous change,
new concepts are bound to emerge based on new patterns of thought. Health has evolved
over the centuries as a concept from an individual concern to a world -wide social goal
and encompasse{i the whole quality of life. A brief account of the changing concepts of
health is given below:
1. Biomedical concept
Traditionally, health has been viewed as an "absence of disease", and if one was free from
disease, then the person was considered healthy. This concept, known as the "biomedical
concept" has the basis in the "germ theory of disease" which dominated medical thought
at the turn of the 20th century. The medical profession viewed the human body as a
machine, disease as a consequence of the breakdown of the machine and one of the
doctor's task as repair of the machine (4). Thus health, in this narrow view, became the
ultimate goal of medicine.
The criticism that is levelled against the biomedical concept is that it has minimized the


role of the environmental, social, psychological and cultural determinants of health. The
biomedical model, for all its spectacular success in treating disease, was found inadequate
to solve some of the major health problems of mankind (e.g., malnutrition, chronic
diseases, accidents, drug abuse, mental illness, environmental pollution, population
explosion) by elaborating the medical technologies. Developments in medical and social
sciences led to the conclusion that the biomedical concept of health was inadequate.
2. Ecological concept
Deficiencies in the biomedical concept gave rise to other concepts. The ecologists put
forward an attractive hypothesis which viewed health as a dynamic equilibrium between
man and his environment, and 'disease a maladjustment of the human organism to
environment. Dubos (5) defined health saying: "Health implies the relative absence of
pain and discomfort and a continuous adaptation and adjustment to the environment to
ensure optimal function". Human ecological and cultural adaptations do determine not
only the occurrence of disease but also the availability of food and the population
explosion. The ecological concept raises two issues, viz. imperfect man and imperfect
environment. History argues strongly that improvement in human adaptation to natural
environments can lead to longer life expectancies and a better quality of life - even in the
absence of modern health delivery services (6).
3. Psychosocial concepts
Contemporary developments in social sciences revealed that health is not only a
biomedical phenomenon, but one which is influenced by social, psychological, cultural,
economic and political factors of the people concerned (6). These factors must be taken
into consideration in defining and measuring health. Thus health is both a biological and
social phenomenon.
4. Holistic concept
The holistic model is a synthesis of all the above concepts. It recognizes the strength of
social, economic, political and environmental influences on health. It has been variously
described as a unified or multidimensional process involving the well-being of the
whole person in the context of his environment. This view corresponds to the view held
by the ancients that health implies a sound mind, in a sound body, in a sound family, in
sound environment. The holistic approach implies that all sectors of society have an
effect on health, in particular, agriculture, animal husbandry, food, industry, education,

housing, public works, communications and other sectors (7). The emphasis is on the
promotion and protection) of health.
CONCEPT OF DISEASE There have been many attempts to define disease. Webster
defines disease as "a condition in which body health is impaired, a departure from a state
of health, an alteration of the human body interrupting the performance of vital
functions". The Oxford English Dictionary defines disease as "a condition of the body or
some part or organ of the body in which its functions are disrupted or deranged". From an
ecological point of view, disease is defined as a maladjustment of the human organism to
the environment" (80). From a sociological point of view, disease is considered a social
phenomenon, occurring in all societies (81) and defined and fought in terms of the
particular cultural forces prevalent in the society. The simplest definition is, of course,
that disease is just the opposite of health - i.e., any deviation from normal functioning or
state of complete physical or mental well-being - since health and disease are mutually
exclusive. These definitions are considered inadequate because they do not give a
criterion by which to decide when a disease state begins, nor do they lend themselves to
measurement of disease.
The WHO has defined health but not disease. This because disease has many shades
("spectrum of disease" ranging from in apparent (sub clinical) cases to severe manifest
illness. Some diseases commence acutely (e.g., fool poisoning), and some insidiously
(e.g., mental illness rheumatoid arthritis). In some diseases, a "carrier" state occur in
which the individual remains outwardly healthy, and is able to infect others (e.g.,
typhoid fever). In some instances, the, same organism may cause more than one clinical
manifestation (e.g., streptococcus). In some cases, the same disease may b; caused by
more than one organism (e.g., diarrhoea). Some diseases have a short course, and some a
prolonged course. I is easy to determine illness when the signs and symptoms an
manifest, but in many diseases the border-line between normal and abnormal is
indistinct as in the case of diabetes hypertension and mental illness. The end-point or
final outcome of disease is variable - recovery, disability or death of the host.
Distinction is also made between the words disease, illness and sickness which are not
wholly synonymous. The tern "disease" literally means "without ease" (uneasiness) disease, the opposite of ease - when something is wrong with bodily function. "illness"
refers not only to the presence of specific disease, but also to the individual's perceptions

and behaviour in response to the disease, as well as the impact 0 that disease on the
psychosocial environment (82). "Sickness' refers to a state of social dysfunction. Susser
(83) has suggested the following usage.
Disease is a physiological/psychological dysfunction; Illness is a subjective state of the
person who feels aware of not being well.
Sickness is a state of social dysfunction, i.e., a role that the individual assumes when ill
("sickness role").
The clinician sees people who are ill rather than the disease! which he must diagnose and
treat (84). However, it is possible to be victim of disease without feeling ill, and to be ill
withou1 signs of physical impairment. In short, an adequate definition of disease is yet to
be found - a definition that is satisfactory 01 acceptable to the epidemiologist, clinician,
sociologist and the statistician.
The Domain of Nursing:
Any science has a domain, which is the view or perspective of the discipline. The domain
contains the subject, central concepts, values and beliefs, phenomena of interest, and the
central problems of the discipline. The domain of

medicine is the diagnosis and

treatment of disease. Nursing's domain is the identification and treatment of clients'

health care needs at all levels of health in all health care settings. Because the domain of
a science can comprise many variables, it is helpful to have a model for conceptual
understanding. Nursing has a model or paradigm that explains the linkages of science,
philosophy, and theory accepted and applied by the discipline (Alligood and marrinerTomey, 2002). The elements of nursing's paradigm direct the act of the nursing




philosophy, theory, educational

experience practice, and literature identified with the profession (Alligood and MarrinerTomey, 2002). Nursing identified its domain in a paradigm that includes four linkages the
person, health, environment situation, and nursing. person refers to the recipient of
nursing care, including individual clients, families, and the community. The person is
central to the care being provided. Because the person's needs are multidimensional, it is
important that nursing provides care that is individualized to the client's needs.


Health is defined in different ways by the client, the clinical setting, and the health care
profession . It is the goal of nursing care. The American Association (ANA) (1995)
defines health as dynamic state of being which the developmental and behaviour potential
of the individual is realized to the t extent possible." Health is dynamic and continuously
changing. The nurse is challenged to provide can based on the client's individualized
level of health and the care needs at the time of care delivery.
Environment situation includes all possible conditions affecting the client and the
setting in which health care needs occur. For example, a client's level of health and health
care needs can be influenced by factors the home, school, workplace, or community. An
adolescent girl with immune-mediated (or type 1) diabetes may need to adapt her care
regimen to physical activities of school, to the demands of a part-time job, and to the
timing of social events, such as her. There is continuous interaction between the client
and the environment. This interaction can have positive and negative effects on the
person's level of health and health care. Nursing has a unique focus in helping clients ~in
all situations achieve a stable or improved level of health.
Nursing is the "diagnosis and treatment of human responses to actual or potential health
problems" For example, a nurse does not medically diagnose client's heart condition but
instead assesses the client response to the disease and develops nursing diagnosis of
fatigue, change in body image, and altered ing. From these nursing diagnoses, the nurse
creates individualized plan of care. Nurses use cal thinking skills to integrate knowledge,
experience, attitudes, and standards into the individualized plan of for each client.
A theory is a set of concept definitions relationships, and assumptions that project a
systematic View of phenomena. For example, Orem's self-care deficit theory defines
nursing as a helping service, a creative effort to help people (Fawcett, 1995). In addition,
Orem's theory suggests that the goal of nursing is to help people to meet their own
therapeutic self-care demands. From this theoretical view, nursing assists clients by
acting for, doing, or guiding physical and/or psychological support. Orem's theory
contains a detailed framework of self-care concepts that are linked in such a way as to
explain, describe, or predict the type of nursing care that will assist clients to achieve a


better level of health. A theory is a way of seeing through a "set of relatively concrete and
specific concepts and the propositions that describe or link the concepts" (Fawcett, 1999).
A nursing theory is a conceptualization of some aspect of nursing communicated for the
purpose of describing, explaining, predicting, and/or prescribing nursing care (Meleis,
1997). For example, Orem's theory (2001) explains the factors within a clients' living
situation that support or interfere with the client's self-care ability. It is important to note
that this theory has value in helping nursing design nursing interventions to pro- mote the
client's self-care in managing an illness such as diabetes or arthritis.
Theories constitute much of the knowledge of a discipline, and theory and inquiry are
vital linkages to each other (Fawcett and others, 2001). Nursing theories pro- vide nurses
with a perspective to view client situations, a way to organize data, and a method to
analyze and interpret information. When a nurse uses Orem's theory in practice, the nurse
assesses and interprets the data to determine the client's self-care needs, self-care deficits,
and self-care abilities in the management of a disease. The theory then guides the nurse to
design individualized nursing interventions. Application of nursing theory in practice
depends on the nurse's knowledge of nursing and other theoretical models, how these
models relate to each other, and the use of these models in designing nursing
Nursing is a learned profession, a science, and an art (Rogers, 1990). Nurses need a
theoretical base to exemplify the science and art of the profession when they pro- mote
health and wellness for their clients, whether the client is an individual, a family, or a
Components of a Theory :
As previously stated, a theory is a set of concepts, definitions, and assumptions or
propositions to explain a phenomenon. The theory explains how these elements are
uniquely related in the phenomenon. It is developed after extensive research, which
allows the re- searcher to see a clear perspective of all components of a phenomenon. For
example, Kristin Swanson studied the phenomenon of caring by conducting extensive
inter- views with clients and their professional caregivers (Swanson, 1991). Swanson's
theory of caring defines five components of caring: knowing, being with, doing for,
enabling, and maintaining belief. These components provide a foundation of knowledge
for the direction and delivery of caring nursing practice. Swanson's theory provides a


basis for identifying nurse, caring behaviors, which can then be tested, to determine to if
caring can improve client health outcomes.




Concepts. A theory consists of interrelated concepts. Concepts are mental formulations

of an object or event that come from individual perceptual experience (Alligood and They
are ideas, mental images. Concepts help to describe or label phenomena (Alligood and
using Neuman Systems Model (1972) as an example, there are concepts that affect the
client system. Some of these concepts are physiological, psychological, sociological ad
environmental or related to health and wellness, prevention, stressors, and defense
mechanisms (Meleis, 1997).
Definitions: The definitions within the description of a theory convey the general
meaning of the concepts in a manner that fits the theory. These definitions also describe
the activity necessary to measure the constructs, relation ships, or variables within a
theory (Chinn and Kramer, 2004; For example, Neuman Systems Model defines clients
as people who are anticipating stress or who are dealing with stress. Thus nurses who use
Neuman's theory in practice focus their care on client responses that could be labeled as
stressful (Meleis, 1997). These responses are within the domain of nursing (Meleis,
Assumptions. Assumptions are statements that describe concepts or connect two
concepts that are factual. Assumptions are the "taken for granted" statements that
determine the nature of the concepts, definitions, purpose, relationships, and structure of
the theory (Meleis, 1997; Chinn and Kramer, 2004). The assumptions in neuman Systems
Model are that clients are dynamic; the relationships between the theory's concepts
influence a client's protective mechanisms and determine a client's response; clients have


a normal range of responses; stressors attack flexible lines of defense followed by the
normal lines of defense; and nurse's actions are focused on primary, secondary, and
tertiary prevention (Neuman, 1972).
Identify domain and goals of nursing.
Provide knowledge to improve nursing administration, practice, education, and
Guide research to establish empirical knowledge base for nursing.
Identify area to be studied.
ldentify research techniques and tools that will be used to validate nursing
.Identify nature of contribution that research will make to advancement of
Formulate legislation governing nursing practice, research, and education.
Formulate regulations interpreting nurse practice acts so that nurses and others
better understand laws.
Develop curriculum plans for nursing education.
Establish criteria for measuring quality of nursing care, education} and
Guide development of nursing care delivery system.
Provide systematic structure and rationale for nursing activities.

Phenomenon. Nursing theories focus on the phenomena of nursing and nursing care. A
phenomenon is an aspect of reality that can be consciously sensed or experienced
(Meleis, 1997). Examples of phenomena of nursing include caring, self-care, and client
responses to stress. In Neuman Systems Model (1972), phenomena include all client
responses, environmental factors, and nursing actions. Within a specific discipline,
phenomena are part of the domain of the discipline. In nursing, phenomena reflect the
domain of nursing practice.
Types of Theory:
The general purpose of a theory is important because it specifies the context and situation
in. which the theory applies (Chinn and Kramer, 1999). Theories have different purposes
and may be classified by levels of abstraction (grand theories versus middle-range


theories) or the goals of the theory (descriptive or prescriptive). Theories may describe,
predict, or prescribe activities for the phenomena of interest.
Grand theories are broad in scope and complex and therefore require further
specification through research before they can be fully tested. A grand theory is not
intended to provide' guidance for specific nursing interventions, but to provide the
structural framework for broad, abstract ideas about nursing.

Theories that have more limited scope, less abstraction, address specific phenomena or
concepts and reflect practice (administration, clinical, or teaching) are considered
middle-range theories. The phenomena or concepts tend to cross different nursing fields
and reflect a wide variety of nursing care situations, such as uncertainty, incontinence,
social support, quality of life, and for example, Mishel's theory of uncertainty in illness
(1988, 1990) focuses on the experience of clients with cancer while living with continua;
uncertainty. The theory provides a basis for nurses to assist in appraising and adapting to
the uncertainty and the illness response.
Descriptive theories are the first level of theory development. They describe phenomena,
speculate on why phenomena occur, and describe the consequences of phenomena. They
have the ability to explain, relate, and in some situations predict nursing phenomena
(Meleis, for example, theories of growth and development describe the maturation
processes of an individual at various ages. Descriptive theories do not di- specific nursing
activities, but may help to explain client assessments.
Prescriptive theories address nursing interventions predict the consequence of a specific
nursing intervention. In nursing, a prescriptive theory should designate the prescription
(i.e., nursing interventions), the conditions under which the prescription should occur,
and consequences (Meleis, 1997). Prescriptive theories are on oriented, which tests the
validity and predictability a nursing intervention. These theories guide nursing recharch
to develop and test specific nursing interventions. For example, Mishel's theory of
uncertainty predicts that increasing the coping skills of clients gynecological cancer
assists their ability to deal with uncertainty of the cancer diagnosis and treatment. Thus
the theory provides a framework to design interventions that support and bolster clients'
coping resources.


Theoretical Models:
A theoretical model refers to global ideas about the individuals, groups, situations, or
events of interest to a specfic discipline from the view of the theorist. Theories focus
more specifically on the events and phenomena of discipline and are specific enough to
contribute to a d basis for nursing. Development of theory enhances ing science, which
involves the generation of knowledge.

Although this knowledge can be used with

knowledge from other disciplines, it is designed to advance and support nursing practice
and health care.
There are multiple nursing theories, some of which are presented in this and other
chapters in the text. It is important to understand the influence of theories from other
disciplines and their effects on nurses' clinical practice and client care and to use them in
developing innovative nursing interventions.

Relationship Of Theory
to the Nursing Process
and Client Needs
Historically, nursing theories were studied in an isolated academic environment
independent of nursing practice. Many nurses argued that theories were not relevant to
what occurs in clinical practice. There is, however, a contemporary move toward nursing
science or evidence based practice in which theories are tested and used to describe or
predict client outcomes of nursing care. For nursing to grow as a profession, knowledge
is needed to predict with confidence the types of nursing interventions that will improve
client outcomes. Nursing concepts and theories have evolved since Florence Nightingale,
who, in establishing the discipline of nursing, spoke with firm conviction about the nature
of nursing as a profession that required knowledge distinct from medical knowledge. The
overall goal of this knowledge has been to explain the practice of nursing as different and
distinct from the practice of medicine, psychology, and social work.
Theory generates nursing knowledge for use in practice. The integration of theory into
nursing practice is the basis for professional nursing. Nurses use the nursing process as a
means to determine the individual needs of clients. The nursing process is central to the
domain of nursing. However, the nursing process is not a theory it provides the process
for the delivery of nursing care, not the knowledge component of the discipline. The


process is a systematic approach for nursing care that allows a nurse to apply theory. For
example, a theory of caring influences what to assess, how to determine client needs, how
to plan care, how to select individualized nursing interventions, and how to evaluate
client outcomes. Useful theories are adaptable to different clients and all care settings.

Interdisciplinary Theories
To practice in today's health care systems, nurses need a strong scientific knowledge base
from nursing and other disciplines, such as the physical social, and behavioral sciences.
Knowledge from these other disciplines includes relevant theories that explain
phenomena. An interdisciplinary theory explains a systematic view of a phenomenon
specific to the discipline of inquiry, such as Erickson's development_theory.
Systems Theory:
A system is made up of separate components. The parts rely on one another, are
interrelated, share a common purpose, and together form a whole. A system has a specific
purpose or goal and uses a process to achieve that goal. The content is the product and
information obtained from the system.
Input is the information that enters the system. Output is the end product of a system.
Feedback is the process through which the output is returned to the system. Systems can
either be open or dosed. An open system interacts with its environment, exchanging
information between the system and the environment. Factors that change the
environment can also have an impact on the system. A closed system is one that does not
interact with the environment. An example of a closed system is a chemical reaction
occurring under specific conditions.
One example of an open system is the nursing process. The purpose of the nursing
process is to provide systematic and individualized client care. The process is the five
components assessment, nursing diagnosis, planning, implementation, and evaluation.
The content is the information obtained and used from each component. The nursing
process is an open system because the nurse applies the process to interact with the client
care environment. The nursing process continually changes as the client's nursing needs
Change. Input to the system comes from the client's assessment data (e.g., how the client
interacts with the environment). The output is re- turned as feedback to the system (e.g.,


the client's response to nursing interventions designed to assist the client to successfully
or unsuccessfully function in the environment).
using theories may have a systems model as the theoretical base. For example, Neuman
(1972, 1995) defines total-person model of wholism and an open systems aproach. As an
open system, the person interacts with the environment. The environment is both external
and internal, and the person interacts with stressors from the environment that affect the
1952 Hildegard E. Peplau 1960 Faye G. Interpersonal process is maturing force
Abdellah Irene L. Beland Almeda Martin




Ruth V. Matheney 1961 Ida Jean Orlando

determine nursing care.


1964 Ernestine Weidenbach 1966 Lydia E.

Hall 1966 Joyce Travelbee 1967 Myra E.
Levine 1970 Martha E. Rogers
1971 Dorothea E. Orem 1971 Imogene M.
King 1974 Sr. Callista Roy
1976 Josephine G. Paterson Loretta T.
1978 Madeleine M. Leininger 1979 Jean
1979 Margaret A. Newman 1980 Dorothy
E. Johnson 1981 Rosemarie Rizzo Parse
1989 Patricia Benner and
Judith Wrubel

Interpersonal process alleviates distress;

Helping process meets needs through art
of individualizing care. Nursing care is
person directed toward self-love.
Meaning in illness determines how
people respond. Holism is maintained by
conserving integrity. Person-environment











reference toward goal setting. Stimuli

disrupt an adaptive system.
Nursing is an existential experience of





Caring is moral ideal: mind-body-soul
engagement with another. Disease is a





Subsystems exist in dynamic stability.


Indivisible beings and environment cocreate health.

Caring is central to the essence of
nursing. It sets up what matters, enabling
connection and concern. It creates
possibility for
mutual helpfuIness.

client interaction with
environment including
interactions from the



Nursing process

Clients health status


for returning to the



following domains.






Client successfully or
unsuccessfully functions
in the environment
Basic Human Needs:
Maslow's hierarchy of needs is an interdisciplinary theory at is useful for designating
priorities of care. The hierarchy of basic human needs includes five levels of priority.


most basic, or first, level includes physiological needs, such physical and psychological
security. The third level contains love and belonging needs, including friendship, social
relationships, d sexual love. The fourth level encompasses esteem and Self esteem and
needs, which involve self-confidence, usefulness achievement, and self-worth. The final
level is the need for self-actualization, the state of fully achieving potential and having
the ability to solve problems and cope realistically with life's situations. Maslow's
hierarchy is extremely useful to nurses who must continually prioritize agent's nursing
care needs. Basic physiological and safety are usually the first priority, especially when a
client severely dependent physically. However, the nurse may counter situations in which
a client has no emergent physical or safety needs. Instead, high priority is given to e
psychological, socio cultural, developmental, or spiritual needs of the client.
Clients entering the health care system generally ve unmet needs. For example, a person
brought to an emergency department experiencing acute pneumonia an unmet need for
oxygen, the most basic physiological need. An older woman in a high crime area may be
concerned about physical safety and, while hospitalized have a need for psychological
security because of fear that her home will be burglarized. A widowed homemaker whose
children have moved away may feel that she does not belong or is not loved. Nurses in all
practice settings strive to help clients and their families meet these needs.
The hierarchy of needs is a useful way for nurses to plan individualized care for a client.
One need may take priority over another (such as restoration of an adequate airway
before the nurse educates the client in adjusting to in emotional conflict). The nurse uses
priorities to organize nursing diagnoses, develop goals and expected out- comes, and
select nursing interventions.
Health and Wellness Models:
Health and wellness theoretical models are designed to help health care professionals
understand the relationship between these two concepts and the client's attitudes toward
health and health practices. Knowledge of models assists nurses in understanding and
predicting the client's health behaviors, including use of health services and adherence to
recommended therapies . An understanding of these models is important when meeting
the health promotion and disease prevention needs of the client.
Stress and Adaptation:


Stress and adaptation are universal and dynamic. Everyone experiences stress and
attempts to adapt to life stressors. Stressors and stress responses are physiological and
behavioral. As a result, the models that explain the stress response are usually bio
behavioral and provide the framework for care of clients experiencing stress. Chapter 30
explains the more prominent theories and demonstrates how these models are used in
nursing practice.
Developmental Theories:
Human growth and development is an orderly predictive process that begins with
conception and continues through death. There are a variety of well-tested theoretical
models that describe and predict behavior and development at various phases of the life
Psychosocial Theories:
Nursing is an eclectic discipline that strives to meet the holistic needs of clients in their
physiological, psychological, socio cultural, developmental, and spiritual do- mains.
There are theoretical models that explain and/or predict client responses in each of these

Selected Nursing Theories:

definitions and theories-of nursing can help the nursing student understand how the roles
and actions of nurses fit together. The following sections describe, in chronological order
of theory development, concepts basic to selected nursing theories.
Nightingale's Theory:
Contemporary authors are beginning to explore Florence Nightingale's work as a
potential theoretical and conceptual model for nursing. Meleis (1997) notes that
Nightingale's concept of the environment as the focus of nursing care and her suggestion
that nurses need not know all about the disease process are early attempts to differentiate
between nursing and medicine.
Nightingale did not view nursing as being limited to the administration of medications
and treatments but rather as being oriented toward providing fresh air, light, warmth,
cleanliness, quiet, and adequate nutrition (Nightingale, 1860). Through observation and


data collection, she linked the client's health status with environmental factors and
initiated improved hygiene and sanitary conditions during the Crimean War.
Nightingale 1860

To facilitate "the body's

Peplau 1952









appropriate noise, nutrition,




socialization, and hope.




Abdellah 1960


interaction Nursing is a significant,

between nurse and client therapeutic,
process (peplau, 1952).
(Peplau, 1952)

Henderson 1955




To work independently with systems to faclitate natural

other health




(Marriner- humans




Tomey and Alligood, 2002), interpersonal relationships

Rogers 1970

assisting client in gaining Nurses




independence as quickly as perform



possible (Henderson, 1966); basic

Orem 1971



to help client gain lacking 1966).


King 1971





individuals, families,
Neuman 1972

and society; to be kind and

caring but also intelligent,
competent, and technically

Leininger 1978








others, 1960).

well prepared to provide



(Marriner- "Unitary

Tomey and Alligood, 2002)

Roy 1979



along life process. Client

continuously changes and

To maintain and promote coexists with environment.

health, prevent ill- ness, and
Watson 1979

care for and rehabilitate ill


and disabled client through

Brenner and Wrubel 1989

"humanistic science


of nursing" (Rogers, 1970)







To care for and help client becomes necessary when

client is unable to fulfill

attain total self-care



To use communication to









needs (Orem, 2001).

Nursing process is defined
as dynamic interpersonal



individuals, client, and health care sysfamilies, and groups in tem (King, 1981).
attaining and maintaining Stress reduction is goal of
maximal level of total systems model of nursing





purposeful practice. Nursing actions are

in primary, secondary, or
tertiary level of prevention

To provide care consistent (Neuman, 1972).

with nursing's emerging With this trans cultural care
science and knowledge with theory, caring is the central
caring as central focus knowledge and practice.
(Chinn and Kramer, 2004)

This adaptation model is

based on the physiological,




demands placed on

of psychological, sociological,

client, assess adaptation to independence
demands, and help client modes (Roy, 1980).




philosophy and since of




To promote health, restore interpersonal
client to health, and prevent comprising in- interventions

(Marriner-Tomey that result in meeting human


and Alligood, 2002)

To focus on client's need for
caring as a means of coping
with stressors of illness
(Chinn and Kramer, 2004)

needs (Watson, 1979, 1985).

Caring Is central to the
essence of nursing. Caring
creates the possibilities for



possibilities for connecting

with and concern for others
(Benner and Wrubel, 1989).

Nightingale provided basic concepts and propositions that could be supported and used
for practice in nursing. Nightingale's "descriptive theory" provides nurses with a way to
think about nursing with a frame of reference that for causes on clients and the
environment. Nightingale's letters and writings direct the nurse to act on behalf of the
client. Her principles were visionary and encompassed the areas of practice, research, and
education. Most important, her concepts and principles shaped and delineated nursing
practice. Nightingale taught and used the nursing process, noting that ('vital observation
[assessment] ...is not for the sake of piling up miscellaneous information or curious facts,
but for the sake of saving life and in- creasing health and comfort."
Peplau's Theory
Hildegard Peplau's theory (1952) focuses on the individual, the nurse, and the interactive
process; the result is the nurse-client relationship (Yamashita, 1997). According to this
theory, the client is an individual with a felt need, and nursing is an interpersonal and
therapeutic process, nursing goal is to educate the client and family and to help the client
reach mature personality development. The nurse strives to develop nurse-client
relationship in which the nurse serves as a resource person, counselor, and surrogate.
For example, when the client seeks help, the nurse and t first discuss the nature of the
problem and the e explains the services available. As the nurse-client relationship
develops, the nurse and client mutually de- the problem and potential solutions. The
client gains this relationship by using available services to meet , and the nurse assists the
client in reducing anxiety related to the health care problem. Peplau's theory is unique in
that the collaborative nurse-client relationship creates a "maturing force" through which
interpersonal effectiveness meets the client's needs. When the client's original needs have


been resolved, new needs may emerge. The nurse-client interpersonal relationship is
characterized by the following overlapping phases orientation identification, explanation,
and resolution.
Henderson/s Theory :
Virginia henderson defines nursing as "assisting the individual, sick or well, in the
performance of those activities that will contribute to health, recovery, or a peaceful death
and that the individual would perform unaided if he or she had the necessary strength,
will, or knowledge". The process of nursing strives to do this as rapidly as possible, and
the goal is independence. Henderson organized in to the theory 14 basic ``needs of the
whole person and includes phenomena from the following domains of the client
Physiological, psychological, socio cultural, spiritual, and developmental. together the
nurse and client work in unison to meet these needs and attain client-centered goals.
Abdellahs Theory:
Nursing theory developed by Faye Abdellah and others (1960) emphasizes delivering
nursing care for the whole person to meet the physical, emotional, intellectual social, and
spiritual needs of the client and family. when using this approach, the nurse needs
knowledge and skills in interpersonal relations, psychology, growth development,
communication, and sociology, as well as a knowledge of the basic sentences and specific
nursing skill. The nurse is a problem solver and decision maker the nurse formulates an
individualized view of the client's , need which may occur in the following four areas:
1. Comfort, hygiene, and safety
2. physiological balance
3. Psychological and social factors
4. Sociological and community factors
Johnson /s Theory
Dorothy Johnson's theory of nursing (1968) focuses on how the client adapts to illness
and how actual or potential stress can affect the ability to adapt. The goal of nursing is to
reduce stress so that the client can move more easily through recovery. According to
Johnson, the nurse assesses the client's needs in behavioral subsystems. Under normal
conditions tile client functions effectively in the environment. When stress disrupts
normal adaptation, however, behavior becomes erratic and less purposeful. The nurse


identifies this inability to adapt and provides nursing care to resolve problems in meeting
the client's needs.
Rogers' Theory
Martha Rogers (1970) considered the individual (unitary human being) as an energy field
coexisting within the universe. The individual is in continuous interaction with the
environment and is a unified whole, possessing personal integrity and manifesting
characteristics that are more than the sum of the parts (Rogers, 1970). The unitary human
being is a "four dimensional energy field identified by pattern and manifesting
characteristics that are specific to the whole and which cannot be predicted from the
knowledge of parts". The four dimensions used in Rogers' theory-energy fields, openness,
pattern and organization, and dimensionality-are used to derive principles related to
human development.
Orem's Theory
Dorothea Orem (1971) developed a definition of nursing that emphasizes the client's selfcare needs. Orem defines self-care as a learned, goal-oriented activity directed to- ward
the self in the interest of maintaining life, health, development, and well-being. The goal
of Orem's theory is to help the client perform self-care. According to Orem, nursing care
is necessary when the client is unable to fulfill biological, psychological, developmental,
or social needs. The nurse determines why a client is unable to meet these needs, what
must be done to enable the client to meet them, and how much self-care the client is able
to perform. The goal of nursing is to increase the client's ability to independently meet
these needs.
Neuman's Theory
Betty Neuman's theory (1995) defines a total-person model for nursing, incorporating a
wholistic concept and an open-systems approach . Neuman believes"that nursing is
concerned with the whole person. The goal of nursing is to assist individuals, families,
and groups in attaining and maintaining a maximal level of total wellness (Neuman and
Young, 1972). The nurse assesses, manages, and evaluates client systems. Nursing
focuses on the variables affecting the client's response to the stressor.
Nursing actions in dude the primary, secondary, and tertiary levels of prevention. Primary
prevention focuses on strengthening a line of defense through the identification of actual
or potential risk factors associated with stressors. Secondary prevention strengthens

internal defenses and resources by establishing priorities and treatment plans for
identified symptoms, and tertiary prevention focuses on readaptation. The principal goal
in tertiary prevention is to strengthen resistance to stressors through client education and
to assist in preventing a recurrence of the stress response Alligood and Marriner-Torney.

Leininger's Theory:
Leininger's cultural care diversity and universality theory states that care is the essence of
nursing and the, dominant, distinctive, and unifying feature of nursing. Human caring
varies among cultures in its expressions processes, and patterns. To provide care to clients
of unique cultures the nurse selects interventions from one of the following:

.Culture care preservation and maintenance

Culture care accommodation, negotiation, or both

Culture care restructuring and repatterning

King's Theory:
Flmogene King's goal attainment theory focuses on three dynamic interacting systems:
personal, interpersonal, and social. A personal relationship forms between client and
nurse. The nurse-client relationship is the vehicle for the delivery of nursing care, which
King defines as a dynamic interpersonal process in which the nurse and client are
affected by each other's behavior, l as well as by the health care system. The nurse's goal
is to use communication to assist the client in reestablishing or i maintaining a positive
adaptation to the environment.
Roy's Theory
Sister Callista Roy's adaptation theory views the client as an adaptive system. According
to Roy's model, the goal of nursing is help the person adapt to changes in physiological !
needs, self-concept, role function, and interdependent relations during health and illness.
The need for nursing care arises when the client cannot adapt to internal and external
environmental demands. All individuals must adapt to the following demands:
1. Meeting basic physiological needs
2. Developing a positive self-concept
3. Performing social roles
4. Achieving a balance between dependence


i The nurse determines what demands are causing problems for a client and assesses how
well the client is adapt- ing to them. Nursing care is then directed at helping the client
adapt. For example, a postoperative client who has a significant blood loss and now has a
low hematocrit value needs nursing interventions designed to assist the client in adapting
to the associated fatigue. The nurse I may design interventions to allow sufficient rest.

Watson's Theory:
Jean Watson's philosophy of transpersonal caring defines the outcome of nursing activity
in regard to the humanistic aspects of life. The action of nursing is directed at
understanding the interrelationship between health, illness, and human behavior. Nursing
is concerned with promoting and restoring health and preventing illness.
Watson's model is designed around the caring process, assisting clients in attaining or
maintaining health or in dying peacefully. This caring process requires that the nurse be
knowledgeable about human behavior human responses to actual or potential health
problems, individual needs, how to respond to others, and strengths and limitations of
the client and family, as well as those of the nurse. In addition, the nurse comforts and
offers compassion and empathy to clients and throw families. Caring represents all of the
factors the nurse uses to de- liver health care to the client.
Benner and Wrubel's Theory:
The primacy of caring is a model proposed by Patricia Benner and in this model, caring is
central. Caring creates possibilities for coping; enables possibilities for connecting with
and concern for others, and allows for the giving and receiving of help. As defined in this
theory, caring means that persons, events, projects, and things matter to people. Caring
itself presents a connection (Edwards, 2001). Caring represents a wide range of
involvement (e.g., caring about one's family, caring about one's friend- ships, and caring
about one's clients). Benner and Wrubel see the personal concern as an inherent feature of
nursing practice. In caring for one's clients, nurses help clients recover by noticing those
interventions that are successful and that can guide future care giving (Edwards, 2001).
Chapter 7 describes this theory and other theoretical perspectives on caring within the
nursing context.
Application of nursing theory in practice depends on nurses having knowledge of the
theories, as well as an understanding of how the theories relate to one another. Theories

are the organizing frameworks for the science of nursing and the substantive approaches
for nursing care. They provide critical thinking structures to guide clinical reasoning and
problem solving.
The Link Between Theory and Knowledge Development in Nursing
Nursing has its own body of knowledge that is both theoretical and practical. Theoretical
knowledge includes and "reflects on the basic values, guiding principles, elements, and
phases of a conception of nursing" (Meleis, 1997). The goals of theoretical knowledge
stimulate thinking and create a broad understanding of the "science" and practices of the
nursing discipline.
Practical knowledge is not organized in the same manner as theoretical knowledge.
Practical knowledge or the "art" of nursing is based on nurses' experience in providing
care to clients. It is achieved through personal know- ing gained through reflection on
care experiences, synthesis, and integration of the art and science of nursing.
An earlier discussion in this chapter described the types of nursing theories and indicated
that theories provided direction to nursing research. The relationships of components in a
theory help to drive the research questions for understanding nursing phenomena. For
example, the relationship of components within Orero's self- care deficit theory has led
nurse researchers to test approaches for their efficacy in improving self-care. The
relationship between nursing theory and nursing research helps to build the discipline's
knowledge base. As more research is conducted, the discipline learns to what
" extent a given theory can be useful in providing knowledge that improves client care.
note that one view of the relationship between research and theory is a spiral
This spiral represents the interaction between theory and research and an underlying
assumption that research increases nursing's knowledge base. Research is linked to theory
in two ways: generation of theory and testing of theory Theory-generating research is
designed to discover and

describe relationships of phenomena without imposing

preconceived notions (e.g., hypotheses) of what the phenomena under study mean (Chinn
and Kramer, 2004).
In theory-generating research, the investigator makes observations with an open mind in
order to view a phenomenon in a new way. For example, a researcher may want to
understand end-of-life surrogate dedsion making. In this example, the researcher

interviews surrogate decision makers. From these interviews, the researcher would make
objective observations about the surrogate decision making process, resulting in an initial
theory of surrogate decision making.
Theory testing research is used to determine how accurately a theory describes a nursing
phenomenon. The investigator has some preconceived notions as to how the phenomenon
is described and generates research questions or hypotheses to test the assumptions of the
theory. Using the previous example of surrogate decision making, the researcher may test
elements of the theory. For example, interviews of decision makers indicated that more
knowledge about end of life care expectations was needed. The researcher may then
initially test an educational pro- gram on end-of-life care for groups of surrogate
caregivers. No one study can test all components of a theory; the theory is tested through
a variety of research activities.
The result of theory-generating or theory-testing research is to increase nursing's
knowledge base. As a result, nurses are able to incorporate research-based interventions
into the practice of the discipline. As these research activities continue, not only does the
knowledge and science of nursing increase, but also clients are the recipients of best
evidence-based nursing practice.
As an art, nursing relies on knowledge gained from practice and reflection of past
experiences. As a science, nursing draws on scientifically tested knowledge that is
applied in the practice setting. But it is the "expert nurse" who transports the art and
science of nursing into the scientific realm of creative caring.

Unit III Nursing Process

The nursing process is a systematic, logical method of providing individualized nursing
care. Box 4-1 provides characteristics of the nursing process. The purposes of the nursing
process are:


To identify a client's health status and actual or potential health care problems or

To establish plans to meet the identified needs

To deliver specific nursing interventions to meet those needs

The components of the nursing process follow a logical sequence, but more than one
component may be involved at anyone time
Figure 4

In 1961, the nursing process was defined at the Cartholic University of America. It was
developed as a template for thinking that was exclusively for nursing. Although the
process was designed with registered nurses in mind, use of the nursing process provides
a common way of thinking for all licensed nurses. All licensed nurses collect data for
assessment. They plan, implement, and evaluate. Through the data they collect and
through their ongoing evaluation of the client, contribute to the nursing diagnoses that
RNs are responsible for making.

Components of the Nursing Process

The nursing process consists of five steps: assessing, diagnosing, planning,
implementing, and evaluating. Nursing theorists may use different terms to describe these
steps. For example, nursing diagnosis may sometimes be called analysis. Implementation
(implementing) may be called intervention or intervening. However, the activities of the


nurse using the process are similar. An overview of the five-phase nursing process is
shown in
Table 4

The system is open and flexible to meet the unique needs of client, family,
group, or community.

It is cyclic and dynamic. Because all phases are interre- lated, there is no
absolute beginning or end.

It is client centered; it individualizes the approach to each client's particular


It is interpersonal and collaborative. It requires the' nurse to communicate

directly and consistently with clients to meet their needs.

It is planned.

It is goal directed.

It permits creativity for the nurse and'client in devising ways to solve the
stated health problem.

It emphasizes feedback, which leads either to reassess- ment of the problem

or to revision of the care plan.

It is universally applicable. The nursing process is used as a framework for

nursing care in all types of health care settings, with clients of all age

The nursing process "provides the framework in which nurses use their knowledge and
skills to express human caring" and to help clients meet their actual and potential health
problems. The nursing process has unique properties that enable it to respond to the
changing health status of the client.
Role of the Nurse in Nursing Process
Nurse is one of the important members of the health care team, should be familiar with
all aspects of the nursing process. They should be specially educated in those aspects that
fall within their scope of practice. Within each step of the nursing process, there will be
functions performed by the nurse, functions carried out in collaboration with or under the
direction of the RN, and functions implemented by the RN. The importance of
understanding the entire process cannot be overemphasized.

The nursing process:

1. Helps students transfer classroom knowledge to the clinical setting
2. Provides structure and guidance for the nurse as they provide client care
The specific duties carried out by the nurse or given below.
Collecting, organizing, validating, and
documenting client data.

To establish a database about the client's

response to health concerns or illness and the
ability to manage health care needs
i Diagnosing
:Analyzing and synthesizing data ".

To identify client strengths and health

problems that can be 'prevented or resolved
by collaborative and independent nursing'
interventions .

To develop a list of nursing diagnoses and

collaborative problems
To develop an individualized care plan that
specifies client goals/desired outcomes and
Determining how to prevent, reduce, or related nursing interventions
resolve identified implement nursing
individualized, and goal-directed manner
Carrying out



To assist the client to meet desired

promote wellness; prevent
nursing goals/outcomes;
.illness and disease; restore health; and
facilitate coping with altered functioning

To determine whether to continue, modify, or

Measuring the degree to which terminate the plan of care.
goals/outcomes have been achieved and
identifying factors that positively or
negatively of care influence goal

Assessment is the systematic collection, organization, validation (proving or supporting),
and documentation of data information. All phases of the nursing process depend on urate
and complete data collection. Nursing assessments focus on a client's responses to a
health problem. The joint commission on Accreditation of Healthcare Organizations
(JCAHO, 2001) recommended that each client receive a documented assessment on
admission to an agency. The initial assessment is usually done by the RN.

In some situations, ongoing assessments are also done only by RNs. This may be stated in
the nurse practice act of state or may be a management decision of a particular facility.
The nurse is responsible for contributing by collecting data. The nurse is also responsible
for reading the assessment prior to beginning care of assigned clients.
The assessment process involves four closely related activities collecting data, organizing
data, validating data, documenting data.
Collecting Data
Data collection is the process of gathering information about a client. It must be both
systematic and continuous, and it must reflect a client's changing health status.
A client's database (baseline data) includes information from many sources: (1) The
nursing health history, (2) nurse's physical assessment, (3) the physician's history and
physical examination, (4) results of laboratory and diagnostic tests, and (5) information
contributed by other health personnel. (See Components of a Nursing Health History
Client data should include past history as well as current. problems. For example, a
history of an allergic reaction to penicillin is a vital piece of historical data. Current data
relate to present circumstances, such as pain, nausea, or sleep pat- terns. To collect data
accurately, both the client and nurse must participate actively.
Data can be subjective or objective. Subjective data, also referred to as symptoms, are
apparent only to the person affected. Itching, pain, and feelings of worry are examples of
subjective data. Subjective data include the client's sensations, feelings, values, beliefs,
attitudes, and perception of personal health status and life situation. Information supplied
by family members and significant others is also considered subjective.
Objective data, also referred to as signs, are detectable by an observer or can be tested
against an accepted standard. They can be seen, heard, felt, or smelled. For example, a
discoloration of the skin or a blood pressure reading are objective data. During the headto-toe assessment, the nurse obtains the objective data needed to validate subjective data.
A complete data- base of both subjective and objective data provides a baseline for
comparing the client's responses to nursing and medical interventions.
Biographic Data ,
Client's name, address, age, sex, marital status, occupation, religious preference, health


care financing, and usual source of medical care

Chief Complaint or Reason for Visit
The answer given to the question "Why did you come here today?"
History of Present Illness

Provocation or palliation: what causes it, what relieves it

Quality and quantity: type of pain and intensity .

Region or radiation: where it is, where it goes .

Scale of pain: 1 to 10

Timing: when it began, how long it lasts, and how often it occurs

Past History

Childhood illnesses

Childhood immunizations .Allergies

Accidents and injuries

Hospitalization for serious illnesses

Medication: all currently used prescription and over- the-counter medication, such
as aspirin, nasal spray, vit- amins, or laxatives

Family History of Illness

.Heart disease, cancer, genetic abnormality


Personal habits: tobacco, alcohol, coffee, etc.


Sleep/rest patterns

Activities of daily living (ADLs): any difficulties in per- forming the basic


Social Data

Client's support system: family, friends, professional counseling

Ethnic affiliation

Highest level of education

Occupation and employment: Has illness affected ability to work?

Health insurance

Home and neighborhood conditions (if applicable)

Psychological Data

Major stressors .

Usual coping patter

Communication style

Sources of Data
The client is the primary source of data. All sources other than the client are considered
secondary sources. The nurse should indicate on the nursing history when the data are
obtained from a secondary source (a parent, a cousin, a friend).
Client Records -:
The nurse must always consider the information in client records in light of the present
situation. For example, if the most recent medical record is 10 years old, it is likely that
the client's health practices and coping behaviors have changed.
Data Collection Methods
The primary methods used to collect data are observing, inter- viewing, and examining.
Observation occurs whenever the nurse is in contact with the client or support persons.
Interviewing is used mainly while taking the nursing health history.

Observation is gathering data by using the senses. Although nurses observe mainly
through sight, most of the senses are engaged during careful observations. Examples of
client data observed through four of the five senses are shown in Table 4-2 .

"I feel weak allover when 1 exert myself."


Client states he has a cramping pain in his abdomen, States, "I feel sick to my

"I'm short of breath,"

"He doesn't seem so sad today," wife states,

"I would like to see the chaplain before surgery,"


Blood pressure 99/50 + Apical pulse 104 ,

Skin pale and diaphoretic

Vomited 100 mL green-tinged fluid .

Abdomen firm and slightly distended

Active bowel sounds auscultated in all four quadrants .Lung sounds clear
bilaterally; diminished in right lower lobe

Cried during interview

Holding open Bible

Has small silver cross on bedside table




Overall appearance (body size, general

weight, posture, grooming); signs of
distress or discomfort; facial and body
gestures; skin color and lesions;
abnormalities of movement; nonverbal
demeanor (e.g., signs of anger or anxiety);
religious or cultural artifacts (e.g., books,
icons, candles, beads)
Body or breath odors
Breath and heart sounds; bowel sounds;
ability to communicate; language spoken;
ability to initiate conversation; ability to
respond when spoken to; orientation to
time, person, and place thoughts and
feelings about self, others, and health status
Skin temperature and moisture; muscle
strength (e.g., hand grip); pulse rate,
rhythm, and volume; palpatory lesions (e.g.,
lumps, masses, nodules)


Observation involves interpretation of data.

The nurse and the RN work together

(Collaborate) to determine the meaning of the observation.

An interview is a planned communication or a conversation l purpose. In interviews, the
nurse gets or gives information; identifies problems of mutual concern; evaluates change;
teaches; and provides support, counseling, or therapy. Interviewing is a process the nurse
applies in most phases of the 19 process. During the assessment phase, however, the try
purpose of the interview is to gather data. One example of the interview is the admission
The physical examination or physical assessment is a systematic data-collection method
that uses the senses of sight, 19, smell, and touch to detect health problems. To conduct
the examination, the nurse uses techniques of inspection, auscultation, palpation, and
percussion .
To complete the assessment phase, the nurse records client Accurate documentation is
essential and should include all data collected about the client's health status. Data are led
in a factual manner and not interpreted by the nurse. (ample, the nurse records the client's
breakfast intake objective data) as "coffee 240 ml, juice 120 ml, 1 egg, and 1 )f toast," not
as "appetite good" (a judgment). A judgment or conclusion such as "appetite good" or
"normal appetite" may have different meanings for different people.
To increase accuracy, the nurse records subjective data in the client's own words.
Restating what someone says increases the chance of changing the original meaning.

Diagnosis is the second phase of the nursing process. In this phase, nurses use criticalthinking skills to interpret assessment data and identify client strengths and problems. As
mentioned, this phase is the responsibility of the RN. The nurse discusses the collected


data with the RN. The RN identifies appropriate nursing diagnoses for the client and
initiates the nursing care plan.

A nursing diagnosis is a statement about an alteration in the client's health status. It refers
to a condition that nurses are licensed to treat. A medical diagnosis is made by a
physician and refers to a condition that only a physician can treat. Table 4-3 compares
medical and nursing diagnoses, and collaborative problems.

The identification and development of nursing diagnoses began formally in 1973, and the
First Canadian- Conference took place in 1977. In 1982, the conference group accepted
the name North American Nursing Diagnosis Association (NANDA), recognizing the
participation and contributions of nurses in the United States and Canada. NANDA
updates its list of nursing diagnoses every two years.
In 1990, NANDA adopted an official working definition of nursing diagnosis: "Nursing
diagnosis is a clinical judgment about individual, family, or community responses to
actual and potential health problems/life processes. Nursing diagnoses provide the basis
for selection of nursing interventions to achieve outcomes for which the nurse is
Linda Carpenito provided a definition of nursing diagnosis which is perhaps easier to
understand. According to her, nursing diagnoses are" actual or potential health problems
which nurses, by virtue of their education and experience, are capable and licensed to


These definitions imply the following:

Registered nurses are responsible for making nursing diagnoses. Nurses and other
nursing personnel contribute data to the process of diagnosing, and implement
specified nursing care.

Nursing diagnoses describe a continuum of health states: deviations from health,

presence of risk factors, and areas of improved health.

The domain of nursing diagnosis includes only those health states that nurses are
educated and licensed to treat. For example, nurses are not educated to diagnose
or treat diseases like diabetes mellitus. This task is legally within the practice of
medicine. Yet nurses can diagnose and treat Deficient Knowledge, Ineffective
Individual Coping, or Imbalanced Nutrition, all of which may accompany
diabetes mellitus.

A nursing diagnosis is a statement made only after through, systematic data



Components of a NANDA:
Nursing Diagnosis
A nursing diagnosis has three components: the problem, qualifier(s), and etiology.
Problem (Diagnostic Label)
The problem statement, or diagnostic label, describes the client's health problem or
response for which nursing theory is given in clear, concise terms. The purpose of the
nursing diagnosis is to direct the formation of client goals and desired outcomes. It may
also suggest some nursing interventions.
Defining characteristics are the cluster of manifestations (signs and symptoms) that
indicate the presence of a particular diagnostic statement.
When a NANDA label is followed by the word "(specify)", the nurse states the area in
which the problem occurs. For example, Deficient Knowledge (medications) or Deficient
Knowledge (dietary adjustments) specify the particular area in which teaching is needed.
Qualifiers are added to some NANDA statements to give additional meaning to the
diagnostic statement. For example:

Impaired (made worse, weakened, damaged, reduced, deteriorated).

Decreased (smaller in size, amount, or degree)

Ineffective (not producing the desired effect)

Etiology (Related Factors and Risk Factors)

The etiology piece of the nursing diagnosis identifies factors, contributing to, or probable
causes of, the health problem. It gives direction to the required nursing therapy and
enables the nurse to individualize the client's care.
Two-Part and Three-Part Nursing Diagnosis Statements
Most nursing diagnoses are written as two-part or three-part statements. Basic two-part
statements are used for potential problems or "at risk for" statements. They include the
problem (NANDA label) and the etiology. The two parts are joined by the words related
to to imply a relationship. Some NANDA labels contain the word specify. For these, the


RN adds words to indicate the problem more specifically. For example, "Noncompliance
(specify)" might become "Non- compliance (diabetic diet)" related to denial of having
Basic three-part statements are used for actual problems. The basic three-part nursing
diagnosis statement is called the PES format and includes:
1. Problem (P): Statement of the client's response (NANDA label).
2. Etiology (E): Factors contributing to or probable causes of the response.
3. Signs and symptoms (S): Defining characteristics manifested by the client.
Situational Low Self-Esteem related to (r/t)
Rejection by husband as manifested by (a.m.b.)
Signs and Symptoms
Hypersensitivity to criticism; states, "1 don't know if I can manage by myself" and rejects
positive feedback
Planning is the third step in the nursing process. Planning is a systematic phase of the
nursing process that involves decision making and problem solving. In planning, the
nurse refers to the client's assessment data and diagnostic statements for direction in
formulating client goals. All planning is aimed at preventing, reducing, or eliminating the
client's health problems. The product of the planning phase is a client care plan.
The input of the nurse and support persons is essential if a plan is to be effective. Nurses
do not plan for the client, but encourage the client to participate as actively as possible in
shaping a plan. In a home setting, the client's sup- port people and caregivers are the ones
who implement the plan of care. Its effectiveness depends largely on them.

According to the NCLEX-PN test plan, the Nurse role in the planning phase is to do
the following:
1. Assist in the formation of the goals of care:

Participate in identifying nursing interventions required to achieve goals

Communicate client needs that may require alteration of the goals of care

2. Assist in developing the plan of care:


Involve the client and healthcare team members in the selection of nursing

Plan for the client's safety, comfort, and maintenance of optimum functioning.

Select nursing interventions for delivery of client's care (Anderson 2000, 233.)

Types of Planning
Planning begins with the first client contact and continues until the nurse-client
relationship ends, usually when the client is discharged from the health care agency.
Initial Planning:
The RN who performs the admission assessment usually develops the initial
comprehensive plan of care. Planning should be initiated as soon as possible after the
initial assessment, especially because of the trend toward shorter hospital stays. The nurse
can assist with data collection.
Ongoing Planning
Ongoing planning is done by all nurses who work with the client. As nurses obtain new
information and evaluate the client's responses to care, they can individualize the initial
care plan further.
Discharge Planning:
Discharge planning involves anticipating and planning for needs after discharge. It is a
crucial part of comprehensive health care and should be addressed in each client's care
plan. Although many clients are discharged to other agencies (e.g., nursing homes),
follow-up care is increasingly being delivered in the home. Effective discharge planning
begins at first client contact and involves comprehensive and ongoing assessment to
obtain information about the client's ongoing needs. For more about discharge planning.

Desired Outcomes



Monitor intake and output

Decreased oral intake



Urinary output> 30 ml/hr

Fatigue, weakness



Difficulty swallowing

1.005+ 1.025




Excess fluid loss



increased Serum Na normal

metabolic rate
Defining Characteristics
Insufficient intake

Mucous membranes moist

Skin turgor good
No weight loss
8 hour intake =

Negative balance of intake

and output


Dry mucous membranes

Poor skin turgor
Concentrated urine
Rapid, weak pulse
Falling B/P
Weight loss

Nursing Care Plans

The-end product of the planning phase of the nursing process is a formal or informal plan
of care. An informal plan is a plan of action that exists in the nurse's mind. For example,
the nurse may think, "Mrs. Phan is very tired. I will need to rein- force her teaching after
she is rested." A formal nursing care plan is a written guide that organizes information
about the client's care. Nurse students will practice writing care plans as part of their
study of the nursing process. This process is discussed below.
The most obvious benefit of a formal written care plan is that it provides continuity of
care. When nurses use the client's nursing diagnoses to develop goals and nursing
interventions, the result is a holistic, individualized plan of care that will best meet the
client's unique needs.


Standardized care plans specify the nursing care for the groups of clients with common
needs (e.g., all clients with , myocardial infarction). Individualized care plans are tailored
to meet the unique needs of a specific client-needs that are not addressed' by the
standardized plans.
Care plans include the actions nurses must take to address the client's nursing diagnoses
and produce the desired outcomes and a timeline for accomplishing the goal. The
complete plan of care for a client is made up of several different documents.
Kardex Care Plans:
Kardex is a trade name for a system in which client information and instructions for some
of the client's.care are kept on a large card in a central file, making information quickly
accessible. The Kardex usually contains information about diet, activity levels, self-care
hygiene needs, treatments, and procedures. Kardex information may change frequently. It
is usually recorded in pencil so that the Kardex can be changed and kept up to date. It is a
temporary record for ongoing care, and it does not become part of the client's medical
Computerized Care Plans
Computers are increasingly being used to create and store nursing care plans. The
computer can also generate both standardized and individualized care plans. Nurses
access the client's stored care plan from a centrally located terminal at the nurses' station
or from terminals in client rooms. Examples of a computerized student care plan can be
found on the companion website. Regardless of whether care plans are handwritten,
computerized, or standardized, nursing care must be individualized to fit the unique needs
of each client. The nurse uses standardized care plans for predictable, commonly
occurring problems and an individual plan for unusual problems or problems that need
special attention.
Student Care Plans
Because student care plans are a learning activity as well as a plan of care, they may be
more lengthy and detailed than care plans used by working nurses. To help students learn
to write a care plan, educators generally require that it be individualized. They may also
require a column be included for "Rationale" after the nursing intervention column. A
rationale is the scientific principle given as the reason for selecting a particular nursing
intervention. Table 4-4 shows how such a care plan would be made.

Guidelines for Writing Nursing Care Plans

The student may find it helpful to follow these guidelines' when writing nursing care
1. Date and sign the plan. The date the plan is written is essential for evaluation,
review, and future planning. The nurse's signature demonstrates accountability to
the client and to the nursing profession, since the effectiveness of nursing actions
can be evaluated.
2. Use these category headings: Nursing Diagnoses," "Goals/Desired Outcomes,"
"Nursing Orders/Interventions," "Rationales," and "Evaluation." Include a date
for the evaluation of each goal.
3. Use standardized medical or English abbreviations and key words, not complete
sentences, to communicate your ideas. For example, write "Turn and reposition
q2h" rather than "Turn and reposition the client every two hours."
4. Refer to procedure books or other sources of information rather than including all
the steps on a written plan.
5. Tailor the plan to the unique characteristics of the client by ensuring that the
client's choices, such as preferences about the times of care and the methods used,
are included. This reinforces the client's individuality and sense of control. For
example, the written nursing order "Provide prune juice at breakfast rather than
regular juice" indicates that the client was given a choice of beverages.
6. Ensure that the nursing plan incorporates preventive and health maintenance
aspects as well as restorative ones. For example, carrying out the order "Provide
active-assistance ROM (range-of-motion) exercises to affected limbs q2h"
prevents joint contractures and maintains muscle strength. and joint mobility.

Ensure that the plan contains orders for ongoing assessment of the client (e.g.,
"Inspect incision q8h").

8. Include collaborative and coordination activities in the plan. For example, the
nurse might ask a nutritionist or physical therapist about specific aspects of the
client's care.
9. Include plans for the client's discharge and home care needs. It is often necessary
to consult and make arrangements with the community health nurse, social
worker, and specific agencies that supply client information and needed


Setting Priorities Priority setting is the process of identifying nursing diagnoses and
interventions in order from most important or critical to least important. Life-threatening
problems, such as loss of respiratory or cardiac function, are given highest priority.
Health-threatening problems, such as pain and decreased cop- ing ability, are assigned
medium priority because they may result in delayed development or cause destructive
physical or emotional changes.
Desired Outcomes


Nursing orders


status q4h rate depth
amount and color of
b. Monitor results of
blood gases chest x-ray
studies and incentive
spirometer volume as
c. Monitor level of

A,b,c,d.To identify
progress toward or
airway clearance
to poor
drowsiness retain
nursing orders to
identify progress.
indicates problem
not resolved.
causes increased
Respiratory rate
may be decreased
Does not need to
be reinstructed as

exchange as
evidenced by
1. Absence of pallor

cyanotic but still


Goal partially met. Vital signs q4h(TPR,BP)


Productive cough

Goal met. Cough

moderate amounts

Instruc breathing and

techniques.Remind to
perform and assist


yellowpink tinged q3h.Support

and correct techniques.
encourage.(4/17/01,JW May still need
because of fatigue
and pain.
secretions so they
can be coughed up
and expelled.
not Maintain fowlers or Gravity allows for
semi fowelers position
excursion of at least
Airway High priority
Clearance related to viscous
secretions secondary to fluid
volume deficit and 2.
shallow chest
expansion secondary to pain
and fatigue

functioning is a lifethreatening problem.
nurse's primary concern
must be to promote the
oxygenation by addressing
the etiologies of this

Deficient Fluid Volume: High priority

intake insufficient to replace
fluid loss related to fever
and diaphoresis

Severe fluid volume deficit

is life threatening. Although
not that severe for this client
it is a high priority problem
because it is also a
Clearance. Collaborative
efforts to improve hydration
(intravenous flut ids).The
nurse must immediately and
continuously assess and prof mote hydration. severe for
this client, it is a highpriority problem because it
is also a diaphoresis

Anxiety related to (1) Medium priority

difficulty breathing and
concerns over work and
parenting roles.

Although the client is

concerned about work and
parenting olesmust provide
symptomatic relief of the
periods of dyspnea because


oxygenation by causing her
to breathe ineffectively and
increasing the rate at which
she uses oxygen. these are
not a threat to life. Also,
treatment of her highpriority
roles problem, Ineffective
Airway Clearance, will
relieve one of the etiologies
of this problem (dyspnea).
Meanwhile, the nurse
Imbalanced Nutrition: Less Low priority
than Body Requirements
related to decreased ,

problem is
currently health threatening,
but it could be if it were to
persist. It will almost
certainly resolve in a day or
two as the medical problem
is treated. If the medical
problem does not resolve
quickly, this will change to a
medium priority.

Risk for Altered Family Low priority

temporary unavailability of
father to provide child care.

Clients child is currently

being cared for. If the
husband returns as planned,
this potential problem will
not develop into an actual
problem. No interventions
are needed at present, except
for continued assessment
and reassurance.
Nurses frequently use Maslow's hierarchy of needs :when setting priorities. In Maslow's
hierarchy, physiologic needs that are basic to life (like air, food, and water) are listed at
the base of the pyramid. They receive higher priority than the need for security or
activity. Growth needs, such as self-esteem, are not perceived as "basic" in this
framework. So, nursing diagnoses such as Ineffective Airway
'I Clearance and Impaired Gas Exchange would take priority over nursing diagnoses like
Anxiety or Ineffective Coping.
Establishing Client Goals/Desired Outcomes
After establishing priorities, the nurse and client set goals for each nursing diagnosis. On
a care plan the goals/desired outcomes describe, in terms of observable client responses,
what the nurse hopes the client will achieve by implementing the nursing orders, (Note:
The terms goal and desired out- come are used interchangeably in this text,)


Long- term and short-term goals.

Goals may be short term or long term, A short-term goal might be, "Client will raise right
arm to shoulder height by Friday," In the same con- text, a long-term goal might be,
"Client will regain full use of right arm in 6 weeks," Long-term goals are often used for
clients who live at home and have chronic health problems and for clients in nursing
homes, extended-care facilities, and rehabilitation centers,
Developing desired outcomes from nursing diagnoses.
Goals are drawn from and relate to the client's nursing diagnoses, The problem clause
contains the unhealthy response; it states what should change. For example, if the nursing
diagnosis is "Risk for Deficient Fluid Volume related to diarrhea and inadequate intake
secondary to nausea," the related goal statement might be: "Maintain fluid balance, as
evidenced by urinary output in balance with fluid intake, normal skin turgor, and moist
mucous membranes."
In this example, a general goal (fluid balance) is stated as the opposite of the problem
(Deficient Fluid Volume) and then followed by a list of observable desired outcomes. If
achieved, the outcomes would be evidence that the problem, Deficient Fluid Volume, has
been prevented.
For every nursing diagnosis, there must be at least one desired outcome that, when
achieved, directly demonstrates resolution of the problem clause.
Components of goaudesired outcome statements.
Goaldesired outcome statements should usually have the following four components:
.Subject. The subject, a noun, is the client, any part of the client, or some attribute of the
client, such as the client's pulse or urinary output. The subject may be omitted in goals; it
is assumed that the subject is the client unless indicated otherwise.
.Action verb: The verb specifies an action the client is to per- form, for example, what
the client is to do, learn, or experience.
.Measurable outcome modifiers: Conditions or modifiers may be added to the verb to
explain the circumstances under which the behavior is to be performed. They explain: .
How-Walks with the help of a walker When-After attending two group diabetes classes,
lists signs and symptoms of diabetes.
Where-When at home, maintains weight at existing level
What-Discusses Food Pyramid and recommended daily servings


Criteria of desired performance. The criteria indicate the standard by which a

performance is evaluated, or the level at which the client will perform the behavior. These
criteria may specify time or speed, accuracy, distance, and quality. Examples include:
Fig : Maslows

To establish a time-achievement criterion, the nurse asks,

"Howlong?"-"Weighs 7S kg by April"
To establish an accuracy criterion, the nurse asks
'How far//?"-"Lists five out of six signs of diabetes in 2 weeks"
To establish distance, the nurse asks, "How far?"- "Walks one block per day"
To establish quality, the nurse asks, "What is the expected standard?" -"Administers
insulin using aseptic technique in 3 days"
WRITING GOALS/DESIRED OUTCOMES. Students should follow these guidelines
when writing desired outcomes:
Table Box 4.5




























1. Write goals/outcomes in terms of client responses, not nurse activities. Begin each
goal statement with "the client will" to focus on client behaviors and responses.
Avoid statements that start with enable, facilitate, allow, let, or permit, which
indicate what the nurse hopes to accomplish, not what the client will do. Correct:
Client will drink 100 cc of water per hour (client behavior). Incorrect: Maintain
client hydration (nursing action).
2. Be sure that desired outcomes are realistic for the client's capabilities, limitations,
and designated time span, if it is indicated. Limitations include finances,
equipment, family support, social services, physical and mental condition, and
time. For example, the outcome "Measures insulin accurately" may be unrealistic
for a: client who has poor vision due to cataracts.
3. Ensure that the goals/desired outcomes are compatible with the therapies of other
professionals. For example, the outcome "Will increase the time spent out of bed
by 15 minutes each day" is n9t compatible with a physician's prescribed therapy
of bed rest.
4. Make sure that each goal is derived from only one nursing diagnosis. For
example, the goal "The client will increase the amount of nutrients ingested and
show progress in the ability to feed self" is derived from two nursing diagnoses:
Feeding Self-Care Deficit and Imbalanced Nutrition: Less than Body
5. Use observable, measurable terms for outcomes. Avoid words that are vague and
require interpretation or judgment by the observer. Phrases like "increase daily
exercise" and "improve knowledge of nutrition" can mean different things to
different people. They are not clear and specific enough to guide the nurse when
evaluating client responses.


6. Make sure the client considers the goals important and I values them. 'The nurse
must actively listen to the client '... to determine personal values, goals, and
desired outcomes in relation to current health concerns. Clients are usually
motivated to reach goals they consider important. They may resist goals they feel
they are told they "should do."
Table 4-6 shows how outcomes are derived from nursing diagnoses.
Nursing Diagnosis


healthy Desired outcomes

Impaired physical mobility: Improved mobility ability
inability to bear weight on to bear weight on left leg.
inflammation of knee joint.

Ambulate with crutches by

end of the week. Be able to
stand without assistance by
end of the month.

Airway Effective airway clearance
clearance related to poor
cough effort, secondary to
incision pain and fear of
damaging sutures.

Lungs will be clear to

auscultation during entire
postoperative period. No
skin pallor or cyanosis by 12
hours postoperation. Within
24 hours after surgery, will
demonstrate good cough


The nurse working in long-term or home care may be assigned greater responsibilities
related to care planning. Once the initial assessment has been completed by the RN, the
care plan will be developed as a collaborative process. The LPN/LVN will be responsible
for implementing, evaluating, and reporting back to the RN on the achievement of the
client's goals. Most long-term facilities and home care agencies have regularly scheduled
client care conferences so that the health care team can interact and plan for the client's
future needs.

Implementation :
Implementation is the fourth step of the nursing process, in which selected nursing
interventions and activities occur. Nursing interventions are the actions that are initiated
by the nurse to achieve client goals. The specific strategies should focus on eliminating or
reducing the cause of the nursing diagnosis.


Types Of Nursing Interventions

Nursing interventions are identified and written during the planning step of the nursing
process. However, they are actually performed during the implementing step. McCloskey
and Bulechek (2000) define a nursing intervention as "any treatment, based upon clinical
judgment and knowledge, that. a nurse performs to enhance patient/client outcomes."
Nursing interventions include:

Direct care: An intervention performed through interaction

with the client such as giving a back massage ';

Indirect care: An intervention performed away from but on ': behalf of the
client, such as obtaining a referral for physical therapy.

Nurseinitiated: Independent interventions are those "activities that nurses are

licensed to initiate on the basis of their knowledge and skills. An example of an
independent action is planning and providing special mouth care for a client
based on a diagnosis of Impaired Oral Mucous Membranes.

Physician-initiated. Dependent interventions are activities carried out under the

physician's orders or super- vision, or according to specified routines.

Collaborative actions: Collaborative nursing activities reflect the overlapping

responsibilities between health personnel. A collaborative problem is a type of
problem that nurses manage using both independent and physician-prescribed

interventions. independent nursing interventions for a collaborative problem focus mainly

on monitoring

the client's condition and preventing development of the potential

complication. For example, physician might order physical therapy to teach the client
crutch-walking. The nurse would be responsible for informing the physical therapy
department and for coordinating the client's care to include the physical therapy sessions.
When the client returns to the nursing unit, the nurse would assist with crutch-walking
and collaborate with the physical therapist to evaluate the client's progress.

The nurse is responsible for explaining, assessing the need for, and administering the
medical orders. The RN writes nursing orders to individualize the medical order based on
the client's status. For example, for a medical order of "Progressive ambulation, as
tolerated," the nursing orders might be: 1. Dangle for 5 min, 12 h post-op
2. Stand at bedside 24 h post-op; observe for pallor, dizziness, and weakness.
3. Check pulse before and after ambulating. Do not progress if pulse 110.

Usually, several possible interventions can be identified for each nursing diagnosis. The
nurse's task is to choose those that are most likely to achieve the desired client outcomes.
Implementing Skills
Nurses employ a wide variety of skills in providing client care:
Cognitive:(intellectual) skills include problem solving decision making, critical thinking,
and creative thinking. They are crucial to safe, intelligent nursing care.
Interpersonal skills are all the verbal and nonverbal activities people use when
communicating directly with one another. The effectiveness of a nursing action often
depends largely on the nurse's ability to communicate with others. Even when giving
medication to a client, the nurse needs to understand the client and in turn be understood.
A nurse who is delegating a nursing action also needs to be understood.
Interpersonal skills: are necessary for all nursing activities. Caring, comforting,
referring, counseling, and support- ing are just a few. They include conveying knowledge,
attitudes, feelings, interest, and appreciation of the client's cultural values and lifestyle.

Technical skills: are "hands-on" skills such as manipulating equipment, giving injections,
doing dressing changes, moving, lifting, and repositioning clients. These tasks, called
procedures or psychomotor skills, always require communicating with the client.
However, they also require knowledge and, frequently, manual dexterity. The number of
technical skills expected of a nurse has greatly increased in recent years because of the
increased use of technology, especially in acute care hospitals.
Basic Procedures For Nursing Interventions
All procedures follow a basic format. You need to perform several steps whenever you
begin a procedure. These steps provide safeguards for the client and aid in your
organization. Procedure Basic Procedure Steps and Admission Information, demonstrates
the use of the procedure template.
The nurse should develop an understanding of the rationale (scientific reasoning) for each
intervention. You will find rationales in italics for many steps of the procedures.


Process of implementing:The process of implementing normally includes: reassessing

the client, determining the nurse's need for assistance, implementing nursing orders,
delegating and supervising, and documenting nursing actions.
Reassessing the Client just before implementing an order, the nurse must reassess the
client to make sure the intervention is still needed, because the client's condition may
have changed. For example, Gayle Fischer has a nursing diagnosis of Disturbed Sleep
Pattern related t~ anxiety and unfamiliar surroundings. During rounds, the nurse
discovers that Gayle is sleeping and there': fore defers the back rub that had been planned
as a relaxation strategy.
New data may indicate a need to change the priorities of care or the nursing strategies.
For example, a nurse begins to teach Ms. Eves, who has diabetes, how to give herself
insulin injections. Shortly after beginning the teaching, the nurse realizes .that Ms. Eves
is not concentrating on the lesson. Subsequent discussion reveals that she is worried
about her eyesight and fears she is going blind. Realizing that the client's level of stress is
interfering with her learning, the nurse ends the lesson and documents the clients concern
on the teaching plan. The physician should be informed so that arrangements can be made
for a consultation if needed. The nurse also should validate the client's concerns and
communicate actions that have been taken.
Determining the Nurse's Need for Assistance:

.The nurse is unable to implement the nursing strategies safely alone (e.g., turning
an obese client in bed).

.Assistance would reduce stress on the client (e.g., turning a person who
experiences acute pain when moved).

.The nurse lacks the knowledge or skills to implement a particular nursing activity
(e.g., a nurse who is not familiar with a particular model of oxygen mask needs
assistance the first time it is applied).

Implementing Nursing Orders (Strategies):

It is important to explain to the client what will be done, what sensations to expect, and
what the client is expected to do. For many nursing actions, it is also important to ensure
the client's privacy, for example, by closing doors, pulling curtains, or draping the client.
It is the responsibility of the delegator to assess the capabilities of e staff member being


assigned the task. Delegating does not relieve the nurse of the ultimate responsibility for
the task. When in doubt, the nurse and the unlicensed person should work together until
the unlicensed person's understanding of the assigned task d ability to perform it are
Documenting Nursing Actions:
After carrying out the nursing orders, the nurse completes the implementing phase by
recording the interventions and client responses in the nursing progress notes. These are a
part of the agencies

permanent record for the client. Nursing actions must not be

recorded in advance because, on reassessment, the nurse may find that the action should
not or cannot be implemented for example, a nurse is authorized to inject 10 mg of
morphine the sulfate subcutaneously to a client, but the nurse finds that the clients
respiratory rate is 4 breaths per minute. This finding contraindicates the administration of
morphine (a respiratory depressant). The nurse withholds the morphine and reports the
clients respiratory rate to the nurse in charge and! or physician.
The nurse may record routine or recurring activities (e.g.; mouth care) at the and of a
shift. In the meantime, the nurse maintains a personal record of these interventions. Many
agencies have special forms for this type of recording.
In some instances, it is important to record a nursing action immediately after it is
implemented. Recorded data about a client must be up to date, accurate, and available to
other nurses and health care professionals. This is particularly true of the administration
of medications and treatments.

immediate recording helps safeguard the client, for

example, from receiving a second dose of medication.

Nursing actions are communicated verbally as well as in writing. When a client's health is
changing rapidly, the charge nurse and/or the physician may want to be kept up to date
with verbal reports.

Interdisciplinary documentation forms require the nurse to chart in a timely manner.

When others are using the same form, delayed charting may find the nurse without a
place to document, making it necessary to document a late entry.
Nurses also give verbal reports at a change of shift and on a client's discharge to another
unit or health agency.


Evaluation is the fifth and last phase of the nursing process,

but many times the

evaluation phase is overlooked.

Evaluation: is review of interventions to determine their effectiveness. An interventionmay be discarded as ineffective without taking-time to discover why it did not "work.
One thing that-sefs-the nurse apart from a CNA is the knowledge and ability to evaluate.
Clients need to be evaluated all day long. The best way to evaluate an intervention is to
determine if the objective from the written care plan has been met, and if not, why not
Through evaluating, nurses accept responsibility for their action indicate interest in the
results of the nursing actions and demonstrate a desired to replace in affective action
with more effective one. After determining whether a goal has been met, the nurse writes
an evaluative statement (either on the care plan or in the nurse's notes). These notes help
the RN to review and modify the nursing care plan, so that individualized nursing care
can continue. Once the care plane is modified, the nursing process cycle begins agains.

Controlling is the function of management that involves, setting standards ,measuring
performance against those standards ,reposting the results and taking action. Employees
who feel they can influence their environment have

some control over their destinies

,thus increasing job satisfaction and motivation. Organization also need some control
over productivity, innovation and quality outcomes.
Quality control is a specific type of controlling, refers to activities that evaluate, monitor
or regulate services rendered to consumers. In nursing, the goal of quality care would be
to ensure quality while meeting intended goals. Quality control when viewed
simplistically can be broken down into three basic steps:
1. Criterion or standard is determined
2. Information is collected to determine if the standard has been met.
3. Educational or corrective action is taken if the criterion has not been met.

To understand quality control, the nurse manager must become familiar with the process
and the terminology used and quality assurance and quality improvement as follows
Philosophy is a system of motivating belief and principles that direct actions of a
particular group during goal pursuit. The philosophy of a nursing department determines
goals oft/1 nursing workforce, which in turn influence patient care objectives established
by each nurse,
Accountability is the obligation to provide a reasoning for one's actions to the per who
delegate authority for that action. The conscientious nurse exhibits accountability to ward
her his employer, the patient, and government agency or insurance company that pays/
the patient's health care.

A Nursing care outcome is the end result of nursing interventions, a measurable change
in the state of a patient's health that is occasioned by nursing action.

A Criterion is the value-free name of a variable that is known to be a reliable indicator of

quality, e.g. it has been shown that the type and amount of a nurse's educational
preparation affect the quality of her or his patient care decisions.
A standard is the desired quality, quantity, or level of performance that is established as a
criterion against which workers performance will be measured.


A norm is current level of performance of a selected work group with reference to a given
An objective is a goal towards which effort is directed. To be effective a goal should be
expressed in observable, measurable terms and should include a target date for fulfilment.
A critical clinical indicator is a quantitative measure that can be used as a guide to
monitor and evaluate the quality of important patient care activities.
Measurement is the objective process of determining capacity, quantity or dimension of
an object; phenomenon, or outcome.
Evaluation is a subjective judgment based on objective measurement.
Feedback is the information about system performance that is reflected back into the
system on a basis for monitoring system operation.
Quality health care is the appropriate application of medical science knowledge to patient
care, while balancing the hazards associated with each intervention with the benefits
resulting from the intervention.
Communication is an enabling process that allows information to be transfered and I
ideas to be translated into action.
Continuous quality improvement is the ongoing process of monitoring structure, process,
and outcome indicators in order to identify signal events, significant trends, and
opportunities for change that will guide health care professionals in preventing patient
care problems and improving already satisfactory patient services.

The effectiveness of a particular nursing intervention is the extent to which desired

outcomes are attained through use of the intervention.


The efficiency of a particular nursing intervention is determined by computing the

interventions cost-benefit ratio or the relationship between monetary value of the
resources expanded and monetary value of results achieved.
A peer is a colleague of equal status and ability who is engaged in practice in a similar
unit in the same agency and can accurately assess the appropriateness of an associate
response to a patient care needs.
Nursing peer review is the evaluation by a group of practicing professional nurse peers of
the quality of nursing care implemented by another nurse.
Quality control as a process has certain specific steps as follows: 1. Establishment of
control standards or criteria. Identify the information relevant to criteria. 3, Determine
ways to collect the information. 4. Collect and analyse the information.

5. Compare collected information with established criteria. 6. Make a judgment about

7. Provide information and if necessary, take corrective action regarding findings of
appropriate sources.
8. Determine ways to collect the information.


Standard is an predetermined baseline condition or level of excellence that comprises a
model to be followed and practiced. They have distinguishing characteristics; they are
predetermined, established by an authority and communicated to and accepted by the
individuals affected by the standards, because standards are used as measurement tools
and they should be measurable and achievable.
There are different types of standards which can be used to direct and control nursing
actions. Standards can be differentiated as relating to nursing structure, process and
outcomes a organizational standards outcome, levels of acceptable practice within the


institution itself, e.g., each organization develops a policy and procedure manual that
outlines its specific standards. These standards will minimize or maximized in terms of
the quality of service expected. Standards of practice allow the organization to measure
more objectively unit and individual performance. The recommended relationship
between the nursing department and other departments in a health agency are structural
standards, because they refer to the organizational structure in which nursing is
implemented. Criteria that specify desired methods for specific nursing intervention are
process standard, because they refer to the process or series of events through which care
is administered. Descriptive statement of desired patient care results are outcome
standards, because patients results are outcomes of nursing interventions.

Koont and Weitrich (1988) have identified the following eight types of standards the most
organization must establish:
1. Physical standards, which include patient activity ratings to establish nursing care
hours per patient day.
2. Cost standards, which include the cost per patient day.
3. Capital standards, which include the review of monetary investment or new

4 Revenue standards, which include the revenue per patient day for nursing care.

4. Programme standards, which guide the development and implementation of

programmes to meet client needs.
5. Intangible standards which include staff development or personnel orientation
6. Goal standard, which outline qualitative goals in short and long term planning.
7. Strategies plan standard, which outline check points in developing and
implementing the organisations strategic plan.

All these standards provides the yardstick for measuring quality care, e.g. outcome
standards are defined in terms of what the patient will know, do, express or experience
and reflect nursing also for physiological, emotional and mental well-being. These
outcome measures to be the most valid indicators of quality care, and recently evaluation
of hospital care have focused on structure and process standards also. The structure
standards which are often set by licensing and according bodies ensure a safe and
effective environment but do not address the actual care provided. The process standards


may be documented in patient care plans, procedure manuals, or nursing protocol

statements, e.g. fetal heart sounds and blood pressure were checked according to
established policy.
( An audit is a systematic and official examination of a record, process or ,account to 1
evaluate performance. Auditing in health care organization provide managers with a
means of applying control process to determine the quality of service rendered. Nursing
audit is the

process of analysing data about the nursing process of patient outcomes to evaluate the
effectiveness of nursing interventions. The audits most frequently used in quality control
include outcome, process and structure audits.
1. Outcome audit Outcomes are the end results of care; the changes in the patients
health status and can be attributed to the delivery of health care services.
Outcome audits determine what results if any occurred as result of specific
nursing intervention for clients.
These audits assume the outcome accurately and demonstrate the quality of care
that was

provided. Example of outcomes traditionally used to measure quality

of hospital care include mortality, its morbidity, and length of hospital stay.
2. Process audit Process audits are used to measure the process of care or how the
care was carried out. Process audit is task oriented and focuses on whether or not
practice standards are being fulfilled. These audits assume that a relationship
exists between the quality of the nurse and quality of care provided.

Structure audit Structure audit monitors the structure or setting in which patient
care occurs, such as the finances, nursing service, medical records and
environment. This audit assumes that a relationship exists between quality care
and appropriate structure. These above audits can occur retrospectively,
concurrently and prospectively.

1. Encourages followers to be actively involved in the quality control process.

2. Clearly communicates standards of care to subordinates.

3. Encourages the setting of high standards to maximise quality instead of setting
minimum safety standards.
4. Implements quality control proactively instead reactively.
5. Uses control as a method of determining why goals were not met.
6. Is positively active in communicating quality control findings.
7. Act as a role model for followers in accepting responsibility and accountability
for nursing actions.
1. In conjunction with other personnel in the organisation establishes clear-cut,
measurable standards of care and determines the most appropriate method for
measuring if those standards have been met.

Selects and uses process, outcome and structure audits appropriately as quality
control tools.

3. Assesses appropriate sources of information in data gathering for quality control.

4. Determines discrepancies between care provided and unit standards and seeks
further information regarding why standards were not met.
5. Uses quality control findings as a measure of employee performance and rewards,
coaches, counsels, or disciplines employees accordingly.

Keeps abreast of current government and licensing regulations that affect quality


(TOM) Total quality management also referred to as continuous quality improvement
(COI) is a philosophy developed by Dr W. Edward Deming. The TOM system was first
implemented in
the Japanese auto industry following world war II, under the leadership of Dr Diming
and: was highly successful in Japanese management system. During 1980s, health
agencies have adopted the philosophy of TOM or COI, which has been used to improve
productivity in other industries.
Dr Deming used following principles for total quality management (1986).
1. Create a constancy of purpose for the improvement of the products and

2. Adopt a philosophy of continual improvements.

3. Focus on improving processes, not on inspection of products.
4. End the practice of awarding business on price alone, instead minimize total
cost by working with a simple supplier.
5. Improve constantly every process of planning, producing and service.
6. Institute job training and retraining.
7. Develop the leadership in the organisation.
8. Drive out fear by encouraging employees to participate actively in the
9. Foster interdepartmental co-operation, and breakdown barriers between
10. Eliminate slogans, exhortations, and targets for the workforce.
11. Focus on quality and not just quantity; eliminate quota systems if they are in
12. Promote team work rather than individual accomplishments; eliminate the
annual rating and merit system
13. Educate/train employees to maximise personal development.
14. Charge all employees with carrying out the total quality management
Dr Deming is an American management consultant whose organisational improvement
methods are based on continuous improvement of all work process and unrelenting
attention to consumer needs and desires. He used the following points to outline the steps
for implementing total quality management (1982).
1. Individual employees are both suppliers of input and customers of others output.
2. All work processes are subject to continuous improvement to increase customer
3. Customers' needs and experience with service are determined and communicated
throughout the

agency. '

4. Managers are responsible for improving organisational systems, so that workers

can improve performance.
5. Employees at all levels must be trained in TOM and taught how to perform
properly all all job functions.


6. Each department should generate statistical measurement data that shall empower
employees to improve work processes.
7. Data collection of quality assessment occurs at the employee level. Employees
participate with quality assessment personnel in data analysis.
8. A collaborative approach is used to integrate all suppliers into the TOM process.
9. Team work is needed to foster problem solving and eliminate barriers between
specialty areas and roles.
10. Corporate culture must change, by establishing long-term goals to support quality,
maintaining performance standards overtime, empowering employees, openly
demon. starting quality monitoring and developing problem solving circles at
organizational level.
In 1994, Glasser argues that five basic conditions must be met if workers are to do quality
work as follows:
1. The work environment must be warm and supportive. The workers must trust

Workers should be asked to do only useful or purposeful work. They should feel
that they are contributing to a worthwhile need.

3. Workers must be asked to do the best they can.

4. From the time, workers are hired, lead managers should guide the process of
helping them learn, to evaluate their work continually. Based on this ongoing
evaluation lead managers will then encouraging workers to improve the quality of
what they do.
5. Quality work is always felt good.

He also says that all lead managers must learn what quality actually is, teach it to all in
the organization, and then listen carefully to any worker who has an idea of how it may
be further improved.
Simpson (1994) argues that the cost of the quality care made up of the aggregate cost of
non-conforming plus the cost of conforming to customer requirement. The five elements
that make up the cost of quality are:
1. Cost of preventing mistakes (Employee training)


2. The cost of appraisal (auditing and quality assurance) .The cost of failure (errors
and omissions)
3. The cost of exceeding requirements (Producing information nobody needs).
4. The cost of lost opportunities (lost market share and reduced revenues).
Ideally, everyone in the organization should participate in quality control because each
individual benefits from it, quality control gives employees feedback about their current
quality care and how their care can be improved.
As a direct care giver, staff nurses are in an excellent position to monitor nursing practice
by identifying problems and implementing corrective actions that have the greatest
impact on patient care. The primary purpose of the nursing profession is to provide ever
high quality care to patients and clients. Moreover, the nurses are the major provider of
health care, and must assum )leadership role when measuring the quality of their services
and documenting their cost
The world trend of professional accountability to an enlightened public can no longer be
ignored by nursing. We nurses easily use the words "Quality Nursing" but have we
defined what we mean by Quality? Do we know our deficiencies? Are we ready to admit
our deficiencies to our peers? Are we taking steps to remedy them? Only by such self
regulation we can retain our identity with the health professional as nature partners.
Meaning of terms:
1. Quality A judgment of what constitutes good or bad.
2. Audit-A systematic and critical examination to examine or verify.
3. Nursing audit-(a) It is the assessment of the quality of nursing care, (b) uses a
record as an aid in evaluating the quality of patient care.
Brief History of Nursing Audit:
Nursing audit is an evaluation of nursing service. Before 1955 very little was known
about lie concept. It was introduced by the industrial concern and the year 1918 was the
beginning medical audit.


George Groword, pronounced the term physician for the first time medical audit. Ten
years later Thomas R Pondon MD established a method of medical audit based on
procedures used by financial account. He evaluated the medical care by reviewing the
medical records.
First report of nursing audit of the hospital published in 1955. For the next 15 years,
nursing audit is reported from study or record on the last decade. The programme is
reviewed from record nursing plan, nurses notes, patient condition, nursing care. .
Nursing Care Audit
Audit related to the planning, delivery and evaluation of care. It is an important
component: of nursing care.
Medical audit. The systematic, critical analysis of the quality of medical care, including
the procedures for diagnosis and treatment, the use of resources, and the resulting
outcome and quality of life for the patient.
Definition of Nursing Audit
1. According to Elison "Nursing Audit refers to assessment of the quality of clinical
2. According to Goster Walfer
a. Nursing Audit is an exercise to find out whether good nursing practices are
b. The audit is a means by which nurses themselves can define standards from
their point of

view and describe the actual practice of nursing.

Purposes of Nursing Audit

1. Evaluating Nursing care given,
2. Achieves deserved and feasible quality of nursing care,
3. Stimulant to better records,
4. Focuses on care provided and not on care provider,
5. Contributes to research.
Methods of Nursing Audit There are two methods:


Retrospective view-This refers to an in depth assessment of the quality

after the patient has been discharged, have the patients chart to the source
of data.

The concurrent review-This refers to the evaluations conducted on behalf

of patient who are still undergoing care. It includes assessing the patient at
the bedside in relation to pre-determined criteria, interviewing the staff
responsible for his care and review in the patients record and care plan.

Method to Develop Criteria

1. Define patient population,
2. Identify a time framework for measuring outcomes of care,
3. Identify commonly recurring nursing problems presented by the defined patient
4. State patient outcome criteria,
5. State acceptable degree of goal achievement,
6. Specify the source of information,

7. Design and type of tool.

Quality assurance must be a priority,

Those responsible must implement a programme not only a tool,

A coordinator should develop and evaluate quality assurance activities,

Roles and responsibilities must be delivered,

Nurses must be informed about the process and the results of the programme,

Data must be reliable,

Adequate orientation of data collection is essential,

Quality data should be analysed and used by nursing personnel at all levels.


Advantages of Nursing Audit

1. Can be used as a method of measurement in all areas of nursing,
2. Seven functions are easily understood,
3. Scoring system is fairly simple,
4. Results easily understood,
5. Assesses the work of all those involved in recording care,
6. May be a useful tool as part of a quality assurance programme in areas where
accurate records of care are kept.
Disadvantages of the Nursing Audit:
1. Appraises the outcomes of the nursing process, so it is not so useful in areas
where the nursing process has not been implemented,
2. Many of the components overlap making analysis difficult,
3. Is time consuming,
4. Requires a team of trained auditors,
5. Deals with a large amount of information,
6. Only evaluates record keeping. It only serves to improve documentation, not
nursing care.
Audit Committee Before carrying out an audit, an audit committee should be formed,
comprising of a minimum of five members who are interested in quality assurance, are
clinically competent and able to work together in a group. It is recommended that each
member should review not more than 10 patients each month and that the auditor should
have the ability to carry out an audit about 15 minutes. If there are less than 50 discharges
per month, then all the records may be audited, if there are large number of records to be
audited, then an auditor may select 10 per cent of discharges.


Training for auditors should include the following:

A detailed discussion of the seven components.

A group discussion to see how the group rates the care received using the notes of
a patient who has been discharged; these should be anonymous and should reflect
a total period of care not exceeding two weeks in length.

Each individual auditor should then undertake the same exercise as above. This is
followed by a meeting of the whole committee who compares and discuss its
findings, and finally reach a consensus of opinion on each of 1he components.

Steps to Problem Solving Process in Planning Care

A. Collects patient data in a systematic manner:
1. Includes description of patients pre-hospital routines,
2. Has information about the severity of illness,

Has information regarding lab tests,

4. Has information regarding vital signs,

5. Has information from physical assessment etc.

b. States nurses diagnosis,

c. Writes nursing orders,
d. Suggests immediate and long term goals,
e. Implements the nursing care plan,
f. Plans health teaching for patients,
g. Evaluates the plan of care.

Retrospective audit is a method for evaluating the quality of nursing care by examining
the nursing care as it is reflected in the patient care records for discharged patients. In this
type of audit specific behaviours are described then they are converted into questions and
the examiner looks for answers in the record.
For example the examiner looks through the patient's records and asks:
a. Was the problem solving process used in planning nursing care
b. Whether patient data collected in a systematic manner

c. Was a description of patient's pre-hospital routines included?

d. Laboratory test results used in planning care?
e. Did the nurse perform physical assessment? How was information used?
f. Were nursing diagnosis stated?
g. Did nurse write nursing orders? and so on.
A profession concerns for the quality of its service constitutes the heart of its
to the public. An audit helps to ensure that the quality of nursing care desired and feasible
is I achieved. This concept is often referred to as quality assurance. )
Standard is an established rules or basis of comparison in measuring or judging capacity,
I quantity context and value of objects in the same category. The term norm is frequently
used synonymously with standard in the literature. Selected standards are reliable and
relevant for the category being compared, e.g. standard of ideal height and weight. .
Standard is a broad statement of quality. It is a definite level of excellence or adequately
IS required, aimed at or possible. It agreed upon achieved level of performance,
considered proper and adequate for a specific purpose against which actual performance
is compared.

So standard is an acknowledged measure of comparison for quantitative or qualitative

value, criterion, norm. According to dictionary, norm is an authoritative standard
(weblter); a pattern described as typical. It is a rule, a pattern and authoritative standard, a
type, the ordinary more frequent value of statement.

Importance of Standard
A standard is a practice that enjoys general recognition and conformity among
professionals n authoritative statement by which the quality of practice, service or
education can be judged. One of the determinants of profession is that members of the

profession adopt standards of practice of their calling, establish criterion by which

conformance to the standards will be measured and have the primary responsibility for
seeing that the standards an forced. If the professional groups abdicates its
responsibilities, the public may step in set standards for it. When the system is
functioning optimally, the profession and agents he public collaborate to establish
whatever laws or legal processes are necessary for designation and application of
A standard is a means of determining what something should be. In the case of nursing
practice standards are the established criteria for the practice of nursing. Standards are
aments that are widely recognized as describing nursing practice and are seem as ing
permanent value. A nursing care standard' is a descriptive statement of desired quality
against which to evaluate nursing care. It is guideline. A guideline is a recommended 1 to
safe conduct, an aid to professional performance.
A nursing standard can be a target or a gauge. When used as a target, a standard is a 1ning
tool. When used as a gauge against which to evaluate performance a standard is control
device. The following terminology clarify the relationship of nursing care standards other
planning and control devices.

Objective is a concrete statement of intention, an external goal towards which

effort is directed.

A criterion is the value free description of variable believed to be an indicator of

patient are quality.

A norm is the current level of performance of a particular criterion, as determined

by description study of the target population.

A model is a phenomenological analogy used to describe something that cannot

be directly observed and about which deeper understanding is sought.

A patient problem is an active or potential need, condition or complication that

derives from the patient diagnosis or care and indicates needs for intervention.

A nursing problem is a difficult situation encountered by a care giver in pursuing

nursing goals.

A quality improvement is the process of establishing optimum standards of

nursing practice and planning or providing care that meets those standards.


A nursing order is a prescribed action issued in the form of a command by one

nurse to other nursing personnel.

Nursing audit is the process of analysing data about the nursing process or patient
outcomes to evaluate the effectiveness of nursing intervention.

A standard is a performance model that results from integrating criteria with norms and
used to judge quality of nursing objectives, orders and methods. One method of nursing
quality improvement is nursing audit, in which patient outcomes are measured against
nursing standards and performance criteria to determine the efficacy of nursing actions.
Purposes of Standards
No profession in the coming decades can afford to be isolated from the reality of being
accountable for efficiency and effectiveness of the services provided by its members. To t
accountable is to be answerable for quality. Each profession faces the need to establish its
value in the field of health care, in terms of availability, quality, cost and effectiveness.
Professional accountability is thus a vital part of nursing management.
In order to provide a high quality of care, it is necessary that nurses develop standard c
care and appropriate evaluation tools so that professional aspect of assurance and
attention will be given to the individual needs and response to clients. Setting standard is
the firs step in structuring evaluation system. The following are some of the purposes of
1. Standards give direction and provide guidelines for performance of nursing staff.

Standards provide a baseline for evaluating quality of nursing care, ranging frorr
excellent care to unsafe care.

3. Standards help improve quality of nursing care, increase effectiveness of care and
improve efficiency.
4. Standards may help to improve documentation of nursing care provided, i.e.
maintaining record of care.
5. Standards may help to determine the degree to which standards of nursing care
maintained and take necessary corrective action in time.
6. Standards help supervisors to guide nursing staff to improve performance.
7. Standards may help to improve basis for decision-making and devise alternative
system for delivering nursing care.

8. Standards may help justify demands for resources association. 9. Standards my

help clarify nurses area of accountability.
10. Standards may help nursing to define clearly different levels of care.
The purposes of publishing, circulating and enforcing nursing care standards are to:
1. improve the quality of nursing care,
2. decrease the cost of nursing, and
3. determine the nursing negligence.

Nursing standards improve nursing care quality by focusing the nurses efforts toward
appropriate goals and heightening their motivation for goal achievement. Standards can
decrease care costs by eliminating non-essential nursing activities. Establishing nursing
negligence consist of determining that there is a standard of care governing the client
situation and that harm could be foreseen if the standard was not met; proving that nurse
failed to meet the relevant standard; and determining that the nurse's failure to meet the
standard caused harm to the patient.
Nursing is a service profession. Services rendered by nurses are essential to clients and
welfare. Therefore, the profession as whole is accountable for the quality of care
delivered by individual nurses.
Characteristics of Standard
The characteristics of standards which undo that standard:

Statement must be broad enough to apply to a wide variety of settings.

must be realistic, acceptable, attainable

of nursing care must be developed by members of the nursing profession;

preferable nurses practicing at the direct care level with consultation of experts in
the domain.

should be phrased in positive terms and indicate acceptable performance, i.e.

good, I excellence etc.

Of nursing care must express what is desirable optional level.


must be understandable and stated in unambiguous terms.

must be based on current knowledge and scientific practice.

must be reviewed and revised periodically.

may be directed towards an ideal, i.e. optional standards or may only specify the
minimal care that must be attained, i.e. minimum standard.

And one must remember that standards that work are objective, acceptable, achievable
and flexible.
Sources of Nursing Care Standards:
It is generally accepted that standards should be based on agreed up achievable level of
performance considered proper and adequate for specific purposes. The standards can be
established, developed, reviewed or enforced by variety of sources as follows:

Professional organization, e.g. Associations, TNAI.

Licensing bodies, e.g. Statutory bodies, INC, SNC.,

Institutions/health care agencies, University Hospitals, Health Centres.

Department of institutions, e.g. Department of Nursing. .Patient care units, e.g.

specific patients' unit.

Government units at National, State and Local Government units. Individual e.g.
personal standards.

Classification of Standards
There are different types of standards used to direct and control nursing actions.
Standards can be normative or empirical. Normative standards describe practices
considered 'good' or 'ideal' by some authoritative group. Empirical standards describe
practices actually observed in a large number of patient care settings. Here the normative
standards describe a higher quality of performance than empirical standards. Generally
professional organizations (TNAI, ANA or NAI) promulgate normative standards where
as low enforcement and regulatory bodies (INC/MCI) promulgate empirical standards.
Nursing care standards can be divided into ends and means standards. The ends standards
are patient-oriented; they describe the change as desired in a patient's physical status or
behaviour. The means standards are nursing oriented, they describe the activities and


behaviour designed to achieve the ends standards. Ends (or patient outcome) standards
require information about the patients. A means standard calls for information about the
nurses performance. Standards are expected to understandable, achievable and
measurable. Standards established for whatever sources and however developed, must be
available to members of the nursing staff on the patient care units.

Standards can be classified and formulated according to frames of references (used for
setting and evaluating nursing care services) relating to nursing structure, process and
outcome, because standard is a descriptive statement of desired level of performance
against which to evaluate the quality of service structure, process or outcomes.
Structure Standard
A structural standard involves the 'set-up' of the institution. The philosophy, goals and
objectives, structure of the organization, facilities and equipment, and qualifications of
employees are some of the components of the structure of the organization, e.g.
recommended relationship between the nursing department and other departments in a
health agency are structural standards, because they refer to the organizational structure
in which nursing is implemented. It includes people money, equipment, staffing policies
etc. and the evaluation of structure is designed to find out the effectiveness in terms of the
degree to which goals are achieved and efficiency in terms of the amount of effort needed
to achieve the goal.
The structure is related to the framework, that is care providing system and resources that
support for actual provision of care. Evaluation of care concerns nursing staff, setting and
the care environment. The use of standards based on structure implies that if the structure
is adequate, reliable and desirable, standard will be met or quality care will be given.
Process Standard Process standards describe the behaviours of the nurse at the desired
level of performance.

The criteria that specify desired method for specific nursing

intervention are process standards. A process standard involves the activities concerned
with delivering patient care. These standards measure nursing actions or lack of actions
involving patient care. The standards are stated in action-verbs, that is in observable and
measurable terms, e.g. "the nurse assesses", "the patient demonstrates". The focus is on
what was planned, what was done and what was communicated or recorded. Therefore,
the process standards assist in measuring the degree of skill, with which technique or


procedure was carried out, the degree of client participation or the nature of interaction
between nurse and client.
In process standard there is an element of professional judgment, i.e. determining, the
quality or the degree of skill. It includes nursing care techniques, procedures, regimens,
Outcome Standards Descriptive statements of desired patient care results are outcome
standards, because patient's results are outcomes of nursing interventions. Here outcome
as a frame of reference for setting of standards refers to description of the results of
nursing activity in terms of the change that occurs in the patient. An outcome standard
measures change in the patient health status. This change may be due to nursing care,
medical care or as a result of variety of services offered to the patient. Outcome standards
reflect the effectiveness and results rather than the process of giving care.
n quality assurance outcomes are stated in positive terms as the nursing goal is to
improve the health status of client. "Quality assurance" is assuring excellence. It
encompasses necessary changes or improvements to ensure survival. It involves
identifying standards for excellence, evaluating care against those standards and then
taking action to correct deficiencies and achieve the standards. "Excellence" is a variable
on a continuum that will differ from institution to institution or person to person. It is a
value judgment made by the health care provider with many factors being considered
such as type of institution and the consumer. The three essential elements of quality
assurance are standards, surveillance and corrective action. In order to assure quality,
standards must be first established, or the definition of excellence, then standards are
monitored and evaluated for achievement and feedback from the evaluation is utilized for
corrective action.
Thus, structural standards are agency or group-oriented, process standards are nurseoriented, and outcome standards are patient-oriented. For example the nursing department
formal table or organization is a structural standard; a nursing care objective (if written in
the form of patient behaviour) is an outcome standard.
In order to provide a higher quality of care however, it is necessary that nurses develop
standards of patient care and appropriate evaluation tools, so that professional aspects of


nursing involving intellectual and interpersonal activities will be ensured and attention
will be given to the individual needs and responses to patients.
As stated earlier, formulation of standards is the first step towards evaluating the nursing
care delivery. The standards serve as a base by which the quality of care can be judged.
This judgment may be according to a rating or other data that reflect the conformity of
existing practice with the established standards. The standards must be written, regularly
reviewed and well-known by the nursing staff.
Standards can be established to appraise care according to many approaches. The most
common approaches are based on structure, process and outcome. The nursing
organization or structure is usually evaluated according to structure standards, the
activities or delivery of care are evaluated by process standards and the patients status is
evaluated by outcome standards. But all those type standards are interrelated and can be
used to evaluate various aspects in a nursing care.


General Nursing care is the person to person application of scientific principles for the
sake of achieving a physician's therapeutic purpose for the patients. A physician studies
and tests a patient and the manifestation of his illness and wellness. No defines the
therapeutic purpose and designs and prescribed a therapeutic programmed. Some of those
actions he carries out himself, some are carried out by others, many by nurses who also
assist his directly in his diagnostic and therapeutic measures. Nurse's observation and
recording of patients conditions and response to therapy aids the physician in carrying
out his therapeutic purpose.
Health the patient to attain and maintain health is the ultimate aim of nursing. This is also
the aim of the physician, the dieticians, medico social worker and others working in the
hospital. Each group has a distinctive contribution to make and independent upon others
for the accomplishment of common purpose. There is certain amount of overlapping of
activities of various medical and paramedical groups. The nurse in charge of the ward is
the key person who coordinate the supports the activities of all groups. In emergencies
the physician often asks the nursing officer to carry out certain therapeutic measures for


which he alone is responsible. Similarly in the absence of a dietician and a medico social
worker the nurse may take on both these duties. The major functions and activities of the
nurses and classified as follows:

Those dealing with organization and control of the patient's environment and to
secure for him maximum mental and physician comfort.

Those concerned with him immediate personal care.

Those performed under the direction and in co-operation with the physician.

Administrative duties of ward management.

Responsibilities of Head Nurse

The head nurse is the nursing officer overall in charge of a ward unit. She is responsible
to the medical officer in charge as well as the matron for efficient performance of her
own duties and those of nursing personal placed under her charge. This dual authority
over her

activities sometimes leads to conflict and clash of personalities. The functional authority
of physician requires the nursing officer to carry out his instructions for treatment of the
patients whereas he has no authority to relieve her of the patients whereas he has no
authority to relieve her of her duties or change her if she does not perform her functions
adequately. That is the responsibility of the matron or the CO. Similarly in ward
management there might be orders and counter orders originating from two sources of
authority over her 10wledge and a thorough understanding of each others responsibilities
to manage a ward efficiently. Some of the important duties of a head nurse are listed

Carrying out the instructions of the medical officers regarding treatment of

patients, observing and recording the progress of treatment and generally assisting
the medical officer to achieve his therapeutic aim.

General cleanliness and upkeep of the ward and its surrounding areas to provide
neat and cheerful environments for the patients.

Supervision of care and maintenance of buildings, furniture, fittings and arranging

their reports through the OM.


Keeping the ward equipment in optimum state of readiness by prompt repairs and
replacement through condemnation boards.

Assignment or duties for patients care to the staff working is the ward taking into
consideration the capabilities of each.

t. Indenting the collection of various items of medical and OM and other stores.

Ensuring that all specimens are sent to the laboratory in time and results collected
when due.

Maintaining strict control over accounting and distribution of controlled and

dangerous drugs.

Requisition of diet as per instructions of the medical officer and ensuring that the
diets and extras are distributed to patients as per the requisition.

Ensuring that sufficient linen is available in the ward.

Maintenance of all the registers and documents required in the ward.

Overall supervision of all that happens in the ward is to ensure that the patients
treatment and recovery is as smooth and pleasant as possible.

Training of nursing and other personnel working in the ward.

Bedside Nursing Hours

Various studies have been carried out by means of job analysis and work study to
determine the actual number of bedside nursing hours per day for a patient. It obviously
depends upon type of patient and the severity of his illness. An actually ill patient or a
child patient will require more attention than a chronically ill adult patient. The following
figures may be taken as a guide to calculate average bed side nursing hours for different
categories of patients:
a. Adult medical/surgical

3-3Y2 hours

b. Maternity

4 hours

C. New born

2-2Y2 hours

d. Infants

5-5Y2 hours

e. Older children

4-5Y2 hours


f. Communicable disease

4Y2-5 hours

g. Important patients


h. Intensive care patients

7 -17Y2 hours

For planning purposes it may be convenient to work on 3 hours per day per patient in our
Indian conditions.
Nurse Patient Ratio:
The consensus of nursing leaders and hospital administrators indicates that there is no
reliable method by which a general standard can be applied to determine the ratio of
nurses to the patients. There are a number of factors which influence the same:
a. Size and layout of the ward-open or partitioned.
b. Types of cases-acute, chronic, mental, children.
c. Type of hospital-teaching, non-teaching or research.
d. Number of important patients
e. Type of equipment-modern labour service devices, central services or obsolete methods
.f. Amount of domestic and house keeping work carried on staff nurses/nursing aids.
g. Amount of paper work and documentation carried out by nurses.
h. Length of stay of patients.
Assignment of Duties:
As already stated in this book there are three patterns of assignment of duties among the
nursing staff available in a ward unit.
a. Functional method
b. Case method
c. Team method
Functional Method
In this method various basic nursing functions is TPR, medicines, injections, treatment
procedures and so on are divided amongst the available staff allotting one or two nurses
per function for the entire word. The advantages are saving of equipment; the individual
nurses become skilled in their particular function, best utilsation of aptitudes, saving of
time and so no. The disadvantages are: that the patient is compartmentalized, he feels


insecure as he is tended by a number of nurses, there is hardly any opportunity for staff
development and the work becomes repetitive and monotonous.
Case Method:
A few patients are completely assigned to each staff nurse and she carries out the total
nursing care of her group of patients. It has the advantage that the patients are
emotionally secured, the nurse gots the satisfaction of seeing the patient through all
stages of diseases and management. But this method requires large number of nurses.

Team Method
An experienced staff nurse is made responsible for the care of a group of patients with the
help of a set of junior nurses and nursing aids. She gets the nursing done under the
supervision in addition carrying out the important duties and procedures her. The nurse
acts as a head nurse for a limited number of patients and as a leader of a team. This
method satisfied the emotional needs of the patient as well as development and job
satisfaction of entire nursing team.

Documentation of Records
There are various records maintained by the head nurse. These may be administrative
nature or other clinical records concerned, with the medical and nursing care of the
patient. A list of records/documents maintained in the worked is given below. Specimen
headings of some of the records are given in Appendix B.
a. Day and night report book.
b. Temperature, pulse and respiratory recording book.
c. Treatment book/injection book. d. Sponge book.
e. Duty roster for the staff.
f. Instructions book which the head nurse carries with her when she accompanies the
medical officer on his daily ward rounds.
g. Controlled and local purchase drugs accounting book separate register is maintained
for dangerous drugs.
h. SIL and OIL register


i. Despatch book.
j. Inventories of various stores items held in her charge.
k. Breakage book.
I. Memo book or medical officers call book specially for CMO in case his attention in
required in the ward outside normal working hours.
m. Telephone message book specially meant for receiving laboratory results of serious
patients when required urgently.
n. Intake and output chart record.
o. Demand books for various stores, like medical stores, dry and wet dispensary, quarter
master stores and red cross stores.
p. Out pass book for male wards.
q. Urine test report and weight record specially for medical cases.
r. ESR and weight record register for tuberculosis patients. S. Complaint book for
maintenance and repairs.
t. Suggestions books for officers and officers family ward only
.u. Admission and discharge book.
v. Scale of hospital diets and extras
Ww. Standing orders for patients.
x. Fire officers.
y. Instructions for special radiological' examination like VP, barium meal, barium enema,
cholicystography and soon. )
Community-Based Nursing
Community-based nursing involves the acute and chronic care of individuals and
families that enhances their capacity for self-care and promotes autonomy in decision
making (Ayers, Bruno, and Langford, 1999). Care takes place in community settings


such as the home or a clinic; however, the focus is nursing care of the individual or
family. The nurse's competence is based on critical thinking and decision making at the
level of the individual client-assessing health status, selecting nursing interventions, and
evaluating outcomes of care. Because direct care services are provided where clients
live, work, and play, it is important for community-based nursing to remain individual
and family oriented and to appreciate the values of a community (Zotti, Brown, and
Stotts, 1996).
The philosophical foundation for community-based nursing is the human ecological
model, which conceptualizes human systems as open and interactive with the
environment (Chalmers and others, 1998). In an ecological model the individual is
viewed within the larger systems of family, community, culture, and society. The social
interaction units seen in Figure 3-2 depict four circles: the inner circle of the client and
the immediate family, the second circle of people and settings that have frequent contact
with the client and family, the third circle of the local community and its values and
policies, and the outer circle of larger social systems such as government and church
(Ayers, Bruno, and Langford, 1999). A nurse in a community-based practice must
understand the interaction of all of the units while caring for the client and family in their
natural environment. The nurse will typically become involved in the domain of the first
three circles when providing health care. For example, a home health nurse working with
a newly diagnosed diabetic client will work closely with the client and family to establish
a comprehensive plan for the client's health. The nurse may become involved in knowing
the habits or lifestyle patterns when the client is with friends and co
workers to anticipate ways to plan the client's exercise schedule and meal routines.
Knowing the resources available in the community (e.g., medical supply shops for
glucose monitoring supplies and local diabetes association support groups) enables the
nurse to provide comprehensive support for the client's needs.
With the individual and family as the clients, the context of community-based nursing
is family-centered care within the community. This focus requires the nurse to have a
strong knowledge base in family theory, principles of communication, group dynamics,
and cultural diversity. The nurse learns to partner with clients and families so that ultimately the client and family assume responsibility for their health care decisions. The
family becomes involved in planning, decision making, implementation, and evaluation
of health care approaches. )


Holistic nursing
Holistic nursing regards and treats the mind-body-spirit f the client. Nurses use holistic
nursing as relaxation therapy, guided imagery, music therapy, simple touch, massage, and
prayer. Such interventions affect the whole person (mind-body-spirit) and are effective,
economical, noninvasive, non pharmacological complements to medical care. Holistic
interventions can be used to augment standard treatments, to replace interventions that
are ineffective or debilitating, and to promote or maintain health (Dossey, Keegan, and
Guzzetta, 2000). The American Holistic Nursing Association maintains Standards of
Holistic Nursing Practice that define and establish the scope of holistic practice and dl
level of care expected from a holistic nurse Holistic Nurses' Association, 1998).

Team Nursing Modular Nursing


Team nursing was developed in 1950s (under grant from the WK Kellogg foundation)
directed by Eleanor Lambertson at Teachers College, Columbia University in New York
city. It has been developed in an effort to decrease the problems associated with the
functional organization of patient care. Majority of people felt that despite a continued
shortage of professional nursing staff, a patient care system had to be developed that
reduced the fragmented care that accompanied functional nursing.
Team nursing was designed to accommodate several categories of personnels in meeting
the comprehensive nursing needs of a group of clients. Team nursing is based on
philosophy in which a group of professional and nonprofessional personnels work
together to identify, plan, implement and evaluate comprehensive client-centered care.
The key concept is a group that works together toward a common goal, providing
qualitative 1 comprehensive nursing care.
In team nursing ancillary personnel collaborate in providing care to a group of patients
under the direction of a professional nurse. Actually the team nursing involves
decentralization of a nursing unit and professional head nurses authority, in which the
unit divided into teams. Each team composed of team leader, team members and patients.
Staff and clients are usually divided evenly, often written unit proximity such as a wing
of floor. Comprehensive care for the client is the responsibility of the entire team, but is
led by the team leader who should be a registered nurse. Assignments are made according
to the capabilities of the members and respond to the needs of the group of clients.
In team nursing team leader, the nurse is responsible for knowing the condition and needs
of all the patients assigned to the team and planning individual care. The team leader
duties vary depending on the patients' needs and workload. These duties may include
assisting team members, giving direct personal care to patients, teaching and coordinating
patient care activities.

It includes all healthcare personnel in the groups functioning and goals

Feelings of participation and belonging are facilitated with team members

Workload can be balanced and shared .


Division of labor allows members the opportunity to develop leadership skills

Every team member has the opportunity to learn from and teach colleagues

There is a variety in the daily assignment

Interest in client's wellbeing and care shared by several people reliability of

decisions is increased

.Nursing care hours are usually cost-effective.

The client is able to identify personals who are responsible for his care

.All care is directed by a registered nurse continuity care is facilitated, especially

if team are constant

.Barriers between professional and nonprofessional workers can be minimized;

the group efforts prevail

.Everyone has the opportunity to contribute to the care plan. .


Establishing the team concept taken time, I effort and constancy of personnel.
Merely assigning people to a group does not make them a 'group' or 'team'

Unstable staffing patterns make team nursing difficult

All personals must be client centered .

The team leader must have complex skills and knowledge, i.e. communication,
leadership organization, nursing care, motivation and other skills

There is less individual responsibility and. independence regarding nursing


Team nursing usually associated with democratic leadership. Group members are given
as much autonomy as possible when performing assignment

tasks, although

responsibility and accountability are shared by the team collectively he need for excellent
communication and coordination skills makes implementing team nursing organization
difficult and requires great self discipline on the part of the team members. Team nursing
allows each member to contribute their special expertise, or skills. recognizing the


individual worth of all employees and giving team members autonomy result 1 high job
Progressive/ patient care
Progressive client care is a method in which client-care areas or units provide various
levels f care, e.g. (i) intensive care unit for the critically I, (ii) post intensive care unit,
(iii) regular care nits, (iv) convalescent unit, (v) self care unit.
Here the clients are evaluated with respect to level (intensity) of care needed. As they
progress towards increased self care (as they become ethically ill or in need of intensive
care or monitoring), they are marked to units/wards staffed to best provide the type of
care needed he merits and demerits of progressive patient ire as follows.

Efficient use is made of personnel and equipment

Clients are in the best place to receive the care they require

use of nursing skills and expertise are maximized due to different staffing patterns
of each unit

Clients are moved towards self care independence is fostered where indicate

Efficient use and placement of equipment is possible

Personnel have greater probability to function toward their fullest capacity.


There may be discomfort to clients who are moved often

Continuity care is difficult, even though are possible

Long-term nurse-client relationships are difficult to arrange

Heavy emphasis is placed on comprehensive, of written care plan

There is often times difficulty in meeting administrative need of the organization,

staffing evaluation, and accreditation.

Primary nursing:
Primary nursing, developed in the early 1970s, uses some of the concepts of case method.
It involves total nursing care, directed by a nurse. on a 24-hour basis as long as the client


is under care. As originally designed, this method requires a nursing staff comprised
totally of registered. staff nurses. Here one specific nurse is the client's nurse, at all times
directing, planning evaluating and teaching. The primary nurse is essentially, on call all
the time and arranged coverage when away. Actually, the primary nurse assumes 24-hour
I responsibility for planning the care of one or more patients from admission or the start
of treatment to discharge or the treatments end. During work hours the primary nurse
provides total direct care for that patient. When the primary nurse is not on duty, care is
provided by other junior nurses who follow the care plan established by the primary
nurse, that means, even though the primary nurse is the director of care for clients,
segments of care are often delegated.
As stated earlier, it uses some concepts of case method leads to confusion. The difference
exists in the fact that case method involves a specified segment of time, i.e. shift where as
the primary nursing is 24-hour responsibility for as long as care needed by the client.
Although this method is designed for use in hospitals, this structure lends itself well to
home health nursing, hospital nursing and other health care delivery enterprise.
An integral responsibility of the primary nurse is to establish clear communication
between the patient, the doctor, the associate nurses and other team members.
Although the primary nurse establishes the nursing care plan, feedback in sought from
others in coordinating the patient care. The combination of clear interdisciplinary groups
communication and consistent, direct patient care by relatively few nursing staff allows
for holistic, high quality patient care. It gives job satisfaction, once nurse develop skill in
primary nursing care delivery, they feel challenged and rewarded.

There is opportunity for the nurse to see the client and family as one system

Nursing accountability, responsibility and independence are increased

The nurse is able to use a wide range of skills, knowledge and expertise

This method potentates creativity by the nurse; work satisfaction may increase

.The scene is set for increased trust and satisfaction by the client and nurse.


Demerits :

The nurse may be isolated from colleagues

There is little avenue for group planning of < client care ,

Nurses must be mature and independently .It competent

It may be cost effective

Staffing patterns may necessitate a heavy client load

An inadequate prepared or educated primary nurse may be incapable of

coordinating a multidisciplinary team or identifying complex patient needs and
condition changes

The role and functions of the nurse manager and in organizing groups for patient care are
as follows:
1. Periodically evaluates the effectiveness of the organizational structure for the
delivery of patient care.
2. Determines if adequate resources and support exist before making any changes in
3. the organization of patient care.
4. Examines the human element in work redecision and support personnel during
adjustment to changes.
5. Uses committees to facilitate group goals, not to delay decision.
6. Teaches group members how to avoid group think.
7. Inspires the work group toward a team effort.
8. Organizes work activities to attain organizational goals.
9. Group activities in a manner that facilitates coordination within and between
10. Uses a patient care delivery system that maximizes resources people, material and
11. Organizes work in a manner that facilitates communication.
12. Uses committees structure to increase the quality and quantity of work
13. Uses knowledge of group dynamics for goal attainment.


A client entering a healthcare setting is at risk for acquiring infections because of lowered
resistance to infection, microorganisms and invasive procedures. The nurse comes in
contact with a variety of microorganisms and thus must practice 'infection control'
techniques to avoid spreading them to clients. The nurse is responsible for teach- ing
clients about infection, mode of transmission, reasons for susceptibility, and infection
Infection Process:
An infection is an invasion of the body by pathogens, or microorganism capable of
producing disease. The development of an infection occurs in a cyclical process that
depends on the following six elements
An infectioIfwil1 develop if this cyclical chain remains intact. To prevent the spread of
micro- organism, the cycle must be interrupted. Nurses use respective practices to break
the chain, so that infection will not occur.
Infection Agent :
The pathogenic organisms include bacteria, viruses, fungi and protozoa and more
prevalent agents that are capable of causing infection. The most common pathogen and
their infections are given..
The reservoir for growth and multiplication of microorganism is the natural habitant of
the organism. The possible reservoir that supports organism pathogenic to humans
includes other human (e.g. TB syphillis, HIV, HBV), animals (Rabies-dog), food (CI
botulinum) water, milk and inanimate object e.g. soil, gas gangrene, tetanus).


Portal of Exist:
The exist from the reservoir is the point of escape for the organism. The organism cannot
extend its influence unless it moves away from its original source. There usually a
primary exist route for each type of organism. In human common escape routes are as
1. Skin and mucus membrane, e.g. S. aureus, cause yellowish drainage. P. aeruginde
causes greenish drainage.
2. Respiratory tract e.g. Mycobacterium tubercle causes tuberculosis.
3. Gastro urinary tract. 4. GI tract.
4. Reproductive tract, e.g. STDs, HIV.
5. Blood -serum hepatitis.
Modes of Transmission:
An organism may be transmitted from its reservoir by various means of routes. Some
organisms can be transmitted by more than one route.


.Direct contact, e.g. Staphylococcus, T. palladium, herpes simplex .Indirect contact, e.g.
Measles virus, HBV, Enterococcus and pseudomonal organisms. .Droplet contact, e.g.
influenza virus. M tuberculosis.
.Droplet nuclei, e.g. influenza virus, Pneumococcus, V-Z virus .Dust, e.g. Aspergillus


Contaminated items, e.g. M. tuberculosis

water, e.g. Vibrio cholerae
drugs solution, e.g. Pseudomonas organism
blood, e.g. hepatitis B virus
food, e.g. Salmonella, Staphylococcus, Enterobacter, etc. and Klebsiella


Insects, e.g. mosquitoes-e.g. falciparum .

Fleas, ticks, e.g. Rickettsia typhi and R. prowazekii

Cows, Dogs, e.g. Brucella organisms

Portal of Entry:
The portal of entry is the point at which organism enters the host. The entry route often is
the same as the exist route. The urinary, respiratory, gastro- intestinal,-reproductive tract
and the skin are common entry points.
Susceptible Host:
For microorganism to continue to exists, they must find a source that is acceptable (a
host) and overcome any resistance mounted by the host defenses. Susceptibility is the


degree of resistance and individual has to pathogens. An organism or parasite potential to

produce disease depends on a variety of factors which includes following:

Number of organisms or parasites

Virulence of organism or its ability to cause disease

Competence of a person's immune system .

Ability to enter and survive in the host .

Length and intimacy of the contact between a person and the microorganisms .

Susceptibility of the host.

Course of Infection:
An understanding of the course of infection by stages in the development of an infection
is necessary if the nurse is to intervene and disrupt the infection cycle. An infection
progresses through the different phases which includes, incubation period, prodromal
stage, full stage of illness, convalescent phase.

Incubation Period:
Incubation period is the interval between the invasion of the body by the pathogen or
entrance of pathogen into the body and the appearance of the first symptoms of infection,
e.g. chickenpox 2-3 weeks, common cold 1-2 days, tetanus 2 to 21 days. .
Prodromal Stage:
A person is most infectious during this stage. It is an internal from onset of nonspecific
signs and symptoms (malaise, low grade fever, fatigue) to more specific symptoms;
During this time, micro- organisms grow and multiply; and client is more capable of
spreading disease to others.
Full Stage of illness:
Full stage of illness is an interval when client manifests signs and symptoms specific
type of I infection. The presence of specific signs and] symptoms indicates the full stage
of illness. The types of infection determine the length of illness and the severity of
manifestations. Symptoms that are limited or restricted to a discrete area are I referred to


as localized symptoms, whereas systematic symptoms are manifested throughout the

entire body.
Convalescent Period:
Convalescent period represents recovery from j the infection. It is an interval when acute
symtoms of infection disappear and the person returns to healthy state length of recovery
depends on severity of infection and clients general state of health; recovery may take
several days to months.
Defenses against Infection :The body has normal defenses against infection. Normal
body flora that reside side and outside of the body protect a person from several
pathogens. Each organ system has defense, mechanism that minimize exposure to
infectious microorganism as follow. .
Skin :
In skin intact multilayered surface is a body's first line of defense against infection, that
is, it provides barrier to microorganisms. The shedding of outer layer of skin all removes
organism that adhere to skin outer layers. The sebum contains fatty acid that kills some
bacteria. These factor that may alter defense are cut abrasions, puncture wounds, areas of
laceration; failure to bathe regularly and excessive bathing reduces sebum.
Mouth :
Intact multilayered mucosa of mouth provides mechanical barriers to microorganisms.
Saliva produces in the mouth, washes away particles containing microorganism and it
contains microbial inhibitor, e.g. lysozyme, factors that alter defense are lacerations,
trauma, extracted teeth, poor oral hygiene, dehydration.
Respiratory Tract:
Cilia lining upper airway, coated by mucous will trap inhaled microbes and sweep them
outward in mucous to be expectorated or swallowed. Microphages of respiratory tract
engulf and destroy microorganisms that reach lungs alveoli. The factors that may alter
defence here are smoking high concentration of oxygen and carbon dioxide, decreased
humidity, cold air, etc.

Urinary Tract


The flushing action of urine flow washes away microorganism on lining of bladder and
urethra. An infect multilayered epitheliums of the tract provide barrier to microorganism.
The factors which may alter defense here are obstruction to normal flow by any means.
Gastrointestinal Tract
Here the acidity of the gastric secretions chemically destroys microorganisms incapable
of surviving low pH. The rapid peristalsis in small intestine prevents retention of bacterial
content. The factors which alter defense here are administration of antacids, delayed
motility resulting from impaction of fecal content in large bowel or mechanical
obstruction by masses.
At puberty, normal flora causing vaginal secretion to achieve low pH, which inhibits
growth of many microorganisms. Antibiotics and oral contraceptives disrupting normal
flora, which alter defence.
In addition the inflammatory response is a protective vascular and cellular reaction that
neutralizes pathogens and repairs body cells. Normal flora, body system defenses and
inflammation are all non specific defenses that protect against microorganisms regardless
of prior exposure. The immune system is composed of separate cells and molecules
resistant to disease. Certain responses of the immune system are non- specific, whereas
others are specific defenses against specific pathogens. If any of the body's defense fails,
an infection can quickly progress to a serious health problem. The factors which affecting
immunological defense mechanism are as follow:

Increasing age


Poor nutrition

Inherited condition

Type of disease process


The term nosocomial is taken from the Greek word nosocomium meaning healthcare
facility. A nosocomial infection is one that is acquired in a hospital or other health agency.
This is a far- reaching and serious problem. A hospital is one of the most likely places for

acquiring an infection because it harbors a high population of virulent stains of

microorganisms that are usually resistant to antibiotics. Nosocomial infections not only
extend hospital care for the patient but also increase cost for both patient and hospital.
Iatrogenic infection is a type of nosocomial infection resulting from the diagnostic or
therapeutic procedure, e.g. insertion of catheter in urinary tract may develop infection.
Nosocomial infection may be exogenous or endogenous. An exogenous infection caused
by microorganism, from another person, may exist as normal flora (e.g. S typhi, CI
tetanl). An endogenous is an infection caused by the patients own normal microorganism becoming altered and overgrowing or being transferred from and body site to
Nosocomial infections are most commonly transmitted by direct contact between health
personnel and patient or from patient to patient.
The nurse is responsible for providing the patient with a clean and safe environment. The
conscientiousness and accuracy of the nurse in performing clean and aseptic procedures
incre- ases the effectiveness of infection control.
Concepts of Asepsis:
The nurses efforts to minimize the onset and spread of infection are based on the
principles of aseptic technique.
Asepsis is the absence of germs or pathogens. Aseptic technique is the efforts to keep a
client as free from hospital microorganisms as possible. The two types of aseptic
techniques, the nurses usually practice, are medical and surgical asepsis.

Medical asepsis Medical asepsis or clean technique includes procedures used to reduce
the number of microorganisms and prevent their spread. changing a clients bed linen
daily, hand washing and using clean medicated cups are example of medical asepsis. The
practicing basic principles of medical asepsis in client care are as follows:

Wash hands frequently but especially before handling foods, before eating, after
using a handkerchief, after going to the toilet, before and after each client contact,
and after removing gloves.


Keep solid items and equipment from touch- ing the clothing, carry soiled linen or
other used articles so that they do not touch the uniform

Do not place solid bed linen or any other items on the floor, which is grossly
contaminated, it increases contamination of both surfaces

Avoid having clients, cough, sneezing, or breath directly on others. Provide them
with disposable tissues, and instruct them as indicated to cover their mouth and
nose to prevent spread by airborne droplet

Move equipment away from you when brush- I ing, dusting or scrubbing articles.
This helps prevent contaminated particles from settling on the hairs, face and

Avoid raising dust use a specially treated cloth or a dampened cloth. Do not shake
linens. Dust and thin particles constitute a , vehicle, by which organisms may be
trans ported from one area to another .

Clean the least soiled areas first and then the more soiled ones. This helps preyent
having the cleaner areas soiled by the dirtier areas

Dispose of soiled or used items directly into appropriate containers. Wrap items
that are moist from body discharge or drainage in water proof containers such as
plastic bags, before discarding into the refuse holder so that handler will not come
in contact with them.

Pour liquids that are to be discarded, such as bath water, mouth rinse and the like
directly into the drain so as to avoid splattering in the sink and on to you

Sterilize items that are suspected of containing pathogen. After sterilization, they
can be managed by clean technique

Use practices of personal grooming that help prevent spready microorganism, i.e.
sham- pooling, nail cutting, avoid wearing rings, etc.

Follow guidelines conscientiously for isolation in barrier technique as prescribed

by agency.

Surgical asepsis:
Surgical asepsis or sterile technique, includes procedures used to eliminated
microorganisms from an area. Sterilization destroys all microorganisms, and their spores
sterile techniques is practiced by nurses in the operating room and treatment areas, where
sterile instruments and supplies are used, i.e. care of surgical wounds, urinary catheter
insertion, invasive procedures and surgery.


The practicing basic principles of surgical asepsis are as follows:

Only a sterile object can touch another sterile object, unsterile touching sterile
means conta- mination has occurred

Open the sterile packages so that the first edge of the wrapper is directed away
the worker to avoid the possibility of a sterile surface touching unsterile clothing.
The outside of the sterile package is considered contaminated

Avoid spilling any solution on a cloth or paper used as a field for a sterile set up.
The moisture penetrates through the sterile cloth or paper and carries organism by
capillary action so contaminate the field. The wet field is considered contaminated
if the surface immediately below it is not sterile

.Hold sterile objects above the level of the waist. This will help ensure keeping
the object within sight and prevent accidental contamination

Avoid talking, coughing, sneezing or reaching over a sterile field or object. This
helps prevent contamination by droplets, from the nose and the mouth or by
particles dropping from the worker's arms

Never walk away from or turn your back on a sterile field. This prevents possible
contamination while the field as out of the worker's view

All items brought into contact with broken skin, or used to penetrate the skin in
order to inject substances into the body, or to enter normally sterile body cavities,
should be sterile. These items include dressing used to cover wounds and
incisions, needles for injections and tubes, catheter used to drain urine from the
bladder, etc.

Use dry, sterile, forceps when necessary, forceps soaked in disinfectant are not
considered sterile

Consider the edge (outer one inch) of a sterile field to be contaminated

Consider an object contaminated if you have any doubt as to its sterility.


The roles and responsibilities of the nurses in infection control are as follows:

.Providing staff education on infection control .Reviewing infection control

policies and procedures


.Reviewing client medical records and

laboratory reports to recommend

appropriate. isolation procedures .

Screening client record for community. acquired infection .

Consulting with employer health departments concerning recommendation to

prevent and control the spread of infections p1 among personnel such as
tuberculosis testing

Gathering statistics regarding the epidemiology of nosocomial infections

.Notifying public health department of incidences of communicable diseases

.Conferring with all hospital departments to investigate unusual events or clusters

of infection

.Educating clients and families

.Identifying infection control problems with equipment

Checking microorganism sensitivity to antibiotics in use and reminding medical

staff of resistance.

Teaching about Infection Control

Clients should be taught to use basic principles asepsis at home and in public facilities.
Teaching about medical aspects and infection control is a challenging nursing
The following are examples of medical aseptic practices used in home:

Wash hands before preparing food and before eating

Prepare food at temperature sufficiently high to ensure that they are safe to eat

Use care with cutting boards and utensils and wash hands, before and after
handling raw meat

.Keep food refrigerated, especially those containing mayonnaise

Wash raw fruits and vegetables before serving them

Use pasteurized milk

Wash hands after using the bathroom

Use individual personal care items, such as wash cloths, towels, tooth brushes.

Observe infection prevention in public facilities by following these guidelines:


Wash hands after using any public bathroom

Use paper towels or hot air dryers in restroom .

Use individually wrapped drinking straws

Use tongs to lift food from common service trays in caterings food stores, and
salad bars.

The community reinforces medical aseptic practices in several ways which includes
the following:

Use of sterilized coombs and brushes in barber and beauty shop

Examination of food handlers for evidence of disease

.Enforcement of frequent hand washing by food handlers.

Gowning for Isolation:

The use of gowns in isolation is important primarily to protect clothing from getting
soiled while administering patient care. The gown also prevents contact with infections
microorganisms that could have exited from the patient. Donning, and isolation gown, is
indicated when caring for patients with diseases characterized by heavy drainage,
infectious and acute diarrheal and other gastrointestinal disorders, respiratory disorder,
skin wounds or burns and urinary disorders.
The supply needed for gowning for isolation is as 'isolation gown'. Isolation gowns open
at the back with ties at the neck and the waist. This i keeps the gown securely closed,
protecting the back of the uniforms, as well as the fronts. The gown should be long
enough to cover the uniform i and have a long sleeves with cuffs for added protection.

The nurse gowns for isolation for the following reasons:

To prevent the nurse from contracting an infection from patients

To prevent medical personnel from contaminating the patient 'who has a disease
affecting the immune system.

The steps for gowning for isolation are discussed in


Donning Gloves :
Nurses or healthcare personnel wear/don gloves if there is any possibility of contact with
infectious material. Nurses wear gloves for all types of patient care for the following

To protect the nurse and the nurses family from disease

To protect the patient from the nurse, who may be considered a contaminator to
the patient

To protect the personnel from contact with the infectious microorganism.

The supply needed for donning gloves is a 'pair of gloves'. The steps of the
donning gloves are discussed in Table 5.3.

Donning a Mask
A mask should be worn for the following purposes:

To prevent the wearer from inhaling microorganism that travel on airborne

droplets for short distances or that remain suspended in the air for longer periods

To prevent inhaling pathogens if resistance is reduced or if being transported to

another area (patient use)

To discourage that wearer from touching the mouth, ) use, or eye and from
transmitting infection material.

The steps of donning 'isolation mask' are enlisted in Table 5.4.


Double Bagging :
A single bag is adequate if the contaminated articles can be placed in the bag without
contamination of the outside of the bag. Double bagging is recommended when it is
impossible to keep the outer surface of the single bag, free from contamination. The
second bag should be labeled for color coded to alert nursing personnel and to prevent
contamination of housekeeping personnels when handling contaminated material.
Double bag can be used for safe remove of any article from room. Double bagging has
purposes, i.e. to prevent spread of microorganism to the surrounding area and to prevent
potential accidental exposure of personnel to contaminated article. The supplies and
equipment needed for double bagging are as follows:

Single isolation bag

Special color coded bag

Holder for isolation bag

Isolation gown, mask and clean gloves

Holder for laundry bags

The steps to be followed for double bagging are given in the Table.


Isolation Technique
The type of isolation technique followed will depend on transmissibility of the pathogen.
The use of environmental barriers will keep pathogens in a confined care, i.e. private
room, isolation room, closed door, protective gown, masks and gloves and shoe covers.
The nurse follows isolation technique to prevent the transmission of infection from
micro- organisms by preventing pathogens from leaving the room of the infected patient
or from entering the room of a highly susceptible patient.
The supplies and equipment needed for isolation technique are as follows:

Isolation/gown, masks, gloves

Clean linen

Single and double isolation bags

Paper towels

Running water

Soap with dispenser

Holder for isolation bag and laundry bag.

The steps to be followed in an isolation technique are enlisted in the Table.


Preparing for Disinfection and Sterilization

There are two methods of sterilization and disinfection, i.e. physical method and
chemical method:
1. Physical method will include steam under pressure (autoclave), boiling water,
radiation, dry heat
2. Chemical method will include gas (ethylene oxide) and chemical solutions.
The nurse follows basic clean or aseptic technique to interrupt the infection process in
order to prevent and control the spread of infections. The supplies and equipment needed
for preparing for disinfection are gloves, running water, scrub brush and for sterilized
clean cloth wrapper.

The step to be followed in preparing for disinfection and sterilization are enlisted in the


Medical Hand washing :

Hand washing is a vigorous, brief rubbing together of all surfaces of hands lathered in
soap, followed by rinsing under a steam of water. The purpose is to remove soil and
transient organisms from the hands and to reduce total microbial; counts over time. It is
the most important preventive technique for interrupting the infection process.
Hand washing is the single most important I means for preventing the spread of
infections. It is frequently, however, incorrectly or inadequately done in an attempt to
save time. Unfortunately, this may cause increased infections and longer patient
hospitalization at increased cost. Contaminated hands are a prime cause of cross
The need for hand washing depends on the type, intensity, duration and sequence of
activity. Hand washing of nurses recommended the following situations:
1. Upon arising at the clinical unit prior to beginning a period of duty. This will
serve to decrease the microorganism transported to the hospital from external
environment. Nurses also wash their hands prior to leaving the area for rest and
meal break in order to decrease the special of microorganism to other areas of the
hospital and to themselves.

Before contact with clients who are susceptible to infections, e.g. newborn
infants, clients with leukemia, organ transplant recipients and HIV+ve cases, in
order to prevent the spread of microorganisms.

3. After caring for an infected clients.


Prior to performing any clean duties such as preparing medications, handling

food trays, assembling equipment or selecting clean linen.


After touching organic material, i.e. after performing any duties involving
contaminated articles such as bedpans, surgical dressings, soiled tissues or dirty


Before performing invasive procedures such as administration of injections,

catheterization and suctioning.


Before and after handling dressing or touch- ing open wounds.


Between contact with different clients in high risk units.

9. After removing disposable gloves or handling contaminated equipment.

The supplies needed for hand washing are as follows:

Soap as provided by the hospital; this may be liquid in a foot controlled

dispenser, bar soap' or a papersheet with soap in it

Stick or brush for cleaning fingernails

Warm running water, preferably with foot or knee control

Disposable towels or warm air dryer washing are enlisted in

Problem Solving and Nursing Process

In nursing a problem arises, when a client is unable to meet healthcare need. Problem
solving basic life skill; identifying a problem and then taking steps to resolve, it is a
matter of common sense. Different approaches to problem solving field different results,
some of which are more. Successful than others. Problem solving is a specific method for
obtaining a solution, and it is used by nurses to assist clients in meeting healthcare needs.
The problem solving method used in clinical nursing practice is a six-step model that
enables the nurse to make judgments and these judgment are as follows:

Encountering problem

Data collection

Identifying exact nature or problem (exact nature of problem specified)

Determining the plan of action

Carrying out the plan of action

Evaluation of the outcome of plan, plan continuation, modification or termination.


The trial and error method of problem solving involves testing and number of solutions
until one is found that works for that particular problem. This method is not efficient for
the nurse and can be dangerous to the client, it is therefore, not recommended as guide for
nursing practice and can be moved to scientific method.
The scientific method of problem solving in a testable, systematic process for solving
problems. There are seven steps to this method, which are used in clinical practice when
the nurse wants to investigate specific nursing intervention or phenomenon are as follows

Problem identification .Data collection

Hypothesis formulation

Plan of action developed to test hypothesis (selecting plan of action.

Testing hypothesis

Interpretation of results

Evaluation resulting in conclusion or revision of the study.

The use of the scientific method enables nurses to do clinical research to expand the
scientific basis for nursing practice.
The nursing process is a method of organizing and delivering nursing care. To understand
its functions, components and interactions, the nurse should have a working knowledge
of the nature of the process. A process is a series of steps or components leading to
achievement of a goal, which includes the following:






Assessment it is a collection, validation and communication of clients data. The purpose

is to make a judgment about the client's health status, ability to manage his or her own
healthcare, and need for nursing. And plan individualized holistic care that draws on
clients strengths and is responsive to changes in client condition.


During the step, the nurse:

establishes the data base, which includes nursing history, physical assessment,
review of the client record and nursing literature and consultation with the clients
support people and healthcare professionals

continuously updates the data base -validates the data

communicates the data.

Diagnosing it is the analysis of client data to identify client strengths and health problems
that independent nursing action can prevent or resolve. When data analysis reveals an
actual or potential health problem that nursing interventions can prevent or resolve, the
problem if termed as 'nursing diagnosis'. The purpose of diagnosing is to develop a
prioritized list of nursing diagnosis. During the step the nurses activities includes the

Interpreting and analyzing client data

Identifying client strength and client health problems

Formulation and validating nursing diagnosis .Developing a prioritized list of

nursing diagnosis.

Planning: It is the establishment of client goals objectives outcomes by the nurse,

working with the client, that prevent reduce or resolve problems identified in the nursing
diagnosis, and the determination of related nursing interventions most likely to assist the
client and achieving these goals. The purpose of plan is to develop individualized plan of
care. In addition plan of care also specified, the nursing assistance needed by the client to
meet the human needed, and the nursing interventions dictated by the plan of medical
care. In this step, the nursing activities include:
.Establishing priorities. Writing client goals objectives and developing an evaluative
strategies .Selecting nursing interventions .Communicating the plan of nursing care.
Implementing: It involves the carrying out of the plan of care. Its purpose is to assist
clients to achieve desired goals, which includes all interventions performed by nurses to
promote well- ness, prevent disease or illness, restore health and facilitate coping with
altered functioning. The activities of the nurses in this step includes the following:

Carrying out the plan of care. Continuing data collection and modifying the plan
of care as needed

Documenting care.


Evaluating: It is measuring the extent to which the client has achieved the goal specified
in the plan of care, identifying factors that positively or negatively influenced the goal
achievement; revise plan of care if necessary. The purpose of evaluation is to continue,
modify or terminate nursing care. In this step nurse does the following:

Measure how well the client has achieved desired goals/ objectives

Identify factors that continue to the client success or failure

Modify the plan of care if indicated.

When the nursing process is used to organize and deliver nursing care, the client becomes
an active participant in an individualized healthcare process. The client receives
comprehensive and consistent care. When used properly, the nursing process achieves for
the client scientifically based holistic, individualized care; the opportunity to work
collaboratively with nurses and continuity of care. Nurses who use the nursing process in
a thoughtful and systematic way achieve a clear and efficient plan of action by which the
entire nursing team can achieve results for clients; the satisfaction that they are receing is
out of an important difference in the lives of their clients; and the opportunity to grow
professionally, as nurses evaluate the effectiveness of intervention.

BT Basavanthappa 2004, Fundamentals of nursing, Ist edition Jaypee

brothers medical publishers (p) Ltd., NEW DELHI


BT Basavanthappa 2004 Nursing Administration, Ist edition Jayppee

brothers Medical Publishers (p) Ltd., NEW DELHI




Kasthuri sundar Rao 2000, An introduction to community health

nursing 3rd edition, B.I. Publications CHENNAI.


KNpark 2005 Text book of preventive and social medicine 18th edition.
M/S. Banasidas Bhanot Publishers, Jabulpul




Potter Perry 2005, Fundamentals of Nursing 6th edition MOSBY

Publications Missouri.