Nursing is an art and a science.

Earlier emphasis focused on care of the sick patient; now, the promotion of health is stressed.

American Nurses Association (ANA) definition, 1980: Nursing is the diagnosis and treatment of the human response to actual and potential health problems.

Practitioner—involves actions that directly meet the health care and nursing needs of patients, families, and significant others; includes staff nurses at all rungs of the clinical ladder, advanced practice nurses, and community-based nurses.

Leader—involves actions, such as deciding, relating, influencing, and facilitating, that affect the actions of others and are directed toward goal determination and achievement; may be a formal nursing leadership role or an informal role periodically assumed by the nurse.

Researcher—involves actions taken to implement studies to determine the actual effects of nursing care to further the scientific base of nursing; may include all nurses, not just academicians, nurse scientists, and graduate nursing students.

Nursing theories help define nursing as a scientific discipline of its own.

The elements of nursing theories are uniform: nursing, patient, environment, and health—also known as the paradigm or model of nursing.

Nightingale was the first nursing theorist; she believed the purpose of nursing was to put the patient in the best condition for nature to restore or preserve health.

Theories range from broad to limited in scope.

More recent nursing theorists include:

Technology, education, society values, demographics, and health care financing all have an impact on where and how nursing is practiced.

Unsuccessful cost-containing measures and a growing uninsured population led to the passage of the Patient Protection and Affordable Care Act of 2010, also known as health care reform in the United States. Emphasis is on preventive health care and coordination of care. Specific provisions phased in through 2015 ensure more options for people with pre-existing conditions that previously caused exclusion from coverage; allowing young people to stay on parent or family insurance policies until age 26; eliminating lifetime limits on coverage; providing small-business tax credits to provide coverage to employees; providing rebates on Medicare prescription costs; providing funding to states to expand Medicaid coverage; state insurance exchanges to offer more coverage for all citizens; preventive health services offered without extra cost; and linking payments to quality outcomes. For more information, go to www.healthcare.gov.

More patients are expected to enter the health care system, particularly in primary care, requiring more health care providers, more nurses, and more health care facilities.

Registered professional nurses with advanced training, education, and certification are allowed to practice in expanded scope.

This includes nurse practitioners, nurse-midwives, nurseanesthetists, and clinical nurse specialists.

Scope of practice and legislation vary by state.

Master’s degree preparation is the current requirement for most APN roles; however, many certificate programs have trained APNs in the past 40 years. In addition, doctoral programs are becoming increasingly available, with emphasis on the practice role of APNs.

In Canada and other countries, the growth of the number of APNs in practice has been slower than in the United States, except for midwives in many cases.

Every professional registered nurse must be licensed through the state board of nursing in the United States to practice in that state or the College of Nursing to practice in a Canadian province.

Although the state primarily regulates and restricts practice, the framework for scope of practice actually depends on a four-tier hierarchy: (1) the ANA Scope and Standards for Nursing Practice; (2) the particular state Nurse Practice Act; (3) the facility policies and procedures where the nurse is practicing; and (4) the nurse with her or his individual self-determination and competencies. Indeed, it is the nurse’s responsibility to maintain competency and practice within the appropriate scope.

Continuing education requirements vary depending on state laws, facility policies, and area of specialty practice and certification. Continuing education units can be obtained through a variety of professional nursing organizations and commercial educational services.

Many professional nursing organizations exist to provide education, certification, support, and communication among nurses; for more information, contact your state nurses’
association, state board of nursing, or the ANA, 8515 Georgia Avenue, Suite 400, Silver Spring, MD 20910, 800-274-4ANA, www.nursingworld.org.

The Doctor of Nursing Practice (DNP) was introduced in 2005 to ensure that nursing can meet the demands of the changing health care system with the highest level of scientific knowledge and practice expertise.

Nursing curriculum and the nursing role has expanded to meet the demands of an aging, chronically ill population; advanced technology in the acute care setting; and expanding preventive strategies and community-based care to promote a healthier population. A wide variety of certifications offered through the American Nurses Credentialing Center (www.nursecredentialing.org) acknowledge advanced preparation of nurse practitioners, clinical nurse specialists, home health nurses, case management nurses, and many other specialties.

A recent addition to the certification arena is that of the clinical nurse leader, which has a master’s degree requirement. It is defined as a nursing generalist whose role is to improve the quality of nursing care. The clinical nurse leader provides direction at the point of care, collaborates with the health care team, provides risk assessment, and implements quality improvement strategies based on evidence-based practice.

Adequate nursing staffing is essential to reduce nurses’ dissatisfaction, burnout, and high turnover rates, as well as reduce patient mortality. Studies have linked inadequate staffing to increased patient mortality.

The Institute of Medicine (IOM) of the National Academies has focused on deficient health care systems as the cause of medical errors that are preventable and result in about 50% of adverse events and patient deaths. The IOM offers recommendations for improving systems and processes in health care organizations to ultimately improve patient safety. For more information, refer to the website www.iom.edu.

The Agency for Healthcare Research and Quality has compiled a wide array of patient safety literature as a resource for all types of health care providers and settings, available at http://psnet.ahrq.gov/default.aspx.

The Joint Commission is also committed to improving safety for patients in health care organizations. The National Patient Safety Goals were implemented in 2003 to help address specific concerns for patient safety by health care setting, including ambulatory care, long-term care, behavioral health care, home care, hospital, laboratory services, and office-based surgery. New goals are introduced yearly with suggested performance measures to meet the goals. These are available at www.jointcommission.org/standards_information/npsgs.aspx. See Box 1-1 for selected National Patient Safety Goals.

Nurses may be at risk for personal harm in the workplace. The ANA has sponsored initiatives to improve nurses’ personal safety. The Position Statement: Risk and Responsibility in Providing Nursing Care acknowledges that there may be
limits to the personal risk a nurse can assume in providing care in any clinical setting.

The Centers for Disease Control and Prevention estimates that 380,000 health care workers are injured by needles and other sharps each year, increasing the risk of hepatitis B, hepatitis C, and human immunodeficiency virus. Nurses sustain the largest percentage of these injuries. The ANA’s “Safe Needles, Save Lives” (www.needlestick.org) campaign was key in promoting the use of safety devices. Nurses and other health care workers are protected by the Needlestick Safety and Prevention Act (P.L. 106-430), which requires health care organizations to use needleless or shielded-needle devices, obtain input from clinical staff in the evaluation and selection of devices, educate staff on the use of safety devices, and have an exposure control plan.

The physical work environment, which includes patient handling tasks such as manual lifting, transferring, and repositioning patients, can also place nurses at risk for musculoskeletal disorders such as back injuries and shoulder strains. The ANA’s “Handle with Care” campaign (www.nursingworld.org/handlewithcare) aims to prevent such injuries and to promote safe patient handling through the use of technology and assistive patient-handling equipment and devices.