Definitions of Nursing

Several well-known definitions of nursing indicate that the basic themes of health, illness, and caring have existed since Florence Nightingale described nursing. Following are two such examples:

In 1980 the ANA defined nursing as “the diagnosis and treatment of human responses to actual and potential health problems.”¹ In this context, a nurse caring for a person with a fractured hip would focus on the patient’s possible responses to immobility, pain, and loss of independence.

The widely accepted ANA definition of nursing was reaffirmed in the 2010 edition of the ANA’s Nursing: A Social Policy Statement to reflect the continuing evolution of nursing practice:

This definition reflects nurses’ increasing role in promoting health and wellness and advocating for the recipients of care.

Nursing’s View of Humanity

Nursing theorists are in widespread agreement that an individual has physiologic (or biophysical), psychologic (or emotional), sociocultural (or interpersonal), spiritual, and environmental components or dimensions. In this text the human individual is considered “a biopsychosocial spiritual being in constant interaction with a changing environment.”⁴ The individual is composed of dimensions that are interrelated and not separate entities. Thus a problem in one dimension may affect one or more of the other dimensions. An individual’s behavior is meaningful and oriented toward fulfilling needs, coping with stress, and developing one’s self. However, at times an individual needs help to meet these needs, cope successfully, or develop his or her unique potential.

Scope of Nursing Practice

Like all health care professions, nursing’s scope of practice has a flexible boundary that reflects the changing needs of society and advancement of knowledge. The essential core of nursing practice is to deliver holistic, patient-centered care. It includes assessment and evaluation, administration of a variety of interventions, patient and family teaching, and being a member of the interdisciplinary (also referred to as the interprofessional) health care team.

The extent that individual nurses engage in the scope of practice depends on their educational preparation, experience, and role, and is guided by individual state laws. To enter into practice, a nurse must complete an accredited program and pass an examination verifying the nurse has the skills necessary to provide competent care. Entry-level nurses with associate or baccalaureate degrees are prepared to function as generalists. At this level, nurses provide direct health care and focus on ensuring coordinated and comprehensive care to patients in a variety of settings. They work collaboratively with other health care providers to manage the needs of individuals and groups.5,6

With experience and continued study, nurses may specialize in an area of practice. Certification is a formal way for nurses to obtain professional recognition for their expertise in a specialty area. A variety of nursing organizations offer certification in a number of nursing specialties.⁷ Certification usually requires a certain amount of clinical experience and successful completion of an examination. Recertification usually requires ongoing clinical experience and continuing education. Common nursing specialties include ambulatory care; cardiovascular care; critical care; women’s health; diabetes education; nursing informatics; and geriatric, medical-surgical, perinatal, emergency, psychiatric/mental health, and community health nursing.

Additional formal education and experience can prepare nurses for advanced practice. An advanced practice nurse (APN) or advanced practice registered nurse (APRN) is a nurse with at least a master’s degree in nursing; advanced education in pathophysiology, pharmacology, and health assessment; and expertise in a specialized area of practice. Examples of APNs/APRNs are clinical nurse specialists, clinical nurse leaders, nurse practitioners, nurse midwives, and nurse anesthetists. In addition to managing and delivering direct patient care, APNs/APRNs have roles in health promotion, case management, administration, research, and interdisciplinary health systems.⁷ Nurses with a PhD typically serve as faculty in schools of nursing, policy analysts, and researchers. However, they are being increasingly employed in clinical settings as clinical experts and health care system executives.

In response to patient care needs and in anticipation of the needs of the current and future health care system, the doctorate of nursing practice (DNP) degree was endorsed in 2004 by the American Association of Colleges of Nursing (AACN). The DNP moves the educational preparation for advanced nursing practice from the master’s degree to the doctoral level. It is designed for nurses seeking a practice-focused terminal degree in nursing. The DNP degree moves nursing in the direction of other health professions that offer practice doctorates (e.g., pharmacy [PharmD], psychology [PsyD], and physical therapy [DPT]).⁸

Diverse Populations.

Patient populations are more diverse than ever. Americans are living longer, in part due to advances in medical science, technology, and health care delivery. As the population ages, the number of patients with chronic conditions increases. Unlike those who receive acute, episodic care, patients with chronic conditions have a multitude of needs. They see a variety of health care providers in various settings over an extended period. Nurses are also caring for a more culturally and ethnically diverse population. Immigrants, particularly undocumented immigrants and refugees, often lack the resources necessary to access health care. Inability to pay for health care is associated with a tendency to delay seeking care, resulting in illnesses that are more serious. Boxes throughout this book emphasize the influence of such factors as gender, culture, and ethnicity on nursing practice.

Consumerism.

Health care is a consumer-focused business. Patients today are active participants in their health care and expect high-quality, coordinated, and financially reasonable care. Health information is readily available. Many patients eagerly seek information about their health problems and health care from media and Internet sources. They gather information so that they can have a voice in making decisions about their health care. As a nurse, you must be able to help patients access and use appropriate health care information (Fig. 1-2).

Many changes in health care systems that influence nursing care delivery were initiated by the government, employers, insurance companies, and regulating agencies in an effort to provide more cost-effective health care. Historically, the most notable event related to changing reimbursement patterns was the institution of prospective payment systems in the Medicare program. With these changes, hospitals were no longer reimbursed for all costs. Instead, payment for hospital services for Medicare patients was based on flat fees determined by the diseases and problems treated during the admission. Private and other public health care systems followed suit by introducing managed care systems that use prospective payment as a means of offering cost-effective health care delivery. In health maintenance organizations (HMOs) and preferred provider organizations (PPOs), charges are negotiated in advance of the delivery of care using predetermined reimbursement rates or capitation fees for medical care, hospitalization, and other health care services.

These same third-party payers demand outcome-based quality care that is provided at a price affordable for both individuals and society. Payment for health care services or pay-for-performance programs reimburse hospitals for their performance on quality-of-care measures. These measures include clinical outcomes, patient safety, patient satisfaction, adherence to evidence-based practice, and adoption of information technology. Payment for care can be withheld if a patient develops certain health care conditions during a hospital stay (e.g., pressure ulcer) or if something happens to the patient that is considered preventable (e.g., acquiring a catheter-related urinary tract infection).⁹

The American Nurses Association is the primary professional nursing organization. There are numerous professional specialty organizations, such as the American Association of Critical-Care Nurses (AACN), Association of periOperative Registered Nurses (AORN), and Oncology Nursing Society (ONS). Professional organizations have numerous roles in promoting quality patient care and professional nursing practice. These include developing standards of practice and codes of ethics, supporting research, and lobbying for legislation and regulations. Major nursing organizations also promote research into the causes of errors, develop strategies to prevent future errors, and address nursing issues that affect the nurse’s ability to deliver patient care safely. Many nurses join a professional organization to keep current in their practice and network with others who are interested in a particular practice area.

Delivery of Nursing Care

Nurses deliver patient-centered care in collaboration with the interdisciplinary health care team and within the framework of a care delivery model. Today a variety of care delivery models are being used in view of nursing shortages, state-mandated nurse-patient ratios, economic issues, and increased acuity of patient conditions.

A team nursing model uses a professional nurse as a team leader. As a team leader, you organize and manage the care for a group of patients with other ancillary workers such as licensed practical/vocational nurses (LPN/LVNs) and unlicensed assistive personnel (UAP). In this model, you have the authority and accountability for the quality of care delivered by team members during a work period.

In a total patient care model, you assume accountability for the complete care of a patient or group of patients during the assigned shift. In this model, you are responsible for planning and providing all care.

In a primary nursing model, you are responsible for a patient or caseload of patients over a period of time.¹² You provide care during assigned shifts, and coordinate and communicate all aspects of patient care with other disciplines and those who provide care when you are absent. Care delivered within a primary care model strengthens the nurse-patient relationship through a focus on continuity of care and interdisciplinary collaboration.