Socialization to Professional Nursing Roles

Socialization to Professional Nursing Roles
2 Socialization to Professional Nursing Roles

Hallmark Features A focus on foundational knowledge related to professional nursing Includes nursing history, nursing theory, ethics, and legal aspects, etc. An overview of professional nursing roles, issues, and changes in the profession Discusses nurses as healthcare providers, learners and teachers, and leaders.

Discuss professionalism and nursing.
Learning Objective 2.1 Discuss professionalism and nursing.

Common Mistakes (cont’d)
writing an unattainable, unrealistic objective writing objectives unrelated to stated goal cluttering an objective with unnecessary information making an objective too general so that the outcome is not clear

Nursing as a Profession
A profession is distinguished from other kinds of occupations by Requirement of specialized training Orientation toward service, either to a community or an organization The standards are determined by its members

Nursing as a Profession
The education involves a complete socialization process Debates about whether nursing is a profession

Challenges for the Nursing Profession
Level of entry into practice Multiple levels Associate degree Diploma Baccalaureate degree Gaps between education and practice Professional identity: job versus career

Nursing as a Discipline and Profession
History and trends in the education of nursing Earliest type of education was in hospitals Emergence of baccalaureate and associate degree programs Shift from diploma (hospital-based) programs to associate and baccalaureate

Nursing as a Discipline and Profession
ANA 1965 position paper Proposing master’s degree as minimum education for entry level nurse Definition of profession, six conceptualizations A discipline is a branch of knowledge Disciplines are divided Academic–research and education

Professional–Component of Clinical Practice
Standards of clinical nursing practice Reflect values and priorities Provide direction for professional nursing practice Provide a framework for evaluation

Define the Professions Accountability
ANA established standards of clinical nursing practice Six standards of practice known as nursing process Nine standards of professional performance

Describe socialization to professional nursing.
Learning Objective 2.2 Describe socialization to professional nursing.

Professional Socialization
Socialization is a learned process Professional socialization is to internalize a professional identity Social control is intrinsic Capacity of a social group to regulate itself through conformity and adherence to group norms Sanctions are used to enforce norms Norms become internalized standards

Professional Socialization
Agents of socialization are the people who initiate the socialization process Children – family, teachers, peers, media Adults – superiors, subordinates in the workplace, peers, people of other social groups Nursing students – clients, faculty, health professionals, and professional colleagues Nursing – preceptors, mentors, staff development on the job

Compare socialization models.
Learning Objective 2.3 Compare socialization models.

Process of Professional Socialization
Models that describe the process of socialization Simpson Hinshaw Davis

Simpson Model Three phases Proficiency Attachment Internalization

Hinshaw Model Three phases Transition Attachment Internalization Value and standards

Davis Model Six stages Initial innocence Labeled recognition of incongruity “Psyching out” Role simulation Provisional internalization Stable internalization

Ongoing professional socialization and resocialization Process does not terminate with graduation or start of a new job

Three models of career stages or development Kramer’s Postgraduate Resocialization Model Reality shock Dalton’s Career Stages Model Development of competencies derived from experience Benner’s Stages from Novice to Expert Implications of teaching and learning

Analyze elements of and boundaries for nursing roles.
Learning Objective 2.4 Analyze elements of and boundaries for nursing roles.

Role Theory Role theory emerged from sociology
A role is a set of expectations associated with a position in society

Role Theory Elements of roles Ideal Perceived Performed
The socially prescribed or agreed-upon rights and responsibilities associated with the role Perceived How a person believes he or she should behave in this role Performed What the person actually does

Role Theory Role performance factors include Health status
Personal and professional values Needs of clients and support person Politics of employing agency

Role Theory Role transition is the process by which a person assumes or develops a new role Two components associated with role behaviors Norms Values

Role Theory Role transition is influenced by many factors Individual
Interpersonal Organizational

Boundaries for Nursing Roles
Five determinants form boundaries for nursing roles Theoretical and conceptual frameworks The nursing process Standards of nursing practice Nursing practice acts National and international codes of ethics

Learning Objective 2.5 Discuss ways to manage role stress and strain while enhancing professional identity.

Role Stress and Role Strain
Factors associated with role stress for nurses Little control in the job High demands Few supportive relationships

Role stress may create role strain Common role stress problems Role ambiguity Role conflict Role incongruity Role overload or underload Role over-qualification or under-qualification

Four major causes for role conflict for nurses Professional bureaucratic work conflict Different views concerning what nursing is and should be Discrepancy between the nursing and medical view of what the nurse’s role should be

Strategies for relieving role stress Priority setting and time management Rewriting job descriptions for clarity Integrating multiple roles into a larger whole

Characteristics of a Positive Self-Concept
Characteristics of a person with a positive self-concept Future orientation Copes with life’s problems and disappointments Helps others and accepts help Can see and value uniqueness in all individuals Feels emotion but does not allow feelings to affect behavior

Characteristics of a Positive Self-Concept
To develop a positive self-concept Accept your present self but have a better self in mind Set attainable goals Develop expertise

Preventing Burnout Personal goal setting Problem identification
Long- and short-term goals Problem identification What is causing the stress Problem-solving strategies See Table 2–3 Time management skills Delegation

Overcoming Procrastination
Caring for one’s self

Historical Foundations of Professional Nursing
3 Historical Foundations of Professional Nursing

Learning Objective 3.1 Discuss the historical development of nursing from ancient times to the present.

History of Nursing Primitive societies Traditional female roles

History of Nursing Ancient civilizations Midwives, wet nurses
Belief about disease imbedded in superstition and magic Earliest recording of healing practice is a 4,000 year old tablet Earliest documentation of law governing medicine is Code of Hammurabi dating to 1900 B.C.

History of Nursing Egyptian culture Hebrew culture Christian culture
Ebers papyrus oldest medical text, approximately from 1550 B.C. Mummification or embalming Hebrew culture Mosiac Health Code Christian culture The Bible mentions nurses in Old Testament Ancient civilizations

History of Nursing African culture Indian culture China
Midwife, herbalist, wet nurses, caregivers Indian culture Male nurses China Acupuncture Herbal remedies

History of Nursing Greece Rome Mythology
Hippocrates, father of medicine Rome Public sanitation

Discuss the role of religion in the development of nursing.
Learning Objective 3.2 Discuss the role of religion in the development of nursing.

History of Nursing Role of religion Benevolence as a Christian value
Parabolani Brotherhood Knighthoods Knights Hospitallers of St. John of Jerusalam Teutonic Knights Knights of Lazarus Specialized institutions supported by the church

History of Nursing Other groups Military and secular orders
Islamic women Sisters of Charity Deaconess groups

Discuss the influence of war on the development of nursing.
Learning Objective 3.3 Discuss the influence of war on the development of nursing.

Development of Modern Nursing
Deaconess Institute at Kaiserwerth, Germany Recognized the need for services of women in caring for the sick, poor, children, and female prisoners Developed a training school for nurses at Kaiserwerth Deaconess movement spread to 4 continents

Development of Modern Nursing
Florence Nightingale Kaiserwerth pupil Recruited during the Crimean War to care for soldiers Transformed the environment by setting standards Used the honorarium to develop the Nightingale Training School for Nurses

Development of Nursing in America
Augustinian Sisters in Canada – first hospital in Canada, 1639 Sisters of Charity of St. Joseph’s in Maryland – Mother Elizabeth Seton Religious orders developed nursing education and nursing services Catholic and Protestant churches developed hospitals across the country

Describe the contributions of selected nurses to nursing and society.
Learning Objective 3.4 Describe the contributions of selected nurses to nursing and society.

Related to the need to care for sick and injured soldiers Civil War Dorothea Dix Louisa May Alcott Harriet Tubman Sojourner Truth

Related to the need to care for sick and injured soldiers World War I Vassar Training Camp combined university and hospital training – Isabel Stewart Army School of Nursing – Annie Goodrich World War II United States Cadet Nurse Corps

Nursing Image The following job description was given to floor nurses by a hospital in 1887: In addition to caring for your 50 patients, each nurse will follow these regulations: see 1887 Job Description

1903: North Carolina, New Jersey, New York, Virginia enacted voluntary licensure laws Regulated the use of the title Registered Nurse (RN) 1915: American Nurses Association draft of a model nurse practice act 1923: All 48 states had nursing licensure laws or registration

1935: Mandatory licensure act passed in New York that went into effect in 1949 1971: Idaho became the first state to recognize advanced practice 1992: Eddie Bernice Johnson was the first nurse to be elected to the United States House of Representatives

Learning Objective 3.5 Analyze the contributions of selected nurses and the nursing profession to society from a historical perspective.

Historical Leaders in Nursing
The founders Rufida Jeanne Mance Florence Nightingale Mary Seacole Clara Barton Lucy Osborne Linda (Melinda) Richards

The founders Mary Mahoney Ceclia Makiwane Lillian Wald Mary Breckinridge Loretta C. Ford

The men John Ciudad St. Camillus de Lellis James Derham Walt Whitman Luther Christman Richard Henry Carmona

The risk takers Clara Maass Edith Cavell Sharon Lane Barbara Fassbinder

The social reformers Sojourner Truth Dorothea Lynde Dix Harriet Tubman Lavinia Dock Margaret Sanger Mary Elizabeth Carnegie Mabel Staupers

Compare and contrast the history of nursing and
Learning Objective 3.6 Compare and contrast the history of nursing and the history of caring.

Nursing: A History of Caring
“Modern” history is the idea of caring Symbiotic relationship between the history of Nursing Caring Women & Feminist Movement

Learning Objective 3.7 Discuss the development of professional nursing organizations and their role in advocating for nurses and healthcare.

Professional Nursing Organizations
Nursing organizations are divided into three types Those that represent all nurses Those that meet the needs of nurses within specialties Those that represent special interests

American Nurses Association (ANA) National professional organization for all registered nurses in the United States Headquarters – Washington, D.C. The name Nurses Associated Alumnae was changed to ANA in 1911 Became a federation of state nurses’ associations in 1982

American Nurses Association (ANA) Mission: To foster high standards of nursing, promote the rights for nurse in the workplace, project positive view and lobby Congress on healthcare issues Official publication: American Journal of Nursing and American Nurse

National Student Nurses’ Association (NSNA) Established in 1952 Mission: To organize, represent, and mentor students preparing for initial licensure as registered nurses Official publication: Imprint

National League of Nursing (NLN) Mission: To promote excellence in nursing education to build a strong and diverse nursing workforce Began in 1893 as the American Society of Superintendents of Training Schools for Nurses, later the National League for Nursing Education (NLNE)

National League of Nursing (NLN) In 1952, the NLNE and the Association for Collegiate Schools of Nursing and the National Organization for Public Health Nursing combined to form the NLN Official publication: Nursing Education Perspectives

American Association of Colleges of Nursing (AACN) National voice for baccalaureate and higher-degree nursing education programs Official publication: Journal of Professional Nursing

International Council of Nurses (ICN) Founded in 1899 as the world’s first and widest international organization for health professionals Mission: To represent nursing worldwide, advancing the profession and influencing health policy

International Council of Nurses (ICN) Five core values of ICN Visionary leadership Inclusiveness Flexibility Partnership Achievement Official publication: International Nursing Review

Sigma Theta Tau International Founded in 1922 as an international honor society for nursing Member of the Association of College Honor Societies

Sigma Theta Tau International Mission: To support learning, knowledge, and professional development of nurses committed to make a difference in health worldwide Official publication: Journal of Nursing Scholarship

Specialty Nursing Organizations Represent special interests of nurses from a practice perspective Provide educational opportunities for members Special-Interest Organizations Address special needs of nurses from minority groups

Chapter 1 The Professional Nurse
Leddy & Pepper’s Conceptual Bases of Professional Nursing

Introduction Nurse, nourish, nurture: all come from Latin root nutrire
Professional nurses Assume ultimate accountability for client outcomes Supervise, educate LPN/LVNs, UAP Use science as basis for professional practice, art when modifying care approaches

Introduction (cont’d)
Six essential features of professional nursing: Provide caring relationship that promotes health, healing Assess, attend to full range of human responses, experiences Integrate subjective, objective data

Introduction (cont’d)
Six essential features of professional nursing: Use professional judgment, critical thinking Use scholarly inquiry Strive for social justice by influencing social, public policy

Characteristics of Professional Nursing Practice: The Hood
Professional Nurse Contributions Model Nurses: members of interdisciplinary team Circular form of model designates how interprofessional health care team surrounds health care consumers Outer circle emphasizes importance of all team members working cohesively for benefit of care recipients

Characteristics of Professional Nursing Practice: The Hood (cont’d)
Professional Nurse Contributions Model Outer circle of model Altruistic attitude Caring Compassion Commitment Competence Confidence

Characteristics of Professional Nursing Practice: The Hood (cont’d)
Professional Nurse Contributions Model Innermost circle depicts Clinical skills Cognitive skills Communication skills

The Multiple Roles of the Professional Nurse
Caregivers Client advocate Teacher Change agent Coordinator Counselor Colleague Lifelong learner

Challenges to the Returning Professional Nursing Student
Nurses who return to school assume role of student, resulting in many lifestyle changes: Chaos, personal sacrifices Increased expenses for school needs Decreased time with family Lack of support from work environment Entering unfamiliar learning situations

Skills for Educational Success
In ideal educational situations, students and faculty interact with each other as colleagues Traditional education or Authoritarian expert Educative-caring education or Egalitarian interactions Nurses Focus educational efforts on refining previously learned skills while establishing theoretical foundations for professional practice

Skills for Educational Success (cont’d)
Reading Reading assigned material Listening, speaking Effective speaking, listening Asking questions to avoid making errors in education, health care settings

Skills for Educational Success (cont’d)
Writing Essential mode of communication for nurses Must use critical, reflective thinking Learning to evaluate information, especially from world wide web. Effective writing, appropriate writing style

Question A diploma graduate who has been a practicing RN for 5 years is considering returning to school for a BSN. The nurse says she’s not sure it is worth the money to return to school. What emotion is this nurse possibly experiencing? Discomfort, chaos Fear, anger Acceptance, certainty Jealousy, resentment

Answer A. Discomfort, chaos
Rationale: Nurses who return to school assume the role of student, which results in many lifestyle changes. The added responsibilities of returning to school may result in chaos and personal sacrifices.

Professional Image and Physical Appearance
Nursing caps became obsolete in 1970s White uniforms abandoned for colorful scrub suits, dresses Cartoons, other distracting designs in scrub attire fail to project professional image

Professional Image and Physical Appearance (cont’d)
Cleanliness, safety are priorities: Clean clothing, well-manicured natural nails Clean shoes decrease spread of infections Avoid dangling earrings, necklaces to prevent injury Tongue piercing impairs clarity of nurse’s speech Visible body piercing, extensive tattooing might create distress for some clients

Organizational Skills for Educational and Professional Success
Key organizational skills for success: Managing information Setting priorities to meet deadlines Organizing personal libraries, files Staying abreast of latest information

Organizational Skills for Educational and Professional Success (cont’d)
Key organizational skills for success: Refine test-taking skills Prepare for tests ahead of time Alleviate test anxiety Managing personal time Keep schedule or calendar Learn to say no, ask for help

Socialization and Resocialization into the Nursing Profession
Socialization: process of making someone ready for particular societal role Professional socialization Formation, internalization of professional identity congruent with professional role

Socialization and Resocialization into the Nursing Profession (cont’d)
Resocialization: occurs when someone adapts role to new setting Significant environmental changes (changing job, moving to different practice setting, returning to school) stimulate resocialization

Role Theory Role contains three key pieces: values, attitudes, behaviors Students must adjust how they meet all current life roles to avoid role conflict Role conflict: arises when roles assumed by person compete with each other for time, attention

Shane’s Returning-to-School Syndrome Honeymoon - nurses feel energetic about learning new things Conflict - turbulent negative emotions (anger, helplessness, depression) Reintegration - nurses question why they decided to pursue higher degree Integration - ability to blend original culture of work with new culture of school

Bridge’s Managing Transitions People undergo transitions (psychological adaptations to changes) whenever exposed to changes Three-step process to facilitate transitions: starts with ending, finishes with beginning: Letting go The neutral zone The new beginning

Development of a Professional Self-Concept
Encompasses Beliefs about oneself, personal interpretations about past, present, future Development of professional self-concept (how person perceives oneself as a nurse) follows same path as development of personal self Personal self-concept cannot be separated from professional self-concept

Development of a Professional Self-Concept (cont’d)
Encompasses Professional self-system emerges from personal self Benner’s Novice-to-Expert Model Describes stages in progression of patient care expertise that can result from practice nursing experience

Professional Nursing Roles Helping, teaching-coping Diagnostic, patient monitoring Effective management of rapidly changing situations Administration, monitoring of therapeutic interventions, regimens

Professional Nursing Roles Monitoring of, ensuring quality of health care practices Organizational, work role competencies

Characteristics of a Profession
Authority to control its own work Exclusively unique body of knowledge Extensive period of formal training Specialized competence Control over work performance Service to society Self-regulation

Characteristics of a Profession (cont’d)
Credentialing systems to certify competence Legal reinforcement of professional standards Ethical practice Creation of collegial subculture Intrinsic rewards Public acceptance

Three levels of education qualify people to take licensing exam: Associate’s Degree in Nursing (ADN) Diploma Nursing Program Baccalaureate Degree in Nursing (BSN)

Intellectual Characteristics Body of knowledge on which professional practice is based Specialized education to transmit body of knowledge to others Ability to use knowledge in critical, creative thinking

Body of Knowledge Professional practice based on body of knowledge derived from Experience (leading to expertise) Research (leading to theoretical foundations for knowledge, practice) Liberal arts education serves as hallmark of professional education

Specialized Education National Council of State Boards of Nursing (NCSBN) coordinates efforts to license registered, practical nurses Graduate nursing education programs offer advanced education Postgraduate nursing education leads to doctorate in nursing

Using Knowledge by Critical Thinking
Nurses as critical thinkers exhibit these habits of mind: Confidence Contextual perspective Creativity Flexibility Inquisitiveness

Using Knowledge by Critical Thinking (cont’d)
Nurses as critical thinkers exhibit these habits of mind: Intellectual integrity Intuition Open-mindedness Perseverance Reflection

Creative Thinking Ability to think outside what usually is done Results in novel approaches to client care Must be tempered by critical thinking to avoid hazardous solutions

Reflective Thinking Purposeful analysis about what one is currently doing, what one has done Reflection on action a retrospective analysis of action taken

Independent Clinical Decision Making
Independent decisions to solve problems in clinical practice Nurses act prematurely because of inadequate information, insufficient time to generate alternative approaches

Nursing Process Systematic thinking method to process information about specific client-care situations Problem-solving approach that consists of five steps: Assessment Diagnosis Planning Implementation Evaluation

Nursing Process (cont’d)
Effective use of nursing process requires critical, creative, reflective thinking

Question To avoid hazardous solutions, the professional nurse must temper creative thinking with_________. Contextual perspective Reflective thinking Reflective action Critical thinking

Answer D. Critical thinking
Rationale: Creative thinking is the ability to think outside what usually is done and results in novel approaches to client care. It must be tempered with critical thinking to avoid hazardous solutions.

Service to Society Students still enter nursing to help people or to care for people Five conceptualizations of caring: Caring as human trait Caring as moral imperative Caring as affect Caring as interpersonal interaction Caring as therapeutic intervention

Service to Society (cont’d)
International Council of Nurses (ICN), American Nurses Association (ANA) State boards of nursing provides copies of Nurse Practice Act (NPA) upon initial licensure Provide legal reinforcement against incompetence Specifies legal definition of nursing practice, minimal education preparation for licensure Imposes penalties for illegal, unethical, negligent practice

Autonomy and Self-Regulation
Independence, willingness to take risks, accountability for one’s actions, self-determination, self-regulation. State Boards of Nursing (SBN) Regulates professional nursing practice by issuing professional licenses to qualified individuals

Autonomy and Self-Regulation (cont’d)
National Council of State Boards of Nursing (NCSBN) Developed licensure examinations for professional, practical nursing

A Collegial Subculture (Accrediting, Professional, and Student Nursing Organizations)
Professional nursing organizations: two categories: General-purpose nursing organizations Specialized nursing organizations Participation in specialty nursing organization links nurses who practice in particular area Creates subcultures of nurses with common interests within nursing profession

A Collegial Subculture (Accrediting, Professional, and Student Nursing Organizations) (cont’d)
National League for Nursing American Association of Colleges of Nursing National Council of State Boards of Nursing American Nurses Association The International Council of Nurses Sigma Theta Tau International National Student Nurses’ Association

Question What is the purpose for nurses to participate in professional organizations? Links to other nurses in specific area of practice Creates sense of moral belonging, imperative To have regulation of professional nursing practice Boost ability to make ethical practice decision

Answer A. Links to other nurses in specific area of practice
Rationale: Professional nursing organizations foster the development of collegial relationships among nurses. Participation in a specialty nursing organization links nurses who practice in a particular area and creates subcultures of nurses with common interests within the nursing profession.

Ethical Practice Guiding principles:
Respect for human dignity, uniqueness Protection of confidential information Acts to safeguard persons Responsibility, accountability for nursing actions Maintenance of nursing competence

Ethical Practice (cont’d)
Guiding principles: Use of informed judgment Participation in research, other activities Participation in activities to improve, implement nursing standards Integrity to profession Collaboration with other health care professionals, consumers

Societal Acceptance: Legal Reinforcement of Professional Standards
Emerging profession because of barriers to fulfilling all criteria for professional stature Multiple levels of education for entry to practice Specialists in particular area of practice Failure to unite, lack of working collectively Nurses viewed as hired help Disparity in salary related to multiple levels of education

Summary and Significance to Practice
Professional nursing: Involves change, growth throughout various stages of career Moral, ethical practice needed to provide what is best for clients

Summary and Significance to Practice (cont’d)
Effective implementation of roles for professional nursing requires: Deep commitment, authentic caring Genuine compassion, technical competence Self-confidence, cognitive, clinical, communication skills Ability to work in, cope with non-stop change, highly complex systems, chaos

Ethical Foundations of Professional Nursing
4 Ethical Foundations of Professional Nursing

Learning Objective 4.1 Explain how nurses can help clients clarify their values to facilitate ethical decision making.

Challenges and Opportunities
Values Conflicts Nurses’ established values and beliefs may conflict with clients’ Ethical-Legal Conflicts “Right” thing to do versus what is legal

Values Highly personal Freely chosen
Enduring beliefs or attitudes about the worth of a Person Object Idea Action

Values Derived from Cultural, ethnic, religious background Societal traditions Peer group Family Form the basis for behavior, guide choices and decisions Moral Nonmoral

Values Exist within a person and affect the person’s relationship with others Awareness of one’s values is necessary to make ethical decisions

Values Transmission Learned through observation and experience
Family, community, cultural and society influences Values are acquired gradually

Values Transmission Professional values of the nurse are acquired during socialization into nursing from Nursing experience Teachers Peers

Values Transmission Nurses hold values that relate to competence and compassion Nurses need to be Value-neutral Nonjudgmental

Values Clarification Process by which individual values are identified, examined, and developed No one set of values is right for everyone Identified values can be retained or changed Act on free choice Fosters personal growth

Values Clarification “Valuing process” components include Cognitive
Affective Behavioral

Identifying Personal Values
Nurses need to understand their values about Life Health Illness Death Ability to identify personal values leads to better understanding of situations that may affect care

Helping Clients Identify Values
Help identify how values influence and relate to a particular health problem List alternatives Examine possible consequences of choices Choose freely Feel good about the choice Affirm the choice Act on the choice Act with a pattern

Explain the uses and limitations of professional codes of ethics.
Learning Objective 4.2 Explain the uses and limitations of professional codes of ethics.

Morals and Ethical Behavior
Morals are personal ethics guiding behavior and choice Ethics beliefs of a particular group Similar to ethics Individual’s personal standards of what is right and wrong in conduct, character, and attitude Ethics refers to the moral standards of a particular group

Learning Objective 4.3 Discuss how cognitive development, values, moral frameworks, and codes of ethics affect decision making.

Moral Development Process of learning what ought to be done and what ought not to be done Morality Moral behavior Moral development

Theories of Moral Development
Lawrence Kohlberg Theory focuses on structure of thought about moral issues Moral development progresses through three levels and six stages Not always linked to age or growth and development

Lawrence Kohlberg People progress to different level of moral development, ranging from Egocentric actions Concern for society

Kohlberg’s Levels and Stages Level I premoral or preconventional Stage 1: Punishment and obedience orientation Stage 2: Instrumental-relativist orientation Level II conventional Stage 3: Interpersonal concordance Stage 4: Law and order orientation Level III postconventional, autonomous or principled Stage 5: Social contract, legalistic orientation Stage 6: Universal-ethical principles

Defining Issues Test (DIT) Carol Gilligan Challenged Kohlberg’s theory in Its application to females Absence of concepts of caring, compassion, relationships, and responsibility

Gilligan’s care perspective is organized around Responsibility Compassion (care) Relationships

Justice or fairness based on idea of equality Typically followed by men Ethic of care Typically followed by women Gilligan’s stages Stage 1: Caring for oneself Stage 2: Caring for others Stage 3: Caring for oneself and others

Moral and Ethical Theories or Frameworks
Two classifications of theories of ethics Consequential: Teleology Nonconsequential: Deontology Virtue ethics Caring

Moral and Ethical Principles
Ethical principles that help guide decision making Autonomy Respect for person Nonmaleficence Beneficence Justice Fidelity Veracity

Learning Objective 4.4 Discuss common bioethical issues currently facing healthcare professionals.

Ethics in Nursing Ethics Bioethics
Is a study of morality and an activity Refers to practices, beliefs, and standards of behavior Bioethics Applies to life sciences and healthcare in an in disciplinary settings

Ethics in Nursing Nurses are accountable for their ethical conduct
Scopes and Standards of Practice

Learning Objective 4.5 Analyze ways in which nurses can enhance their ethical decision making abilities.

Nursing Codes of Ethics
Formal statement of a group’s ideal and values Higher than legal standards Established by the International Council of Nurses First adopted in 1953, revised 1973

Nursing Codes of Ethics
ANA adopted Code of Ethics in 1950, revised 2001 Code of Ethics for Nurses with Interpretive Statements

ANA Nursing Code of Ethics
Purpose Succinct statement of ethical obligations and duties Nonnegotiable ethical standard Expression of nursing’s commitment to society

Canadian and Australian Nurses Code of Ethics
Purposes Inform the public of minimum standards Professional commitment Outline ethical considerations Guidelines for professional behavior Guide for self-regulation Responsibility when assuming care for clients

Types of Ethical Problems
Decision-focused What should I do? Action-focused Moral distress. What can I do?

Making Ethical Decisions
Catalano’s five step ethical decision-making algorithm for the nurse Identification of potential ethical dilemma Collect, analyze, and interpret data State the dilemma Can be resolved Cannot be resolved

Identify the moral principles involved in ethical decision making.
Learning Objective 4.6 Identify the moral principles involved in ethical decision making.

Questions to ask For whom is the decision being made? Who should be involved in making the decision, and why? What criteria should be used in determining who makes the decision? What degree of consent is needed by the subject?

When compromise is necessary, the desirable outcome is preservation of each person’s integrity

Strategies to Enhance Ethical Decision Making
Become aware of one’s own values and ethical aspects of nursing situations. Be familiar with nursing code of ethics. Understand the values of other health care professionals.

Strategies to Enhance Ethical Decision Making
Participate on ethics committees. Participate in or establish a nursing ethics group. Participate in or establish educational ethics rounds.

Describe the advocacy role of the nurse.
Learning Objective 4.7 Describe the advocacy role of the nurse.

Advocacy Advocacy = providing support for a patient’s rights/best interests Three models of nurse advocacy Rights protection Values-based Respect-for-persons

Advocacy To be an advocate a nurse needs
Self-knowledge Professional knowledge Advocacy encompasses range of approaches Legal Self Collective Citizen

Advocacy Defining attributes of patient advocacy include
A therapeutic nurse-patient relationship in which to secure patient’s freedom and self-determination Promoting and protecting patients’ rights to be involved in decision making and informed consent Acting as an intermediary between patients and their families or significant others, and between them and health care providers

Advocacy An advocate support clients decisions can involve Action
Nonaction

Advocacy Underlying client advocacy are clients individual rights
To select values deemed necessary to save own life To decide which course of action will best achieve the chosen values To dispose of values in a way they choose without coercion by others

Advocacy To be a client advocate involves Being assertive
Recognizing that the rights and values of their clients and families must take precedence when they conflict with those of health care providers Ensuring that clients and families are adequately informed to make decisions about their own health and healthcare

Advocacy To be a client advocate involves
Being aware that personal conflicts may arise over issues that require consultation, confrontation, or negotiation between the nurses and administrative personnel or between the nurse and physician Working with unfamiliar community agencies or lay practitioners Political action

Legal Foundations of Professional Nursing
5 Legal Foundations of Professional Nursing

Identify primary sources of law and
Learning Objective 5.1 Identify primary sources of law and types of legal actions.

Scientific development and new technological advances Critical care units – Surgical technologies Genetic engineering and the identification of disease-carrying genes

Changes in the health care system Providing new roles for nursing Advanced practice nurse (APN) Expanded roles = added responsibilities

The Judicial System Four primary sources of law Constitutions Statutes
Administrative laws Decisions of court (common law)

Types of Legal Actions Civil (private) Criminal Between individuals
Disputes between an individual and society

Learning Objective 5.2 Describe the nurse practice act as
the legal boundary of nursing.

Safeguarding the Public
Permissive laws, first laws applicable to nursing in the United States No restrictions on nursing practice 1923 all states had nurse registration laws

Safeguarding the Public
State authority responsible for nursing practice within the state is the state board of nursing National Council of State Boards of Nursing (NCSBN)

Nurse Practice Acts Guides for states in developing their nurse practice acts State board of nursing is the governing body for regulation State boards of nursing and state nurses association collaborate with nurse practice acts

Nurse Practice Acts Nurse Practice acts include
Authority of board of nursing Scope of Practice Licenses and titles Requirements for licensure Protects titles Identifies grounds for disciplinary action

Credentialing Determines and maintains competence

Licensure Process by which state government agency grants permission to an individual to engage in a given profession who has proven competency Types of licensure Mandatory Permissive

Licensure Licenses may be revoked for just cause
Nurse may appeal decision One state licensure vs. practices across state lines Nurse Licensure Compact Model Legislation provides information Advanced practice Many states require different license

Controversy Regarding Licensure
ANA’s position licensing is function of professional association, not the law Registration Listing an individual’s name and other information on an official roster Certification Validation that a nurse has met minimum standards of competence

Accreditation Accredited status given by an organization to institutions, programs, or services that meet predetermined standards and criteria Standards of care Used to evaluate quality of care Derived from multiple sources Developed from ANA standards of nursing practice

Entry to practice BSN AND Hospital Diploma

Potential Liability Areas
Negligence Conduct lacking due care Malpractice Professional misconduct or the failure to meet the requisite standard of care May be intentional or unintentional Five elements of proof of nursing malpractice

Potential Liability Areas
Nursing negligent actions may occur with Medication errors Burning a client Client falls Failure to assess and take appropriate action

Strategies to Reduce Medical Errors
Increase staff Experienced nurses Reduce interruptions and distractions Improve information exchange Nurses obtain their own liability insurance coverage Available through the ANA or private companies

Documentation Medical record is legal source of information about patient Credible document must be Comtemporaneous Accurate Truthful Appropriate

Delegation Process of a nurse to direct another person to perform nursing task Nurse is accountable and responsible for the care given his or her clients NCSBN developed Decision Tree for Delegation

AACN five factors affecting delegation Potential for harm Complexity of task Problem solving and necessary innovations Unpredictability of outcome Level of interaction with client required

Learning Objective 5.3 Discuss essential legal aspects of malpractice, informed consent, adverse event reports, DNR orders, euthanasia, and death-related issues.

Restraints Limit activity of client Chemical Physical
Only used with physician’s written order

Informed Consent An agreement when client accepts treatment/procedure
Nurse’s role Witness exchange between client and physician Establish that client understands Witness client signature

Informed Consent Three major elements of informed consent
Voluntarily given Client must be competent to understand Client receives adequate information to be ultimate decision maker

Informed Consent Three groups who cannot provide consent
Minors Unconscious or injured Mentally ill or incompetent Adverse events and risk management Record of an adverse or unusual occurance

Adverse Events and Risk Management
Adverse event or incident report should make all facts known Adverse event reports are not part of client’s medical record, but should be noted

Adverse Events and Risk Management
Risk-management department Reviews all adverse event reports Identifies risks Controls occurrences Prevents damage Controls legal liability Determines need for further investigation

WILLS A declaration by a person about how the person’s property is to be disposed after death A valid will must Be made by person of sound mind Not be unduly influenced by anyone else Nurse may act as witness Do-not-resuscitate orders (DNR) “no-code”

ANA Recommendations Client’s values and choices highest priority
Advanced directive or surrogate makes decisions for incompetent client DNR discussed with client, family, and designated decision maker Clear documentation

ANA Recommendations Separate from other aspects of a client’s care
Request change in assignment if conflicts with nurse’s beliefs Advance healthcare directive Statement made before receiving healthcare specifying the client’s wishes

ANA Recommendations Three types Living will
Durable power of attorney for healthcare Medical or physician directive

ANA Recommendations Questions to ask on admission
Does the client have basic information on advanced healthcare directives? Does the client wish to initiate an advance healthcare directive? Did the client bring one that was prepared in advance? Has the client discussed end-of-life-choices?

Euthanasia The act of painlessly putting to death persons suffering
Legally wrong in Canada and the United States Voluntary euthanasia/assisted suicide Dying individual desires control over time and manner of death

Death and Related Issues
Legal issues surrounding death Death certificate Labeling of deceased Autopsy Organ donation Inquest into the cause or manner of a death

Learning Objective 5.4 Examine the nurse’s role in identifying
and assisting the impaired nurse.

The Impaired Nurse One whose practice is deteriorated because of substance abuse Three victims of the impaired nurse Client Colleagues Impaired nurse

The Impaired Nurse Actions to take when a nurse suspects an impaired colleague Do not let them care for clients Report unsafe practices Document suspicious behaviors or incidents Confront individual with another person Respect nurse’s right to confidentiality and privacy Avoid being judgmental

Examine the problem of sexual harassment in nursing.
Learning Objective 5.5 Examine the problem of sexual harassment in nursing.

Sexual Harassment Unwelcome sexual advances of any kind occurring
As a condition of employment As the basis for employment decisions At a work place where work is interfered or creates an intimidating, hostile, or offensive working environment

Nurses as Witnesses Called to testify as a defendant in a malpractice or negligence action Provide testimony about care provided to the plaintiff Provide testimony as an expert witness

Learning Objective 5.6 Consider how the collective bargaining process is used to improve nursing practice.

Collective Bargaining
Formalized decision making process between management and labor to negotiate Wages Conditions of employment Work hours Work environment Fringe benefits of employment

Written contract Controversial among nurses Necessary to obtain control of nursing practice and economic security Moral dilemma in the event of a strike Process includes recognition of a certified bargaining agent

Collective bargaining agent Union Trade association Professional organization United American Nurses Largest labor union for registered nurses in the United States Established in 1999 by ANA

Grievances Any dispute, difference, controversy, or disagreement arising out of the terms and conditions of employment Four main categories Contract violations Violations of federal and state law Management responsibilities Violation of agency rules

Theoretical Foundations of Professional Nursing
6 Theoretical Foundations of Professional Nursing

Describe the nature of knowledge development.
Learning Objective 6.1 Describe the nature of knowledge development.

Traditional gap between academia and practice Nursing theory considered ethereal and unrelated to the “real world” of nursing by practicing nurses One theory or many Multiple and diverse approaches Allows application to what is the “best fit” Does this best serve the profession?

Worldviews and Knowledge Development
Theory A system of ideas proposed to explain something Provide knowledge to improve practice Guides practice, education, and research Provides professional autonomy Study helps develop analytical skills

Nursing theory Not formally integrated at an everyday level Not part of nursing education when first developed 1950s’ practice based on principles and traditions

Florence Nightingale first proposed nursing knowledge as different and distinct from medical knowledge

Different theories represent different worldviews Individuals who think and see the world in different ways create them Provide contrasting paradigms Provide different traditions and approaches to science and knowledge development

One paradigm: Positivist approach Nineteenth-century Age of Enlightenment Natural law Linear Cause and effect using experimental research methods General to specific

Second paradigm: Constructivist Science is embedded in time because truth is dynamic Reality not fixed Truth is found in one’s experiences Research uses naturalistic settings and observational methods

Categories of theories Philosophy Nature of things, aims to provide broad understanding Nursing conceptual models Form interrelationships among concepts and definitions to provide organized perspective

Categories of theories Grand theory General, broad, and complex Middle-range theory Narrower focus, refined through series of studies See Table 6−1

Learning Objective 6.2 Differentiate among the terms concept, conceptual framework, conceptual model, theory, construct, proposition, and hypothesis.

Defining Terms Concepts Concepts may be Building blocks of theory
Abstract ideas or mental images Concepts may be Readily observable or concrete Indirectly observable or inferential Nonobservable or abstract

Defining Terms Four concepts of the metaparadigm of nursing
Person or client Environment Health Nursing

Theory Development in Nursing
Theory and conceptual framework differ in levels of abstraction Conceptual framework more abstract Provides overall view to focus thoughts Umbrella under which concepts exist Conceptual model/conceptual framework A graphic illustration of a conceptual framework

Supposition or system of ideas to explain a given phenomenon Relates concepts by using definitions that state significant relationships between concepts Knowledge development Deductive or inductive approach

Theory testing Deductive approach Compares outcomes with relationship predicted by hypothesis drawn from theory and linked to concept Theory generation Inductive approach use

Five kinds of knowledge Revealed Intuitive Rational Empirical Authoritative

Ways of knowing framework Empirical Esthetic Personal Ethical

Analyze the development of theory in nursing.
Learning Objective 6.3 Analyze the development of theory in nursing.

Nursing Theory Development
Source of discussion and debate regarding uniqueness Borrowed or shared Result in diversity of theories

Compare the theoretical approach of selected nurse theorists.
Learning Objective 6.4 Compare the theoretical approach of selected nurse theorists.

Nightingale’s Environmental Theory
Florence Nightingale, first nurse theorist

Nightingale’s Environmental Theory
Five environmental factors Pure or fresh air Pure water Efficient drainage Cleanliness Light, especially direct sunlight Deficiencies in these factors result in poor health

Peplau’s Interpersonal Relations Model
Hildegard Peplau was a psychiatric nurse Based on psychoanalytic theory, principles of social learning, concepts of human motivation and personality development

Henderson’s Definition of Nursing
Virginia Henderson, known for Textbook of the Principles and Practices of Nursing Formulated a definition of the unique function of nursing Basic to definition are assumptions about the individual

Maintain physiological and emotional balance Assistance to achieve health and independence or a peaceful death Necessary strength, will, or knowledge to achieve or maintain health

Maintain physiological and emotional balance Nurses focus to help individuals and families in Breathing Eating and drinking adequately Eliminating body wastes Moving and maintaining a desirable position Sleeping and resting

Maintain physiological and emotional balance Nurses focus to help individuals and families in Selecting suitable clothing Maintaining body temperature within normal range by adjusting clothing and modifying the environment Keeping the body clean and well groomed to protect the integument

Maintain physiological and emotional balance Nurses focus to help individuals and families in Avoiding dangers in the environment and avoiding injuring others Communicating with others in expressing emotions, needs, fears, or opinions

Maintain physiological and emotional balance Nurses focus to help individuals and families in Worshipping according to one’s faith Working in such a way that one feels a sense of accomplishment Playing or participating in various forms of recreation

Maintain physiological and emotional balance Nurses focus to help individuals and families in Learning, discovering, or satisfying the curiosity that leads to normal development and health, and using available heath facilities

Rogers’ Science of Unitary Human Beings
Martha Rogers theory presented in 1970 Views person as a irreducible whole The whole is greater than the sum of its parts Humans are dynamic energy fields in continuous exchange with environmental fields Behaves as a totality

Rogers’ Science of Unitary Human Beings
Rogers’ theory applied to nursing practice Focus on the person’s wholeness Seek to promote symphonic interaction between the two energy fields to strengthen the coherence and integrity of the person Coordinate the human field with rhythmicities of the environmental field Direct and redirect patterns of interactions between the two energy fields to promote maximum health potential

Orem’s Self-Care Deficit Theory of Nursing
Dorothea Orem’s theory published in 1971 Referred to as the self-care deficit theory of nursing Based on theories of self-care, self-care deficit, and nursing systems

Self-care theory based on four concepts Self-care Self-care agency Self-care agent Dependent-care agent Self-care requisites Universal requisites Developmental requisites Health deviation requisites Therapeutic self-care demand

Self-care deficit theory, five methods of helping Acting or doing for Guiding Teaching Supporting Providing an environment promoting individual’s abilities to meet current and future demands

Three types of nursing systems Wholly compensatory Partly compensatory Supportive-educative

King’s Goal-Attainment Theory
Imogene King’s theory based on mutual goal setting of the nurse and patient Three dynamic interacting systems Personal Interpersonal Social

Transactions are purposeful interactions that lead to goal attainment, characteristics are Social exchange, bargaining, and negotiating Perceptual accuracy in nurse-client interaction Goal attainment

King’s seven hypotheses in goal-attainment theory Perceptual congruence Communication increases mutual goal setting Satisfaction in nurses and clients increases goal attainment Goal attainment decreases stress and anxiety Goal attainment increases learning and coping

King’s seven hypotheses in goal-attainment theory Role conflict decreases transactions Congruence in role expectations and performance increases transactions

Neuman Systems Model Betty Neuman based on Gestalt theory and others
Focus on the wellness of the client in relation to environmental stressors and reactions to stressors

Neuman Systems Model Five client system variables Physiological
Psychological Sociocultural Developmental Spiritual

Neuman Systems Model Client is a basic structure with central core of energy surrounded by two lines of resistance Inner or normal line of defense Flexible line of defense

Neuman Systems Model Stressor is any environmental force that alters the system’s stability Internal stressors Interpersonal; stressors Extrapersonal stressors Created stressors

Neuman Systems Model Adapting to stressor is known as reconstitution
Nursing interventions focus on three preventive levels Primary prevention Secondary prevention Tertiary prevention

Roy’s Adaptation Model
Callista Roy’s theory is based on Harry Helson’s work in psychophysics Focuses on individuals as a biopsychosocial adaptive system Employs a feedback cycle Input Throughput Output

Roy’s Adaptation Model
Adaptive responses contribute to health Each person’s adaptive level is unique and constantly changes Classes of stimuli Focal stimuli Contextual stimuli Residual stimuli

Benner’s Novice to Expert
Patrica Benner’s thinking was influenced by Virginia Henderson and Herbert Dreyfus Adapted Dreyfus and Dreyfus model of skill acquisition and skill development to clinical practice nursing

Five levels Novice Advanced beginner Competent Proficient Expert

As one moves through the levels, four aspects of performance change Movement toward abstraction Shift from analytical to intuition Viewing the situation from relevant bits to complex whole Detached observer to fully engaged in the situation

The Caring Theories Provide a link between generic caring and the uniqueness of nursing Caring is a central concept to the practice of professional nursing

The Caring Theories Core value encompassing Altruism Autonomy
Human dignity Integrity Social justice

The Caring Theories The caring theorists, see Table 6−2 Jean Watson
Madeleine Leininger Roach, Boykin, and Schoenhofer

Watson’s Human Caring Theory
Jean Watson believes that caring is central to nursing Two major assumptions Care and love constitute the primal and universal psychic energy Care and love are requisite for our survival and the nourishment of humanity

Watson’s Human Caring Theory
Major elements Carative factors Transpersonal caring relationship Caring moment/caring occasion

Leininger’s Culture Care Diversity and Universality Theory
Madeleine Leininger’s Sunrise Model depicts her theory Caring and culture are inextricably linked

Leininger’s Culture Care Diversity and Universality Theory
Transcultural nursing focuses on comparative study and analysis of different cultures and subcultures Goal of transcultural nursing is to develop a scientific body of knowledge to provide culture-specific and culture-universal nursing practices Focuses on diversity and universality

Kolcaba’s Theory of Comfort
Comfort is the immediate and holistic experience of being strengthened through having the needs met for three types of comfort Relief Ease Transcendence

Kolcaba’s Theory of Comfort
Four contexts of experience Physical Psycho-spiritual Social Environmental With this theory nurses identify unmet comfort needs of clients

Mishel’s Uncertainty in Illness Theory
Theory developed from information processing model used by psychology Uncertainty is the inability to determine meaning of illness-related events when decision maker can’t assign value to objects or events.

Assumption of this theory are Uncertainty is a cognitive state Uncertainty is neutral until interpreted as desirable or aversive Adaptation is the desired outcome The relationships among illness moves from uncertainty to adaptation

Assumption of this theory are People function in far-from-equilibrium states Major fluctuations in far-from-equilibrium enhance receptivity to change Fluctuations result in repatterning

One Model Versus Several Models
Advantages to a single, universal model Further development of the profession Common framework Promotes understanding about nurse’s role in nontraditional settings

One Model Versus Several Models
Advantages to a single, universal model Other disciplines have several models, which allows exploration of phenomena in different ways and viewpoints Increase an understanding of the nature and scope of nursing Fosters full scope and potential of discipline

Identify the relationship between nursing process and nursing theory.
Learning Objective 6.5 Identify the relationship between nursing process and nursing theory.

Relationship to Theories to the Nursing Process and Research
Assessing Diagnosing Planning Implementing Evaluating

Socialization to Professional Nursing Roles

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