The Nursing Profession E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: Public Health/Robert Wood Johnson Foundation
• Sprache: Englisch

Seitenzahl: 881

Veröffentlichungsjahr: 2011

Beschreibung

The Nursing Profession: Development, Challenges, and Opportunities is designed to be a resource for those who are interested in or touched by nursing. This book is designed in part to complement the report by the Institute of Medicine on the future of nursing. Readers—whether researchers or practitioners, foundation or government officials, students, or simply lay people interested in nursing—should use this volume to gain a better understanding of the nursing profession and the issues with which those in the field and related fields are grappling. Major topics include:

• The history of nursing
• The nursing profession
• Current issues and challenges, including the nursing shortage, educating and training nurses, utilizing advanced practice nurses to their fullest, quality and cost, long-term care, community-based care, gender and power, and new areas for nursing
• A vision for the future

The book begins with a comprehensive review of the nursing field by Diana Mason, the Rudin Professor of Nursing at the Hunter-Bellevue School of Nursing, City University of New York, and former Editor-in-Chief of the American Journal of Nursing. Mason’s chapter is followed by reprints of twenty-five of the most influential or significant articles on nursing—some of them classic pieces dating back to Florence Nightingale, others presenting more current thinking on critical issues. This kind of source material is rarely found in one place.

Leseprobe

CONTENTS

Foreword

Preface

Editors’ Introduction

Acknowledgments

Review of the Nursing Field

The Nursing Profession: Development, Challenges, and Opportunities

A Brief History of Nursing

The Nursing Profession

Current Issues and Challenges

Opportunities: A Vision For The Future

The History of Nursing and the Role of Nurses

Chapter 1: Notes On Nursing: What It Is, And What It Is Not

Chapter 2: The Nature of Nursing

Development of A Concept

Unique Function

Nursing Practice

Nursing Research

Nursing Education

Summary

Chapter 3: A Caring Dilemma: Womanhood and Nursing in Historical Perspective

The Meaning of Caring

Caring As Duty

The Professed Nurse

The Hospital Nurse

The Influence of Nightingale

The Contradictions of Reform

A Different Vision

Beyond The Obligation To Care

Altruism With Autonomy

Chapter 4: Nursing as Metaphor

Chapter 5: Stages of Nursing’s Political Development: Where We’ve Been and Where We Ought to Go

Stage 1

Stage 2

Stage 3

Stage 4

In Pursuit of Stage 4

Conclusion

Acknowledgments

Chapter 6: Knowledge Development in Nursing: Our HistoricAL Roots and Future Opportunities

The Early Years

The Transition Years

Nursing Research Becomes Nursing Science

Future Opportunities

Acknowledgments

Nursing Education and Training

Chapter 7: The Goldmark Report

The Nurse in Public Health

Hospital Training School

Chapter 8: Career Pathways in Nursing: Entry Points and Academic Progression

Traditional Entry Points into Nursing

Emerging Entry Points

Moving Along The Education Continuum

Conclusion

Chapter 9: Nursing the Great Society: The Impact of the Nurse Training Act of 1964

Influences Inside Nursing

Influences Outside Nursing

Public and Private Activism

How A Private Agenda Became Public Policy

The Political Climate Chills

Growth On Two Levels

Nursing’s Aspirations

Afterword

Acknowledgments

Advanced Practice Nursing

Chapter 10: Role and Quality of Nurse Practitioner Practice: A Policy Issue

Chapter 11: Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: A Randomized Trial

Methods

Results

Comment

Acknowledgment

Chapter 12: Nurse-Midwives and Nurse Anesthetists: The Cutting Edge in Specialist Practice

Brief History

Nurses Or Something Else

Complement Or Substitute?

Money

Conclusions

Acknowledgments

Chapter 13: Lessons Learned from Testing the Quality Cost Model of Advanced Practice Nursing (APN) Transitional Care

The Quality Cost Model of APN Transitional Care

What Has Been Learned

Questions Remaining To Be Answered

Chapter 14: Reaching Consensus on a Regulatory Model: What Does This Mean for APRNs?

How Did This Historic Agreement Come About?

What is The New Aprn Regulatory Model?

What Does This Mean To Currently Licensed APRNS?

How Will The Model Impact NP Education, Certification, and Licensure?

Implementation of The Model

How Will A Uniform Regulatory Model Impact APRNS?

The Nursing Workforce/Nursing Shortages

Chapter 15: Implications of an Aging Registered Nurse Workforce

Methods

Results

Comment

Acknowledgments

Chapter 16: Global Nurse Migration

Migration and The Global Healthcare Workforce

Policy Implications For The U.S. Nursing Workforce

Summary

Quality, Safety, and Cost

Chapter 17: Nurse-Staffing Levels and the Quality of Care in Hospitals

Methods

Risk Adjustment and Characteristics of The Hospitals

Results

Discussion

Acknowledgments

Chapter 18: Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction

Methods

Results

Comment

Acknowledgments

Chapter 19: Nurse Staffing in Hospitals: Is There a Business Case for Quality?

Study Data and Methods

Acknowledgments

Specialty Practice in Nursing

Chapter 20: Long-Term Care Policy Issues

Poor Quality of Care and Weak Regulatory Enforcement

Inadequate Nursing Home Staffing Levels

Nursing Facility Reimbursement Reform

Corporate Ownership Transparency

Home and Community-Based Services

Public Financing of Long-Term Care

Summary

Chapter 21: The Future of Home Care

The Legacy of Home Care

Medicare: Home Care’s Second Coming

Reining in A Benefit Out of Control

Home Care’s Future

Chapter 22: Follow the Money: Funding Streams and Public Health Nursing

The Perspective of Public Health

Changes Over Time

Financing Public Health

The Impact on Nursing

Health Reform and Managed Care

What About Nursing?

Chapter 23: Swamp Nurse

Chapter 24: Role of the School Nurse in Providing School Health Services

School Nurse Definition

Background

School Nurse Role

School Nurse Activities

School Health Services Team

Professional Preparation For School Nurses

Conclusion

Recommendations

Afterword

The Editors

Cover Photo: The Evolving Face of Nursing

Mural by Meg Seligman

Photo by Steven Weinik

For years, the most popular mural in Philadelphia, the “city of murals,” was the nursing mural (“A Tribute to Nursing”) on the side of a building at Broad and Vine Streets. That mural focused on the history of nursing rather than its future. When the wall became compromised, the city enlisted the support of the Independence Foundation and others to commission a new nursing mural by internationally known muralist Meg Seligman. After interviewing many nurses who spoke about the various dimensions of their current work and opportunities for innovations in health care, Seligman designed a mural that focused on contemporary nursing with links to its past and future. Titled “The Evolving Face of Nursing,” the 6,500 square foot mural incorporates the faces of nurses and key images that convey the intellectual, creative, and emotional work of nursing through images and symbols. This dynamic mural changes color and emphasis at night through the use of LED lighting—a feature that Seligman used for the first time in this mural. The mural was unveiled on October 6, 2010. The cover photograph by Philadelphia-based photographer, Steven Weinik, shows its location within the community, symbolizing the work of diverse nurses with individuals, families, and communities.

Copyright © 2011 by the Robert Wood Johnson Foundation, Route One and College Road East, Princeton, New Jersey 08543. All rights reserved.

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With the exception of the chapter by Diana Mason, no part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax [phone], or on the Web at www.copyright.com. Requests to the publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, 201-748-6011, fax [phone], or online at www.wiley.com/go/permissions.

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Library of Congress Cataloging-in-Publication Data

The nursing profession : development, challenges, and opportunities / editors, Diana J. Mason, Stephen L. Isaacs, David C. Colby; foreword by Risa Lavizzo-Mourey. — 1st ed.

p.; cm. — (Robert Wood Johnson foundation health policy series) Complements: The future of nursing / Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institue of Medicine. c2011.

Includes bibliographical references.

ISBN 978-1-118-02881-0 (pbk.); 978-1-118-12220-4 (e-bk.); 978-1-118-12221-1 (e-bk.); 978-1-118-12222-8 (e-bk.)

1. Nursing—Practice—United States. 2. Nursing—United States. 3. Leadership—United States.

I. Mason, Diana J., 1948- II. Isaacs, Stephen L. III. Colby, David C. IV. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. Future of nursing. V. Series: Robert Wood Johnson Foundation series on health policy.

[DNLM: 1. Nursing—trends—United States—Collected Works. 2. Nurse’s Role—United States—Collected Works. WY 16 AA1]

RT82.N8684 2011

610.73—dc22

2011006933

We dedicate this book to the memory of C. Patrick Crow, who died shortly after editing its lead chapter. Over the course of the past fifteen years, Pat edited both the Robert Wood Johnson Foundation Anthology and its Series on Health Policy. He was an extraordinary editor and, even more important, an exemplary human being. We shall miss him.

SLI, DCC, DJM

FOREWORD

Like the other four books in the Robert Wood Johnson Foundation Health Policy Series,1The Nursing Profession: Development, Challenges, and Opportunities focuses on a discipline or profession that has been a Foundation priority for many years. Strengthening the nursing profession has been of central importance to the Robert Wood Johnson Foundation over its nearly forty-year existence, and we have devoted more than $200 million to the growth and improvement of nursing education and practice. Our dedication to nursing continues the legacy of our founder. In his personal philanthropy and as the head of his own New Brunswick-based foundation, Robert Wood Johnson was genuinely interested in improving nursing, and gave generously to amplify the role of nurses in improving health. The foundation that bears his name has sustained that commitment.

As far back as 1973, the Foundation awarded a series of grants to develop an emerging field—nurse practitioners—an idea that was, at the time, untested and controversial. These grants demonstrated that nurse practitioners could provide high-quality primary care services in remote rural areas and underserved inner cities. Since that time, the Robert Wood Johnson Foundation has invested in:

Strengthening nursing school faculty and leadershipAddressing nursing shortagesImproving the nursing workforceConducting research on nursingDeveloping public health nursingEstablishing nurse-run school health centersImproving hospital nursing

And this is only a partial list.

The Nursing Profession: Development, Challenges, and Opportunities begins with a comprehensive review of the nursing field by Diana Mason, the Rudin Professor of Nursing at the Hunter-Bellevue School of Nursing, City University of New York, and former editor-in-chief of the American Journal of Nursing. Mason’s chapter is followed by reprints of twenty-four of the most influential or significant articles on nursing—some of them classic pieces dating back to Florence Nightingale, others presenting more current thinking on critical issues. This source material is rarely found in one place.

The Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine (IOM) issued its report in October 2010. It sets forth a blueprint for nursing that can guide policymakers and those in the health care professions. We hope that The Nursing Profession: Development, Challenges, and Opportunities will be a worthy companion to the IOM report. Both publications illustrate our dedication to improving a field that is so critical to the nation’s health and are especially timely, because “a reformed health care system must include an adequate supply of well-trained professionals who can deliver care to all Americans. Nurses are at the center of this discussion.”2 I am pleased and proud that the Robert Wood Johnson Foundation has played an important role in nursing’s development and will continue to do so in the future.

Risa Lavizzo-Mourey, MD, MBA

President and CEO

The Robert Wood Johnson Foundation

Princeton, New Jersey

May 2011

NOTES

1. Isaacs, S. L., & Knickman, J. R., (Eds). Generalist medicine and the U.S. health system. San Francisco: Jossey-Bass, 2004; Lear, J. G., Isaacs, S. L., & Knickman, J. R. (Eds). School health services and programs. San Francisco: Jossey-Bass, 2006; Warner, K. E., Isaacs, S. L., & Knickman, J. R. Tobacco control policy. San Francisco: Jossey-Bass, 2008; Meier, D. E., Isaacs, S. L., & Hughes, R. G., (Eds). Palliative care: Transforming the care of serious illness. San Francisco: Jossey-Bass, 2010.

2. Rother, J., & Lavizzo-Mourey, R. Addressing the nursing shortage: A critical element in health reform. Health Affairs 28, w260–w264 (2009).

PREFACE

SUSAN B. HASSMILLER

Susan B. Hassmiller, PhD, RN, FAAN, serves as the Robert Wood Johnson Foundation Special Adviser on Nursing and Director of the Initiative on the Future of Nursing.

May we hope that, when we are all dead and gone, leaders will arise who have been personally experienced in the hard, practical work, the difficulties, and the joys of organizing nursing reforms, and who will lead far beyond anything we have done!

—Florence Nightingale

The Robert Wood Johnson Foundation and Institute of Medicine (IOM) became partners in 2008 to develop the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the IOM. A core product of the Initiative was an IOM report called The Future of Nursing: Leading Change, Advancing Health, which was issued in October 2010.1 The report examined the capacity of the nursing workforce to meet the demands of a newly reformed health care system, keeping in mind the needs of an aging population and the emphasis on care in the community. It made a series of recommendations that address a range of public policy and system changes, including vital roles for nurses in designing and implementing a more effective and efficient health care system. The committee’s ultimate goal was to improve patient care and health care outcomes.

The Robert Wood Johnson Foundation has continued the Future of Nursing Initiative by partnering with AARP to facilitate a national campaign to encourage the adoption of the recommendations, and as stakeholders in the nursing and policy communities feel the need, come up with additional recommendations or priority areas on which to work. We will continue to raise the notion of the value to society of investing in a strong, well-educated, and empowered nursing workforce. Partners in this campaign include leaders from government, business, policy, academia, medicine, and of course, nursing. A National Summit on Advancing Health through Nursing was held in Washington, DC, at the end of November 2010, to mark the official start of the campaign.

The IOM committee working on the report was heavily influenced by the best thinking of those who study and practice nursing, including authors of the articles reprinted in The Nursing Profession: Development, Challenges, and Opportunities. I can think of no better place for those who are interested in or touched by nursing to gain an understanding of the history of the current issues facing the nursing profession than this anthology. It is my sincere hope that readers of this book will be inspired by the authors—both past and present—who influenced the field.

Together, The Future of Nursing: Leading Change, Advancing Health report and The Nursing Profession: Development, Challenges, and Opportunities lay the groundwork for understanding where the field has been, where it stands currently, and where it needs to go in the future in order to address the issues facing nursing and improve the health of all Americans.

NOTE

1.http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx

EDITORS’ INTRODUCTION

DIANA J. MASON, STEPHEN L. ISAACS, AND DAVID C. COLBY

This book is designed to be a resource for those who are interested in or touched by nursing. We have tried to capture the field in a single volume and to share the best thinking of those who study and practice it. Readers—whether researchers or practitioners, foundation or government officials, students, or simply laypeople interested in nursing—should use this volume to gain a better understanding of the nursing profession and the issues with which those in the field and related fields are grappling.

An initial challenge for the editors was determining how to present the wealth of information in an engaging, readable way—one that would satisfy both those deeply knowledgeable in the field as well as those less familiar with nursing. This challenge was relatively easy to overcome because The Nursing Profession: Development, Challenges, and Opportunities is the fifth volume in a series whose format, according to the reviews, appears to be working. We adopted that format, one that consists of a comprehensive review article, followed by reprints of the twenty-four or so most influential or important articles in the field.

Finding a knowledgeable, highly respected expert on nursing—one who is a good writer to boot—to do a comprehensive review of the field presented a second challenge. Fortunately, one of us—Diana Mason—met all of the requisites, and she has written the lead chapter, which covers the field in its entirety (with the exception of the specifics of clinical nursing). Among the topics that Dr. Mason covers are:

The history of nursingThe nursing professionCurrent issues and challenges, including the nursing shortage, educating and training nurses, utilizing advanced practice nurses to their fullest, quality and cost, long-term care, community-based care, gender and power, and new areas for nursingA vision for the future

The most daunting challenge, not surprisingly, turned out to be selecting the articles or book chapters for reprint. How to choose twenty-four that represent the most important or influential in a field with such an extensive, high-quality literature? As a first step, we asked more than thirty experts for their top picks. From their suggestions, plus those gleaned from our own experience and literature reviews, we compiled an initial list of roughly 200 articles or book chapters that were potential reprint candidates.

The three editors discussed each of the articles and winnowed the list gradually. We wanted to be sure to include pieces that were of historical importance (such as a selection from Florence Nightingale’s Notes on Nursing and the Goldmark Report), that influenced the field (such as Mary Mundinger’s article on nurse practitioners in the Journal of the American Medical Association and Linda Aiken’s article, also in JAMA, on hospital nursing), that captured basic aspects of the profession (such as Susan Reverby’s article on womanhood and nursing and Claire Fagin and Donna Diers’ short commentary, Nursing as Metaphor), and that synthesized issues in a clear and compelling manner (for example, the articles by Peter Buerhaus and colleagues on the nursing shortage and by Connie Mullinex and Dawn Bucholtz on nurse practitioners). We organized the reprints by topic, roughly following the major themes presented in Mason’s review chapter and tried, though with only partial success, to strike an equitable balance in the number of reprints within each category.

We realize that many worthy pieces are not included in the twenty-four that are reprinted in the book. It is likely that another team of editors would have come up with a somewhat different list of reprints. We believe, however, that the final list represents a fair sample of the most important and influential articles in the nursing field.

As Risa Lavizzo-Mourey observed in her foreword, this book is designed in part to complement the report by the Institute of Medicine on the future of nursing. In that regard, we are honored to have a preface by Susan Hassmiller, the executive director of the IOM’s Initiative on the Future of Nursing, and an afterword by Donna Shalala and Linda Burnes Bolton, the chair and vice chair of IOM committee that prepared the report.

With the passage of Patient Protection and Affordable Care Act in 2010 and its implications for the way health services are delivered, the condition of nursing in our nation will be more important than ever. The combination of the IOM report and this book will, we hope, promote greater understanding of the nursing field; educate the nursing, health care, student, and policy communities, as well as the interested public; and help inform a nursing agenda that will lead to improving the health and well-being of all Americans.

ACKNOWLEDGMENTS

We are particularly grateful to David Keepnews for his in-depth, detailed reviews of two drafts of the opening chapter to the book. He also recommended writings for us to consider, as did the following people: Patricia Archbold, Geraldine “Polly” Bednash, Patricia Benner, Amy Berman, Peter Buerhaus, Mary Chaffee, Sally Cohen, Donna Diers, Claire Fagin, Patty Franklin, Kristine Gebbie, Catherine Gilliss, Charlene Harrington, Susan Hassmiller, Maureen “Shawn” Kennedy, Christine Kovner, Ellen Kurtzman, Afaf Meleis, Mathy Mezey, Mary Naylor, Susan Reinhard, Marla Salmon, Ellen Sanders, Nancy Sharp, Julie Sochalski, Virginia Tilden, Marita Titler, Antonia Villarruel, Colleen Conway-Welch, and Patricia Yoder-Wise. The final decision on which articles to reprint was made solely by the editors, taking into consideration the guidance of these experts.

At the Robert Wood Johnson Foundation, we wish to acknowledge David Morse and Fred Mann for their wise counsel, Sarah Pickell for her research and editorial assistance, Mary Beth Kren for locating source materials, Rose Littman for facilitating communications among the editors, Hope Woodhead and Sherry DeMarchi for overseeing the book’s distribution, Mimi Turi for managing the budget and contract arrangements, and Risa Lavizzo-Mourey for her support and guidance.

We also recognize the work of Shirley Tiangsing in translating printed text of the reprints into an electronic format.

Elizabeth Dawson, research and editorial director at Health Policy Associates, did outstanding work in conducting research, overseeing the production process, proofreading, and resolving with great aplomb all of the problems that arose. We are very appreciative of her efforts.

DJM, SLI, DCC

REVIEW OF THE NURSING FIELD

An Original Article

Diana J. Mason, “The Nursing Profession: Development, Challenges, and Opportunities”

THE NURSING PROFESSION: DEVELOPMENT, CHALLENGES, AND OPPORTUNITIES

DIANA J. MASON

CHAPTER CONTENTS

A Brief History of Nursing The Beginnings of Modern NursingThe Professionalization of NursingWar and the Development of NursingModern Nursing: Education, Specialization, and CertificationThe Nursing Profession Defining NursingThe Nursing WorkforceNurses’ Employment: Where Nurses Work (and What They Do)Organized NursingNursing ResearchCurrent Issues and Challenges The Nursing ShortageBuilding an Educated Workforce to Meet Contemporary and Future NeedsFull Utilization of Advanced Practice Registered NursesQuality and Costs in Acute CareLong-Term CareCommunity-Based CareGender and PowerOpportunities: A Vision for the Future Innovative Models of CareEnsuring that the Nation Fully Utilizes Its Nursing Workforce

Nursing has a long and important legacy. Nurses have served as advocates for a better, safer, more humanistic health care system, and for public policies that promote the health of the nation throughout the profession’s history.

Lillian Wald in 1893 founded the Henry Street Settlement that provided home care to New York City’s poor immigrants on the Lower East Side of Manhattan when no other providers would serve them.1Margaret Sanger was a public health nurse whose fight for the reproductive rights of women from 1916, when she established the nation’s first birth control clinic, to her death in 1966 changed the nation’s policies on access to birth control information and services.2Ruth Watson Lubic, the first nurse to receive the John A. and Catherine D. MacArthur Foundation’s “Genius Award,” has spent the last half century as a leader in reframing childbearing as a “normal” life experience rather than a disease. She founded one of the first freestanding, nurse-midwife-run childbearing centers in the nation and spread her model to the South Bronx and Washington, D.C., where she has improved outcomes for mothers and babies.Connie Hill is a pediatric nurse manager on a respiratory unit at Chicago’s Children’s Hospital, where she refused to accept the notion that her urban community could not muster the resources to support long-term ventilator-dependent children and their families after hospital discharge. She formed a coalition of stakeholders to bring about the policy, system, and financial changes needed to accomplish this.3

The legacy of nurses such as these continues to be enriched by those who follow their example and refuse to be bound by others’ views of their profession or of women’s place in society and the health care system. Nurses are expert clinicians, researcher-scientists, policymakers, chief executive officers of hospitals and their own organizations, primary care providers, independent practitioners, deans of schools of nursing in research-intensive universities, heads of foundations, and leaders in every segment of society. Every day, nurses innovate to keep people alive, prevent pressure ulcers and infections, reduce pain and suffering, and ease the transition from life to death. They screen schoolchildren’s ability to see and hear, teach older adults and their family caregivers how to manage illnesses such as congestive heart failure, provide outreach to the homeless, counsel those with mental illness, and are otherwise present during some of the most intense, joyous, painful, difficult, and profound times of people’s lives.

Yet nurses face significant barriers to providing the care that people need, and they are often excluded from policymaking in workplaces, boardrooms, and government entities. Legal and regulatory barriers to the full utilization of nurses persist, limiting the nation’s ability to use its health care workforce efficiently and effectively. Other barriers are not specific to nurses but impede them from fully using their expertise. For example, nurses are skilled in managing chronic illness and coordinating care, but most payers do not cover these services.

Most policy discussions about nursing have focused on nursing shortage—a focus that overlooks the innovations and perspectives nurses can offer to improve both the way health care is delivered and the overall well-being of Americans. Certainly, the shortage is a complex problem of supply and demand. With the doubling of the nursing workforce over the past 25 years, it has become clear that the demand is outpacing the nation’s ability to educate and retain enough nurses. In fact, the demand part of the equation speaks to how valuable nurses are to the nation’s health care system. But there are two pitfalls that should be avoided in addressing the shortage. First, much of the focus has been on how to recruit more new nurses, with insufficient regard for how to retain and better utilize qualified nurses and decrease unnecessary demands on their time. Second, although nurses are part of most discussions about the health care workforce, they are often excluded from discussions of how to transform health care. Meeting these challenges requires an understanding of the complex realities of nursing and the important policy issues that confront the nation.

A BRIEF HISTORY OF NURSING

In her insightful discussion of the gradual professionalization of nursing during the nineteenth century and the first half of the twentieth, historian Susan Reverby describes the inherent tension between duties and rights that increased as nursing emerged from traditional “women’s work”:

Nursing was organized under the expectation that its practitioners would accept a duty to care rather than demand a right to determine how they would satisfy this duty. Nurses were expected to act out of an obligation to care, taking on caring more as an identity than as work, and expressing altruism without thought of autonomy either at the bedside or in their profession. Thus, nurses, like others who perform what is defined as “women’s work” in our society, have had to contend with what appears as a dichotomy between the duty to care for others and the right to control their own activities in the name of caring.4

These tensions between rights and duties continue to haunt nursing to this day.

The Beginnings of Modern Nursing

Prior to Florence Nightingale, daughters and wives were expected to care for infirm relatives. It wasn’t until the Crimean War (1853–1856) that Nightingale, regarded by many as the mother of modern nursing, performed the work that indelibly marked the profession and the development of health care delivery, leaving a legacy of data-driven, altruistic practice.

Nightingale violated prevailing tenets of the privileged class of England in the early 1800s to become a nurse. Her work at the British military hospital at Scutari, begun in November 1854, was groundbreaking. She collected data on the causes of death among the soldiers and demonstrated that a significant number were due to poor nutrition and unsanitary, toxic environmental conditions at the hospital. The changes she instigated in the hospital dramatically improved clinical outcomes.5,6

Her treatise, Notes on Nursing: What It Is and What It Is Not,7 defined nursing as creating the conditions for nature to take its course in healing a person—conditions such as a clean and nontoxic environment, fresh air, good nutrition, comfort, rest, and emotional support. While ostensibly deferring to the military surgeons at the hospital in keeping with gendered role expectations of the day, she used her connection with a reporter at the London Times to get front-page coverage of the problems at the hospital. The reports sparked public outrage, and she got the supplies, equipment, and support that she needed. Nightingale went on to transform the British, Indian, and military health services.

Nightingale also upgraded and formalized nursing education and the role of nurses. She transformed the image of the drunken, untrustworthy nurse immortalized as Sarah Gamp in Charles Dickens’s Martin Chuzzlewit, to that of an educated, ethical, caring “lady.” Indeed, Nightingale was referred to as “the lady with the lamp,” because of her habit of making rounds night and day, tending to ill soldiers, and overseeing her nursing staff with a comportment that challenged the Gamp stereotype of nurses. She established the Nightingale School of Nursing at what is now St. Thomas Hospital in England, and replaced physician oversight of nursing services with an independently funded women’s nursing organization. This work coincided with other experiments in modern nursing in Germany and France and became the model for educating nurses in Western countries.8,9

In the United States, the Civil War had demonstrated the need for trained nurses, although both men and women tended to wounded soldiers on both sides of the conflict. Walt Whitman was among these untrained nurses, as were Harriet Tubman and Sojourner Truth, two women born into slavery and committed to promoting freedom and human rights as conditions necessary for a healthy nation.10 After the war, urbanization disrupted family relationships and gender roles, opening new opportunities for women and leading to the emergence of more formalized nursing education and practice.

The Professionalization of Nursing

By the late 1800s, the professionalization of nursing was well under way. In 1873, New York City’s Bellevue Hospital became the first in the country to establish a program of nursing education based on the Nightingale model. New Haven Hospital and Massachusetts General Hospital quickly followed. Between 1890 and 1900, about 400 training schools for nurses opened across the country.11 These hospital programs offered diplomas in nursing and an apprentice-style education in which students cared for patients in hospitals under the tutelage of a nursing supervisor. Later viewed as an exploitation of women, these students worked long hours, six days a week.

Once they graduated, most of the new nurses sought employment in private homes. This situation persisted until the Great Depression stripped families of their ability to hire nurses. Later, the Hill-Burton Act of 1946 boosted the numbers of hospital nurses by providing funds for the construction of new hospitals across the country, giving acute care preeminence in the American health care system and initiating an unquenchable demand for hospital nurses that continues to this day.12

In the early years of this professionalization, Isabel Hampton Robb, who in 1889 became the first head of the Johns Hopkins School of Nursing, promoted the idea that nurses were motivated by altruism and the moral responsibility to care for and promote the health of others, regardless of the setting.13 Motivated by this vision of the mission of nursing, nurses began venturing into poor communities to educate women about home hygiene, healthy living, and nutrition. The most noteworthy of these nurses was Lillian Wald.

Wald was born into a well-off family in Cincinnati, Ohio, that later moved to Rochester, New York, where she attended a boarding school. She decided to dedicate her life to nursing and enrolled in the New York Hospital Training Program in 1889. She coined the name “public health nursing” for nurses who served poor and middle-class families in their homes and communities. She taught classes in health promotion and disease prevention. In 1893, Wald founded the Nurses Settlement, which became known as the Henry Street Settlement, to better address the horrific living conditions and poor health of immigrants living on the Lower East Side of Manhattan. In addition to providing health and hygiene classes, she and a group of nurses made home visits, often navigating unsafe, unclean environments, as immortalized in the famous photograph of a Henry Street nurse going from one tenement to another across the rooftops, which also saved them time.

Wald also started the Visiting Nurse Service of New York, occupational health nursing, and school health nursing. Before the phrase was coined, she recognized what we now know as “the social determinants of health,” arguing that preventing illness was cheaper than caring for the ill. She understood that children cannot be healthy without having an opportunity to play under safe conditions, so she started the first playground in the city. At a time when there was a bureau for the protection of animals but no comparable federal oversight for the welfare of children, she became a leading advocate for the first federal Children’s Bureau. She also knew that the arts can enrich the emotional lives of people worried about how to provide the next meal for a family, so she opened a theater as part of the settlement house. She believed that war does not create health, so she actively opposed the nation’s involvement in the First World War.14 Although social work also claims her, nurses view Wald as an exemplar of the profession’s promise of innovation, altruism, and reformation and its understanding of the family and community context of individual health.

Source: Visiting Nurse Service of New York, www.vnsny.org; c. 1905

But not all nurses were as well educated—or as visionary—as Wald. In fact, the lack of standardization among the hospital training programs that had mushroomed in the late 1800s prompted a movement to secure legal registration of nurses. North Carolina became the first state to enact a registration law, doing so in 1903, followed by New York, New Jersey, and Virginia. By 1917, 45 states had passed nurse practice acts, most of which authorized boards of examiners to ensure, among other things, that an applicant to become a registered nurse met the necessary criteria. These included graduation from an approved training program.15,16

Throughout the ensuing decades, states refined their legal definitions of nursing. Legal scholar Barbara Safriet documented that early medical practice acts were written so broadly that they precluded other professions from claiming health care roles that were independent of physician supervision.17 This issue has been central to nursing’s battle for independence and authority over its own practice.

War and the Development of Nursing

Wartime has provided opportunities for nurses to make significant advances in both science and professional status. The American Red Cross, founded in 1905 by congressional mandate to ensure the availability of relief and aid during national crises, formed its nursing services under the leadership of the nurse Jane Delano in 1909. The Red Cross played a critical role in providing nurses at military and Red Cross hospitals during World War I. To ensure a continuing supply of nurses during the war, the Army School of Nursing was established, along with a “training camp” at Vassar College that set the stage for nursing education to move into universities.18 Following both World Wars, the skills and knowledge that nurses needed to care for the wounded expanded and were carried into civilian nursing practice.

The Vietnam War also advanced nurses’ roles and responsibilities. Nurses were essential providers of emergency, trauma, and rehabilitative care, but their contributions to the war went largely unrecognized until Morley Safer focused a segment of 60 Minutes on the post-traumatic stress disorder experienced by many nurse veterans of that war.19

Nonetheless, the military has been a place for nurses to advance their careers and the profession. To this day, when a flood of wounded and dying soldiers comes through the door of a military hospital, an “all hands on deck” attitude prevails, and legal barriers to what nurses and other health care professionals do melt away. A recent example is that of Rear Admiral Kathleen Martin, a nurse who commanded Bethesda’s National Naval Medical Center in 1999 and 2000. In 2007, another nurse, Major General Gale Pollack, served as the Acting Surgeon General of the United States Army for nine months following media reports of poor care at Walter Reed Medical Center. She was the first woman and nonphysician to serve as Army Surgeon General. Both of these nurses also served as chief of the Army Nurse Corps.

Modern Nursing: Education, Specialization, and Certification

After World War I, the nation confronted a shortage of nurses and continuing problems with the lack of standards for nursing education. Nurses had died while caring for people who took ill during the influenza epidemic of 1918, and hospitals expanded diploma nursing programs with little regard for the quality of the education. In 1919, the Rockefeller Foundation funded a Committee for the Study of Nursing Education. The Committee’s report, issued in 1923 and known as the Goldmark Report, was critical of hospital training programs and called for a separation of education from service and moving nursing education into universities.20

Since the Goldmark Report was issued, nursing education and practice have been studied repeatedly by national commissions, all of which have reached remarkably similar conclusions.21 After the Second World War, the Carnegie Corporation provided partial funding for what became known as the Brown Report (after staff member Esther Lucille Brown, a social scientist), published in 1948.22 Its recommendations on nursing education echoed those in the Goldmark Report, but also called for a differentiation between “professional” and “technical” nursing and the expansion of nursing practice in community settings.

The recommendation was taken up in the 1950s by Mildred Montag, founder and director of the first nursing program at Adelphi University in New York in 1942 and subsequently a professor at Columbia University’s Teacher’s College. Montag developed a proposal that was funded by the W. K. Kellogg Foundation to educate technical nurses in associate degree programs at seven junior colleges and a hospital.23 Thus began a continuing debate about the appropriate roles and education of nurses, as associate degree nursing programs proliferated without adoption of the “technical nurse” moniker. Most important, the Brown Report and Montag’s work led to an end of the dominance of hospitals in the education of nurses. Thereafter, most hospital diploma nursing programs either closed or partnered with community colleges and universities. As of 2008, there were only 69 diploma nursing programs left in the country.

Following World War II, more women (and a few men), often from families of little means, enrolled in universities to be educated as nurses. They were supported, in part, by the GI Bill and, later, by the federal Nurse Training Act of 1964.24 The funding enabled them to enter a profession—and the middle class. There was also a need for nurses with a stronger foundation in the sciences. As the education of nurses moved into colleges and universities, nursing faculty had to meet academic standards. In the 1960s, the federal nurse-scientist program provided support for postgraduate nurses to obtain doctorates in fields such as physiology, psychology, anthropology, and sociology.25 These nurse-scientists led the profession’s efforts to build its scientific base.

The number of baccalaureate schools of nursing increased, and in 1956 Columbia University opened the country’s first graduate program in a clinical nursing specialty. The women’s movement and social upheavals of the 1960s and 1970s encouraged nurses to seek the education and authority commensurate with their greater responsibilities. Baccalaureate and master’s degree programs prepared registered nurses who resisted the outdated role of the nurse as the physician’s handmaiden and aimed at claiming control over their profession. They carved out their own sphere of practice and developed new roles, including clinical nurse specialists and nurse practitioners.

The development of this latter role has been particularly significant. In 1966, pediatrician George Silver and University of Colorado nursing dean Loretta Ford developed a postbaccalaureate program to prepare nurses, in collaboration with pediatricians, to provide primary care to underserved children.26 The program was so successful that nurse practitioner certificate programs proliferated as a way to address the shortage of primary care physicians. These programs moved from being affiliated with schools of medicine to being full-fledged graduate programs in schools of nursing.

Just as medicine evolved from a generalist to a specialist focus, nursing specialties emerged over the years. Since the late 1800s, nurses had specialized in public health, midwifery, and anesthesia. But it wasn’t until the late 1960s, with the expansion of intensive care units, that subspecialties took hold. To meet the need for nurses capable of exercising assessment and monitoring skills in high-tech environments, nursing developed subspecialties in critical care, such as neonatal, cardiac, and neurosurgical. Other subspecialties arose around specific diseases and clinical conditions, clinical settings and services, procedures, and populations.

The first certification examination for a specialty was offered by the American Association of Nurse Anesthetists in 1945, after more than a half century of nurse-administered anesthesia.27 In 1991, the American Nurses Association (ANA) formed the American Nurses Credentialing Center to promote excellence in practice. To date, it has certified over 250,000 nurses in various specialties. Specialty nursing organizations realized that providing certification is a revenue-generating activity, and many have developed their own certification programs.

The American Nurses Credentialing Center also developed a designation for hospitals that demonstrate excellence in nursing practice—the Magnet Recognition Program. The nursing shortage of the 1980s led to widespread reports of poor working conditions that were undermining nurses’ ability to deliver safe patient care and causing nurses to leave practice. Some hospitals had no trouble recruiting and retaining highly qualified nurses. These hospitals had reputations for excellence in nursing care, and nurses considered them to be good places to work. A group of nurse-researchers who were fellows of the American Academy of Nursing examined best practices for ensuring excellence in nursing in 41 hospitals from around the country that fit this description.28 Interviews with the hospitals’ chief nursing officers and staff nurses revealed the key elements. These were further refined and used to evaluate hospitals that apply for Magnet designation. This designation has driven changes in nursing practice and hospital environments.

Throughout the years, nursing practice has evolved along with advances in science and technology. Nurses have been key to making modern, high-tech hospitals more hospitable. It can be argued, however, that caring for patients has shifted from creating conditions for patients to heal—the purpose of nursing as defined by Nightingale—to tending to machines that monitor patients and deliver therapies. In fact, the worst of hospital nursing today loses sight of the patient in the maelstrom of modern-day medical and technological complexity. The best of nursing keeps the patient as the focal point and seeks to integrate the various technologies that have become markers of acute care institutions.

THE NURSING PROFESSION

Defining Nursing

Health care used to be defined as the province of physicians who diagnosed and treated disease—a perspective that left nurses and other providers struggling to define their roles. Was nursing more than what physicians wanted nurses to do? Did nurses have any specialized knowledge and skill that was different from that of physicians? Could nursing exist apart from medicine? Did it have its own intrinsic value? Full utilization of nurses requires an understanding of the answers to these questions.

Caring in a nursing context demands expert knowledge about, and the ability to integrate, the physical, psychological, emotional, and social dimensions of health; skill in administering supportive care; superb critical thinking and clinical judgment; honed assessment skills; proficiency in coordinating care and advocacy, and more.29

There are three classic definitions of nursing. Nightingale viewed nursing as activities “to put the patient in the best condition for nature to act upon him.”30 One hundred years later, Virginia Henderson, an influential thinker at Columbia University Teachers College and the Yale School of Nursing, provided a definition that was adopted by the International Council of Nurses and published by the American Journal of Nursing. Hers was the first to clearly articulate nurses’ independent functions:

The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible. This aspect of her work, this part of her function, she initiates and controls; of this she is a master.31

Henderson’s definition differentiated nurses’ unique sphere of practice (“independent” functions) versus the commonly understood “dependent” functions—those that depended upon a physician’s order or prescription. Henderson even defined the role of the nurse in relation to physicians and the medical regimen with a patient focus: “In addition, she helps the patient [italics added] carry out the therapeutic plan as initiated by the physician.” And, for the first time, Henderson’s definition clearly articulated the legitimacy of two important health care roles that nurses had long fulfilled: caring for people at the end of life, when recovery is not possible, and promoting the health of people who are not ill.

The third important definition of nursing was included in the landmark New York State Nurse Practice Act of 1972. Because the definition was contained in a statute, it provided legal support for nurses’ independent practice:

The practice of the profession of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential health problems through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and well-being, and executing medical regimens prescribed by a licensed physician, dentist or other licensed health care provider legally authorized under this title and in accordance with the commissioner’s regulations. A nursing regimen shall be consistent with and shall not vary any existing medical regimen.32

The last sentence was written to allay the concerns of physicians who claimed that fully independent nurses could destroy physicians’ authority over patients’ medical care.33 It remains in the state’s practice act.

The New York State law became a model for other states. It enabled nurses to claim a body of knowledge apart from medicine and to have authority over their own practices. The language in the legislation referring to “diagnosing and treating human responses” reflected a movement among nurses to develop nursing diagnoses that centered on the patients’ responses to health problems and were distinct from disease-centered medical diagnoses. Including “potential health problems” in the definition reinforced the importance of disease prevention and health promotion. In contemporary terms, the work defined in this practice act entails care coordination, chronic care management, disease prevention, and health promotion.

In 1980, to help nurses, policymakers, health care administrators, and others conceptualize more clearly the scope of professional nursing, the ANA published Nursing: A Social Policy Statement.34 This document articulated a social context for nursing, describing nurses’ responsibilities to patients and society, and validating an advocacy role for nursing. The most recent version of Nursing’s Social Policy Statement defines the role of the profession as:

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.35

The Nursing Workforce

The nursing workforce is large and diverse. It includes registered nurses (RNs), licensed practical or vocational nurses (LPNs, LVNs), advanced practice registered nurses (APRNs), and direct care workers, such as nursing assistants and home health aides (who are seldom discussed in nursing workforce studies, as they are unlicensed).

Direct Care Workers

Direct care workers include nursing assistants, home health aides, and personal care assistants. The majority work in home and community settings and are key to keeping disabled and elderly people in their own homes. They provide the bulk of care in long-term care facilities and augment the nursing staff in many hospitals. They increasingly care for people who may have severe dementia, paralytic stroke, or other debilitating conditions that are challenging even to professional health care providers.

Although they are not licensed by the states, direct care workers who work in Medicare- and Medicaid-certified facilities or home care agencies are required by the federal government to be certified. The requirements for designating a provider as a certified nursing assistant are completion of 75 hours of training and competence to provide assistance in activities of daily living (such as bathing, feeding, toileting, and ambulating) and to perform certain nursing procedures under the supervision of an LPN or RN.36

Today, there are more than 3 million direct care workers in the United States.37 Almost half are self-employed or work for private households, 42% have some college education, and 88% are women.38 The average direct care worker’s salary is less than $25,000 per year and 45% of direct care workers live in households with an annual income that is less than 200% of the poverty level.39 These positions frequently are low-paid and lack health insurance and other benefits.40

Licensed Practical or Vocational Nurses (LPNs)

As the education of nurses moved from the hospital to the university and community colleges, the role of the LPN (also referred to as vocational nurse in some states) evolved as someone with technical skill—from bathing a patient to administering medications or changing dressings—but without the education for independently assessing patients, diagnosing health problems, developing interventions, and evaluating outcomes. LPNs function under the supervision of a registered nurse, physician, dentist, or other licensed provider. Their education varies from about nine months to two years in length, and is provided largely by vocational training programs.

There are approximately 890,000 LPNs in the United States.41 Ninety-seven percent are women. Two-thirds (67%) are white, one-quarter (26%) are black, and 3% are Hispanic. Fourteen percent have no more than a high school education; 34% have “some” college education; 45%, an associate’s degree; and 5%, a baccalaureate or higher degree. Their average annual salary in 2008 was just over $40,000.42 Approximately one-quarter work in hospitals, 28% in “nursing and personal care facilities,” and 12% in physicians’ offices.43 Twenty-four percent of RNs worked as LPNs prior to their first RN position.44

Registered Nurses

In 2008, there were 3,063,163 RNs in the United States—an increase of 5.3% since 2004. More than 84% are employed in nursing, and this is the highest proportion recorded (see Figure 1).

FIGURE 1.The Nursing Workforce of the United States, 1980–2008

Source: U.S. Department of Health and Human Services, Health Resources and Services Administration. (2010). The Registered Nurse Population: Initial Findings from the 2008 National Sample Survey of Registered Nurses.

Although nurses’ real earnings remained flat in the 1990s, this has now changed. Nurses’ average annual salary in 2008 was $66,973, an increase of over 15% since 2004.45

RNs remain predominantly women (94.2%).46 The RN workforce has aged from 1980 to 2008; in 2008, the average age of an RN was 47 years, illustrating the imperative to increase the pipeline of new nurses as older ones approach retirement.47

Regarding ethnicity, 83.2% of RNs are non-Hispanic white, a drop of over four percentage points since 2000; 5.4% are black or African American; 5.8% are Asian; and 3.6% Hispanic or Latino.48

To qualify as an RN, one of several possible educational programs must be completed: a diploma hospital program; an associate degree program (usually provided by community colleges); a college or university baccalaureate program; or a direct-entry master’s degree program that bypasses the baccalaureate degree for people with bachelor’s degrees in other fields. Graduates from any of these programs are eligible to sit for the RN licensing exam, the NCLEX-RN, required by all states. Over 45% of today’s RNs began their education in associate degree programs; however, only 5.8% of associate degree (ADN) graduates between 1970 and 1994 went on to obtain a master’s degree in nursing or a doctorate by 2004, compared with 19.7% of RNs whose initial nursing education was a bachelor of science in nursing (BSN).49 Nonetheless, the educational preparation of nurses is improving, as illustrated in Figure 2.

FIGURE 2.Highest Nursing or Nursing-Related Educational Preparation, 1980–2008

Source: U.S. Department of Health and Human Services, Health Resources and Services Administration. (2010). The Registered Nurse Population: Initial Findings from the 2008 National Sample Survey of Registered Nurses.

In 2008, 36.8% of all RNs held baccalaureate degrees and 13.2% had a master’s or doctoral degree in nursing.50 Between 1980 and 2008, the percentage of nurses with only a diploma decreased from 54.7% to 13.9%. Among those with advanced degrees, 375,794 had master’s degrees and 28,369 had doctorates.

Advanced Practice Registered Nurses

Advanced practice registered nurses (APRNs) are RNs who have received additional education to expand their scope of practice. They make up 8.2% of the RN population. As of 2008, there were 250,527 APRNs in the United States, an increase of 4.2% since 2004. The demand for APRN services has spread from primary care to all settings. There are four types of APRNs:

Nurse practitioners (NPs), 63.2% of all APRNs (158,348), whose practice may include the assessment, diagnosis, and treatment of disease, albeit with a nursing lens that focuses on patient needs, health promotion, and self-care management.Clinical nurse specialists (59,242), who concentrate on nursing care specific to a population, setting, disease, type of care, or clinical problem; they provide direct care to patients, assist with delineating best practices in care, and teach nurses and other health care workers how to improve the care they deliver to a population; their numbers are declining—by 22.4% since 2004—as nurses increasingly seek preparation as nurse practitioners.Certified nurse anesthetists (38,821) who provide the full range of perianesthesia services, including pain management.Certified nurse midwives (18,492), who focus on women’s health, including childbirthing and gynecologic care for women of all ages.51

Entry into these roles now requires a master’s degree. However, the American Association of Colleges of Nursing has called for the Doctor of Nursing Practice (DNP) to be the educational route for APRNs by 2015.

Others Providing Nursing Care

Hospitals and other health care organizations have often responded to the shortage of licensed nurses by developing new categories of workers, such as “patient care technicians” and “patient care associates,” often nursing assistants or medical technicians who receive additional training by the facility to take on more advanced technical aspects of acute care, such as dressing changes. These workers generally function under the supervision of licensed nurses (RNs or LPNs). In ambulatory care and the operating room, one can find patient care technicians and surgical first assistants who function under the supervision of physicians. Professional nursing organizations have resisted efforts to create new categories of workers who provide nursing care without supervision or oversight by licensed nurses, but the 2009 Institute of Medicine report, Retooling for an Aging America: Building the Health Care Workforce, encourages flexibility in developing new roles for health care workers to care for an increasing number of older adults.52

Additionally, family members provide nursing care that even health care providers find challenging, such as dressing complex wounds or bathing loved ones with dementia.53 There are over 44 million family caregivers over the age of 18 in the United States, providing care that has been valued at $375 billion annually.54 Nurses are increasingly involved in addressing the needs of family caregivers, advocating public policies that will support family caregivers, and partnering with social workers and other health care professionals to reform the health care system in ways that will better prepare family members to provide care in the home.

Although this chapter is confined to the licensed nursing workforce, there is an urgent need to understand and develop the capacity of unlicensed providers as well.

Nurses’ Employment: Where Nurses Work (and What They Do)

The majority (62.2%) of RNs worked in hospitals in 2008.55 This percentage will decline if the nation shifts from an emphasis on acute care to health promotion and chronic care management. Of RNs, 11% work in ambulatory care; 11% in public health or community health settings, including home care; 7% in long-term care facilities; 3% in school health; 3% in nursing education; almost 2% in “insurance claims and benefits”; less than 1% in occupational health; and about 0.4% in a policy, planning, regulatory, or licensing agency.56 These settings have different educational requirements.

Hospital Nursing

Nursing care is the core business of hospitals—people are seldom hospitalized unless they need nursing care. In hospitals, nurses assess patients with complex, often life-threatening health problems, monitor changes in patients’ conditions that could lead to complications, administer medications and check for adverse reactions, prevent hospital-acquired infections, provide emotional support and teaching to patients and families, record the patient’s reactions to care, and participate in interdisciplinary team efforts to prepare the patient for discharge. Patients who only a few years ago would have been in intensive care units are now cared for on regular units (or “floors”), presenting challenges to so-called “floor nurses” who must have unprecedented knowledge and skills in managing complex care for seriously ill patients.

In 2004, almost 30% of all hospital nurses worked on a general or specialty inpatient unit and 17% in critical care.57 Some hospitals have all-RN staff. Others continue to use some LPNs, although the percentage of LPNs working in hospitals has declined in recent years.58,59 The clinical nurse leader—a new nursing role conceived in 2004 at a meeting of the American Association of Colleges of Nursing—is a master’s level staff nurse who has the additional training to examine quality-of-care outcomes and develop evidence-based practice for a clinical unit or a population of patients. Clinical nurse leaders are now used extensively by the Veterans Health Administration.

In the hospital setting, APRNs serve as nurse-midwives; surgical first assistants in the operating room; clinical nurse specialists who provide specialty consultation on diabetes, wounds, and myriad other clinical conditions; nurse anesthetists who provide perianesthesia care in both inpatient and outpatient departments; and nurse practitioners throughout the hospital.

Nurse managers or administrators oversee patient care units (formerly called nursing units) and are responsible for managing scores of staff members and multimillion-dollar budgets for personnel, supplies, and equipment. Increasingly, nurse managers have one or more master’s degrees in nursing, business, or health care administration. They focus on improving the quality and safety of care and use data to monitor and improve clinical and financial performance.

The hierarchy of nursing management usually includes a clinical director of nursing or a director of clinical services to whom a number of nurse managers report, and a chief nursing officer who is often the vice president for patient care services, responsible for interdisciplinary clinical services as well as nursing. Because of their clinical, management, and business acumen, nurses can be found in the roles of chief operating officer or chief executive officer in hospitals and health systems. Nurses also hold key positions in quality and performance improvement departments, infection control, employee health, and other departments. This description of nurse administrators applies to other health care settings as well.

Primary and Ambulatory Care

In primary and ambulatory care, nurses’ roles vary by educational preparation. Licensed practical nurses may conduct basic assessments of patients, administer medications, collect specimens, and provide basic teaching. RNs can do these tasks, as well as conduct higher-level assessments of the less obvious patient health needs, conduct common examinations, counsel patients and families about illnesses and their management, and provide telephone follow-up as needed.

Nurse practitioners perform comprehensive health assessments, diagnose and treat disease, suture wounds and do other technical procedures, and engage in all of the activities described for the RN. In 1999, there were 45,200 NPs in primary care; by 2005, the number was 82,622. Between the mid-1990s and mid-2000s, NPs were the fastest growing group of primary care providers, with an annual increase in the number of NPs per capita of 9.4%, compared with 3.89% for physician assistants and 1.17% for primary care physicians.60

Home Care