NURSING NUR2407A-Dimensions of Nursing Exam 1 study guide/EXAM 1 STUDY GUIDE Chapters 1 2, Exams of Health sciences

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EXAM 1 STUDY GUIDE

Chapters 1 2 4 5 14 17

Chapter 1

Define evidence-based practice

Evidence-Based Practice In professional nursing today, there is an increasing emphasis on evidence-based practice. Almost all of the currently used nursing theories address this issue in some way. Simply stated, evidence-based practice is the practice of nursing in which interventions are based on data from research that demonstrates that they are appropriate and successful. It involves a systematic process of uncovering, evaluating, and using information from research as the basis for making decisions about and providing client care.^7 Many nursing practices and interventions of the past were performed merely because they had always been done that way (accustomed practice) or because of deductions from physiological or pathophysiological information. Clients are now more sophisticated and knowledgeable about health-care issues and demand a higher level of knowledge and skill from their health-care providers. “Evidence-based practice is the practice of nursing in which interventions are based on data from research that demonstrates that they are appropriate and successful.” The development of information technology has made evidence-based practice in nursing a reality. In the past, nurses relied primarily on units within their own facilities for information about the success of treatments, decisions about health care, and outcomes for clients. Nursing education now requires nursing students to perform Web-based research for papers and projects so that by the time of graduation, they feel comfortable accessing a wide range of the best and most current information through electronic sources. Of course, one of the key limiting factors of evidence-based practice is the quality of the information on which the practice is based. Evaluating the quality of information on the Web can be difficult at times. The first step in developing an evidence-based practice is to identify exactly what the intervention is supposed to accomplish. Once the goal or client outcome is identified, the nurse needs to evaluate current practices to determine whether they are delivering the desired client outcomes. If the current practices are unsuccessful or if the nurse feels they can be more efficient with fewer complications, research sources need to be collected. These can be from published journal articles (either electronic or hard copy) and from presentations at research or practice conferences, which often present the most current information.

Then a plan should be developed to implement the new findings. This process can be applied to changing policy and procedures or developing training programs for facility staff. Research data should always be used when initiating new practices or modifying old ones. Review difference between roles: position, job, occupation, profession, professional, and what is professionalism  Position: A group of tasks assigned to one individual  Job: A group of positions similar in nature and level of skill that can be carried out by one or more individuals  Occupation: A group of jobs similar in type of work that are usually found throughout an industry or work environment  Profession: A type of occupation that requires prolonged preparation and formal qualifications and meets certain higher level criteria (discussed later in this chapter) that raise it to a level above that of an occupation^1  Professional: A person who belongs to and practices a profession (The term professional is probably the most misused of all these terms when describing people who are clearly involved in jobs or occupations, such as a “professional truck driver,” “professional football player,” or even “professional thief.”)  Professionalism: The demonstration of high-level personal, ethical, and skill characteristics of a member of a profession^2 Identify the traits that define a profession Trait Approach Of the many researchers and theorists who have attempted to identify the traits that define a profession, Abraham Flexner, Elizabeth Bixler, and Eliza Pavalko are most widely accepted as the leaders in the field. These three social scientists have determined that the following common characteristics are important:  • High intellectual level  • High level of individual responsibility and accountability  • Specialized body of knowledge  • Knowledge that can be learned in institutions of higher education  • Public service and altruistic activities  • Public service valued over financial gain  • Relatively high degree of autonomy and independence of practice

 • Need for a well-organized and strong organization representing the members of the profession and controlling the quality of practice  • A code of ethics that guides the members of the profession in their practice  • Strong professional identity and commitment to the development of the profession  • Demonstration of professional competency and possession of a legally recognized license^4 Review how nursing compares with other professions NURSING AS A PROFESSION How does nursing compare with other professions when measured against these widely accepted professional traits? The profession of nursing meets most of the criteria but falls short in a few areas. High Intellectual Level In the early stages of the development of nursing practice, this criterion did not apply. Florence Nightingale raised the bar for education, and graduates of her school were considered to be highly educated compared with other women of that time. However, by today's standards, most of the tasks performed by these early nurses are generally considered to be menial and routine. On the other hand, as health care has advanced and made great strides in technology, pharmacology, and all branches of the physical sciences, a high level of intellectual functioning is required for even relatively simple nursing tasks, such as taking a client's temperature or blood pressure using automated equipment. On a daily basis, nurses use assessment skills and knowledge, have the ability to reason, and make routine judgments based on clients’ conditions. Without a doubt, professional nurses must function at a high intellectual level. High Level of Individual Responsibility and Accountability Not too long ago, a nurse was rarely, if ever, named as a defendant in a malpractice suit. In general, the public did not view nurses as having enough knowledge to be held accountable for errors that were made in client care. This is not the case in the health-care system today. Nurses are often the primary, and frequently the only, defendants named when errors are made that result in injury to the client. Nurses must be accountable and demonstrate a high level of individual responsibility for the care and services they provide.^5 The concept of accountability has legal, ethical, and professional implications that include accepting responsibility for actions taken to provide client care and for the consequences of actions that are not

performed. Nurses can no longer state that “the physician told me to do it” as a method of avoiding responsibility for their actions. Specialized Body of Knowledge Most early nursing skills were based either on traditional ways of doing things or on the intuitive knowledge of the individual nurse. As nursing developed into an identifiable, separate discipline, a specialized body of knowledge called nursing science was compiled through the research efforts of nurses with advanced educational degrees.^6 As the body of specialized nursing knowledge continues to grow, it forms a theoretical basis for the best practices movement in nursing today. As more nurses obtain advanced degrees, conduct research, and develop philosophies and theories about nursing, this body of knowledge will increase in scope and quantity. Evidence-Based Practice In professional nursing today, there is an increasing emphasis on evidence-based practice. Almost all of the currently used nursing theories address this issue in some way. Simply stated, evidence-based practice is the practice of nursing in which interventions are based on data from research that demonstrates that they are appropriate and successful. It involves a systematic process of uncovering, evaluating, and using information from research as the basis for making decisions about and providing client care.^7 Many nursing practices and interventions of the past were performed merely because they had always been done that way (accustomed practice) or because of deductions from physiological or pathophysiological information. Clients are now more sophisticated and knowledgeable about health-care issues and demand a higher level of knowledge and skill from their health-care providers. “Evidence-based practice is the practice of nursing in which interventions are based on data from research that demonstrates that they are appropriate and successful.” The development of information technology has made evidence-based practice in nursing a reality. In the past, nurses relied primarily on units within their own facilities for information about the success of treatments, decisions about health care, and outcomes for clients. Nursing education now requires nursing students to perform Web-based research for papers and projects so that by the time of graduation, they feel comfortable accessing a wide range of the best and most current information through electronic sources. Of course, one of the key limiting factors of evidence-based practice is the quality of the information on which the practice is based. Evaluating the quality of information on the Web can be difficult at times.

The first step in developing an evidence-based practice is to identify exactly what the intervention is supposed to accomplish. Once the goal or client outcome is identified, the nurse needs to evaluate current practices to determine whether they are delivering the desired client outcomes. If the current practices are unsuccessful or if the nurse feels they can be more efficient with fewer complications, research sources need to be collected. These can be from published journal articles (either electronic or hard copy) and from presentations at research or practice conferences, which often present the most current information. Then a plan should be developed to implement the new findings. This process can be applied to changing policy and procedures or developing training programs for facility staff. Research data should always be used when initiating new practices or modifying old ones. Public Service and Altruistic Activities When defining nursing, almost all major nursing theorists include a statement that refers to a goal of helping clients adapt to illness and achieve their highest level of functioning. The public (variously referred to as consumers , patients , clients , individuals , or humans ) is the focal point of all nursing models and nursing practice. The public service function of nursing has always been recognized and acknowledged by society's willingness to continue to educate nurses in public, tax-supported institutions and in private schools. In addition, nursing has been viewed universally as an altruistic profession composed of selfless individuals who place the lives and well-being of their clients above their personal safety. In the earliest days, dedicated nurses provided care for victims of deadly plagues with little regard for their own welfare. Today, nurses are found in remote and often hostile areas, providing care for the sick and dying, working 12-hour shifts, being on call, and working rotating shifts. Review how students should use recourses like websites, journals Websites: Friends or Foes? Have a paper or report to do for class? Need information on pheochromocytoma, Smith-Strang disease, Kawasaki disease? No problem, look it up on the Web, right? Well, yes and no. Without question, there is a tremendous amount of information about almost any subject available just a few mouse clicks away. But the bigger question is, How good is that information? Anyone can post almost anything online these days, and there are no organizations or agencies that oversee or review the information for quality, accuracy, or objectivity. So how are you supposed to know what is good and what is not? Although there is no foolproof method for determining the quality of any given website, some telltale markers can point you in the right direction when you are rating the quality of the information you seek. Marker 1: Peer Review

All major professional journals have a peer-review process that requires any manuscripts submitted to be reviewed by two or three professionals who are considered experts, or at least knowledgeable, in the subject matter. Peer review is one of the key elements in ensuring the accuracy of the information in the manuscript. When considering a Web source, look for a clear statement of the source of the information and how that information is reviewed. If the information is from an established source, such as a recognized professional journal, it has been peer reviewed and has a higher degree of accuracy. Examine the format and writing style of the document. If it seems to be very choppy, or if the style, tone, or point of view changes throughout the article, it is an indication that it was not well edited and probably not peer reviewed. Use the information with caution. Marker 2: Author Credentials The name of the author and his or her titles and credentials should be listed. Be cautious if no author or publisher is listed. Of course, anyone can use another person's name as the author, but it is relatively easy to cross-check authors’ names through other databases, such as those found in libraries. Before accepting the information as gospel, it is probably worth looking up the author and seeing what other articles or books he or she has written. Another key to determining author credentials is to establish who owns the website. In general, personal website pages are less likely to contain authoritative information. You can also look at the last three letters in the website address. The ones that end in .gov, .org, or .edu tend to have higher-quality information. Also, see whether the information has a copyright. If the information is copyrighted, the person felt strongly enough about what he or she was posting to go to the effort of making sure that no one else could use it as their original information. Marker 3: Prejudice and Bias Although there is almost always a small degree of prejudice and bias in all written material, most legitimate authors strive to be as objective as possible. Many times, if you read a document with a critical eye, you can discern obvious prejudicial viewpoints. See if the author has a vested interest in the content of the document. For example, an article about the effects of tobacco use on the respiratory system written by a scientist who was hired by the R. J. Reynolds Company would probably have a decidedly different viewpoint than an article written by a scientist who was employed by the National Health Information Center. See if contact information is provided by the author and who the sponsor or publisher of the document is. If these are not provided, be suspicious about the information. Marker 4: Timeliness

Of course, all of us want the most recent information we can find and sometimes mistakenly assume that because it is on the Web, it is new. Some forms of the Web have been around since Tim Berners-Lee invented the World Wide Web in 1989, so some of the material can be very outdated. See if you can determine when the site was last updated and how extensively the information was revised. It is also a good practice to look to other sources (e.g., Web, journals, books) to compare the material for currentness. Many websites have links where you can access other related information. If those links have messages such as “Page not found” or “Link no longer available,” be extremely cautious with the information. Good links should connect you to other reliable sites. Marker 5: Presentation Although the old saying is that “you can't tell a book by its cover,” experienced Web surfers can often tell a lot about a website by its presentation. Some look well developed and professional, and others look very amateurish. There is no guarantee that the slick-looking websites are better, but it is one factor to consider in the overall evaluation of the information you are seeking. Take a look at the graphics. They should be balanced with the text and help explain or demonstrate information in the text. If the graphics seem to be just decorative, it should raise a red flag about the content of the site. Some sites use a compressed format that requires special programs such as Adobe Acrobat to view them. If you do not have access to these programs, the information in the site is unusable. Move on to the next site. In summary, the Internet can be a valuable source of information about a wide variety of subjects. However, each source needs to be evaluated carefully. Following the five markers discussed here will place you on the path to deciding the quality of the information presented in any website. Review Nurses’ Code of Ethics: ANA Do nurses have autonomy and independence of practice? Why or why not.

Autonomy and Independence of Practice

Historically, the handmaiden or servant relationship of the nurse to the physician was widely accepted.^11 It was based on several factors, including social norms. For example, women became nurses, whereas men became physicians; women were subservient to men, the nature of the work being such that nurses cleaned and physicians cured. In terms of the relative levels of education of the two groups, the average nursing program lasted for 1 year, whereas physician education lasted for 6 to 8 years. Unfortunately, despite efforts to expand nursing practice into more independent areas through updated nurse practice legislation, nursing retains much of its subservient image. In reality, nursing is both an

independent and interdependent discipline. Nurses in all health-care settings must work closely with physicians, hospital administrators, pharmacists, and other groups in the provision of care. In some cases, nurses in advanced practice roles, such as nurse practitioners, can and do establish their own independent practices. Most state nurse practice acts allow nurses more independence in their practice than they realize. To be considered a true profession, nursing will need to be recognized by other disciplines as having practitioners who practice nursing independently. Determine the main method in which nurses can gain power in nursing EMPOWERMENT IN NURSING One concern that has plagued nursing, almost from its development as a separate health-care specialty, is the relatively large amount of personal responsibility shouldered by nurses combined with a relatively small amount of control over their practice. Even in the more enlightened atmosphere of today's society, with its concerns about equal opportunity, equal pay, and collegial relationships, many nurses still seem uncomfortable with the concepts of power and control in their practice. Their discomfort may arise from the belief that nursing is a helping and caring profession whose goals are separate from issues of power. Historically, nurses have been mostly powerless, and previous attempts at gaining power and control over their practice have been met with much resistance from groups who benefit from making sure that nurses remain without authority. Nevertheless, all nurses use an authoritative voice in their daily practice, even if they do not realize it. Until nurses understand the sources of their influence, how to increase it, and how to use it in providing client care, they will be relegated to a subservient position in the health-care system. The Nature of Power The term power has many meanings. From the standpoint of nursing, power is probably best defined as the ability or capacity to exert influence over another person or group of persons.^16 In other words, power is the ability to get other people to do things even when they do not want to do them. Although power in itself is neither good nor bad, it can be used to produce either good or bad results. Power is always a two-way street. By its very definition, when power is exerted by one person, another person is affected; that is, the use of power by one person requires that another person give up some of his or her power. Individuals are always in a state of change, either increasing their power or losing some; the balance of power rarely remains static. Empowerment refers to the increased amount of power that an individual or group is either given or gains. Origins of Power

If power is such an important part of nursing and the practice of nurses, where does it come from? Although there are many sources, some of them would be inappropriate or unacceptable for those in a helping and caring profession. The following list includes some of the more accessible and acceptable sources of power that nurses should consider using in their practice:^16  • Referent  • Expert  • Reward  • Coercive  • Legitimate  • Collective Referent Power The referent source of power depends on establishing and maintaining a close personal relationship with someone. In any close personal relationship, one individual often will do something he or she would really rather not do because of the relationship. This ability to change the actions of another is an exercise of power. Nurses often obtain power from this source when they establish and maintain good therapeutic relationships with their clients. Clients take medications, tolerate uncomfortable treatments, and participate in demanding activities that they would likely prefer to avoid because the nurse has good relationships with them. Likewise, nurses who have good collegial relationships with other nurses, departments, and physicians are often able to obtain what they want from these individuals or groups in providing care to clients. Expert Power The expert source of power derives from the amount of knowledge, skill, or expertise that an individual or group has. This power source is exercised by the individual or group when knowledge, skills, or expertise is either used or withheld in order to influence the behavior of others. Nurses should have at least a minimal amount of this type of power because of their education and experience. It follows logically that increasing the level of nurses’ education will, or should, increase this expert power. As nurses attain and remain in positions of power longer, the increased experience will also aid the use of expert power. Nurses in advanced practice roles are good examples of those who have expert power. Their additional education and experience provide these nurses with the ability to practice skills at a higher level than nurses prepared at the basic education level.

By demonstrating their knowledge of the client's condition, recent laboratory tests, and other elements that are vital to the client's recovery, nurses demonstrate their expert power. This knowledge may increase the amount of respect they are given by physicians. Nurses access this expert source of power when they use their knowledge to teach, counsel, or motivate clients to follow a plan of care. Nurses can also use expert power when dealing with physicians. Power of Rewards The reward source of power depends on the ability of one person to grant another some type of reward for specific behaviors or changes in behavior. The rewards can take on many different forms, including personal favors, promotions, money, expanded privileges, and eradication of punishments. Nurses, in their daily provision of care, can use this source of power to influence client behavior. For example, a nurse can give a client extra praise for completing the prescribed range-of-motion exercises. There are many aspects of the daily care of clients over which nurses have a substantial amount of reward power. This reward source of power is also the underlying principle in the process of behavior modification. Coercive Power The coercive source of power is the flip side of the reward source. The ability to reprimand, withhold rewards, and threaten punishment is the key element underlying the coercive source of power. Although nurses do have access to this source of power, it is probably one that they use minimally, if at all. Not only does the use of coercive power destroy therapeutic and personal relationships, but it can also be considered unethical and even illegal in certain situations. Threatening clients with an injection if they do not take their oral medications may motivate them to take those medications, but it is generally not considered to be a good example of a therapeutic communication technique. Legitimate Power The legitimate source of power depends on a legislative or legal act that gives the individual or organization a right to make decisions that they might not otherwise have the authority to make. Most obviously, political figures and legislators have this source of power. This power can also be disseminated and delegated to others through legislative acts. In nursing, the state board of nursing has access to the legitimate source of power because of its establishment under the nurse practice act of that state. Similarly, nurses have access to the legitimate source of power when they are licensed by the state under the provisions in the nurse practice act or when they are appointed to positions within a health-care

agency. Nursing decisions made about client care can come only from individuals who have a legitimate source of power to make those decisions—that is, licensed nurses. Collective Power The collective source of power is often used in a broader context than individual client care and is the underlying source for many other sources of power. When a large group of individuals who have similar beliefs, desires, or needs become organized, a collective source of power exists.^17 For individuals who belong to professions, the professional organization is the focal point for this source of power. The main goal of any organization is to influence policies that affect the members of the organization. This influence is usually in the form of political activities carried out by politicians and lobbyists. Professional organizations that can deliver large numbers of votes have a powerful means of influencing politicians. The use of the collective source of power contains elements of reward, coercive, expert, and even referent sources. Each source may come into play at one time or another. How to Increase Power in Nursing Professional Unity Probably the first, and certainly the most important, way in which nurses can gain power in all areas is through professional unity. The most powerful groups are those that are best organized and most united. The power that a professional organization has is directly related to the size of its membership. According to the ANA, there are approximately 2.7 million nurses in the United States. It is not difficult to imagine the power that the ANA could have to influence legislators and legislation if all of those nurses were members of the organization rather than the 250,000 who actually do belong. This point— that nurses need to belong to their national nursing organization—cannot be emphasized enough. Political Activity A second way in which nurses can gain power is by becoming involved in political action. Although this produces discomfort in many, nurses must realize that they are affected by politics and political decisions in every phase of their daily nursing activities. “By demonstrating their knowledge of the client's condition, recent laboratory tests, and other elements that are vital to the client's recovery, nurses demonstrate their expert power. This knowledge may increase the amount of respect they are given by physicians.”

The simple truth is that if nurses do not become involved in politics and participate in important legislation that influences their practice, someone other than nurses will be making those decisions for them. Nurses need to become involved in political activities from local to national levels. The average legislator knows little about issues such as clients’ rights, national health insurance, quality of nursing care, third-party reimbursement for nurses, and expanded practice roles for nurses, yet they make decisions about these issues almost daily. It would seem logical that more informed and better decisions could be made if nurses took an active part in the legislative process. Accountability and Professionalism A third method of increasing power is by demonstrating the characteristics of accountability and professionalism. Nursing has made great strides in these two areas in recent years. Nurses, through professional organizations, have been working hard to establish standards for high-quality client care. More important, nurses are now concerned with demonstrating competence and delivering high-quality client care through processes such as peer review and evaluation. By accepting responsibility for the care that they provide and by setting the standards to guide that care, nurses are taking the power to govern nursing away from non-nursing groups. Networking Finally, nurses can gain power through establishing a nurse support network. It is common knowledge that the “old boy” system remains alive and well in many segments of our seemingly enlightened 21st- century society. The old boy system, which is found in most large organizations, ranging from universities to businesses and governmental agencies, provides individuals, usually men, with the encouragement, support, and nurturing that allow them to move up quickly through the ranks in the organization to achieve high administrative positions. An important element in making this system work involves never criticizing another “old boy” in public, even though there may be major differences of opinion in private. Presentation of a united front is extremely important in maintaining power within this system. Nursing and nursing organizations have never had this type of system for the advancement of nurses. Part of the difficulty in establishing a nurse support network is that nurses have not been in high-level positions for very long. The framework for a support system for nurses is now in place; with some commitment to the concept and some activity, it can grow into a well-developed network to allow the brightest, best, and most ambitious people in the profession to achieve high-level positions.^16

Chapter 2

Compare healthcare of ancient civilizations to healthcare today. What have the focus, influences,

and interventions changed?

UNDERSTANDING OUR HISTORY

K nowledge about the profession's past can help us understand how nursing developed and even suggest solutions to problems that face the profession today. Several threads run throughout the history of nursing, including society's beliefs about the causes of illness, the value placed on individual life, and the role of women in society. The wars of modern history have also had a significant impact on nursing, particularly in influencing the development of technology and guiding the direction of health care. This chapter is not a treatise on the history of health care and nursing but presents some key historical milestones and individuals that helped to form the foundations of health and nursing care. ORIGINS OF NURSING According to the American Nurses Association (ANA), the modern definition of nursing is the protection, promotion, and optimization of clients’ health and abilities, the prevention of disease and illness, and the alleviation of suffering through the diagnosis and treatment of human response to disease and injury. This comprehensive and modern definition of nursing was only arrived at after centuries of development. However, one of the common elements seen throughout the history of nursing is the belief that by providing care to the ill and injured, including individuals, families, and communities, optimal health and quality of life could be restored or maintained. Before Nursing Current nursing practice is a relatively recent development. The major concern of most early civilizations was the survival of the group, and because illness and injury threatened this survival, many primitive health-care practices grew from processes of trial and error. In prehistoric times, women tended to care for the ill and injured. Evil spirits were thought to be the cause of illness, and the medicine men and women who practiced witchcraft were considered religious figures. Driving Out Demons In ancient Eastern civilizations, starting from about 3500 BC, health care was intertwined with religion. Taoism emphasized balance and the driving of demons out of the ailing body. Acupuncture developed over the next several thousands of years, and medicinal herbs were used in preventive health care.

In Southeast Asia, Hinduism emphasized the need for good hygiene, and written records would soon chronicle a number of surgical procedures. This was also the first culture to document medical treatment outside the home, although women were prohibited from working. The rise of Buddhism around 530 BC caused a surge in interest in health care, with the development of public hospitals, the requirement of high standards for doctors and other hospital workers, and an emphasis on hygiene and prevention of disease. The development of medical knowledge was somewhat hindered by the refusal of physicians to come in contact with blood and infectious body secretions and the prohibition against dissection of the human body. “The major concern of most early civilizations was the survival of the group, and because illness and injury threatened this survival, many primitive health-care practices grew from processes of trial and error.” Ancient Sciences During the same period, the ancient Egyptians’ belief that all disease was caused by evil spirits and punishing gods was changing. Health-care providers from that time showed a well-developed understanding of the basis of disease. Writings from 1500 BC refer to surgical procedures, the role of the midwife, bandaging, preventive care, and even birth control. Women enjoyed a higher status in Egyptian society and even worked in hospitals.^1 Physicians, however, were still men, who served in multiple roles as surgeons, priests, architects, and politicians. The Babylonian Empire, united in 2100 BC, was a civilization that focused on astrology. Its health-care practices included special diets, massage therapy, and rest to drive evil spirits from a body. People would go to the marketplace to seek advice on how to treat their ailments. During the height of the empire, strict guidelines governed doctors’ fees and responsibilities in medical practice. There is also evidence from this period of child care and treatment of some diseases, but most care still took place in the home. By 1900 BC, the Hebrews had formed a nation along the Mediterranean and adopted many of the health practices of their neighbors. They integrated elements of the Egyptian sanitary laws to form the Mosaic Code of Laws which, as in many other cultures, mixed religion and medicine. Caring for widows, orphans, and other strangers in need was part of daily life. Hebrews had good knowledge of anatomy and physiology, especially the circulatory system. Physician-priests routinely performed operations such as cesarean deliveries (named later by the Romans), amputations, and circumcisions. They also enforced rules of purification, performed sacrifices, and conducted rituals related to food preparation.

Understand the influence of Hippocrates. How did he change medicine? How are his teachings

relevant today?

The Father of Medicine Ancient Greek culture focused on appeasing the gods, and its medical practice was no exception. The god Apollo was devoted to medicine and good health. The Greeks performed sacrifices to appease the gods and practiced abortion and infanticide in an attempt to control the population. People took hot baths at spas to improve health, but the sick and injured were cared for at clinics. Although women were held in high esteem, they were not permitted to provide any health care outside the home. Around 400 BC, the writings of Hippocrates began to change medical practice in Greece. One of a roving group of physician-priests, Hippocrates was called “the father of medicine.” His beliefs focused on harmony with the natural law instead of on appeasing the gods. He emphasized treating the whole client —mind, body, spirit, and environment—and making diagnoses on the basis of symptoms rather than on an isolated idea of a disease. He was also concerned with ethical standards for physicians, expressed in the now-famous Hippocratic Oath. (See http://www.medterms.com/script/main/art.asp? articlekey=20909 for a copy of the oath.)

Understand the influences of nursing through the centuries: religion, science, war,

industrialization.

Health Care in the Roman Empire Ancient Romans clung to superstitions and polytheism as the foundations for medical and religious practices. The dominant Roman Empire ruled from around 290 BC and absorbed useful elements of whatever culture it conquered—including the Greeks and Hebrews. The Romans developed quite an advanced system of medicine and a pharmacology that included more than 600 medications derived from herbs and plants. Roman physicians were eventually able to distinguish among various conditions and performed many surgeries. They also did physical therapy for athletes; diagnosed symptoms of infections; identified job-related dangers of lead, mercury, and asbestos; and published medical textbooks. The Romans’ advances in creating an unlimited supply of clean water through aqueducts were critical in maintaining the good health of the citizens, as were central heating, spas and baths, and more advanced systems for sewage disposal. Because the great Roman armies were so crucial to the empire, they developed early hospitals to care for sick and injured soldiers. These were mobile and were staffed by female and male attendants who performed duties that would today be thought of as nursing care:

Cleaning and bandaging wounds, feeding and cleaning clients, and providing comfort to the wounded and dying. In many ways, women enjoyed an equal place in society, and they provided home health care and midwifery. Early Efforts at Nursing Although caring for the ill and injured had become an established element in most early societies, the concept of a special group to provide this care evolved some time later. The concept of “nurse” grew primarily from the care provided by Christian orders of nuns who were solely dedicated to the care of the sick and dying. Even today, these early roots are reflected in Great Britain, where nurses are still referred to as “sisters.” The Sanctity of Life The rise of Christianity, starting from AD 30, brought with it a strong belief in the sanctity of all human life. Christians considered practices such as human sacrifice, infanticide, and abortion—which had been common in Roman society—to be murder. Following the teachings of Jesus meant that caring for the sick, poor, and disadvantaged was of primary importance, and groups of believers soon organized to offer care for those in need. Early writings of the Christian period record women's important role in ministering to the sick and providing food and care for the poor and homeless. Wealthy Roman women who had converted to Christianity established hospital-like institutions and residences for these caregivers in their homes. The term nurse is thought to have originated in this period, from the Latin word nutrire , meaning to nourish, nurture, or suckle a child. The majority of care was still provided by a family member in the home. Most early Christian hospitals were roadside houses for the sick, poor, or destitute who were cared for by male and female attendants alike. The attendants learned from a process of trial and error and from observing others. A Time of Disease The Dark Ages, from roughly AD 500 to 1000, were marked by widespread poverty, illness, and death. Plagues and other diseases such as smallpox, leprosy, and diphtheria ravaged the known world and killed large segments of populations. Health care at this time was almost nonexistent. However, the strong beliefs of the Catholic Church, which was based in Rome, produced monasteries and convents that became centers for the care of the poor and the sick. By AD 500, there were several

religious nursing orders in what is today England, France, and Italy. Men and women worked there and also traveled to rural areas where they were needed, combining religious rituals with home remedies and providing treatments such as bandaging, cautery, bloodletting, enemas, and leeching. The biggest contribution to health care in this period may have been the insistence on cleanliness and hygiene, which lessened the spread of infections. Medieval nurses did not have any formal schooling but learned through apprenticeships with older monks or nuns. Eventually hospitals came to be built outside of monastery grounds. Secular orders were also established, which could provide a wider range of services to the sick because they were not limited by religious restrictions and obligations. “The term nurse is thought to have originated in this period, from the Latin word nutrire, meaning to nourish, nurture, or suckle a child.” Early Military Hospitals At the end of the Dark Ages, there was a series of holy wars and invasions, including the Crusades, which produced many sick and injured who were far from home. Military nursing orders developed to care for the soldiers, but these were made up exclusively of men who wore suits of armor to protect themselves and their hospitals against attacks. These orders, with the emblem of the Red Cross, were extremely well organized and dedicated, and they existed well into the Renaissance. Development of the Modern Nurse It is hard to argue with the fact that technology and scientific advancements have changed the way nurses practice in today's society. However, technological advancements both solve and create problems. Nurses have proven themselves to be highly resourceful in dealing with issues related to technology. Current society readily accepts technology and scientific breakthroughs; however, earlier religion-based societies had more difficulty moving forward with these developments, which were sometimes seen as works of Satan. The Renaissance developed into a battle between progressive thinkers and a very conservative governance structure that resisted change. Health Care in the Renaissance In the intellectual reawakening of the Renaissance in Europe, starting in about 1350, nursing emerged in a recognizable form, although it did not grow steadily as a profession during this period. Inventions from this time include the microscope and thermometer, but the use of more modern diagnoses and treatments was viewed with skepticism. Monastic hospitals still regarded the restoration of health as secondary to the salvation of the soul. Major political changes initiated by the Protestant Reformation in 1517 had the

greatest effect on the health care of the period. In Catholic nation-states, including Italy, France, and Spain, health care remained generally unchanged from that of the Middle Ages, although the number of male nursing orders gradually decreased. By 1500, the majority of health care was provided by female religious orders. A Nursing Hierarchy In the nation-states that broke away from the Catholic Church, such as England, Germany, and the Netherlands, health care soon degenerated to a condition even worse than that of the Middle Ages. The role of women was reduced under Protestant leadership, and the male nurse all but disappeared. Secular nursing orders gradually took over the duties of the many substandard hospitals that had been established in metropolitan areas. The most famous of these was the Sisters of Charity, established in 1600. These orders were the first to establish a nursing hierarchy. Primary nurses were called sisters, and those assisting them were called helpers and watchers. At this time, people began to recognize the benefit of skilled nursing care. The first nursing textbooks appeared, and the use of midwives became widespread. Although hospitals were gaining importance, most clients still received health care at home. The Industrial Revolution (1760–1840) caused a flood of people throughout Europe to move from rural areas into cities, and cramped living situations caused very bad health conditions and the spread of disease and plagues. Factory owners supported some forms of health care to keep their workers on the job, and this led to an early form of community health nursing. The Sisters of Charity expanded their care to include home care. Only a few male nursing orders survived the Protestant Reformation and Industrial Revolution. Several non-Catholic nursing orders were founded, including the one by the famous Quaker, Elizabeth Fry, who established the Society of Protestant Sisters of Charity in London in 1840, which provided training to nurses who cared for the sick and poor, including prisoners and children. NURSING IN THE UNITED STATES Five hospitals existed in America before the Revolutionary War that housed the homeless and the poor and included rudimentary infirmaries. However, there were no identifiable groups of nurses for these infirmaries.^2 Health care in America at this time reflected that of the European countries from which the settlers had come. Infant mortality rates were very high, ranging between 50 and 75 percent. One of the first schools of nursing was established in 1640 by the Sisters of St. Ursula in Quebec, and Spanish and French religious orders would establish hospital-based training schools in the New World over the next 100 years.

In Colonial Times During the Revolutionary War, there was no organized medical or nursing corps, but small groups of untrained volunteers cared for the wounded and sick in their homes or in churches or barns. In 1751, Benjamin Franklin founded Pennsylvania Hospital, the first U.S. hospital dedicated to treating the sick. Between the Revolutionary and Civil Wars, health care in the United States increased markedly with the influx of religious nursing orders from Europe. More early schools of nursing developed at this time. Despite the rapid increase in the number of hospitals, most nursing care was still given at home by family members. Hospitals were considered a last resort and still had very high mortality rates. When the States Went to War The Civil War caused more death and injury than any war in the history of the United States, and the demand for nurses increased dramatically. Women volunteers (as many as 6000 for the North and 1000 for the South) began to follow the armies to the battlefields to provide basic nursing care, although many of them were untrained. Navy Nurses, the American Red Cross, and the Army Nurse Corps all date from this period. Large numbers of women came out of their homes to work in the hospitals, and a number of African American volunteers in the North paved the way for others to enter the health-care field in the future. Technological developments in the 19th century included medications such as morphine and codeine for pain and quinine to treat malaria. The arrival of 30 million immigrants in this century meant that the need for health care increased accordingly. Hospitals sprang up, and many instituted their own schools of nursing. Still, home care was the preferred type of nursing. After 1914 Nursing and nurses still had a very negative image prior to the beginning of World War I. Their primary duties were to carry out the orders of physicians, clean, cook, and empty bedpans. Most of the duties carried out by physicians would fall well within the current-day scope of practice for nurses. However, in the face of the large numbers of injured produced in World War I, nurses’ roles rapidly expanded and they began to be recognized for their skills in providing care and saving lives. Untrained Nurses At the beginning of World War I, there were only about 400 nurses in the Army Nurse Corps, but by 1917, that number had swelled to 21,000. Because many hospitals were recruiting untrained women to

provide basic care, a committee on nursing was formed to establish standards, and eventually the Red Cross began a training program for nurse's aides. This was supported by physicians but opposed by many nursing leaders who were concerned that it relegated nursing to “women's work,” which would be seen as something anyone could do with minimal training. Because nurse's aides were a cheap source of labor, they began to replace more trained nurses in hospitals. Unfortunately, this also resulted in a lower quality of care. “Medieval nurses did not have any formal schooling but learned through apprenticeships with older monks or nuns.” Between Wars After the war, a segment of the nursing profession began to focus on improving the educational standards of nursing care. At the time, 90 percent of nursing care was still given at home, but nurses began to practice in industry and in branches of government outside of the military. The standards of nursing care were low, and external quality controls were nonexistent. The Great Depression took its toll on health care and nursing, as jobs became scarce and many nursing schools closed. At this time, the federal government became one of the largest employers of nurses. The newly organized Joint Committee on Nursing recommended that jobs go to more qualified nurses and that the workday be reduced from 12 to 8 hours, although these measures were not widely implemented. During this period, hospitals became the primary source of health care, supported by hospital insurance programs. As the size of hospitals increased, more nursing jobs became available. Establishing Standards World War II produced another nursing shortage, and in response, Congress passed the Bolton Act, which shortened hospital-based training programs from 36 to 30 months. The new Cadet Nurse Corps established minimum educational standards for nursing programs and forbade discrimination on the basis of race, creed, or sex.^2 Many schools revised and improved their curricula to meet these new standards. To encourage more nurses to enter the military, the U.S. government granted women full commissioned status and gave them the same pay as men with the same rank. By the end of the war, African American and male nurses were also admitted to the armed services. Modern Times: Emerging Specialties

The single largest transformation of the practice of nursing occurred during World War II. Navy and army nurses had such a positive image that it attracted more volunteers than any other occupation at the time. Nurses were revered as selfless heroes under fire in several movies produced during the war. Even nurses captured by the Japanese were allowed to keep practicing because their role was so highly respected. On the battlefields and at rear area hospitals, they often worked together with untrained care providers and physicians, thus initiating the concept of a health-care team. A Team of Nurses The advancements in health care made during World War II required that nurses receive more highly specialized education to meet clients’ unique needs. After the war, many nurses left the profession to raise families, and the spaces were filled by graduates of new programs that trained licensed practical nurses (LPNs) and licensed vocational nurses (LVNs) in just 1 year. At this time, the concept of team nursing came to be widely accepted, although it removed the registered nurses (RNs) from direct client care, requiring them to serve as team leaders. A Growing Need Technical nursing programs, which granted associate degrees (associate degree nurse [ADN]) at 2-year community colleges, were developed to help with the nursing shortage. With the baby boom, the need for nurses continued to grow, and what had been a quick-fix solution began to take a stronger hold. By the mid-1960s, ADNs outnumbered the nurses with baccalaureate degrees (BSN) and the technical LPNs. Also, ADNs won the right to take the same licensing examinations as RN graduates from diploma and BSN programs. Still, as the health-care system became increasingly complicated, some nursing leaders questioned whether 1- or 2-year LPN and ADN programs were adequate to meet the needs of the profession. Slowly, the number of BSN programs and graduate-level programs began to increase. Vietnam: Traveling Hospitals The mobile army surgical hospital (MASH) units that had been developed during the Korean War were replaced during the Vietnam War with medical unit, self-contained transportable (MUST) hospitals, which were staffed by nurses and physicians. Some 5000 nurses served in this war, and for the first time, graduates of 2-year ADN programs were commissioned into the armed services. Several navy nurses were injured in the line of duty, and one army nurse was killed. The efforts of these and other women who served are recognized at the Vietnam Women's Memorial in Washington, dedicated in 1993.

Review the symbols of nursing and what they stood for: lamp, cap, pin

THE EVOLUTION OF SYMBOLS IN NURSING

All professions have symbols that are easily identified and connected with the work and services they provide. In the past, when most of the population was illiterate, these were helpful in distinguishing one professional from another. In modern society, the symbols connect the professions to their historical roots and provide the philosophical basis for the work they do. The Lamp The simple definition of a lamp is a device that provides a continuous source of light for an extended period of time. The first evidence of lamp use can be traced back to 10,000 BC, when a hollowed out stone with oil residue was found in a cave. Early variations on the oil lamp included seashell lamps and coconut lamps. Since then, technology has advanced lamps to clay bowls, pottery, and various types of metals. Pushing Back Darkness The significance of the lamp is really the significance of light. Its origins can be traced back to the first attempts of human beings to control fire and use it as a tool of survival. These early humans soon found that fire was a source of warmth on cold nights, kept wild animals from attacking, and was useful for cooking. Light, first in the form of torches and candles and later in the form of the oil lamp, has been used by human beings for thousands of years to push back the darkness of night. It dispelled fear and allowed people to pursue learning long after the sun went down. The lamp has long been used as a religious symbol. It often represents the eternal flame that dispels darkness and evil. Commonly found in Christian symbolism is the “Lady of Light,” often depicted as radiant and glowing brightly and filled with goodness, purity, and wisdom. The lamp can also represent the flame of life, eventually extinguished by death. As schools and universities developed during the Middle Ages, many adopted the lamp as a symbol of learning. The burning of the lamp signified the continual seeking of knowledge. It also symbolizes the enlightenment that accompanies knowledge. The coats of arms or logos used by many universities contain the image of a lamp.

A Sign of Caring The lamp was first introduced as a symbol for the nursing profession at the time of Florence Nightingale. In addition to her fame as an early health-care reformer and pioneer, she became well known for her role in caring for injured soldiers during the Crimean War. She made history when she took her 38 nurses to Turkey to try to improve the squalid, filthy conditions she found in the primitive British field hospitals. As Nightingale and her nurses made their night rounds, caring for the wounded in unlit wards, they carried oil lamps to light the way. For the wounded and suffering, these lamps became signs of caring, comfort, and often the difference between life and death. Nightingale's lamp was not the often-depicted “genie” or “Aladdin's” lamp. Rather, Nightingale would have used one of the many lamps in circulation around the wards, picking up whichever was closest at hand—an ordinary camp lamp or a Turkish candle lantern. She later became immortalized as the “lady with a lamp” in a poem written by Longfellow (“Santa Filomena”). In our modern society, oil lamps are sometimes used for atmosphere or nostalgic reminders of the past, although when the power goes out, they can be very handy. However, for graduate nurses, the lamp, or its close cousin the candle, retains its significance as a symbol of the ideals and selfless devotion of Florence Nightingale. It also signifies the knowledge and learning that the graduates have attained during their years in the nursing program. Even though the nursing graduates may not physically carry an oil lamp during pinning ceremonies, they symbolically carry the brightly burning lamp of their care and devotion as they minister to the sick and injured in their nursing practice. “The Civil War caused more death and injury than any war in the history of the United States, and the demand for nurses increased dramatically.” The Nursing Pin Unlikely as it may seem, the modern nursing pin can trace its origins to the heavy protective war shields used by soldiers as far back as the Greek and Roman Empires. The primary purpose of these shields was to protect the warriors from the spears, swords, and arrows of the opposing army. Adorned with the emblems of the soldier's country and his particular unit in the army, these ancient war shields also served as a quick way to distinguish friend from foe. During the Crusades, the Knights Hospitallers were formed to provide medical care for the wounded and sick. The Knights wore black tunics over their armor, carried no weapons, and wore a white Maltese cross on chains around their necks. Those wearing this cross became known for their skills in treating the injured and healing the wounded. Since that time, the Maltese cross has been recognized as a symbol of

those who care for the sick. Although large by today's standards, the Maltese cross is often considered the first true nursing pin. The shields of some medieval knights were painted with the coats of arms of the kings they were defending. Only the best knights, recognized for their skills in battle, strength, honesty, and dedication to the service of the king, were permitted to use the king's coat of arms on their shields. The coat of arms displayed to the world the characteristics by which the king wished to be known. A classic example is the symbol of the lion, found on the shields of the knights who served King Richard the Lionheart, which indicated the king's fearlessness and power. Similarly, during the Middle Ages when most of the population was illiterate, tradesmen and craft guilds began adopting symbols as pictorial representations of their services, skills, and crafts. Modern companies use trademarks and brand names in the same way today. Medieval schools and universities also began using symbols to represent their values and goals. The modern practice of “branding the university,” or adopting an official symbol or logo for the school, can be traced back to these early practices. These symbols were embossed on clothing, buttons, badges, and pins that were worn by members of the group. Also traceable to this time in history are the “shields” and badges worn by firefighters and law enforcement officers. Although these shields offer little in the way of protection from arrows and spears, they symbolize official authority and identify the wearer as belonging to a unique, specially trained group. The first modern nursing pin is attributed to Florence Nightingale. After receiving the medal of the Red Cross of St. George from Queen Victoria for her selfless service to the injured and dying in the Crimean War, Nightingale chose to extend the honor she had received to her most outstanding graduate nurses by awarding each of them a “badge of excellence.” The badge or pin she designed for her school is a deep- blue Maltese cross ( Fig. 2.1 ). In the center of the cross is a relief image of Nightingale's head. As the number of nursing schools increased, each program designed a unique pin to represent its own particular values, philosophies, beliefs, and goals. The pinning ceremony is part of a long tradition that acknowledges nursing graduates as belonging to a unique group and identifies them as new members of the health-care community. The historical origins of the pin remind nursing professionals of what it symbolizes. Like the badge worn by law enforcement officers, it is also a sign of their legal authority as licensed professionals. Nursing graduates wear their pins proudly in the work setting as evidence of their successful completion of the nursing program. The Cap

It is rare to see a nurse wearing the traditional “nursing cap” in today's modern hospitals. However, the cap has a long, rich history. Although it may seem sexist by today's standards, throughout much of history, women were required to keep their heads covered with some type of garment. This practice was prevalent in the early Hebrew, Greek, and Roman cultures that served as the roots for modern Western society and the current profession of nursing. A Symbol of Service The origins of what we identify as modern nursing can be traced back to an early Christian era group of women called deaconesses. Deaconesses were set apart from other women of the period by their white head coverings, which indicated that their primary service was to care for the sick. Originally this head covering was more like a veil that nuns wear, but after the Victorian era, it evolved into a cap. During the early centuries of Christianity, groups of deaconesses banded together and formed what later became the religious orders that were so prevalent in the Holy Roman Empire. The former deaconesses, now recognized as religious order nuns, remained the primary providers of care for the sick throughout the Middle Ages. The traditional garb of nuns, the long-robed habit with the wimple or veil, can be considered the first official nurse's uniform. Each religious order had its own unique style of habit and wimple. The order the nun belonged to could be easily identified from the habit or veil she was wearing. Religious orders continued to be the primary source of care for the sick well into the 19th century. However, as the Industrial Revolution progressed and the concept of the modern hospital developed, the care of the sick moved away from religious orders to care by laypeople who did not wear the nun's robe and veil. By the time Florence Nightingale trained at the Institute of Protestant Deaconesses in Germany, the veil had evolved into a white cap that signified “service to others.” However, Florence Nightingale lived and practiced nursing during the Victorian era, which required “proper” women to keep their heads covered. The nursing cap Florence Nightingale wore was similar to the head garb worn by cleaning ladies of the day. It was hood shaped with a ruffle around the face and tied under the chin ( Fig. 2.2 ). This early cap served multiple purposes. It met the requirements of the times for women to keep their heads covered; it kept the nurse's long hair, which was fashionable during the Victorian era, up and off her face; and it kept the hair from becoming soiled. A Cap for Every School In the United States, the first standardized nursing cap is generally attributed to Bellevue Training School in New York City around 1874. The cap's primary purpose was to keep the nurse's long hair from getting