Skip to main content
It looks like you're using Internet Explorer 11 or older. This website works best with modern browsers such as the latest versions of Chrome, Firefox, Safari, and Edge. If you continue with this browser, you may see unexpected results.

Introduction to Nursing (OER): Chapter 1

Influences on Contemporary Nursing Practice

 “And what nursing has to do…is to put the patient in the best condition for nature to act upon him” (Nightingale, p. 133, 1860).

In this chapter, students will learn:

  • how historical figures influence nursing practice
  • the impact of contemporary laws and healthcare policies on nursing practice
  • about nurse theorists who guide nursing practice

Historical Influences on Nursing Practice I

To fully appreciate nursing as both a science and art, this chapter reviews nursing history and describes how nurse pioneers shaped the profession. Originally, health care was provided by priests, monks, knights, nuns, family members, lay midwives. Contemporary nursing practice was developed by meeting the needs of various populations: wartime injuries, public health issues, sanitation, infection prevention, and maternal and infant mortality. 

The duties and responsibilities of nurses have evolved. In the 19th century, nurses were required to care for patients, maintain personal integrity, provide housekeeping duties, and work from 7:00 am to 9:00 pm (Archives of New Zealand, n.d.). The following quote is from a certificate awarded to Elizabeth Bregg at Wellington Hospital in New Zealand during that period (Archives of New Zealand, n.d.).

“You are required to be sober, honest, truthful, trustworthy, punctual, quiet and orderly, cleanly and
neat, patient, cheerful, and kindly. You are expected to become skillful – 

1. In the dressing of blisters, burns, sores, wounds; in applying fomentations, poultices, and 
dressings.
2. In the administration of enemas and the use of the catheter for women.
3. In the management of helpless patients, i.e., moving, changing, personal cleanliness of, 
feeding, keeping warm or cool, preventing and dressing bed sores.
4. In bandaging, making bandages and rollers, and lining splints.
5. To be competent to cook gruel, arrowroot, puddings, and drinks for the sick.
6. To understand ventilation or keeping the ward fresh by night as well as by day. You are to 
be careful that great cleanliness is observed in all the utensils, those used for the secretions 
as well as those required for cooking.
7. To make strict observation of the sick in the following particulars:
The state of excretions, expectorations, pulse, skin, appetite; intelligence, as delirium or stupor; 
breathing, sleep, state of wounds, eruptions; effect of diet or of stimulants and of medicines. 
To “take” the temperature and respiration.
8. And to learn the management of convalescence.”

Originally, nurses were not allowed to marry and were cloistered in dormitories on hospital grounds where they lived strictly disciplined lives (Weatherford, 2010). Students served as free labor, scrubbing floors, doing laundry, and other menial tasks.  Later, nursing education was transformed by strong leaders who introduced the nurse uniform and cap which became a respected symbol of high academic standards (Weatherford, 2010). Despite reforms in education, nurses and students continued to work long hours six days per week (Hurst, 2009). 

Florence Nightingale

Image of Florence Nightingale

Image source: CreativeCommons.com

Florence Nightingale was born on May 12, 1820, into a wealthy family who did not appreciate her desire to care for the sick and injured. She pursed her calling despite the negative social stigma attached to nursing. She enrolled as a nursing student at the German Institute of Protestant Deaconesses in 1850 and became a trailblazing figure who transformed 19th-century healthcare policies. After graduation, she returned to London and improved hospital hygiene practices and sanitation, which decreased the cholera death rate. In 1853 18,000 soldiers were in foreign hospitals during the Crimean War and were neglected and living in unsanitary conditions. The English government asked Nightingale to organize a corps of nurses and within three days, she recruited three dozen nurses and sailed for Constantinople. The military hospital sat on a large cesspool that contaminated the water and building. Using statistics, she discovered that the high rate of death was from infectious diseases rather than combat injuries. Nightingale and her nurses scrubbed floors, walls, beds, linens, and utensils.  She spent every waking moment caring for the soldiers and became known as “the lady with the lamp” who made constant rounds (Selanders, 2019).

Due to her efforts, the death rate was reduced by two thirds within six months. In the summer of 1856, Queen Victoria gave her an engraved brooch which became known as the Nightingale Jewell. She used her gift of $250,000 from the Queen to develop the Nightingale Training School for Nurses at St. Thomas Hospital in London (Biography.com, 2019a).

Image of a Graph developed by Florence Nightingale demonstrating mortality rates from battle versus non battle causes during the Crimean War.

Despite these successes, Nightingale contracted Brucellosis and was homebound by the age of 38. However, she continued to improve healthcare around the world through her writings. She elevated nursing from a lowly occupation to an honorable profession and became known a the first practicing nurse epidemiologist and an expert statistician. Her coxcomb pie charts on mortality rates influenced the direction of medical epidemiology around the world. In 1857, she published her Crimean War research which established the Royal Commission for the Health of the Army. In 1859, she published Notes on Hospitals which addressed administration issues. She served as a consultant in the United States Civil War on field hospital management and consulted with the Indian government on sanitation practices. 1907 she received the Order of Merit from King Edward and in 1908 was the first woman to receive the Freedom Medal of London. In 1910 King George sent a celebratory message on her 90th birthday (Biography.com, 2019a).

Nightingale’s most well-known book, Notes on Nursing: What it is and What it is Not (Nightingale, 1859) shaped contemporary nursing and much of its content remains relevant today. She stated that a nurse’s role “is to put the patient in the best condition for nature to act upon him” (Nightingale, p. 133, 1859). “If a patient is cold, if a patient is feverish, if a patient is faint, if he is sick after taking food, if he has a bedsore, it is generally the fault not of the disease but of the nursing” (Nightingale, p. 8. 1859). However, she recognized that environmental factors such as architecture, sanitation, and administration could render quality nursing care impossible. She also emphasized that the art of nursing should include careful therapeutic communication (Nightingale, 1860).

This video by a well-known nurse, Barbara Dossey, brings Nightingale’s insights to modern-day nursing: https://www.youtube.com/watch?v=mRAoD0-loWM. Miss Nightingale died on August 13, 1910, having lived 90 years.  Before her death, she refused a national funeral and was buried in her family plot in Hampshire England. For more information on this phenomenal nurse, and a look at her home, go to http://www.florencenightingale.org/.   

The English nurse Florence Nightingale was an innovator in displaying statistical data through graphs. In 1858 she devised the typed depicted here, which she named Coxcomb. Like pie charts, the Coxcomb indicates frequency by relative area, but it differs in its use of fixed angles and variable radii.

Image source: Encyclopedia Britannica  https://www.britannica.com/biography/Florence-Nightingale/media/415020/70822

 

Clara Barton

Image Source: National Women’s History https://www.womenshistory.org/education-resources/biographies/clara-barton

Clara Barton was born on December 25, 1821, and became interested in nursing while helping her brother after a severe head injury. She became a teacher at the age of 15 and opened a free public school in New Jersey. In the 1850's she moved to Washington, D.C. and worked as a clerk in the United States Patent Office. During the Civil War, she distributed supplies for the Union Army but was not content. She became an independent nurse and saw combat in Fredericksburg, VA. She cleansed wounds, comforted dying soldiers, and became known as the ‘Angel of the Battlefield’ (Michals, 2015).

She worked with the International Red Cross in Switzerland during the Franco-Prussian War. Upon return to the U.S., after ten years of lobbying, she founded The American Red Cross in 1881. As its first President, she guided the first relief work for victims of natural disasters such as floods and served in that capacity until 1904. She was an autocratic leader who took no salary and often used her own funds to finance relief efforts. She died on April 12, 1912 (Biography.com, 2019b).

 

Lavinia Dock

Image source: Wikipedia

Born on February 26, 1858, Lavinia Lloyd Dock was financially independent. She was inspired by an article to become a nurse and graduated from the Training School for Nurses in 1886 at Belview Hospital in New York. In 1889 she worked with Clara Barton in the Johnstown, Pennsylvania flood. In 1890, she published Materia Medica for Nurses as the first standard nursing textbook. She was appointed by Isabel Hampton Robb as Assistant Superintendent of Nurses at the new Johns Hopkins Hospital. In 1893 she organized the American Society of Superintendent Training Schools and the Nurses Association Alumni which is now known as the American Nurses Association (American Association for the History of Nursing [AAHN], n.d.a; Sklar, 2000).

In 1896 she joined other nurses at the Henry Street Settlement on the lower East Side of New York City and learned much about critical thinking while caring for a large immigrant population.  She developed a strong empathy for oppressed classes and worked for 20 years to transform public health delivery. In 1899 Dock and Ethyl Gordon Fenwick founded the International Council of Nurses. In 1907 she wrote The History of Nursing with Adelaide Nutting. In the same year, her political allegiance shifted from nursing to suffrage when she joined the Equality League of Self-Supporting Women (Sklar, 2000). 

In 1911, she opposed state regulation of prostitution and advocated for the treatment of sexually transmitted diseases. In 1917, she moved to Washington, DC and helped to establish the National Women’s Party and picketed the White House for which she was jailed three times. In 1921 she advocated for the Equal Rights Amendment and in 1947 was honored for her achievements by the international council of nurses. Dock died on April 17, 1956. (AAHN, n.d.a) 

 

Lillian Wald

Image of Lillian Wald, the nurse who started the Henry Street Settlement

Image Source: Wikipedia

Lillian Wald was born on March 10, 1867, to a privileged family of Jewish descent. She is considered one of the most influential and respected social reformers of the 20th century. As a gifted student, she applied to Vassar at the age of 16 but was refused due to her young age. She graduated from the New York Hospital School of Nursing in Manhattan in 1891. She later attended the Women's Medical College to become a physician where she accepted an opportunity to organize classes in-home nursing for immigrants on the Lower East Side of New York City. There she witnessed poor sanitation and living conditions. She left medical school to establish and live within the Nurses' Settlement which became known as the Henry Street Settlement. During this time, she established the first American public-school nursing program. In 1910, the Teachers College at Columbia University established a department of nursing and health where she was appointed as the first professor of nursing. Due to her efforts, most nursing education takes place in academic settings with hospital-based clinical experience (Henry Street Settlement, n.d.; Virginia Commonwealth University, n.d.).

In 1893 she stared the Visiting Nurses Service. Nursing care was provided along with social services and education on many subjects. In 1905 the group included 18 district centers and 4,500 patients. By 1913, the Henry Street Settlement had expanded to seven buildings and two satellite centers. There were 3,000 members and 92 nurses who made over 200,000 visits per year. Referrals came from physicians, individuals, and charitable organizations. Health education classes were offered, and the Boys and Girls Clubs of American were started. Wald coined the term, Public Health Nursing and placed nurses in public schools (Henry Street Settlement, n.d.; Encyclopedia Britannia.com, n.d.).

During World War 1, Wald formed the American Union Against Militarism to combat the war. She and others lead a march of 1,000 women in New York to protest the war. She was a member of the Women’s Peace Party and later created the Women’s International League for Peace and Freedom. She worked with Margaret Sanger on the right for women to have birth control and served in the American Red Cross. She also lobbied for safe industrial workplaces (Encyclopedia Britannia.com, n.d.). Wald authored The House on Henry Street and Windows on Henry Street. 

She received the Lincoln Medallion as an outstanding citizen of New York and was named one of the twelve greatest living American women by the New York Times. In summary, Wald was known as a courageous national leader who campaigned for social reform, public health, and human rights. She influenced and helped to establish the National Association for the Advancement of Colored People, the United States Children’s Bureau, the National Child Labor Commission, and the National Women’s Trade Union and League (Virginia Commonwealth University, n.d.). Wald died on September 1, 1940, at the age of 73. 

 

Isabel Hampton Robb

 Image Source: Medical Archives of the Johns Hopkins Medical Institutions

Isabel Hampton Robb was born on August 26, 1859, in Ontario, Canada. She graduated from the Belview Training Hospital for Nursing in 1883 and worked at St. Paul’s House in Rome, Italy which served American and European travelers. In 1886, she was appointed Superintendent for the Illinois Training School for Nurses at Cook County Hospital in Chicago. There she implemented a grading scale for nurses to prove competencies in nursing practice.  She also developed the curriculum for Lakeside Hospital which became Case Western and was the first to include teachings of Florence Nightingale (AAHN, n.d.b; Case Western Reserve University, n.d.).

She became the first Superintendent at Johns Hopkins School of Nursing in 1889. In 1893 she published Nursing: It’s Principles and Practices which guided nursing curricula over three years. This text included economics, proper hygiene, protocols for bacteriological notes, and proper bed-making and standardized nursing education in the United States and abroad (Medical Archives of the Johns Hopkins Medical Institutions [MAJHM], n.d.).   

Hampton and Dock founded the American Society of Superintendents of Training Schools for Nurses in the United States and Canada which later became the National League for Nursing (Medical Archives of the Johns Hopkins Medical Institutions, n.d.).  In 1896 she became the first president of the American Nurses Association formerly known as the American Nurses Association Alumni (MAJHM, n.d.).

Image of the first nursing class from John Hopkins University with Isabel Hampton Robb

In 1899 Robb helped to establish the American Journal of Nursing and developed a course in hospital economics at Teachers College at Columbia University. Robb, Hampton, Dock, and Nutting were the first professors to teach the course. In 1900 she authored Nursing Ethics and in 1907 Educational Standards for Nurses. She died in 1910 in a tragic streetcar accident (MAJHM, n.d.). She was later inducted into the American Nurses Association Hall of Fame (American Nurses Association, n.d.).

 

 

 

Image Source: Wikipedia. The first nursing class of Johns Hopkins Hospital.

Mary Mahoney

Image of Mary Mahoney, the first African American nurse.

Image Source: Wikipedia

Mary Mahoney was born on May 7, 1845. She began working as an untrained practical nurse at the New England Hospital for Women and Children. She served as a cook, a janitor, and washerwoman until she became the first black woman to graduate from the hospital's nurse training program. She was also one of the three students to graduate from a class of 40 where sixteen-hour days were considered the norm (Hurst, 2009). She was one of the first black members of the Nurses Association Alumni of the United States and Canada and the National Association of Colored Graduate Nurses. She worked as a private duty nurse for prominent Boston families and in 1900 she served as the Superintendent of Howard Orphan Asylum for Black Children in New York (Biography.com, n.d.).

Mahoney is credited as one of the first women to register to vote in Boston. She died on January 4, 1926. She was inducted into the Nursing Hall of Fame in 1976 and was added to the National Women’s Hall of Fame in 1993 (Hurst, 2009).

 

Mary Adelaide Nutting

Image of Mary Adelaide Nutting, nursing supervisor at John Hopkins

Image Source: Wikipedia    

Mary Adelaide Nutting was born on November 1, 1858, in Quebec, Canada. She was a student in the first class of Johns Hopkins Hospital School of Nursing. After graduation, she became a head nurse and was later promoted to Assistant Superintendent. In 1894 she promoted to Superintendent and Principal of the School of Nursing by Isabel Hampton Robb. She worked to transform nursing education where students worked 60-100 hours per week. She changed priorities, removed stipends, expanded curriculum from two to three years, and provided scholarships for needy students (Encyclopedia Britannia, 2019).

While at Johns Hopkins Hospital School of Nursing, Nutting created multiple courses including hospital economics where she taught part-time until 1907. She also developed a six-month preparation course in hygiene, elementary practical nursing, anatomy, physiology, and pharmacology to prepare students for hospital ward work and established the professional library at Johns Hopkins. She was the first nursing professor at Columbia and served as the head of the nursing department until retiring in 1925. Her course in hospital admin, nursing education, public health brought the college international recognition (MAJHM, n.d.).

In 1900 she helped to establish the American Journal of Nursing.  In 1934 she became the honorary president of the Florence Nightingale International Foundation. In 1944 she was the first recipient of the National League for Nursing award titled the Mary Adelaide Nutting Medal.  Before her death on October 3, 1948, she authored several books including The Education and Professional Position of Nurses which reported her research on U.S. schools of nursing (Encyclopedia Britannia, 2019).

 

Mildred Montag

Image Source: Teachers College Columbia University

Mildred Montag was born on August 10, 1908, and died on January 21, 2004. She received a baccalaureate in nursing from the University of Minnesota and a Master of Nursing and Ph.D. from Teachers College Columbia University. She held numerous prestigious tenured positions at St. Luke’s Hospital School of Nursing and Adelphi University (Teachers College Columbia University, 2004).

Her influence on nursing education in the United States and abroad was primarily due to her focus on elevating nursing as a profession. To address the serious nursing shortage caused by World War II, she redefined nursing education by moving programs into community and junior colleges. Before her work, 85% of the nursing curriculum was designed by physicians and hospitals. This evolutionary step moved students into an academic model, which spread across the nation. In 1958 the William W. Kellogg foundation financed pilot programs in seven community colleges across four states. By 1994 there were 868 Associate Degree Nursing programs (Harker, 2017).

The transformation of nursing education included specific sequences: course work, clinical laboratories, and academic preparation. Her work impacted the delivery of nursing care and licensure at various levels of preparation. Her goal was to ensure that patient care be given by well-educated nursing professionals (Harker, 2017). 

 

Other pioneers

Other less known nurses influenced contemporary nursing. Linda Richards was America’s first trained nurse, graduating from the New England Hospital for Women and Children (AAHN, n.d.c). She introduced narrative notes for physicians and nurses to improve clinical communication. Harriet Tubman provided independent nursing care (non-trained) during the Civil War to freed slaves as they journeyed north (Larson, n.d.).

Contemporary Influences on Nursing Practice

Contemporary nursing practice is influenced by multiple external forces that include healthcare laws, health policies, regulations, rising costs, supply of nurses, and changing population demographics. This section emphasizes the dynamic and evolving environment in which nurses work. As society, technology, and healthcare priorities change, the nursing profession changes to meet current needs. 

Healthcare laws and policies 

Healthcare laws have a substantial impact on nursing practice. For example, in 1965, the Social Security Act Amendments, known as Medicare, drastically increased access to healthcare for older adults.  Millions of Americans aged 65 and older gained healthcare insurance for hospital bills. This funding increased hospital admissions substantially (U.S. National Archives & Records Administration, n.d.). For more information, go to https://www.ourdocuments.gov/doc.php?flash=false&doc=99. 

The Prospective Payment System (PPS) was passed by Congress in 1983 and dramatically changed the way hospitals were reimbursed for care. Instead of payment for every medication, supply, and treatment, hospitals were paid a set fee for conditions known as diagnostic related groups (DRGs). When patients were sent home early, hospitals made a profit; however, if a patient needed extensive care, hospitals lost money. This law resulted in new forms of health organizations called prospective payment organizations discussed in Chapter 4. 

Later, the Medicare funding for home health care by skilled nurses drove many nurses into community settings and helped millions of patients at home and out of nursing homes (U.S. Department of Health and Human Services, 2017). For more information go to https://www.medicare.gov/sites/default/files/2018-07/10969-medicare-and-home-health-care.pdf 

The Patient Protection and Affordable Care Act (ACA) of 2010 increased access to healthcare for millions of Americans and changed how care is delivered and prioritized. Wellness and preventive services were added along with a mandate that mental/behavioral healthcare be provided on par with medical care. The law was also designed to promote quality and efficiency in the healthcare system and is currently undergoing substantial changes. However, a key benefit was funding for nurse-based clinics to provide care for underserved populations (Healthcare.gov, n.d.). For more information, go to https://www.healthcare.gov/glossary/affordable-care-act/. 

Health policies are decisions and plans made by governments and agencies to achieve healthcare goals within a society or nation. Usually, a group of legislators and healthcare professionals meets over several months or years to define a vision for the future, establish long-term goals, and short-term benchmarks. The resulting document outlines priorities and expectations for healthcare professionals and funding sources. Over time consensus is built and people are informed through health education initiatives (World Health Organization, n.d.). 

The impact of policy on population health can be drastic. For example, when Florence Nightingale implemented sanitation practices, the rates of infection in wounded soldiers dropped. Some modern health policy changes include anti-smoking campaigns to reduce disease, mammogram screening for early detection of breast cancer, and the Back to Sleep campaign to prevent sudden infant death syndrome. A major initiative by the U.S. government titled Healthy People 2020includes forty-two topic areas and more than 1,200 objectives to improve health for all Americans (Office of Disease Prevention and Health Promotion, n.d.). Topics include the following: preventive care, environmental quality, injury, violence, maternal, infant, child, mental health, nutrition, physical activity, obesity, oral health, reproductive and sexual health, social determinants, substance abuse, tobacco use, and access to care. These national goals strive to overcome health disparities and challenges such as coronary heart disease and stroke.  For more information on this collaborative work go to https://www.healthypeople.gov/2020/Leading-Health-Indicators. 

Nurses are involved in health policy at all levels – global, national, state, and local. As one of the largest groups of healthcare workers, nurses have tremendous potential to inform policies that influence how care is delivered at the point of care. Nurses think “upstream” to solve healthcare issues. Additionally, to focus on the constant stream of patients at the point of care, nurses look for root causes – such as why patients are becoming ill and then work to solve the causative problem. Nurses educate the public, policy planners, and decision-makers so that prevention becomes a key component of healthcare. Nurses know that “Being silent provides an unspoken endorsement of the status quo” and allows others to influence nursing care (Patton, Zalon, and Ludwick, p. 6, 2015).  

  Health disparity and vulnerable populations 

The Code of Ethics for Nurses states that nurses should have a persistent commitment to social justice and the welfare of the sick, injured, and vulnerable in society (Fowler, p. xvi, 2015). However, nurses care for vulnerable populations that do not have equal access to healthcare. Health equity is the “attainment of the highest level of health for all people” (Office of Disease Prevention and Health Promotion, n.d.). For more information, go to https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities. 

Access to healthcare has a profound effect on all aspects of health. When a person lacks funds or the ability to seek routine care, conditions can worsen or become disabling. Waiting to treat diseases can lead to large medical bills, absence from work or school, and lengthier recovery times. Lack of access can stem from unemployment, underemployment, mental illness, lack of transportation, or homelessness (Lenart, 2017). Persons living in rural settings often have fewer resources than persons living in urban settings where healthcare facilities are abundant. Global access to healthcare is also unequal since underdeveloped nations often have far fewer recourses than developed countries.  

Health disparities are differences between the number of persons who have diseases or conditions in various populations. For example, one group might have a lower rate of high blood pressure than another group of people. The cause for this difference might be genetics, ethnicity, gender, age, cultural dietary habits, socioeconomic issues, geography, access to healthcare, or any combination of these factors. The Agency for Healthcare Quality and Research (AHRQ) monitors healthcare disparity and quality through evaluation of over 250 indicators. The most recent AHRQ report (AHRQ, 2017) indicates that access to care in the U.S. varied by state. If patients do not have access to care, then quality cannot be measured.  To learn more about quality improvement measures in healthcare, go to https://www.ahrq.gov/research/findings/ nhqrdr/nhqdr17/ index.html. 

The Code of Ethics for Nurses states that the nursing profession has a persistent commitment to social justice and the welfare of the sick, injured, and vulnerable in society (Fowler, p. xvi, 2015). Therefore, nurses adjust care to meet the needs of persons in various populations using evidence-based data about each group. For example, a nurse caring for an elderly patient who lives in a rural county without home care services would adjust discharge plans based on limited resources. The nurse might teach the patient or family how to perform a procedure because a referral is not available. Therefore, when resources are limited, nurses use critical thinking and creativity to provide quality care and promote the best possible outcomes. 

Rising Healthcare Costs 
According to the National Health Expenditure Projects for 2018-2027, healthcare costs are projected to rise by 5.5% annually and will most likely grow 0.8% faster than the Gross Domestic Product (GDP) (Centers for Medicare & Medicaid Services, n.d.). For more information go to  https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/ForecastSummary.pdf.  These rising healthcare costs will impact nursing practice by influencing decisions made about staffing, supplies, access to care, and prioritization of services. Additionally, patients will make decisions about adherence to healthcare recommendations based on ability to pay. The healthcare industry has a history of being service-oriented, but in recent years has moved toward a business model that can cause tension between staff and management (Potter, Perry, Stockert, and Hall, 2017). 

 Supply and demand of nurses 

The supply of nurses waxes and wanes over time nationally and globally. Over three million nurses make up the largest portion of the U.S. healthcare workforce (American Association of Colleges of Nursing [AACN], 2017). The Bureau of Labor Statistics website projects that 203,700 more nurses will be needed each year through 2026 due to the need for new positions and the number of retiring nurses (https://www.bls.gov/careeroutlook/2018/ article/bachelors-degree-outlook.htm#Healthcareandscience). Despite this need, over 75,000 qualified applicants were not admitted to nursing programs in 2018. This discrepancy in addressing the problem is due to shortages of nursing faculty, clinical sites, preceptors, and funding (AACN, 2017).  

In summary, phenomenal nursing leaders set a strong foundation for modern nursing while current healthcare policies continue to shape the profession. Today, nurses must remain active in determining the standards of nursing practice. Next, the impact of current nursing theorists is discussed. 

Theoretical Influences on Nursing Practice

Nurses study scientific theories to guide critical thinking in nursing practice. Theories provide insights into how nurses should perform work, evaluate health outcomes, and derive meaning from the nurse-patient relationship. 

Definition, scope, attributes, criteria 

A theory is a set of ideas that provides a systematic view of facts to guide clinical decision making. Theories help explain and predict processes. Nursing theories guide nursing practice by providing a unique view of the nurse-patient relationship within healthcare settings. For example, in rehabilitation settings, nurses might use a coaching model to do less for a patient so s/he can master a skill. However, a dying patient may be helped with many simple tasks to provide comfort and reduce pain. 

Theories can be categorized as grand, mid-range, and practice (Potter, Perry, Stockert, and Hall, 2017). The grand theories are broad, complex, and not specific to practice areas. The mid-range theories focus on a concept such as self-care or caring. Practice theories are narrower and guide specific settings or protocols. Theories can also be labeled as descriptive or prescriptive. Descriptive theories explain concepts such as developmental tasks while prescriptive theories offer specific guidance to produce expected outcomes.  

Many theorists describe ways to care for the whole person – body, mind, emotions, and spirit, and most nursing theories offer guidance on four concepts: nurse, patient, health, and environment (Potter, Perry, Stockert, and Hall). The way these factors interrelate make a difference in how the nurse thinks about and delivers care. Each nurse theorist uses assumptions about persons, nurses, health, and environments best suited for the theory. 

How nursing theories guide practice 

Each nurse has a “way of being” a nurse and may or may not be aware of habitual ways of thinking and interacting. Expert nurses are aware of their habits and can override them as needed to best care for individual patients in various settings. Every nurse develops a personal philosophy of nursing that guides daily practice and should be flexible enough to change favorite interaction styles to meet the needs of a person in crisis, a person in denial, or a person in need of firm coaching. During a long career, nurses might use several theories to guide practice but use one that rings true most of the time. Nursing theorists have various ideas about nurses, patients, health, and the environment. The way these factors interrelate make a difference in how the nurse thinks about and delivers care. Nurses’ personal beliefs and values influence how they deliver care to others: 

  • Privacy, preservation of dignity, and confidentiality 
  • When, where, and how to help 
  • Prioritization of patient preferences 

Nursing theories guide nurses toward patient-centered care that is influenced by the patient’s preferences and needs, the situation, the environment, and the nurse’s ability to provide care. Individual nurses make choices regarding nursing practice based on the most current evidence. Expert nurses adjust habitual practices to provide patient-centered care. For example: 

  • In rehabilitation settings, the nurse often takes on the role of a health coach, encouraging the patient to obtain the highest level of wellness possible 
  • In hospice settings, the nurse uses comfort measures to minimize pain and discomfort at the physical, mental, emotional, and spiritual levels.  
  • In settings were mental/behavioral health issues becoming challenging, the nurse maintains strong boundaries and offers dignity and respect and provides a safe environment. 

Historical and modern nursing theorists 

Below is a sample of nurse theorists who shape and guide the profession. For more information on each theory go to http://currentnursing.com/nursing_theory/nursing_ theorists.html: 

  • Patricia Benner - From Novice to Expert 
  • Virginia Henderson - Need Theory 
  • Katharine Kolcaba - Comfort Theory 
  • Madeleine Leininger -Transcultural nursing 
  • Betty Neuman - System model 
  • Florence Nightingale - Environment theory 
  • Dorothea Orem - Self-care theory 
  • Hildegard Peplau - Interpersonal theory 
  • Martha Rogers -Unitary Human beings 
  • Sister Calista Roy - Adaptation theory 
  • Jean Watson - Philosophy and Caring Model 
  • Ernestine Wiedenbach - The Helping Art of Clinical Nursing  

 

NURSING PHILOSOPHIES   Source: http://currentnursing.com/nursing_theory/introduction.html

Theory

Key Points

Florence Nightingale: Legacy of caring

  • Focuses on nursing and the patient environment relationship.

Ernestine Wiedenbach: The helping art of clinical nursing

  • The helping process meets needs through the art of individualizing care.
  • Nurses should identify patients ‘need-for –help’ by:
  • Observation
  • Understanding client behavior
  • Identifying the cause of discomfort
  • Determining if clients can resolve problems or have a need for help

Virginia Henderson: Definition of Nursing and Need Theory

  • Patients require help toward achieving independence.
  • Derived a definition of nursing
  • Identified 14 basic human needs on which nursing care is based. 

Jean Watson: Philosophy and Science of caring

  • Caring is a universal, social phenomenon that is only effective when practiced interpersonally considering humanistic aspects and caring.
  • Caring is central to the essence of nursing.

Patricia Benner: Novice to Expert

  • Described systematically five stages of skill acquisition in nursing practice – novice, advanced beginner, competent, proficient and expert.

CONCEPTUAL MODELS AND GRAND THEORIES

Dorothea E. Orem: Self-care deficit theory 

  • Self–care maintains wholeness; three theories within one nursing theory: Theory of self-care, theory of self-care deficit, and theory of nursing systems
  • Nursing Care is provided along three dimensions: Wholly compensatory (doing for the patient), partly compensatory (helping the patient do for himself or herself); supportive- educative (Helping patient to learn self-care and emphasizing on the importance of nurses’ role

Martha E. Roger’s: Science of unitary human beings

  • Person and environment are energy fields that evolve negentropically
  • Nursing is a basic scientific discipline
  • Nursing is using knowledge for human betterment.                 
  • The unique focus of nursing is on the unitary or irreducible human being and the environment (both are energy fields) rather than health and illness

Sister Callista Roy:  Adaptation model

  • Stimuli disrupt an adaptive system
  • The individual is a biopsychosocial adaptive system within an environment.
  • The individual and the environment provide three classes of stimuli-the focal, residual and contextual.                                   
  • Through two adaptive mechanisms, regulator and cognator, an individual demonstrates adaptive responses or ineffective responses requiring nursing interventions 

Betty Neuman: Health care systems model

  • Neuman’s model includes intrapersonal, interpersonal and extrapersonal stressors.
  • Nursing is concerned with the whole person.  
  • Nursing actions (Primary, Secondary, and Tertiary levels of prevention) focuses on the variables affecting the client’s response to stressors.

Hildegard Peplau: Psychodynamic Nursing Theory

  • Interpersonal process is maturing force for personality. Stressed the importance of nurses’ ability to understand own behavior to help others identify perceived difficulties.
  • Interpersonal processes alleviate distress. The four phases of nurse-patient relationships are: Orientation, identification, exploitations, resolution
  • The six nursing roles are: Stranger, resource person, teacher, leader, surrogate, counselor

Katharine Kolcaba’s Theory of comfort

  • Comfort is desirable holistic outcome of care.
  • Health care needs are needs (physical, psycho spiritual, social and environmental needs) for comfort, arising from stressful health care situations that cannot be met by recipients’ traditional support system.
  • Comfort measures include those nursing interventions designed to address the specific comfort needs.

Madeleine Leininger’s Transcultural nursing, culture-care theory

  • Caring is universal and varies transculturally.
  • Major concepts include care, caring, culture, cultural values and cultural variations
  • Caring serves to ameliorate or improve human conditions and life base.
  • Care is the essence and the dominant, distinctive and unifying feature of nursing

Summary

In this chapter, students learned about: 

  • historical influences on nursing practice 

  • contemporary influences on nursing practice 

  • theoretical influences on nursing practice 

Key Terms

  • Agency for Research and Quality in Healthcare (AHRQ) 

  • Environment 

  • Florence Nightingale 

  • Health 

  • Health disparity 

  • Health equity 

  • Health policy 

  • Healthy People 2020 

  • Henry Street Settlement 

  • Nurse 

  • Patient 

  • Patient Protection and Affordable Care Act (PPACA) 

  • Theory 

  • Vulnerable populations 

Web Resources

Floyd Library - 706.295.6318 | Heritage Hall - 706.295.6321 | Cartersville Library - 678.872.8400 | Marietta - 678.872.8501 | Paulding Library - 678.946.1007
©2015 Georgia Highlands College | ask@highlands.libanswers.com