Honors Project 1

Running Head: Honors Project

Foundations Honors Project Spring 2007

Jennifer I Hendrix

Pittsburg State University

NURS300 Foundations of Nursing Practice

Instructor: Dr. C Giefer

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Abstract

Nursing is an evidenced-based profession focused on the community welfare on an

individual bases. The foundations of nursing practice list it as both an art and a science

with the primary goal the promotion of quality of life throughout the life cycle as it

relates to the individual.

Providing information to the growing needs and the changes made to nursing are the

many books and journals made available to the interested. The contents of this paper are

literature review regarding topics covered as they relate to foundations of the nursing

practice. Included in this review are historical perspectives, professional standards,

critical thinking, caring through the life span, clients with special needs, and the scientific

and psychosocial bases of nursing. Twenty-four articles were used for this research with

at least three articles in each of the seven categories.

The context of the articles in some instances overlap into other categories. This is a

general representation of nursing and how the holistic training experience encompasses

all aspects of care in an overlapping format.

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Foundations Honors Project Spring 2007

Historical Perspectives

Nursing is alive in the present because of the past people and adjustments necessary to

keep it in the times. A look at the metamorphosis though out the history of this profession

gives great insight to how and why the evolvement developed. This evolution still

incorporates much of nursing past. Mannino (n.d.) offers insight into the study of nursing

past. He implies, however, that the study of the past should begin with the present

happenings of nursing so there will be an appreciation of the influence of the past events.

Technological advancements have significant impact in the development of nursing.

Sandelowskli (2000) reminds of the entrance of the mercury thermometer that brought

science to the beside in the late 19th century. “Yet the time required to take and record the

temperatures of many patients, and the maintenance of this delicate instrument, impeded

physicians’ use of it. Accordingly, much of thermometry work, featured in the first

American nursing texts in the 1870’s, was soon delegated to nurses. Nurses became

closely linked with thermometry, obtaining accurate temperatures, maintain accurate

records, and ensuring the cleanliness of the thermometers. Nurses were even encouraged

to think of themselves as thermometers, alert to any changes in the ward atmosphere.”

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This advancement was an “early manifestation of functional nursing, assigning one nurse

to complete a task with all patients.” Prior to the thermometer and other developments,

the nurse may just be assigned on a per patient basis. Today even the mercury has been

discarded for the faster electronic oral and tympanic thermometers.

Critical Thinking in Nursing Practice

“Clinical judgment is viewed as an essential skill for every nurse and distinguishes

professional nurses from those in a purely technical role.” (Lasater, 2007 from Cole,

2002). The transformation from student to professional is the ability to reason as a nurse.

The interpretation of the clients’ wellbeing and the nurses’ reaction are essential for

successful outcomes. Four phases to developing and maintain clinical judgment include:

noticing what is happening with the client (signs/symptom analysis), interpreting the

data, responding appropriately to the clients needs, and reflecting on the incident. “In

other words, the nurse must be cognizant of the patient’s need through data or evidence,

prioritize and make sense of the data surrounding the event, and come to some conclusion

about the best course of action and respond to the event. The outcomes of the action

selected provide the basis for the nurse’s reflection afterward on the appropriateness of

the response and clinical learning for future practice.” (Lasater, 2007).

Clinical judgment related to the client based on the response to real and probable health

problems and/or life processes manifests into a nursing diagnosis. The nursing care

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process is an organized means of planning care. Nurses can attribute to the health care

industry by utilization of NANDA’s one hundred seventy-two diagnoses. These provide a

basis for the selection of interventions and contributions toward measurable goals. The

application of NANDA’s diagnosis also aided in accuracy of documentation and

established better understanding of the patient’s requirements.

Evaluation of patients’ progress is an important role that requires efficient cognitive

skills. Lenburg presses that teacher-focused methods of educating tomorrow’s nurses

provide the future with meritocracy. Competency levels in new graduates are not as the

should (or could) be. This is reasoned not only because of lack of critical thinking and

clinical judgment on the part of the student but the focus is on the style of instruction.

Lenburg put developed the Competency Outcomes and Performance Assessment (COPA)

model. The COPA model has eight core competencies that are arranged by particular

skills necessary to ensure proficient nursing procedures. One of these core competencies

essential to every health care professional is critical thinking.

Lenburg suggest instructors move away from the traditional teaching methods that

establish objectives for learning and promote a teaching environment that reflects

practice-related abilities to be learned. This method will not only make the students test

ready, knowing the objectives, but effective in the real world of nursing.

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Professional Standards in Nursing Practices

The articles found on the standards of nursing were in great abundance. Education is the

priority to maintain a high standard. Nurses are responsible for care of others, research

activities, and continuing education. According to the ANA, “an attitude of inquiry, as

well as introduction to the research process, should be initiated during the undergraduate

education.” “Graduate education must emphasize increasing development of conceptual

abilities, knowledge of the research processes, as well as scientific integrity.”

In another ANA article, the board maintains the importance of adherence to the high

professional and legal standards during the nursing shortage. They address the desire of

legislatures to want to reduce the qualifying measures of licensure. This would be a

detriment to the profession of nursing and the standards currently held by its

professionals. The demand for nurses and caregivers should be restated as a demand for

trained/skilled nurses and caregivers. Lowering the standards would ultimately lower the

care received by the client. One highly trained nurse would be more effective the three

individuals without training or with inadequate training.

“Quality is a broad tern that encompasses various aspects of nursing care.” (Montaivo,

2007). This article explains the National Database of Nursing Quality Indicators

(NDNQI) and the importance of it’s findings. Since Nightingale, it has been important to

not only set standards in nursing care but to evaluate the outcomes of such care. The

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information provide by these reports have made it possible for facilities to equip

themselves and their employees with necessities to offer adequacy and excellence to the

clients. NDNQI also affected the standards of nursing care on a national level by

developing accepted measures in the assessment of the quality of health care. This has

become a “valuable nursing tool to aid in decision making about staffing, skill mix,

patient care processes, and workforce characteristics that affect patient outcomes, thus

influencing directly and indirectly the cost of patient care.”

Caring Through the Life Span

“Nurses in almost all specialties and settings come into contact with older adults on a

regular basis. Knowledge of the particular needs and ways to promote positive outcomes

for older adults is therefore core knowledge for the profession.” (Young, 2003)

Out of pocket expenses and government subsidies are a primary topic for the every

increasing elder population. It wasn’t very long ago that the life span of a male was half a

century but with today’s medical advancements and the push for healthy living the

national average increase by fifty percent. With the passing of Medicare laws and the

expansion of the life span our hospitals face a new dilemma.

Gerontology has become the new nursing specialty. “Gerontological nursing reflects a

broader approach, concerned with health maintenance, illness prevention, and quality of

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life promotion.” (Stotts, Deitrich, 2004). The aging population attribute to the rise in

health care cost and the need for long term care. Edlund and Lufkin address the long term

care planning for the ever ageing baby boomer generation. Unlike years passed, parents

aren’t home with their children when they age. When they reach a point of dependence

they are often faced with choosing a facility that appeal to their needs. Medicare when

initiated was primarily for acute care not intended for long term care. This lack of future

funding will require future recipients to have alternative methods of payment and/or care.

This may include supplemental or private insurance, moving back in with family, day

care or respite care programs, or parish nursing.

Bennett and Flaherty-Robb advocate not more or even better health care for these

individuals, but a change of values that can only happen “with a commitment to embrace

the importance of aging issues by universities that educate primary health care providers,

by health care organizations that decide what health care will be received by elders and

their families and how much that will cost, and by legislators who determine the budgets

for national health priorities.”

Clients with Special Needs

Clients with special needs encompass every person a nurse has the opportunity to come

into contact with. It is the duty and responsibility of the nurse to act in a prompt and

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reasonable manner to need of every individual not only to decipher and address those

needs but also to assist and educate individuals to improve quality of life.

The literary review on the subject incorporated only three of the vast articles and/or

situations that fell within the parameter of this review. These articles cover the topics of

depression and cognitive impairment in older adults, self-mutilation in adolescences, and

gifted yet learning disabilities in children. Although these are seemingly unrelated areas

the topics are linked most significantly to the reason ability of the individuals. The

dynamics of these individuals require skilled nursing to develop satisfactory care plans

suitable to the individuals needs.

“Clinicians can reduce the occurrence of complicating factors with the proactive

approach to evaluation that includes effective detection of cognitive impairment and

referral for more comprehensive assessment when indicated.” (Guy and Steffens, 2007)

Self-mutilation is difficult to diagnoses however it is common for depression to be

included in the list of signs/symptoms. Self-injury can be defined as the deliberately

attempt to harm one’s own body. This is an impulse-control disorder. “Diagnosing self-

mutilation involves not only looking for mental disorders but also looking at other risk

factors and family dynamics.” (Williams and Bydalek , 2007). With the decline of the

nuclear family and the amount of stress put on teenagers, the health care industry should

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find ways to meet the special needs of these individuals. “Initial assessments for self-

mutilation should include a complete skin assessment for cuts and scars.”

The increase of diagnosed cases of ADD/ADHD pronounces the uptrend for learning

disabled children. Assessment of these individuals is done primarily through the PCP.

Education and administration of the care plan (including the evaluation of the

effectiveness of treatment) is the responsibility of the nurse. Horowitz(2007) reminds us

of yet another special need in his article on exceptional children: children who have

learning disabilities yet are gifted in other areas. “This special group… demands a very

different and often unsettling type of attention….Let’s be sure we’re ready for the

challenge!”

Psychosocial bases for Nursing

Addressing the issue of psychosocial aspect in nursing, one would have to realize it is

primary in the foundation of all aspects of nursing. The term refers to the psychological

development of an individual in and within a social environment. Nursing is a social

environment. There will be continuous interactions building an infrastructure of

connection with the care provider located near center.

In an article addressing the care of the care giver, Sorrell (2007) states, “As health care

professionals, we have a responsibility to assess each situation to determine how best to

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assist patients and families in accessing appropriate information and available resources,

including counseling and support groups.” Duty and obligation do not stop at the patient;

in the holistic approach of nursing, it must extend to the families and communities of

these clients.

“Membership of a health profession implies that the individual is socialized and educated

within a specific professional culture.”(Hart and Freeman, 2005) And they go on to point

out, “..nurses are constantly faced with situations which either consciously or

unconsciously challenge their world views, self-image, and their competence.” The

dynamics within those perpetual infrastructures are continuously changing and shaping

the care provider.

Classifications and the development of stagnant ideas are important for unity in the every

changing nurse and the profession of nursing. Diagnostic classifications provide a well

defined tool to communicate. “Gordon observed that a diagnosis is a conceptual model

for interpreting a set of observations and therefore provides a way of understanding and

thinking about the set.” (Gordon 1998) “Because the focus of nursing diagnosis is

abstract, this definition (NANDA) is acceptable to nurses of different theoretical

persuasions and colleagues in other professions.”

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Due to the great differences in influences on each individual and the interpretations of

those influences; it remains necessary to collaborate on certain ideas with a known

benchmark and classification system.

Scientific bases for Nursing

The previous though overlaps with the current topic. One of the themes presented by the

literature found on the scientific aspect of nursing was the standardization of language.

“In attempting to arrive at the truth, I have applied everywhere for information, but in

scarcely an instance have I been able to obtain hospital records fit for any purpose of

comparison.” Florence Nightingale (taken from Dovie, 2006) “Documenting nursing

practice and patient care using a universal language can contribute to nursing’s

autonomy.”

Pirquet’s paper dated 1927, eggs on the nursing community to jump in and take an active

part in the scientific work of the medical profession. Ironically the challenges presented

have come to pass: scientific nursing magazines, independently thinking nurses, and

nurses that are required to have knowledge of anatomy or the pathology of illnesses. It is

hard to imagine the day when a nurse “needed no special knowledge; only that a good

will, physical capacity for work, and common sense were all that should be expected.”

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Perhaps it was the push into the scientific study and autonomy that took the nurses of the

1930’s into the twenty-first century. Now nurses are responsible for research and change

along with the tasks of the past: monitoring patients, informing the doctors, and recording

changes. Nurses have the opportunity to be on the cutting edge of change. As patient

advocates and mediators to legislation, they stand on the frontlines.

Letourneau and Allen (1999) give insight on new forms of scientific research and

collaboration. In their discussion on critical multiplism, they advocate the need to

recognize the importance of objectivity along with personal values (incorporating ethics

with science). “Post-positivistic critical multiplism holds considerable potential for

scientific nursing knowledge development and nursing practice. Critical multiplism

advocates methodological pluralism that gives way to both qualitative and quantitative

methods. As a result, nurse researchers can approach the study of health and holistic

human beings from a wide variety of perspectives. This results in research that more

accurately reflects the nature of holistic nursing practice.”

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References

Bennett, J. A., & Flaherty-Robb, M. K. (2003, May 31). Issues Affecting the Health of

Older Citizens: Meeting the Challenge. The Online Journal of Issues in

Nursing, 8(2)

Doyle, M. (2006, June). Promoting standardized nursing language using an electronic

medical record system. Association of Operating Room Nurses AORN

Journal, 83(6), 1336-1342. 

Edlund, B.J., Lufkin, S. R., & Franklin, B. (2003, May 31). Long-term Care Planning for

Baby Boomers: Addressing an Uncertain Future. The Online Journal of Issues in

Nursing, 8(2)

Gordon, M. (1998, September 30). Nursing Nomenclature and Classification System

Development. The Online Journal of Issues in Nursing, 3(2) 

Guedes, C. (2007, October). Physical Education and Physical Activity: A Historical

Perspective. Journal of Physical Education, Recreation & Dance, 78(8), 31-32,

47-48.

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Hart, A., & Freeman, M. (2004, April). Health ‘care’ interventions: making health

inequalities worse, not better? Journal of Advanced Nursing, 49(5), 502-512. 

Horowitz, S. H. (2007, November/December). Giftedness and LD: Twice Exceptional

and Still Struggling. Children’s Voice, 16(6), 18-19. 

Lasater, K. (2007, November). Clinical Judgment Development: Using Simulation to

Create an Assessment Rubric. Journal of Nursing Education, 46(11), 496-503.

Lenburg, C.B. (1999, September 30). The Framework, Concepts and Methods of the

Competency Outcomes and Performance Assessment (COPA) Model.  The

Online Journal of Issues in Nursing, 4(3).

Letourneau, N., & Allen, M. (1999). Post-positivistic critical multiplism: a beginning

dialogue. Journal of Advanced Nursing, 30(3), 623-630. 

Mannino, A. J. (n.d.) Bringing History of Nursing Up to Date. American Journal of

Nursing. 

Montaivo, I. (2007, September). The National Database of Nursing Quality Indicators

(NDNQI). The Online Journal of Issues in Nursing, 12(3) 

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Muller-Staub, M., Lavin, M.A., Needham, I., & van Achterberg, T. (2006, May). Nursing

diagnoses, interventions, and outcomes – application and impact on nursing

practice: systematic review. Integrative Literature Reviews and Meta-Analyses,

Journal compilation Blackwell Publishing. 514-531. 

Pirquet, C. (1927, September). Should the Nurse Take Part in the Scientific Work of the

Medical Profession? The American Journal of Nursing, 27(9), 757-758. 

Potter, G., & Steffens, D. (2007, November). Depression and Cognitive Impairment in

Older Adults. Psychiatric Times, 24(13), 23.  Retrieved November 6, 2007, from

ProQuest Nursing & Allied Health Source database. (Document ID: 1375824191)

Sandelowski, M. (2000, October). Thermometers & Telephones. American Journal of

Nursing, 100(10), 82-86. 

Sorrell, J. M. (2007, November). Caring for the Caregivers. Journal of Psychosocial

Nursing, 45(11), 17-20. 

Stotts, N. A., & Deitrich, C. E. (2004, August). The Challenge to Come: The Care of

Older Adults.  American Journal of Nursing, 104(8), 40-47. 

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West, E.A., Griffith, W.P., & Iphofen, R. (2007, April). A Historical Perspective on the

Nursing Shotage. MEDSURG Nursing, 16(2). 

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Journal of Issues in Nursing, 11(2). 

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Diagnosis & Treatment. Journal of Psychosocial Nursing, 45(12), 19-23. 

Young, H.M. (2003, May 31). Challenges and Solutions for Care of Frail Older

Adults. The Online Journal of Issues in Nursing, 8(2) 

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Joint Statement on Maintaining Professional and Legal Standards During a Shortage of

Nursing Personnel (1992, August). ANA Nursing World.