ESSENTIALS OF Nursing Leadership & Management EIGHTH EDITION

Introduction It is often said that you do not know where you are going until you know where you have been. More than 40 years ago, Beletz (1974) wrote that most people thought of registered nurses in gender- linked, task-oriented terms: “a female who per- forms unpleasant technical jobs and functions as an assistant to the physician” (p. 432). Interest- ingly, physicians in the 1800s viewed nursing as a complement to medicine. According to War- rington (1839), “. . . the prescriptions of the best physician are useless unless they be timely and properly administered and attended to by the nurse” (p. iv). In its earliest years, most nursing care occurred at home. Even in 1791 when the first hospital opened in Philadelphia, registered nurses continued to care for patients in their own home settings. It took almost another century before nursing moved into hospitals. These institutions, mostly dominated by male physicians, promoted the idea that registered nurses acted as the “handmaidens” to the better-educated, more capable men in the medical field. The level of care differed greatly in these early health-care institutions. Those operated by the religious nursing orders gave high-quality care to patients. In others, care varied greatly from good to almost none at all. Although the image of registered nurses and nursing has advanced considerably since then, some still think of registered nurses as helpers who carry out the physician’s orders. It comes as no surprise that nursing and health care have converged and reached a crossing point. Registered nurses face a new age for human experience; the very foundations of health practices and thera- peutic interventions continue to be dramatically altered by significantly transformed scientific, technological, cultural, political, and social realities (Porter-O’Grady, 2003). The global environment needs registered nurses more than ever to meet the health- care needs of all. Nursing sees itself as a profession rather than a job or vocation and continues with this quest for its place among the health-care disciplines. However, what defines a profession? What behaviors are expected from the members of the profession? Chapter 1 discusses nursing as a profession with its own identity and place within this new and ever-changing health-care system. Professionalism Definition of a Profession A vocation or calling defines “meaningful work” depending on an individual’s point of view (Dik & Duffy, 2009). Nursing started as a vocation or “calling.” Until Nightingale, most nursing occurred through religious orders. To care for the ill and infirmed was a duty (Kalisch & Kalisch, 2004). In early years, despite the education required, nursing was considered a job or vocation (Cardillo, 2013). Providing a definition for a “profession” or “pro- fessional” is not as easy as it appears. The term is used all the time; however, what Features define a professional? According to Saks (2012), several theoretical approaches have been applied to creating a definition of a profession, the older of these looking only at knowledge and expertise, whereas later ones include a code of ethics, prac- tice standards, licensure, and certification, as well as expected behaviors (Post, 2014). Registered nurses engage in specialized education and training confirmed by successfully passing the National Council Licensure Examination (NCLEX®) and receiving a license to practice in each state. Registered nurses follow a code of ethics and recognized practice standards and a body of con- tinuous research that forms and directs our practice. Registered nurses function autonomously within the desig- nated scope of practice, formulating and delivering a plan of care for clients, applying judgments, and utilizing critical thinking skills in decision making (Cardillo, 2013). Professional Behaviors According to Post (2014), professional characteris- tics or behaviors include: ■ Consideration ■ Empathy ■ Respect ■ Ethical and moral values ■ Accountability ■ Commitment to lifelong learning ■ Honesty Professionalism denotes a commitment to carry out specialized responsibilities and observe ethical principles while remaining responsive to diverse recipients (Al-Rubaish, 2010). Communicating effectively and courteously within the work envi- ronment is expected professional behavior. State boards of nursing through the nurse practice acts elaborate expected behaviors in a registered nurse’s professional practice and personal life (National Council of State Boards of Nursing [NCSBN], 2012, 2016). Registered nurses may lose their licenses for a variety of actions deemed unprofessional or illegal. For example, inappropriate use of social media, posting emotionally charged statements in blogs or forums, driving without a license, and committing felonies outside of professional practice may be cause for suspending or revoking a nursing license. Commitment to others remains central to a profession. In nursing, this entails commitment to colleagues, lifelong learning, and accountability for one’s actions. Professionalism in the workplace means coming to work when scheduled and on time. Coming to work late shows disrespect to your peers and colleagues. It also indicates to your super- visor that this position is not important to you. Always portray a positive attitude. Although everyone experiences a bad day, projecting personal feelings and issues onto others affects the work environment. Many agencies and institutions have dress codes. Dress appropriately per the employ- er’s expectations. Wearing heavy makeup, colognes, or inappropriate hairstyles demonstrates a lack of professionalism. Finally, always speak profession- ally to everyone in the work environment. A good rule to follow should be, “If you wouldn’t say it in front of your grandmother, do not say it in the workplace” (McKay, 2017). Work politics often create an unfavorable envi- ronment. Stay away from gossip or engaging in negative comments about others in the workplace. Change the topic or indicate a lack of interest in this type of verbal exchange. Negativity is conta- gious and affects workplace morale. Professionals maintain a positive attitude in the work environ- ment. If the environment affects this attitude, it is time to look for another position (McKay, 2017). Lastly, professional behavior entails honesty and accountability. If a day off is needed, take a personal or vacation day; save sick days for illness. Own up to errors. In nursing, an error may result in injury or death. The health-care environment should promote a culture of safety, not one of pun- ishment for errors. This is discussed more in later chapters. Evolution of Nursing as a Profession Nursing Defined The changes that have occurred in nursing are reflected in the definitions of nursing that have developed through time. In 1859, Florence Night- ingale defined the goal of nursing as putting the client “in the best possible condition for nature to act upon him” (Nightingale, 1992/1859, p. 79). In 1966, Virginia Henderson focused her definition on the uniqueness of nursing: 7e unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible. (Henderson, 1966, p. 21) Martha Rogers defined nursing practice as “the process by which this body of knowledge, nursing science, is used for the purpose of assisting human beings to achieve maximum health within the potential of each person” (Rogers, 1988, p. 100). Rogers emphasized that nursing is concerned with all people, only some of whom are ill. In the modern nursing era, registered nurses are viewed as collaborative members of the health-care team. Nursing has emerged as a strong field of its own in which registered nurses have a wide range of obligations, responsibilities, and accountability. Recent polls show that registered nurses are considered the most trusted group of professionals because of their knowl- edge, expertise, and ability to care for diverse populations. Nightingale’s concepts of nursing care became the basis of modern theory development, and in today’s language, she used evidence-based prac- tice to promote nursing. Her 1859 book Notes on Nursing: What It Is and What It Is Not laid the foun- dation for modern nursing education and practice. Many nursing theorists have used Nightingale’s thoughts as a basis for constructing their view of nursing. Nightingale believed that schools of nursing must be independent institutions and that women who were selected to attend the schools should be from the higher levels of society. Many of Night- ingale’s beliefs about nursing education are still applicable, particularly those involved with the progress of students, the use of diaries kept by students, and the need for integrating theory into clinical practice (Roberts, 1937). The Nightingale school served as a model for nursing education. Its graduates were sought worldwide. Many of them established schools and became matrons (superintendents) in hospitals in other parts of England, the British Common- wealth, and the United States. However, very few schools were able to remain financially indepen- dent of the hospitals and thus lost much of their autonomy. This was in contradiction to Nightin- gale’s philosophy that the training schools were educational institutions, not part of any service agency. The National Council Licensure Examination Professions require advanced education and an advanced area of knowledge and training. Many are regulated in some way and have a licensure or certification requirement to enter practice. This holds true for teachers, attorneys, physicians, and pilots, just to name a few. The purpose of a profes- sional license is to ensure public safety, by setting a level of standard that indicates an individual has acquired the necessary knowledge and skills to enter into the profession. Licensure Licensure for registered nurses is defined by the NCSBN as the process by which boards of nursing grant permission to an individual to engage in nursing practice after determining that the applicant has attained the competency necessary to perform a unique scope of practice. Licensure is necessary when the regulated activities are complex, require specialized knowledge and skill, and involve independent decision making (NCSBN, 2012). Government agencies grant licenses allowing an individual to engage in a professional practice and use a specific title. State boards of nursing issue nursing licenses. This limits practice to a specific jurisdiction. However, as the NCLEX® is a nation- ally recognized examination, many states have joined together to form a “compact” where the license in one state is recognized in another. States belonging to the compact passed legislation adopt- ing the terms of the agreement. The state in which the nurse resides is considered the home state, and license renewal occurs in the home state (NCSBN, 2018a). Licensure may be mandatory or permissive. Permissive licensure is a voluntary arrangement whereby an individual chooses to become licensed to demonstrate competence. However, the license is not required to practice. In this situation a manda- tory license is not required to practice. Mandatory licensure requires a nurse to be licensed in order to practice. In the United States and Canada, licen- sure is mandatory. Licensure by Endorsement If a state is not a member of the compact, registered nurses licensed in one state may obtain a license in another state through the process of endorsement. Each application is considered independently and is granted a license based on the rules and regula- tions of the state. States differ in the number of continuing edu- cation credits required, mandatory courses, and other educational requirements. Some states may require that registered nurses meet the current criteria for licensure at the time of application, whereas others ma